Every finding on record at Jerold Phelps Comm Hosp SNF

Based on interviews and records reviews, the facility did not ensure that an allegation of financial abuse was reported within two hours of notification of the abuse to the State Survey Agency (California Department of Public Health (CDPH)) for one resident (Resident 1).This failure decreased the facility's potential to meet the minimum standards of reporting abuse and ensure Resident 1 would be free from further financial abuse.A review of Resident 1's Face Sheet indicated she was admitted to the facility on [DATE] with a diagnosis of Dementia (a progressive state of decline in mental abilities) associated with Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).On 2/23/26 at 4:49 p.m., CDPH received a fax from the facility of a Report of Suspected Dependent Adult/Elder Abuse form (SOC 341). The SOC 341 was dated 2/20/26 and completed by the facility's Director of Nursing (DON), and indicated Resident 1 was an alleged victim of financial abuse.A review of the facility's undated document titled [Resident 1's] 5-day summary for Alleged Financial Abuse Incident indicated the facility became aware of the allegation of financial abuse toward Resident 1 on 2/19/26 at 3:30 p.m. On 2/19/26 at 3:49 p.m., the abuse coordinator was notified of the allegation. On 2/23/26 at 3:58 p.m., the facility called CDPH and left a message to notify them of the alleged financial abuse. On 2/26/26 at 4:48 p.m., the facility faxed the SOC 341 to CDPH.A review of Resident 1's Short Term Care Plan dated 2/19/26, indicated, Resident [Resident 1] called bank to check balance, was upset d/t [due to] debits from account .A review of CDPH's messages dated 2/19/26 to 2/24/26 indicated no voicemail messages received from the facility.During an interview on 3/23/26 at 10:25 a.m., the Chief Nursing Officer (CNO) confirmed that she was the facility's abuse coordinator. The CNO stated she did not know if CDPH was called to report the incident on 2/19/26. The CNO stated it was her expectation that any staff who suspected abuse should report to CDPH within 2 hours. The CNO stated it was her responsibility to check that allegations of abuse were reported to CDPH within 2 hours.A review of a facility policy and procedure (P&P) titled, Preventing, Identifying, and Reporting Abuse, Neglect, and Exploitation, undated, indicated, It is the policy of this facility to prevent, identify, report, and follow up promptly and appropriately regarding actual or suspected abuse, neglect, and exploitation . Pursuant to Title 42 CFR (Code of Federal Regulations) 483.12 (c) (1) for incidents that involve abuse or result in serious bodily injury, facility must: Call local law enforcement and the Department of Public Health immediately, but not later that 2 hours after the allegation is made.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, seven days a week for a census of 8 residents. This failure contributed to staffing shortfalls: there were no RNs on duty for 7 days between January 2025 and March 2025, thereby creating the potential that residents would not receive RN-specific care such as assessments and intravenous medication administration. Cross reference F838.Findings: During a concurrent interview and record review on 9/11/25 at 4:10 p.m., the DON (Director of Nursing) reviewed the facility nurse staffing schedules dated, January 2025, February 2025, March 2025 and April 2025. The DON confirmed the facility did not have an RN scheduled to work on the following dates: 1/25/25, 3/1/25, 3/9/25, 3/16/25, 3/23/25, 3/27/25, and 3/30/25. The DON stated an RN who was working at the hospital on those dates was assigned to be a hospital float nurse (an RN who provides various duties including working different units like the Emergency Department or general hospital, assisting other nurses with tasks, covering nurses when they take a break, etc.). The DON confirmed the hospital float nurse was not specifically designated to work as an RN at the facility on those dates; the hospital float nurse was available to assist at the facility if needed.During an interview on 9/12/25 at 10 a.m., the DON stated the facility did not have a policy and procedure addressing staffing.During an interview on 9/12/25 at 12:11 p.m. with Quality Officer H (QO H) and Quality Staff I (QS I), QO H stated the facility was not aware staffing requirements were not met, as outlined in the Facility Assessment (comprehensive evaluation process assessing the resident population and the resources needed to provide competent care). The QO H stated they thought a float nurse was adequate. Review of the Facility Assessment titled, Facility Assessment Tool, dated updated 10/5/2023, indicated, . There is a Licensed Vocational nurse on each shift; 12 hour day shift and 12 hour night shift. There is a Resource Registered Nurse (float nurse) available 24 hours a day 7 days a week on site.

Based on administrative interview and record review, the facility failed to ensure a comprehensive facility-wide assessment (evaluation process assessing the resident population and the resources needed to provide competent care) was updated annually and included a staffing plan that ensured Registered Nurse's (RN) worked 8 consecutive hours per day, seven days a week.This failure contributed to staffing shortfalls: there were no RNs on duty for 7 days between January 2025 and March 2025, thereby creating the potential that residents would not receive RN-specific care such as assessments and intravenous medication administration. Cross reference F727.Findings:During an interview on 9/11/25 at 2:45 p.m., the Director of Nursing (DON) stated she did not have an updated facility assessment and provided a facility assessment tool dated, which was last updated 10/5/23. The DON stated the facility was currently working on updating the facility assessment.During a concurrent interview and record review on 9/11/225 at 4:10 p.m., the DON reviewed the facility nurse staffing schedules dated, January 2025, February 2025, March 2025 and April 2025. The DON confirmed the facility did not have an RN scheduled to work on the following dates: 1/25/25, 3/1/25, 3/9/25, 3/16/25, 3/23/25, 3/27/25, and 3/30/25. The DON stated an RN working in the hospital (located down the hall from the facility) was available to assist at the facility if needed but was not specifically designated to work at the facility.Review of the Facility Assessment titled, Facility Assessment Tool, updated on 10/5/23, indicated, . There is a Licensed Vocational nurse on each shift; 12-hour day shift and 12-hour night shift. There is a Resource Registered Nurse (float nurse; an RN who provides various duties including working different units like the Emergency Department or general hospital, assisting other nurses with tasks, covering nurses when they take a break, etc.) available 24 hours a day 7 days a week on site.During an interview on 9/12/25 at 10a.m., the DON stated the facility did not have a policy and procedure addressing staffing.During an interview on 9/12/25 at 12:11 p.m. with Quality Officer H (QO H) and Quality Staff I (QS I), QO H stated the facility was not aware RN staffing requirements were not being met, as outlined in the Facility Assessment (comprehensive evaluation process assessing the resident population and the resources needed to provide competent care). QO H stated they thought a float nurse (from the hospital) was adequate.QO H stated the facility did not have a policy and procedure for their Facility Assessment.

Based on interviews and record reviews, the facility failed to ensure professional standards of practice were conducted for two residents (Resident 3, and Resident 9) of eight sampled residents when insulin orders did not include blood sugar parameters (levels that indicate when blood sugar is considered too high or too low).This failure placed residents at risk for ineffective monitoring of insulin usage and worsening of their Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).Findings:During a review of Resident 3's untitled facility document indicated, the resident was a [AGE] year-old female admitted to the facility on [DATE], with a medical diagnosis that included DM.During a review of Resident 3's physician order report dated 5/28/25 indicated, Insulin glargine (a long-acting type of insulin used to manage blood sugar levels in people with diabetes) pen (a prefilled injection device containing insulin) 100 units/milliliter (specifies the concentration of insulin in one milliliter). Inject 20 units subcutaneously (a layer of fatty tissue just below the skin) at bedtime for DM. The order for insulin glargine dated 5/28/25 did not indicate parameters for blood sugar levels and when to notify a physician when the insulin was supposed to be held (not administered).During a review of Resident 9's History and Physical (H&P) dated 5/8/25 indicated Resident 9 was a [AGE] year-old- female admitted to the facility on [DATE] with a medical diagnosis that included DM.During a review of Resident 9's blood sugar flow sheets from 9/1/25 to 9/10/25 indicated, Resident 9 had episodes of fluctuating blood sugar levels between 236 mg/dl and 91 mg/dl (mg/dL, milligrams per deciliter, a unit of measurement for the concentration of blood sugar (glucose). The medication administration record (MAR) dated from 9/7/25 through 9/10/25 did not indicate the frequency of monitoring blood glucose levels. During a review of Resident 9's Current Scheduled Medication report indicated, Insulin glargine pen, inject 80 units subcutaneously nightly for DM was ordered 5/20/25. The order for Insulin glargine did not show documented evidence that Resident 9 had an order for insulin parameters and when to notify a physician when the insulin was supposed to be held.During an interview and concurrent record review on 9/10/25 at 1:30 p.m., Licensed Staff K (LS K) reviewed the e-MARs (Electronic Medication Administration Record ) for Residents 3 and 9 and confirmed their insulin orders did not have parameters. LS K stated the glucose checks and insulin parameters have not been ordered consistently for residents.During an interview on 9/11/25 at 11:15 a.m., Pharmacist J (PharmD J) stated parameters for insulin should always be ordered for insulin administration. PharmD J stated the standard of practice is for insulin to have parameters, or a sliding scale in the orders. PharmD J stated order-sets for insulin are used and sometimes discussed and reviewed with the physician. PharmD J stated he had not reviewed insulin parameters for Residents' 3 and 9 with the physician. During an interview on 9/11/25 at 2:25 p.m., Physician D stated his standard of practice for writing insulin administration orders included parameters for managing high and low blood glucose levels. Physician D confirmed the orders for insulin parameters were inconsistent and he was working on improving the processes. A review of the facility's policy and procedure (P&P) titled Insulin Utilization not dated, indicated, .Insulin vials will be labeled with a patient specific label with insulin formulation, dose, directions for use and frequency.Two licensed.Health Clinicians will verify the following prior to administration: the LIP [Licensed Independent Practitioner] order, type of insulin, dosage, route, time, and most recent blood glucose level.A review of The American Medical Directors Association's publication titled Diabetes Management in the Long-Term Care Setting revised 2010 indicated, .A systematic facility approach to diabetes management can streamline day-to-day care and reduce the frequency of episodes of hypoglycemia [when blood sugar level is too low], hyperglycemia [when blood sugar level is too high], and other.complications [of diabetes].Make use of standing orders for glucose monitoring and practitioner notification.when the patient is admitted .the practitioner may write an order stating that he or she is to be notified when a patient's blood glucose values are outside of a specific range.When patients are extremely frail or cognitively impaired and their blood glucose levels are poorly controlled, the practitioner may wish to note specific individual blood glucose or symptom parameters in the orders.

Based on interview and record review, the facility failed to ensure Medication Review (MRR) policy and procedures were developed and maintained for scheduled medication reviews and oversight of medication administration.This failure put residents at risk for ineffective monitoring of medications and side effects that could go undetected by licensed staff and delay for the physician to act upon irregularities.Findings:During an interview on 9/11/25 at 11:15 a.m., the facility Pharmacist J (PharmD J) stated he had monthly MRR reviews for each of the residents and reported to the physician and Director of Nursing (DON). PharmD J stated during his MRR reviews he expected a response to any of his recommendations from a physician right away or within 48 hours.Pharm D J stated standard of practice for insulin administration included parameters and blood sugar checks in the orders. Pharm D J stated parameters should be ordered for residents depending on the type of insulin administered. Pharm D J also verified he did not review the residents that received insulin and if parameters were ordered.A review of the Policy and Procedures for the MRR process was requested, the PharmD J stated he was in process of writing the policy and procedures and currently did not have a policy and procedure for the MRR.

Based upon observation, interview, and record review, the facility failed to ensure insulin pens stored in the medication cart were dated with an opened date for three residents (Resident 3, Resident 4, and Resident 8) of a sample of eight residents.This failure increased the facility's potential to administer expired medication and decrease the resident's opportunity to benefit from the full effect of the medication.Findings:During an observation of the Medication Cart and concurrent interview with Licensed Staff K (LSK) on [DATE], at 11:30 a.m., Insulin Pens (Insulin pens are convenient and discreet devices used to administer insulin for managing type 2 diabetes) did not have open dates for three residents. Resident 1's Lantus insulin pen was labeled with a beyond-use-date of [DATE]; Resident 2's Lantus insulin pen was labeled with a beyond-use-date of [DATE]; and, Resident 3 Humalog Kwik pen was labeled with a beyond-use-date of [DATE]. During a concurrent interview, (LS K) verified the insulin pens did not have an opened-date and stated once opened, an insulin pen use is for 28 days.During an interview on [DATE] at 11:20 a.m., the facility pharmacist (PharmD J) stated the insulin pens should be dated with an opened date.A review of the Institute for Safe Medication Practices article titles Storage of Insulin published 2025 indicated, Write the date you open the insulin on the product. On the day you open the insulin vial, pen, or cartridge, or start keeping it outside the refrigerator, write the date on the label. This will help you remember when to stop using it. Insulin expires 28 days after it is opened.

Based on observation, interview and record review, the facility's two consulting Registered Dietitians (RD A and RD B) did not provide nutritional assessments and reassessments, per policy and procedure, for one resident (Resident 6) of eight sampled residents and the facility did not have documentation of an admission nutrition Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) for Resident 6. These deficiencies caused Resident 6 to receive his first post-admission RD nutritional assessment almost two months later which potentially delayed the timely implementation of nutritional interventions designed to assist Resident 6 in attaining his highest practicable physical, mental, and psychosocial well-being.Findings:A review of Resident 6's hospital document titled, Initial Nutritional Assessment, dated 7/30/24 indicated the Registered Dietician A (RD A) had documented, . Low appetite reported. Intake: (less than) 25% . Under subtitled, Objective, RD A documented, Ht: (height) 5'9 (five feet, nine inches) Wt: (weight) 100 lbs. (pounds). Underweight status for ht/wt (height/weight) . RD to f/u (follow up) (in) 2-3 months of per consultation request.During a review of Resident 6's admission document titled History and Physical (H&P), dated 8/13/24indicated Resident 6's diagnoses included Failure to thrive (substantial decline in overall health, including weight loss), Cachexia (significant weight loss and muscle loss), and Iron Deficiency Anemia (low iron causing decreased production of red blood cells.). The H&P also indicated Resident 6 was a candidate for admission to our long-term care facility for support with activities of daily living (basic tasks necessary for self-care and daily functioning like bathing, dressing, eating and toileting), physical therapy, and monitoring of nutrition.A review of Resident 6's initial MDS (resident assessment tool), dated 8/28/24, indicated he was admitted to the facility on [DATE], was 69 inches tall (approximately 5 feet, 7.5 inches in height), and weighed 105 pounds. The MDS assessment indicated Resident 6 triggered Nutrition, which indicated he should have a Nursing Care Plan to address his nutritional needs).Review of Resident 6's medical record titled, Follow-up Nutritional Assessment, dated 10/9/24 indicated RD A documented, .Ht: 5'9 Wt: 110 lbs. Underweight status for ht/wt. Weight gain about 10 lbs. in 3 months. RD to f/u 2-3 months or per consultation request. During a review of Resident 6's medical record, the Certified Dietary Manager (CDM, who was not a registered dietician) documented in a CDM progress note on 8/22/24 that Resident 6's meal intake, .continues to be less than 25% . The CDM's next documentation in Resident 6's medical record was 10/9/24 (almost two months after his admission). A review of Resident 6's Nutritional care plan, dated 6/15/25, indicated interventions included, . Snacks between meals.Monitor weights and report significant weight loss. Dietary evaluation. Encourage nutritional supplements.During a concurrent interview and record review on 9/10/25 at 3:49 p.m., the Director of Nursing (DON), Director of Staff Development (DSD) and MDS nurse (a nurse who coordinates, assesses, and documents patient care in a long-term care or nursing facility using a comprehensive federal tool called the Minimum Data Set (MDS)) reviewed Resident 6's medical record. The DSD stated the CDM documented in Resident 6's medical record on 8/22/24. The DSD stated RD A's first documented assessment of Resident 6's nutritional status was on 10/9/24 and acknowledged the RD B had not documented in Resident 6's medical record between his admission on [DATE] and 10/9/24. The MDS nurse stated the facility did not have a nutritional care plan for Resident 6 prior to 6/15/25. During an interview on 9/10/25 at 5p.m., the CDM stated she had visited Resident 6, encouraged him to have Ensure (R) (a nutritional supplement), but she missed the fact he had no timely nutrition assessment. During a telephone interview on 9/12/25 at 9:39 a.m., RD A stated she worked as a consulting RD at the facility; she provided resident nutritional assessments remotely (she did not physically come to the facility). She stated she routinely did an initial nutritional assessment for new residents and then quarterly assessments thereafter. She stated if a resident was at high risk for nutritional issues she would reassess them every one to two months. RN A stated Resident 6 should have had an initial assessment around 8/13/24. RN A stated she should have reassessed him after a month based on his weight of 105 pounds and diagnosis of Failure to Thrive. When asked why she hadn't reassessed him after a month, she stated she was not sure. During a telephone interview on 9/12/25 at 10:07 a.m., RN B stated she worked at the facility monthly for approximately two to three hours per month and her tasks included kitchen oversight and some resident education. She stated RN A addressed the majority of resident nutritional concerns; she stated she would only do a resident nutritional assessment if requested by RN A. RN B stated a resident who was 5 foot, nine inches tall, weighed 105 pounds and had a diagnosis of Failure to Thrive was a potentially high-risk nutritional resident. Review of facility policy titled, Nutritional Risk Screening and Assessment for . SNF (facility) Patients. undated, indicated, . Initial Assessment: . A nutritional assessment will be completed by RD within one week from admission. Reassessment. The RD will reassess patient within 1 week of consultation. Consultation could be triggered by and of the following: .If the patient is consuming less than 50% of food offered for 5 or more days.

Based on interview and record review, the facility failed to ensure their policy regarding resident abuse indicated the person responsible for investigating abuse allegations was to submit allegations of resident abuse within 2 hours of being made aware and submit an investigation summary within 5 business days to the California Department of Public Health (CDPH). These failures decreased the facility's potential to protect a census of 8 residents from abuse and take appropriate corrective action. Findings: A review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation printed on 4/17/25 was conducted on 4/28/25. Upon review, the P&P did not indicate the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH nor did it indicate a summary of the investigation was to be submitted to CDPH within 5 business days. On 4/28/25 at 10:13 a.m., the CDPH Surveyor requested a copy of the facility ' s P&Ps regarding reporting allegations of abuse to CDPH. The documents were received by CDPH on 4/28/25 at 3:39 p.m. A review of the facility ' s undated P&P titled Abuse Reporting Requirements showed no documented evidence the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH. In an interview on 5/6/25 at 10:54 a.m., the Director of Nursing (DON) acknowledged neither the P&Ps titled Abuse and Neglect Investigation and Abuse Reporting Requirements indicated the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH and the investigation summary was to be submitted to CDPH within 5 business days. The DON stated she was notified of the 2-hour reporting timeframe by the facility ' s Chief Quality Officer and was notified of the 5 day investigation summary timeframe from the CDPH Surveyor.

Based on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was treated with respect and dignity when Certified Nursing Assistant A (CNA A) shaved Resident 1's pubic hair without Resident 1's consent. This failure had the potential to cause risks like cuts, infections, and skin irritations to Resident 1. Findings: A review of Resident 1's Minimum Data Set (MDS- is a standardized assessment tool that measures health status in nursing home residents) dated 1/26/25, indicated Resident 1: -had a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 5 which indicated he had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment; - was dependent on staff for toileting hygiene; - has dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), anxiety (a group of mental health conditions characterized by excessive worry, fear, and avoidance behaviors that significantly interfere with daily life), and depression (a mood disorder characterized by persistent sadness and loss of interest or pleasure in daily activities). During an interview on 4/17/25 at 11:25 a.m., Licensed Nurse B (LN B) stated she observed Resident 1's pubic area was shaved sloppily (in a careless, untidy, or messy way). LN B stated she submitted a report regarding the incident on 4/3/25. LN B stated she also reported her observation to the Director of Nursing (DON) on 4/4/25. During an interview on 4/17/25 at 12:15 p.m., LN C stated she reported what happened to Resident 1 to the DON on 4/4/25. The LN C stated she had been questioned by Human Resources (HR) about Resident 1. The LN C notified HR Resident 1 was unable to give consent to whomever shaved him, and there was no reason for him to be shaved because he was not scheduled to have surgery. The LN C stated she felt Resident 1 had been abused. During an interview on 4/19/25 at 2 p.m., CNA D stated on 3/29/25, she witnessed CNA A shave Resident 1's pubic hair using Resident 1's personal beard shaver. The CNA D stated she and CNA A both worked the 7 a.m. to 7:30 p.m. shift on 3/29/25. The CNA D stated she was confused as to why CNA A shaved Resident 1's pubic hair because Resident 1 had not asked for it and CNA A had not given a reason why she did it. The CNA D stated Resident 1 looked agitated but had not asked CNA A to stop. The CNA D stated on 4/3/25 at around 5 p.m., she received a phone call from CNA A asking her not to tell anybody she had shaved Resident 1's pubic area. The CNA D stated she reported for work on 4/5/25 and informed LN C what CNA A did to Resident 1. During an interview on 4/20/25 at 10:30 a.m., CNA A confirmed she worked with CNA D to provide incontinent care to Resident 1 on 3/29/25. CNA A stated she observed Resident 1 was hurting as she cleaned him from front to back because he had long pubic hair. The CNA A acknowledged she used Resident 1's own personal shaving equipment to shave his pubic hair. The CNA A stated Resident 1 was fine when she started shaving his pubic hair but Resident 1's body language looked like he was uncomfortable with the shaving, so she stopped right away. The CNA A stated the incident was investigated by the DON and a person from HR The CNA A stated she signed a document which indicated she understood she had committed a violation. During an interview on 4/21/25 at 1:07 p.m., the DON stated it was her expectation CNAs would not unilaterally act without discussing and checking with licensed nurses when providing care that is not included in a resident's plan of care. A review of an undated facility document titled Statement of Patient Rights indicated, Patients of this facility have the right to .Considerate and respectful care, and to be comfortable. You have the right to respect for your cultural, psychosocial, spiritual, and personal values, beliefs, and preferences .receive as much information about any proposed .procedure as you may need in order to give informed consent or to refuse a course of treatment. A review of a facility document titled Job Description: Certified Nursing Assistant dated 6/19/2019, indicated, The Certified Nursing Assistant (CNA) employs intellectual, interpersonal, and technical skills to perform basic resident/patient care, under the supervision of the RN (Registered Nurse) or LVN (Licensed Vocational Nurse) . Adheres to all facility policies and procedures .Assists with problem solving and resolution in collaboration with the [LVN], Resource [RN] and [DON] within the Skilled Nursing Facility.

Based on interviews and record reviews, the facility failed to ensure: 1. An allegation of abuse was reported to the California Department of Public Health (CDPH) within 2 hours of awareness of the allegation for one resident (Resident 1) of three sampled residents when Certified Nursing Assistant D (CNA D) and Licensed Nurse E (LN E) did not report when CNA A shaved Resident 1 ' s pubic hair without medical reason and without consent; and, 2. The facility submitted the investigation summary within 5 business days to CDPH. These failures decreased the facility's potential to protect Resident 1 and other residents from abuse and take appropriate corrective action. Cross reference F607. Findings: 1. A review of Resident 1's Minimum Dats Set (MDS- is a standardized assessment tool that measures health status in nursing home residents) dated 1/26/25, indicated Resident 1: -had a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 5 which indicated he had severe cognitive (the mental process involved in knowing, learning, and understanding things) impairment. - was dependent on staff for toileting hygiene; - has dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), anxiety (a group of mental health conditions characterized by excessive worry, fear, and avoidance behaviors that significantly interfere with daily life), and depression (a mood disorder characterized by persistent sadness and loss of interest or pleasure in daily activities). A review of a document titled Report of Suspected Dependent Adult/Elder Abuse faxed to the CDPH on 4/7/25 at 2:03 p.m., from the facility indicated, Date Completed .4/5/2025 .Received report from nursing staff that another staff member unilaterally clipped a [Resident 1's] pubic hair without consulting others. The employee [CNA A] in question was placed on administrative leave pending completion of investigation and follow up action. During an interview on 4/17/25 at 11:25 a.m., LN B stated she observed Resident 1's pubic area was shaved sloppily (in a careless, untidy, or messy way) on 4/3/25. The LN B confirmed she submitted an incident report regarding her observation of Resident 1's pubic area on 4/3/25 at approximately 6 p.m. to the facility's Human Resources (HR) department. LN B stated she also reported her observation to the Director of Nursing (DON) on 4/4/25. During an interview on 4/19/25 at 2 p.m., CNA D stated on 3/29/25, she witnessed CNA A shave Resident 1's pubic hair using Resident 1's personal beard shaver. The CNA D stated she and CNA A both worked the 7 a.m. to 7:30 p.m. shift on 3/29/25. CNA D stated she was confused as to why CNA A shaved Resident 1's pubic hair because Resident 1 had not asked for it and CNA A had not given a reason why she did it. CNA D stated Resident 1 looked agitated while CNA A shaved him but had not asked CNA A to stop. CNA D stated on 4/3/25 at around 5 p.m., she received a phone call from CNA A asking her not to tell anybody she had shaved Resident 1's pubic area. CNA D stated she reported for work on 4/5/25 and informed LN C what CNA A did to Resident 1. During an interview on 4/20/25 at 8:29 p.m., LN E stated CNA D reported to her CNA A shaved Resident 1's pubic hair on 3/29/25. LN E stated she did not know what to do so she reported this to the oncoming nurse, whose name she could not recall. LN E stated she had worked at other facilities and knew that things like shaving were care planned. LN E stated she had observed Resident 1's pubic area after the incident and noticed it was shaved at the center, but there was pubic hair on the sides, and it was not completely shaven. LN E stated the skin was a little red. LN E stated she asked CNA A why she shaved Resident 1's pubic hair and CNA A replied it was for hygiene, and did not elaborate or explain the reason further. LN E stated CNA A did not ask her if she could shave Resident 1's pubic hair. On 4/28/25 a review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation printed on 4/17/25 was conducted. Upon review, the P&P did not indicate the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH. On 4/28/25 at 10:13 a.m., the CDPH Surveyor requested a copy of the facility ' s P&Ps regarding reporting allegations of abuse to CDPH. The documents were received by CDPH on 4/28/25 at 3:39 p.m. A review of the facility ' s undated P&P titled Abuse Reporting Requirements showed no documented evidence the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH. During an interview on 5/1/25, at 1:25 p.m., the DON stated facility staff were expected to report suspected abuse as required. The DON stated CNA D and LN E were mandated reporters of elder abuse and should have reported the allegation as soon as they were aware but no later than 2 hours of becoming aware of the suspicion of abuse on 3/29/25. The DON stated it was her understanding that the reporting requirements on a suspected abuse allegation was to report it immediately or not later than 2 hours. In an interview on 5/6/25 at 10:54 a.m., the DON acknowledged neither the P&Ps titled Abuse and Neglect Investigation and Abuse Reporting Requirements indicated the facility was to report allegations of resident abuse within 2 hours of the facility ' s awareness to CDPH. The DON stated she was notified of the 2-hour reporting timeframe by the facility ' s Chief Quality Officer. 2. During an interview on 4/21/25, at 1:07 p.m., the DON stated she did not provide a 5-day follow-up report to CDPH. On 4/28/25 a review of the facility ' s policy and procedure (P&P) titled Abuse and Neglect Investigation printed on 4/17/25 was conducted. Upon review, the P&P did not indicate the facility was to submit a summary of the investigation to CDPH within 5 business days. In an interview on 5/6/25 at 10:54 a.m., the DON acknowledged the P&Ps titled Abuse and Neglect Investigation and Abuse Reporting Requirements did not indicate the investigation summary was to be submitted to CDPH within 5 business days. The DON stated she was notified of the 5-day investigation summary timeframe from the CDPH Surveyor.

Based on interview and record review, the facility failed to develop a baseline care plan for six (6) of six (6) residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 57) within 48 hours of their admission. This failure can impede continuity of care, cause uncertain communication among facility staff, and render them unprepared for adverse events that might occur right after the residents' admission as well as keeping the resident or representative in the dark of the initial plan for delivery of care and services. Findings: During a review of records on 2/29/24 at 4:30 PM, no baseline care plans, signed by the residents or their representatives, were found among the facility documents. A request was made to the CNO. 48660 During an interview on 03/1/24 at 10 a.m. Licensed Nurse K (LN K) stated new residents signed documents in an admission packet. She did not know if a care plan was developed within 48 hours of admission. She further stated she did not know if residents or their Resident Representative, RR (an individual chosen by the resident or authorized by law to act on behalf of the resident to support decision-making) acknowledged or signed for receipt of a baseline care plan. During an interview on 03/1/24 at 10:30 a.m., the Chief Nursing Officer (CNO) discussed the admission process for new residents. She confirmed there was not a Baseline Care Plan developed within 48 hours of admission. The CNO also stated there were no records of any care plans signed by new residents or their RR, if appropriate. She consulted with Health Information Management (HIM), and they were unable to find any documentation for 6 of 6 residents stating they received and signed for a Baseline Care Plan. A review of the facility's policies titled, Admission documentation requirements dated 9/26/19, and Resident care planning, dated 3/30/23, did not indicate or mention developing a baseline care plan within a resident's admission. A review of the regulatory Health and Safety Code S483.21 Comprehensive Person-Centered Care Planning, S483.21(a) Baseline Care Plans S483.21(a)(1) to S483.21(a)(3)(iv), indicated, the facility must develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . the baseline care plan should be developed within 48 hours of a resident's admission . include minimum health care information necessary to properly care for a resident including, but not limited to - Initial goals based on admission orders, Physician orders, Dietary orders, Therapy services, Social services, PASARR recommendations, if applicable .the facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: the initial goals of the resident, a summary of the resident's medication and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, any updated information based on the details of the comprehensive care plan as necessary.

Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan for 5 of 6 residents (Resident 1, Resident 3, Resident 4, Resident 5, and Resident 57) to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This failure had the potential to negatively impact the residents' quality of life as well as the quality of care and services received. Findings: A review of Resident 1's face sheet (demographics) indicated he was admitted to the facility on [DATE]. His diagnoses included Hypertension (a condition in which the force of the blood against the artery walls is too high), Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear), Depression (a mood disorder that causes a persistent feeling of sadness or loss of interest), Type 2 diabetes (a health condition that affects how your body turns food into energy), and Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Resident 1's Physician Orders included Sertraline with an indication for use: depression related to Parkinson Disease and Trazodone with an indication for use: insomnia and nighttime depression related to Parkinson Disease. Sertraline and Trazodone are psychotropic drugs (medications used to treat mental health disorders). Record review of documents for Resident 1, titled, Patient Care Plan, did not include a care plan for Psychotropic Drug Use for two of two psychotropic drugs. A review of Resident 3's face sheet (demographics) indicated a current admitted [DATE]. Her diagnoses included Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear), Depression (a mood disorder that causes a persistent feeling of sadness or loss of interest), Bipolar Disorder (a mental disordered characterized by mood swings ranging from depressive lows to manic highs), Diabetes (a health condition that affects how your body turns food into energy), and Hyperlipidemia (a condition in which there are high levels of fat particles in the blood). A review of Resident 3's Physician Orders included Risperidone with indications of use: depression associated with bipolar disorder, mania associated with bipolar disorder, and Sertraline with indications of use: depression and anxiety associated with bipolar disorder. Risperidone and Sertraline are psychotropic drugs (medications used to treat mental health disorders). Record Review of documents for Resident 3 titled, Patient Care Plan, did not include a Care Plan for Psychotropic Drug Use for one of two psychotropic drugs. A review of Resident 5's face sheet (demographics) indicated he was admitted to the facility on [DATE]. His diagnoses included Coronary Artery Disease (damage or disease in the heart's major blood vessels), Hypertension (a condition in which the force of the blood against the artery walls is too high), and Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). During an interview and record review on 3/1/24 at 10:30 a.m., with the Chief Nursing Officer (CNO), the CNO stated she had been unable to locate any individualized care plans for Resident 5. She further stated she asked Licensed Nurse D (LN D) to develop care plans for Resident 5. Licensed Nurse D developed a set of individualized care plans for Resident 5, all dated 2/29/24. 27532 A review of Resident 4's admission Minimum Data Set (MDS - federally mandated clinical assessment tool of all residents' functional capabilities in nursing homes identifying health problems) indicated she is [AGE] years old, was admitted [DATE], for debility (state of being weak, feeble, or infirm) and/or cachexia (illness and characterized by muscle mass loss with or without fat mass loss), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities. Some people with dementia cannot control their emotions, and their personalities may change), malnutrition, adult failure to thrive (condition characterized by weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol) among other conditions. Further review of Resident 4's MDS indicated, care areas like cognitive loss/dementia and psychotropic drug use were among other care areas triggered during admission assessment. Care plans for these care areas could not be found among facility documents provided to the Surveyors. During a concurrent observation and interview on 2/27/24, at 8:44 AM, Resident 57 was smoking outside the facility with one of the security staff. Resident 57 stated she smokes every after meals outside the facility. During a concurrent review of records and interview on 2/28/24, at 8:27 AM, the Health Information Manager (HIM) came to assist the CNO generate reports and was requested Resident 57's care plan on smoking. During an observation of medication observation on 2/29/24, at 9:07 AM, Licensed Nurse H (LN H) administered one (1) 5 mg (milligram = unit of measure of mass in the metric system equal to a thousandth of a gram) tablet of Diazepam (a class of medication called benzodiazepine used to relieve symptoms of anxiety and alcohol withdrawal, may also be used treat certain seizure disorders and help relax muscles or relieve muscle spasm) to Resident 57. During review of records provided by the facility, Resident 57's care plans for smoking and Diazepam use could not be found among documents provided by the facility. During a concurrent review of records and interview on 3/1/24, at 9:25 AM, the CNO and Licensed Nurse K (LN K) acknowledged the care plans they just provided dated 2/29/24, were completed the night before. A review of the facility policy titled, Resident care planning, dated effective 3/30/23, indicated, upon admission nurses gather data, input it into the electronic medical record (EMR) system and complete weekly summaries to generate data for the MDS. The MDS auto populate appropriate plans of care for each resident which are initiated and updated as needed by the MDS coordinator and nursing staff. The care plans are reviewed monthly by the Director of Nursing (DON). The policy further indicated; the date the care plan was initiated should reflect the date that the problem was identified. A review of the facility policy titled, Resident assessment (MDS 3.0), date effective 1/20/16, indicated, information derived from the comprehensive assessment enable the staff to plan care that allows the resident to reach his/her highest level of functioning. The policy further indicated, within seven (7) days of the completion of the resident assessment, a comprehensive care plan will be developed.

Based on interview and record review, the Governing Body (individuals such as facility owner(s), chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operation of the facility) failed to ensure to appoint a California Licensed Nursing Home Administrator (NHA) who was responsible for management of the facility. This failure had the potential to result in mismanagement and misguided care of the vulnerable residents and staff of the facility. Findings: During an interview on 2/26/24, at 4:09 PM, the Chief Nursing Officer (CNO) was requested a copy of the license of the facility Administrator. The CNO called the Administrator on her cell phone to check and requested for his Administrator's License. After speaking with the Administrator, the CNO stated, according to the Administrator, if this was not a hospital-based SNF, he would have to have an Administrator License, but it was not required for a hospital-based SNF. During an interview on 2/28/24, at 10:28 AM, when asked if he had an Administrator's License, the Administrator responded he did not have a license. During a review through the California Department of Public Health (CDPH) Licensure and Certification (L & C) verification search page, the query for an NHA license confirmed the Administrator did not have one.

Based on interview and record review, the facility failed to ensure: 1. irregularities (refers to use of medication that is inconsistent with acceptable standards of practice, use without adequate indication, monitoring, in excessive doses, and/or in the presence of adverse consequences, etc.) noted by the pharmacist during drug regimen review (DRR) of two (2) of six (6) residents (Resident 1 and Resident 4) were documented on a separate, written report and sent to the attending physician and the facility's medical director and director of Nursing (DON) and lists, among others the irregularity that the pharmacist identified; 2. the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and any action taken to address it with a rationale for not agreeing with the recommendation; and, 3. the pharmacist followed the different steps in the process of the DRR and the steps to be taken when he identified an irregularity that required action to protect the resident. This failure had the potential to result to unwanted, uncomfortable, or dangerous effects like impairment or decline in the residents' mental or physical condition or functional or psychosocial status, debility, or death of residents in the facility. Findings: During an interview on 2/29/24, at 9:94 AM, the Pharmacy Tech (PT) described his role in the management of pharmacy services in the facility. The PT stated the Pharmacy Consultant (CJ) came to the facility monthly to review each resident's medication. The PT stated the PJ had an excel spreadsheet documenting his reviews with recommendations and added he could print it and provide a copy to the Surveyors. 48660 A review of Resident 1's face sheet (demographics) indicated he was admitted to the facility on [DATE]. His diagnoses included Hypertension (a condition in which the force of the blood against the artery walls is too high), Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear), Depression (a mood disorder that causes a persistent feeling of sadness or loss of interest), Type 2 diabetes (a health condition that affects how your body turns food into energy), and Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Medication Orders printed on 2/29/24 at 10:18 a.m. indicated Resident 1 was prescribed Trazodone (Trazodone is an antidepressant medication used to treat depression and anxiety. It works by helping to restore the balance of a natural chemical in the brain) 100 mg (mg is a milligram, a unit of measure of mass in the metric system equal to a thousandth of a gram) on 7/12/23. A review of a printed Excel spreadsheet which documented the Pharmacist's monthly drug regimen review (DRR) had an entry for Resident 1 under the heading 1/2/2024. The document indicated trazadone taper recommended, action taken: Reported to DON, recommendation: REQUIRES URGENT CLARIFICATION, and was initialed by, ps. The facility was unable to provide any documentation or follow-up in regard to the Pharmacist's recommendation to taper Trazodone for Resident 1. A review of medication orders printed 2/27/23 at 8:32 PM, indicated Resident 4 was prescribed Quetiapine (Quetiapine is an antipsychotic medication - alters brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) 25 mg (milligram = unit of measure of mass in the metric system equal to a thousandth of a gram) on 12/8/23. A review of the printed excel spreadsheet, without heading or official facility logo, indicated a tabulation of the Pharmacist's documentation of the monthly DRR, dated from 11/1/23 to 2/1/24. The tables have five (5) columns. Column 1 lists the names of the facility residents, column 2 contains notes of a combination of findings, action taken, and recommendations, column 3 with heading, Action and contained notes like, reported to DON, etc., column 4 with heading, recommendation, and column 5, without heading but contained the Pharmacist's initials. On the DRR, dated 2/1/24, and across the name of Resident 4, the PC wrote in column 2, consider lower Seroquel dose and in the of recommendations the PC wrote, review antipsychotic order. The PC did not document the irregularity he found and the reason for the recommendation to reduce the medication. During an interview on 3/01/24, at 10:47 AM, the PC confirmed he did the DRR monthly at the facility and reported his findings and any recommendations during the daily utilization review meetings. The PC stated he started sending his excel records to the DON since 12/2023. When asked how he was able to keep track and monitor whether his recommendations were acted upon, the PC acknowledged the need to improve his documentation and process of communicating the DRR and GDR recommendations to the facility.

Based on observation, interview and record review, the facility failed to ensure one of six residents (Resident 57) was informed in advance, by the physician or other practitioner or professional, of the use, the risks and benefits of a psychotropic (class of medication affecting the thoughts and behaviors of the person using the drug) and other medication options. This failure deprived Resident 57 her right to be receive information about the medication or other treatment options as basis for her decision to choose the medication or treatment she preferred. Findings: During an observation of medication administration on 2/29/24, at 9:07 AM, Licensed Nurse H (LN H) administered one (1) 5 mg (milligram = unit of measure of mass in the metric system equal to a thousandth of a gram) tablet of Diazepam (a class of medication called benzodiazepine used to relieve symptoms of anxiety and alcohol withdrawal, may also be used treat certain seizure disorders and help relax muscles or relieve muscle spasm) to Resident 57. During a review of records on 2/29/24, at 3:15 PM, the missing informed consent for Resident 57's Diazepam was requested from the Chief Nursing Officer (CNO) During a concurrent review of record and interview on 3/1/24, at 9:25 AM, the CNO provided the informed consent for diazepam, signed by Resident 57 and the physician, dated 2/29/24. The CNO acknowledged the informed consent was done on 2/29/24. A review of the facility policy titled: Consent for use of psychoactive medications, dated 3/30/23, indicated: the physician is responsible for obtaining informed consent .must document the informed consent in the chart. The policy also indicated: per Title 22 CCR Section 72528(c) requires facility staff to verify that the patient's health record contains such documentation prior to initiating the therapy. The policy further indicated: before initiating the administration of psychoactive drugs which may lead to the inability to regain use of normal bodily function, the ordering provider must obtain informed consent.

Based on observation, interview, and record review, the facility failed to complete a smoking assessment on admission for one of six residents (Resident 57) to determine Resident 57's functional capacity to safely smoke with or without assistance and need for protective devices. This failure had the potential to result to inappropriate care and provision of supervision and protective devices and result in fire hazard to both the resident and facility. Findings: During a concurrent observation and interview on 2/27/24, at 8:44 AM, Resident 57 was smoking outside the facility with one of the security staff. A portable ashtray was positioned by the right side of Resident 57's wheelchair. Resident 57 stated she smoked after meals, outside the facility. During an interview on 2/28/24, at 8:53 AM, when asked if Resident 57 was assessed for smoking, LN B stated Resident 57 was a safe smoker. When LN B was asked where the smoking assessment of Resident 57 was, he could not provide the assessment ,and he would refer to the Health Information Management (HIM)/Information technician (IT) to print out the document from the facility's electronic medical records. During an interview on 2/28/24, at 9:55 AM, Resident 57 when asked if she underwent a smoking assessed and stated she could not say if she was assessed for safety to smoke. A review of the facility's policy titled, Subject: Resident assessment (MDS 3.0), dated effective 1/20/16, and reviewed 2024, indicated purpose was, to assess each resident in a timely manner and provide care appropriate to the resident's needs from admission to discharge .within fourteen (14) or eight (8) days of the resident's admission, a comprehensive assessment of the resident's needs will be made by the interdisciplinary team .the purpose of the assessment is to describe the resident's capability to perform daily life functions and identify significant impairments in functional capacity .information derived from the comprehensive assessment enables staff to plan care that allows the resident to reach his/her highest practicable level of functioning and includes .physical and mental functional status .including determining the resident's need for staff assistance and assistive devices or equipment to maintain or improve functional abilities.

Based on observation, interview and record review, the facility failed to maintain an environment free from accident hazards and provide assistive devices to one (1) of six (6) residents (Resident 57) to prevent avoidable accidents. This failure had the potential to result in cigarette burns to Resident 57 and create a fire hazard to residents, staff and facility. Findings: During a concurrent observation and interview on 2/27/24, at 8:44 AM, Resident 57 was smoking outside the facility by the roadside with one of the security staff. A portable ashtray was positioned by the right side of Resident 57's wheelchair. Resident 57 stated she smoked after meals outside the facility. During a concurrent interview and observation on 2/28/24, at 8:53 AM, Licensed Nurse B (LN B) stated Resident 57 smoked outside the facility after breakfast, lunch and dinner, and sometimes evenings when a staff is free. LN B stated Resident 57 had to be accompanied by staff during her smoke breaks. LN B stated the designated smoking area was 15 feet from the building, with fire extinguisher, and potable ashtray. LN B state Resident 57's cigarettes and lighter were kept in the Nurses' cart inside the locked medication room. Resident 57's family supplied the cigarettes. LN B Stated Resident 57 was a safe smoker, but when asked where Resident 57's smoking assessment was, he could not provide it and referred to the Health Information Manager (HIM)/Information technician (IT) to print the assessment. When it was mentioned that Resident 57 was observed not wearing an apron this date and on 2/27/24, LN B stated they have an apron if she needed it, but that Resident 57 is a low risk. During an observation on 2/28/24, at 9:02 AM, LN B was overheard asking the CNO where to find the apron for Resident 57's use. During a concurrent interview and observation on 2/28/24, at 09:21 AM, LN B brought the blanket that maybe used by Resident 57. When it was pointed out that it looked new, as the blanket was still wrapped in plastic, LN B stated it had not been used. When it was pointed out that the blanket looked flammable as it is made of [NAME] material, LN B stated he would provide documentation that indicated it was safe to be used. During an observation on 2/28/24, at 9:44 AM, the designated smoking area could be seen through the glass portion of the wall adjacent to the Emergency Exit door. The designated smoking area was about 3-4 meters or approximate 10 to 13 and half feet from the Emergency exit door. The blanket was still wrapped in plastic on top of the concrete wall by the fire extinguisher. During an interview on 2/28/24, at 9:55 AM, Resident 57 stated she was instructed to leave her cigarettes and lighter with the nurses, that she had to be accompanied by one of the staff during her smoke breaks. Resident 57 stated she could not recall if she was assessed for safety to smoke. During a concurrent observation and interview on 2/28/24, at 1:45 PM, it was pointed out to the Engineering and Environmental Manager (E&EVS Manager) that the fire extinguisher for their Designated Smoking area was approximately 3-4 meters from the Emergency exit door. The E&EVS Manager stated he measured by steps the place where they positioned the portable ashtray by the roadside where Resident 57 smoked, which is more than 25 feet away. The E&EVS Manager was told they must decide where their designated smoking area should be, should it be by the fire extinguisher attached to the fence wall opposite the Emergency Exit door or by the roadside where they positioned the portable ashtray. During an interview on 3/01/24, at 9:05 AM, when asked if the [NAME] blanket may be used as a protective apron when smoking, the Customer service representative of [NAME] Industries, who supplied the blanket proposed to be used by Resident 57 stated, the blanket was not customized to be used as an apron to protect the wearer from cigarette burns. A review of the product description of the wool blanket, proposed to be worn as protective material for Resident 57 indicated, the wool blanket could be used to keep shock victims warm or to smother clothing fires. A review of the facility policy titled, Smoking policy for in-patients and residents, effective 4/5/23, indicated, It is necessary that a written order to smoke be placed into the resident's chart by the physician, residents will be allowed to smoke in designated areas only, designated area will be 25 feet from all hospital and clinic entrances, exits, and open windows. The policy did not indicate the need to complete a smoking assessment of the resident's capabilities and deficits to determine whether supervision was required, or if adaptive equipment like a smoking apron, cigarette holder or other safety equipment was needed.

Based on observation, interview and record review, the facility failed to develop complete care plans with adequate interventions for four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) that were individualized, implemented, and re-evaluated for worsening pressure ulcer and contact precautions. This failure had the potential for resident decline, harm, and negatively impact the resident's quality of life, quality of care, and services. Findings: During an interview on 4/28/22 at 10:00 a.m., the Interim DON (I-DON), Infection Preventionist (IP), and the Interim Chief Nursing Officer (CNO) were asked why Resident 1 came to the hospital and how she obtained her pressure ulcer. The I-DON stated Resident 1 was found down on the floor at home by meals on wheels and was diagnosed with an infection and altered mentation and was admitted with a skin tear on her back that was treated with a [MEDICATION(S)] (clear occlusive) dressing. Resident 1 was admitted to the Skilled Nursing Facility (SNF) on 6/21/21 for long term care assistance. During a continued interview with the I-DON she stated the resident walks with physical assistance and that she cannot walk or transfer from the bed to a chair by herself. I-DON stated Resident 1 did not like to stay in bed much and sits-up in her chair. When asking the I-DON why the pressure ulcer had progressed, the I-DON stated the resident had been combative at times and refused to let the nurses turn, reposition, and give her care. Resident 1 was on a schedule for Q (every) two hour turning. When questioning the I-DON, IP, and the I-CNO if there was a care plan for the Resident 1 ' s pressure ulcer, they looked at one another and the I-DON stated, Yes. Review of the Care plan for Resident 1 did not show the interventions that were individualized, re-assessed, or updated to reflect the changes in Resident ' s 1 pressure ulcer. When questioned about the care plan updates the I-DON and I-CNO stated they would have to look at that further. During review of the clinical record for Resident 1, the nurses notes indicated Resident 1 ' s non-compliance with care and identification of pressure ulcer starting around the sacral (buttocks) area on 4/10/22. The nurse's notes did not show that preventative measures were helping to prevention further skin breakdown. During an interview on 4/28/22 at 10:30 a.m., the Infection Preventionist (IP) was asked how often skin assessments were performed and she stated skin assessments were performed by the nurses and CNAs (Certified Nurse Assistants) every shift, during showers, and when the resident needs a brief (adult diaper) change. Review of Resident 1's skin assessment/documentation did not show details of the wound assessment with notes, only a check box that the assessment was completed. During an interview on 4/28/22 at 12:00 p.m., Licensed staff D was asked if she takes care of Resident 1 and where she documents how often the resident is turned. Licensed Staff D stated she does take care of Resident 1 and she tries to turn her every 2-hours. The resident often refuses care and becomes combative with the staff, she likes to do what she wants to do when she wants to do it. We document Q2/hour turning on the paper document then enter it into the computer. A copy of the turning report was requested but not received. During an interview on 4/28/22 at 15:00 p.m., Resident 1 was asked about the wound to her sacral area. She stated the wound is taking longer than it should to heal because I sit for long periods of time, and I don ' t like when the nurses come to turn me every 2 hours. Resident 1 stated, I like to do what I want when I want to do it. I know what I must do but I prefer to do things on my own time. Has anyone asked you what you would like she stated No. When asking Resident 1 if she has any pain to the area, she stated, when I sit for long periods of time in my chair it does become uncomfortable. Resident 1 stated the nurses do give me Tylenol, when I have pain. Requested Interdisciplinary Team (IDT) meeting minutes, but none were provided. During an observation and concurrent interview on 4/28/22 at 12:35 p.m., the IP showed the rooms for residents on contact precautions. Resident 4, in room [ROOM NUMBER], was on Full Contact Precautions for [CONDITION(S)]-Resistant Staphylococcus aureus ([CONDITION(S)], is an infection caused by a type of Staphylococcus (staph) bacteria that is resistant to many antibiotics). Resident 2 and Resident 3, in room [ROOM NUMBER], were on Modified Contact Precautions for [CONDITION(S)]. A Physical therapist was observed conducting hand exercises with Resident 2 in room [ROOM NUMBER], not wearing gloves or a gown. During a concurrent interview on 4/28/22 at 13:00 p.m., IP was asked the difference between Modified and Full Contact Precautions. IP stated, We just implemented this process. Modified precautions are used for Residents so they can leave their rooms if they are responsible to wash their hands and cover the skin that is infected, prior to leaving and entering their room. Review of the care plans for Resident 2, Resident 3, and Resident 4 did not indicate that contact precautions were implemented, or the type of treatment and how care should be provided. The facility policy and procedure titled Pressure Ulcer Prevention dated 5/30/19, indicated: 4. Assess the individual ' s skin condition and general comfort. If the individual is not responding as expected to the repositioning regime, reconsider the frequency and method of repositioning. The facility policy and procedure titled Resident Care Planning dated 10/24/19, indicated: The process of evaluation and re-assessment of the resident care plan will occur on a continuing basis as needed until the resident is discharged . All interdisciplinary services shall provide information regarding resident problems, goals, plan of care, treatment, etc. as appropriate. This information should then be recorded in the care plan.

Based on observation, interview, and record review the facility failed to ensure infection control practices were followed for two of three sampled residents (Resident 2 and Resident 3) when Modified Contact precautions were implemented for residents with [CONDITION(S)]-Resistant Staphylococcus aureus ([CONDITION(S)], is an infection caused by a type of Staphylococcus (staph) bacteria that's resistant to many antibiotics). This failure had the potential to lead to the spread of the infection and decline in residents ' health. Findings: During an interview on 4/28/22 at 10:00 a.m., the Infection Preventionist (IP) was asked if there were any residents on isolation precautions aside from COVID-19. The IP stated there were three residents on isolation precautions (precautions are what visitors and staff need to take before entering a resident ' s room to help prevent the spread of germs in the hospital) for [CONDITION(S)]. One resident was in a room by himself and was on Full Contact Precautions. Resident 2 and Resident 3 shared a room, both have colonized (indicates, a person carries the germ in their nose or on their skin, but is not sick with a [CONDITION(S)] infection) [CONDITION(S)] and are on Modified Contact Precautions. When questioning the difference between Full Contact precautions and Modified Contact precautions, IP stated this was something new and, we have implemented it is more for the residents so they can leave their room without a risk of spreading the infection to others. IP stated that anyone entering the room to work with the residents must don full Personal Protective Equipment (PPE). During an observation on 4/28/22 at 12:30 p.m., Resident 2 was sitting up in bed and Physical Thereapist F was leaning against the side of the bed giving Resident 2 range of motion hand exercises. Physical Therapist F was not wearing gloves or a gown when providing therapy to Resident 2. During an interview on 4/28/22 at 15:55 p.m., Physical Therapist F stated she was new at the facility and had only been there for 6-weeks. When questioning Physical Therapist F about the process for a resident on isolation or contact precautions, she stated you must wear a gown, gloves, and a mask. When asked about the modified precautions for the residents in room [ROOM NUMBER] she stated, I have to check with the nurse. I gel in and gel out for hand hygiene or sometimes wash my hands with soap and water. When asked if she was wearing the required PPE when giving Resident 2 hand exercises, she stated I should have worn a gown and gloves, since I was touching the bed and the resident. When Physical Therapist F was asked if she received any infection control training or in-services as a new employee, she stated she was employed by a Physical Therapy group which was a separate department from the hospital and had not received any in-service training from IP or from her department. During an interview on 4/28/22 at 17:10 p.m., the Interim Chief Nursing Officer (I-CNO) and IP, were asked if there was an orientation program for new staff or registry staff. Both the I-CNO and IP stated they did not have a formal orientation process, and needed to create an orientation [program] for new staff and have a procedure to follow. During and interview with the IP on 4/28/22 at 17:20 p.m., she was told Physical Therapist F was observed not wearing PPE while giving hand exercises to Resident 2. IP was asked what the outcome would be if staff did not understand infection control practices and there was lack of oversight and monitoring of infection control practices from the IP. IP stated the infection could be spread to other residents or staff. Review of the facility Policy & Procedure titled, Multidrug-Resistant Organisms and C. difficile, (C. diff also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes diarrhea and [CONDITION(S)] (an inflammation of the colon), dated 7/5/2022, indicated Modified Contact Precautions were less restrictive than full contact precautions: 1. Modified contact precautions is used at this facility for patients or residents that are known or suspected to be actively infected with an [CONDITION(S)] but are determined by nursing staff and Infection Prevention to have low risk for transmission. A patient or resident that can keep wounds (if present) covered and follow infection prevention precautions (e.g., good hand hygiene) is an acceptable candidate for less restrictive, modified contact precautions . 4. How modified contact precautions differ from full contact precautions: a. Staff are not required to don gown and gloves before entering room. Gloves and gown are required only if there will be close contact with the patient or room environment such as repositioning the patient in bed, giving a bed bath, changing a wound dressing, or assisting with bedpan.

Based on observation, interview and record review, the facility did not ensure resident medications were stored according to Policy and Procedure, manufacturer's recommendations, and National Standards when the medication storage room and the pharmacy storage and ambient room temperatures were not monitored. This failure had the potential risk for resident harm or death if medication integrity was compromised and then administered to residents. Findings: During an observation and interview in the Medication Room, on 5/18/21, at 10:19 a.m. with Licensed Staff G, an observation indicated two shelves above the medication carts contained pre-packed medications. Licensed Staff G stated they were stored up there because there was no room in the medication cart. An observation of the all the drawers in the medication cart indicated bottles of supplements, over the counter medications, ointments, eye drops and pre-packed medication packets. He stated the medication refrigerator contained insulin (a diabetic medication that helps lower blood sugar), and was monitored by a centralized electronic monitoring system. He was unable to state what the temperature range should be in the refrigerator. An observation of an LED read out, on the front of the refrigerator indicated a reading of 05. He stated he did not know what that was. He stated if the refrigerator went out of range, the system would notify a manager who would then investigate and correct. He stated insulin needed to stay within a certain temperature range or it would be compromised and would not work effectively to lower blood sugar for the diabetic patient and might result in harm. He stated he was not aware if the room temperature was being monitored by anyone. Licensed Staff G stated he did not know what the facility Policy and Procedure (P&P) was for temperature monitoring. During an observation and interview of the Medication Room, on 5/18/21, at 11:46 a.m., Licensed Staff H stated only the medication refrigerator temperature was monitored. He was unaware if the temperature of the Medication Room was monitored. During an interview in the Medication Room, on 5/18/21, at 3:15 p.m., Licensed Staff H stated Only the medication refrigerators have a centralized monitoring system. He stated the medication room and the pharmacy storage rooms do not have ambient room temperature monitoring. He stated he did not know what the facility P&P was for temperature monitoring. During an observation and interview in the Pharmacy Storage Room, on 5/18/21, at 3:30 p.m., an Automated Medication Dispensing Machine, and attached medication refrigerator, were observed. Observation indicated there was no ambient temperature gauge or monitoring system in the area. Licensed Staff H stated only the Automated Medication Dispensing Machine and medication refrigerator were monitored for temperature. He stated the risk to residents was if the temperature went to high or low and compromised the integrity of the medications and it potentially would not have the desired effect for residents taking the medications. During an interview with Staff C, on 5/20/21, at 9:20 a.m., he stated if a medication refrigerator would go out of range he would receive an alert on his phone and would investigate. He stated there was no ambient room temperature monitoring in the Medication Room or the Pharmacy Storage Room. Review of a document titled General Pharmacy Operations, dated 5/28/20, indicated 4. Space, Equipment and Storage: . D. Drugs are stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security. Review of a document titled Medication Storage, dated 5/28/20, indicated The purpose of this policy and procedure is to describe the storing methods for medications. 3. Medications shall be stored at appropriate temperatures: . b. Room temperature shall be between . 59 degrees Fahrenheit and . 77 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to ensure eight out of eight sampled residents were safe from fire when one resident (Resident 9) was permitted to smoke in an area that had no immediate access to fire extinguishing equipment, cigarettes were being disposed of in a trashcan that contained paper, the resident had not been assessed to be safe to smoke unsupervised and the resident kept his smoking materials in his room. This failure had the potential for smoking materials to ignite a fire that could cause serious harm or death due [MEDICAL CONDITION] smoke inhalation. On 8/19/19 at 6:15 p.m., due to the facility's failure to maintain a safe smoking area for residents and ensure residents were assessed to be safe to smoke unsupervised, Chief Nursing Officer was notified verbally and in writing of Immediate Jeopardy. The Health Facilities Evaluator Nurses informed Chief Nursing Officer (CNO) of the survey team's findings that the resident smoking area had no equipment for extinguishing fire, no safe receptacle for cigarette disposal, the smoking resident had no documentation he had been assessed to be safe to smoke unsupervised or an order to smoke, and the resident was keeping his cigarettes and his lighter in his room. Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident (Standard Operation Manual, Appendix Q). On 8/19/19 at 1:52 p.m., the facility presented an acceptable corrective plan of action, including but not limited to: 1) placing a suitable cigarette receptacle in the smoking area, 2) mounting a fire extinguisher on the wall adjacent to the smoking area and ordering a fire blanket, 3) keeping residents' cigarettes and lighters locked in the medication room, 4) obtaining a physician order [REDACTED]. On 8/21/19 at 10:35 a.m., the abatement (lifting) of Immediate Jeopardy occurred in the presence of Chief Executive Officer after interviews, observations, and record review confirmed the facility implemented the corrective plan of action. On 8/21/1 at 2:35 p.m., Director of Nursing was notified of substandard quality of care identified and that the facility was on extended survey. Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 483.25 Quality of Care that constitute to immediate jeopardy to resident health or safety (level J, K, or L) (Standard Operation Manual, Appendix PP). Findings: During an interview on 8/19/19 at 2:12 p.m., Resident 9 stated he smoked every once in a while. Resident 9 stated he could go out whenever he wanted to, no staff go out with him, he just has to sign out in the book at the nurses' station. When asked where he kept his cigarettes and lighter, Resident 9 stated he kept his own cigarettes and lighter in his room. During an observation on 8/19/19 at 2:51 p.m., Resident 9 was outside smoking on the backside of the building between the cinderblock wall of the facility and the cement retaining wall of the parking lot. Cement walkways led to and from the smoking area, which was under the overhang of the building. No fire extinguisher or fire blanket were in the vacinity, and Resident 9 was not wearing a smoking apron. No ashtray was present in the smoking area. Around the corner, approximately 20 feet from where Resident 9 was sitting, was a trashcan with a clear plastic liner that was half hanging down into trashcan obstructing view of what was inside. Muliple cigarette butts were on the ground surrounding the trashcan. During an observation and concurrent interview on 8/19/19 at 3:15 p.m., Licensed Nurse A confirmed the area where Resident 9 was smoking was the designated smoking area. Licensed Nurse A confirmed there was no fire extinguisher or fire blanket, and no ashtray for cigarette disposal. Licensed Nurse A looked in the trashcan around the corner from the smoking area and stated there were cigarette butts in there. Licensed Nurse A stated he was not aware that there was no equipment in the smoking area to put out a fire if the trashcan or the residents' clothes caught on fire. When asked the location of the nearest fire extinguisher readily available, Licensed Nurse A walked down the path, inside the front lobby, down the hall to the left past the nurses' station before he found one in an alcove. Licensed Nurse A confirmed it was not close to the smoking area. A fire extinguisher was noted down the hall next to the emergency exit near the smoking area, but Licensed Nurse A stated the emergency exit door was locked from the outside. Licensed Nurse A pointed out there was a fire extinguisher across from the nurses' station, which he had not noticed and walked past initially. The fire extinguisher across from the nurses' station was behind a plate of glass that indicated, In Case of Fire, Break Glass. When asked if Resident 9 had signed any kind of consent or waiver related to smoking, Licensed Nurse A searched in Resident 9's medical record, but stated he was unable to find one. Review of facility policy titled Smoking Policy for In-Patients and Residents, dated 4/5/18, revealed, 2. It is necessary that a written order to smoke be placed into the resident/patient chart by the physician. 5. Any smoking products; matches, lighters, pipes, cigars, cigarettes must be kept locked in the medication room in a defined place with resident/patient name. During a record review and concurrent interview on 8/19/19 at 4 p.m., when asked if Resident 9's lighter and cigarettes were in the medication room, Licensed Nurse A stated no, they are in Resident 9's room. Licensed Nurse A reviewed the smoking policy and confirmed it indicated they are to be kept in the medication room. Licensed Nurse A stated he had not known that. When asked if Resident 9 had an order to be allowed to smoke, Licensed Nurse A searched in Resident 9's medical record, and stated no, he does not have one. During an observation on 8/19/19 at 4:57 p.m., the trash can in the smoking area contained wadded up napkins, papers, paper drink cups and approximately 30 to 40 cigarette butts. During an interview on 8/19/19 at 5:10 p.m., Chief Nursing Officer (CNO) stated she did not know if Resident 9 had an assessment done to determine if he was safe to smoke unsupervised. She stated she saw that Resident 9 did not have a physician's orders [REDACTED]. When asked about resident supervision during smoking, CNO stated, There's no direct supervision, (the residents) just let staff know they're going out to smoke, and they go out with no direct supervision. When asked about a cigarette receptacle, CNO stated there used to be a receptacle with sand in it. She stated, It's supposed to be out there. When asked how a fire in the smoking area would be extinguished, CNO stated, We would use an extinguisher from the hallway here or a blanket from the linen closet. When asked where Resident 9's cigarettes and lighter are kept, CNO stated, I was told today that they are in his room. They are supposed to be kept in the narcotic room in his specific bin. During an interview on 8/22/19 at 10:58 a.m., Chief Executive Officer (CEO) stated he did not know if there was a safety plan in place for the smoking area at the facility. When asked if it was anyone's responsibility to monitor the smoking area for a cigarette receptacle, CEO stated not that he was aware of. He stated prior to 8/19/19, he was not aware of what the situation was out there (the smoking area). In response to a request for the facility policy on resident safety, facility policy titled Patient and Staff Safety Plan, dated 4/26/18, was provided. The policy statement indicated, It is the policy of (facility named) to provide a safe environment for patients, visitors, and staff.

Based on interview and record review, the facility failed to monitor for increased potential of adverse consequences for one of two residents (Resident 1), by failing to monitor for the potential for increased bleeding and immediately notify a physician of Resident 1's bruising, an indicator of excessive bleeding, after administration of medications with potential interactions ([MEDICATION NAME] and [MEDICATION NAME]) that can cause excessive bleeding. Resident 1 died of multiorgan failure and acute blood loss. Findings: Review of Resident 1's face sheet (a document that summarizes resident's information) on [DATE], revealed Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's physician orders [REDACTED]. Resident 1's care plan reflected anticoagulation therapy since March of 2013. Resident 1's care plan, last revised [DATE], included an entry Anticoagulant Therapy. The problem identified Resident 1 was at risk for bleeding, bruising related to use of: [MEDICATION NAME] related to heart valve replacement. The goal was Resident / patient would not have covert or overt bleeding or injury x 90 days. Interventions included Staff will Observe for signs/symptoms of bleeding (e.g. tarry stool, blood in urine, bruising, petechiae (pinpoint red or purple spots on the skin due to bleeding)); Monitor drug regime for drugs that increase effects .; Observe for adverse reactions (e.g. fever, [MEDICAL CONDITION], anorexia, nausea, vomiting, cramps, diarrhea, hemorrhages, hemoptysis (coughing blood)). Record review revealed a Physician's Progress Note, dated [DATE] at 10 a.m., and signed by Physician A, indicating pt.(patient) reported to be coughing repeatedly vigorously with phlegm and small amount of blood yesterday. Physical examination revealed (bilateral) rhonchi, few coarse sounds in her lungs. (Rhonchi are abnormal sounds heard when listening to the lungs, often indicating secretions in the airways.) Physician A's assessment was [MEDICAL CONDITION] (inflammation of the airways), and the plan included [MEDICATION NAME] (an antibiotic) 750 milligrams daily. A handwritten Physician Order, dated [DATE] at 10:30 a.m., and signed by Physician A, reflected [MEDICATION NAME] 750 milligrams orally every day for 10 days. There were no new orders related to increased monitoring of Resident 1's INR. [MEDICATION NAME] therapy is monitored by measuring the amount of rise in the international normalized ratio (INR). The target therapeutic increase in patients receiving [MEDICATION NAME] is 2 to 3 in most cases, or 3.5 in those with heart valve replacements. Bleeding is the most common adverse effect of [MEDICATION NAME]. [MEDICATION NAME] - also known by the brand name [MEDICATION NAME] is an antibiotic used to treat pneumonia (inflammation of the lungs sometimes caused by infection) among other things. [MEDICATION NAME] can interact with [MEDICATION NAME] resulting in an increase in the effect of [MEDICATION NAME] as reflected by an increase in the INR. An INR above 5 is normally considered to be a significant increase, requiring immediate reevaluation of therapy. (DiPiro et al., Pharmacotherapy: a pathophysiologic approach, third edition; Koda-Kimble and Young, Applied Therapeutics: The Clinical use of Drugs, seventh edition.) The U.S. Food and Drug Administration website documents [MEDICATION NAME] may enhance the effect of [MEDICATION NAME]. Patients should also be monitored for evidence of bleeding. Patient Counseling Information reveals, Patients should be informed that concurrent administration of [MEDICATION NAME] and [MEDICATION NAME] has been associated with increases .clinical episodes of bleeding. (Retrieved [DATE] from www.accessdata.fda.gov) During an interview on [DATE], Physician B stated, It's usual to increase monitoring the INR when antibiotics are given. Record review revealed a Nurses Note written by Licensed Nurse C, dated [DATE] at 3:47 a.m., three days after starting [MEDICATION NAME], indicating Several areas of ecchymosis (bruising) of various size found on (left) lateral (side) aspect of (patient's) back of unknown origin. There was no documentation in Resident 1's record that Licensed Nurse C notified a physician of the bruising on [DATE]. During an interview, on [DATE] at 8:15 p.m., the author of the note, Licensed Nurse C, stated the bruises were approximately 1 to 1 ,[DATE] inches across, and were dark purple in color. Licensed Nurse C stated the bruises looked new. Licensed Nurse C confirmed she did not notify a physician of the bruises. A Nurses Assessment Report written by Licensed Nurse D, dated [DATE] at 5:47 p.m., revealed Resident 1 was currently receiving [MEDICATION NAME] 750 milligrams by mouth daily for treatment of [REDACTED]. Licensed Nurse D documented Resident 1's skin as Intact, Rash (See comments) and skin color as Appropriate for race. The Comments section included no documentation about the bruising or discoloration to Resident 1's left flank or back noted by Licensed Nurse C earlier that morning. There was no documentation that Licensed Nurse D notified the physician of Resident 1's bruising on [DATE]. During an interview, on [DATE] at 8:50 a.m., Resident 1's family member (Family H) stated she asked Licensed Nurse D about the combination of [MEDICATION NAME] and [MEDICATION NAME] on [DATE]. Family H stated Licensed Nurse D said she wondered about that when she saw the order and agreed to call the physician. A Nurses Note, dated [DATE] at 12:40 p.m., indicated CNAs point out a bruise on left side of patients torso, mildly painful to touch. (Physician B) notified of pt's BP (blood pressure) and of the bruise. Record review of a Patient Lab (Laboratory) Results Report, dated [DATE] at 12:01 p.m., revealed Resident 1's INR was critically high at 6.6. The report also revealed the critically high value was phoned by lab staff to facility staff on [DATE] at 12:02 p.m. A Patient Results Report, dated [DATE] at 11:56 a.m., revealed a critically low value for Resident 1's hemoglobin (the oxygen carrying component of red blood cells) and a low value for Resident 1's hematocrit (the volume percentage of red blood cells in the resident's blood), both indicators of possible bleeding. The report documented these hemoglobin and hematocrit values were phoned by lab staff to facility staff on [DATE] at 11:55 a.m. The nurses notes reflected no documentation that facility staff notified a physician of these values, nor clarification of continuing the medications as ordered. Review of Resident 1's Medication Administration Record, [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. on [DATE] at 8:37 p.m., more than eight hours after the lab notified a licensed nurse of critical lab values. During an interview, on [DATE] at 2:40 p.m., when asked if she had contacted a physician about administering [MEDICATION NAME] to Resident 1 while the Resident 1 received [MEDICATION NAME], Licensed Nurse D stated she asked Physician B when she saw him if he wanted to continue the [MEDICATION NAME], but Physician B gave no response other than a shrug. Licensed Nurse D could not recall what date she spoke to Physician B. Licensed Nurse D also stated, I know there was a delay in stopping the [MEDICATION NAME] and getting labs. Licensed Nurse D stated she told the night shift licensed nurse taking over Resident 1's care, I would hold the [MEDICATION NAME] if I were you. During an interview, on [DATE] at 9:15 a.m., Administrative Staff G was asked how staff was expected to monitor drug regime as reflected in Resident 1's care plan. Administrative Staff G stated she expected them to look it up if not familiar with medication interactions. If a potential interaction was identified, Administrative Staff G stated staff should contact the ordering physician, and not give the medication until clarification can be obtained. During an interview, on [DATE] at 10 a.m., Licensed Nurse F stated he was not aware of interactions between [MEDICATION NAME] and [MEDICATION NAME], and had not looked the medications up in a medication book or online resource. During an interview, on [DATE] at 10:45 a.m., the manager of the off-site pharmacy that dispensed the [MEDICATION NAME] (Manager H) stated resident medication profiles only showed medications dispensed by her pharmacy, although notes could be added to the profile if the pharmacy is notified of medications from other sources. Manager H stated Resident 1's profile did not reflect Resident 1's [MEDICATION NAME]. During an interview, on [DATE] at 2:10 p.m., Consultant Pharmacist I stated he was not aware that [MEDICATION NAME] was added to Resident 1's medication regimen, had not been alerted to the medication when it was ordered [DATE], and did not review Resident 1's medication regimen at the time it was added. Pharmacist I stated, That's a terrible combination. When I hear those two together, I immediately think of skyrocketing (lab tests indicating slowed blood clotting) .If I'd seen that ([MEDICATION NAME] and [MEDICATION NAME]) I would have called, emailed, done everything to alert somebody. Review of Resident 1's Certificate of Death, dated [DATE], revealed Resident 1 died on [DATE] of multiorgan failure (the immediate cause of death) with an acute blood loss of unknown cause leading to the multiorgan failure. During an interview, on [DATE] at 11:15 a.m., Physician A stated, I'm not going to remember anything from June. When asked about prescribing [MEDICATION NAME] for a patient on [MEDICATION NAME], Physician A stated, I know that combination ([MEDICATION NAME] and [MEDICATION NAME]) is a problem. Physician A stated, I may or may not have looked at what medications (Resident 1) was on at the time he prescribed the [MEDICATION NAME]. During an interview, on [DATE] at 5 p.m., Physician B stated he was Resident 1's primary care provider in the community clinic, and followed her in the skilled nursing facility. Physician B stated he was notified of Resident 1's increasing fatigue and bruising on [DATE], and saw her in the skilled nursing facility on that date. Physician B's note, dated [DATE], for the visit on [DATE] revealed Resident 1 had, a bruise at the anterior axillary line (front of the arm pit) on the left extending around the level of T5 ([MEDICATION NAME] vertebra, midback) to the patient's pelvis and an elevated INR, acute blood loss. The plan included comfort care, hold Resident 1's [MEDICATION NAME] and discontinuing the [MEDICATION NAME]. Physician B stated there was no formal or written method by which physicians communicate changes in residents' condition or treatment, relying on verbal communication. Physician B stated he could not recall any notification by Physician A that Physician A prescribed [MEDICATION NAME] for Resident 1 on [DATE]. Physician B stated he believed he first became aware of the [MEDICATION NAME] order on [DATE] when nursing staff contacted him about Resident 1's bruising and increased fatigue. Physician B stated he identified multiorgan failure as Resident 1's cause of death given her multiple disease processes and poor health, and acute blood loss was based on her laboratory values.

Based on interview and record review, the facility failed to review and revise the care plan related to swallowing difficulties for one of five sampled residents (Resident 5) who experienced four incidents within the past year of airway obstruction by inhaled material. This failure resulted in four episodes of choking for Resident 5, leading to Resident 5's death due to aspiration (inhaling an item or liquid into the lungs, which impairs normal breathing). Findings: Record review on [DATE] revealed Resident 5 was admitted to the distinct part skilled nursing facility (SNF). Resident 5's [DIAGNOSES REDACTED]. A nurse's note, dated [DATE] at 6:30 p.m., revealed, "At 1445 (2:45 p.m.), a...resident alerted an RN that...resident needed help." The note revealed staff entered the activity room and found Resident 5 "sitting in a chair at the table and appeared in grave distress." The author of the note, Licensed Nurse A, documented that he initiated the [MEDICATION NAME] maneuver (firm, rapid pressure applied below the breast bone to force air out of the lungs and dislodge food or other objects), but was unsuccessful "dislodging unknown object that was obstructing airway." Resident 5's face turned blue, her body went limp, and breath sounds could not be heard. Resident 5 was moved to the floor and her airway suctioned. Staff from the adjacent emergency room , including a physician, responded to the situation. Resident 5 resumed spontaneous breathing and was transferred by gurney to the acute care emergency department. Review of the emergency room Report, History of Present Illness, dated [DATE], revealed, "Patient had been in the activity room and had choked on pieces of solid food. She was only to eat pureed food (ground or mashed to a soft creamy consistency); however, there were chunks of crackers in her teeth." Due to Resident 5's Advanced Directive specifying Do Not Resuscitate, aggressive interventions were not initiated. Resident 5's condition deteriorated, and she died at 7 p.m. The emergency room physician listed [DIAGNOSES REDACTED]. Aspiration pneumonia, 3. Cardiopulmonary arrest. During a telephone interview on [DATE] at 1:50 p.m., a representative of the county medical examiner's office stated the death certificate listed cardiopulmonary arrest secondary to aspiration pneumonia due to food aspiration as the cause of death, with dementia as a contributing factor. Review of Resident 5's record revealed prior incidents of airway obstruction: A nurse's note, dated [DATE] at 6 p.m., revealed, "At 1740 (5:40 p.m.), resident (5) was sitting (at) bedside eating her dinner....had a mouthful of food and began to choke....Proceeded to administer approx (approximately) 30 abdominal thrusts and resident started to expel chunks of food...." A nurse's note, dated [DATE] at 5:40 p.m., revealed, "Called to room by CNA (certified nursing assistant), R (Resident 5) choking, CNA performed Keimlich (sic), airway open. Continued (with) dinner (without) problems." A nurse's note, dated [DATE] at 5:35 p.m., revealed, "Called into room by CNA, appears to be choking, unable to speak, gargling noises, [MEDICATION NAME] maneaver (sic) done multiple (times). Airway cleared...Lungs cleer (sic) to auscultation (listening to breath sounds with a stethoscope)." A physician's orders [REDACTED].) During a telephone interview on [DATE] at 2:50 p.m., SNF Nurse Manager stated she was aware of Resident 5's earlier choking episodes. SNF Nurse Manager stated she knew Resident 5 had trouble with some foods like rice "but if it had sauce on it, it wouldn't stick in her throat," and she spoke to the dietary department about it. SNF Nurse Manager stated she recalled trying to contact a speech therapist for evaluation of Resident 5's swallowing, but "had trouble reaching her." A request was made for documentation that the physician order [REDACTED]. During an interview on [DATE] at 3:30 p.m., Licensed Nurse B stated she was among staff who responded to Resident 5's choking on [DATE]. Licensed Nurse B stated Resident 5 had a cup of "what looked like tea" with a few "particles" in front of her in the activity room when she began choking. Licensed Nurse B stated Resident 5 would eat anything put in front of her, including non-food items like flowers and napkins. During an interview on [DATE] at 12:30 p.m., Resident 1 stated, "It was freaky the way she (Resident 5) would just eat anything she could get her hands on." Resident 1 stated Resident 5 would ask others for food or take food from their trays. Resident 1 stated he was in the activity room with Resident 5 when Resident 5 choked, and he called for staff to help. He could not recall additional details like what she might have been eating at the time or where she acquired it. Review of Resident 5's care plan Nutritional Status, revised and rewritten on [DATE], indicated her need for a mechanically altered diet and her "Attempts to take food when available and accessible (sic)." It did not address her swallowing difficulties or identify her aspiration risk, nor did it reflect reassessment of the resident and changes to the care plan after three previous episodes of choking. The care plan did not reflect any evaluation and treatment by a speech therapist or interventions related to prior incidents of choking, food seeking behavior or consumption of non food items. Review of facility policy and procedure "Resident Care Planning," dated [DATE], "...evaluation and re-assessment of the resident care plan will occur on a continuing basis as needed until the resident is discharged ...The resident care plan is a current, written, and personalized plan for the individual resident, which indicates the care he/she needs, how it can best be accomplished and the goals which the interdisciplinary team collectively hope to help the resident achieve."