Every finding on record at Laguna Rainbow Nursing Center

Based on observation and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions, when they failed to:Ensure staff served beverages to residents in a clean manner and without the staff members hands touching the rim of the cup.Ensure there are no expired cans in the kitchen. Ensure food and beverage items are stored appropriately and not left open to air. Ensure there is no accumulated residue on condiment containers in the kitchen. This deficient practice is likely to affect all 43 residents identified on the resident census list provided by the Administrator on 03/09/26. If food is not stored, prepared, and served under sanitary conditions, then residents are at an increased risk of contracting foodborne illness.The findings are:Beverage Service: A. On 03/09/26 at 12:33 pm, during an observation of dining service, Registered Nurse (RN) #1 was observed serving a drink to a resident with his bare hands touching the rim of the cup. At 12:35 pm, RN #1 was observed serving another resident a drink while using his bare hands to touch the rim of the cup. B. On 03/09/26 at 12:37 pm, during an interview, RN #1 stated he has been employed at the facility for six months and has not received any specific training related to dining service and distributing drinks to residents. RN #1 stated a cup should never be gripped from the top and should always be given to the resident by holding the side of the cup. C. On 03/11/26 at 2:04 pm, during an interview, the Food Service Director (FSD) stated it is her expectation those assisting residents with dining service do not touch the rim of the cup when serving. The FSD stated cups should be served to residents by holding the side of the cup, and not the top of the cup where residents drink from. The FSD also stated if cups are gripped from the top, it can present a risk for cross contamination and infection when a resident drinks from the cup. Kitchen: D. On 03/12/26 at 11:33 am, during a follow-up tour of the kitchen, the following was observed: Twenty-one, 12-ounce (oz) cans of Stokely's Golden Sweet Whole Kernel Corn with the expiration date of 12/28/2025 located in the dry storage. One, 6-pound (lb.) container of Bountiful Harvest frozen sliced strawberries was cracked with the strawberries left open to air located in the freezer. One, 1-gallon container of Shamrock Farms whole milk with an expiration date of 03/10/26 was unable to be sealed and located in the refrigerator. One, 1-gallon container of [NAME] Golden Italian dressing had large amounts of spilled dressing on the side of the container located in the refrigerator. One, 1-gallon container of Sweet Baby Ray's barbecue sauce had large amounts of spilled sauce on the side of the container located in the refrigerator. E. On 3/12/26 at 11:50 am, during an interview, the Dietary Manager (DM) stated frozen foods should be discarded after one year in the freezer and staff are expected to check the food expiration dates weekly. The DM also stated staff are required to discard expired food and serving expired food can cause residents to become sick. The DM confirmed the kitchen should not contain expired food or beverage items, food and beverages should be stored appropriately, and spilt liquids should be cleaned.

Based on record review and interviews, the facility failed to ensure a resident's Level 1 Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was reviewed for accuracy and completion for 4 (R #2, R #5, R #8 and R #31) of 4 (R #2, R #5, R #8 and R #31) residents reviewed. If the facility fails to review PASARR screenings for accuracy and completion, then residents with serious mental illness or intellectual disability may receive inappropriate placement and care. The findings are: R #2: A. Record review of R #2's face sheet, revealed R #2 was initially admitted into the facility on [DATE] with a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). B. Record review of R #2's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/15/26 revealed R #2 was diagnosed with depression. C. Record review of R #2's PASARR Level 1 Identification Screen, dated 07/29/24, revealed the following: Section C (Identification of Mental Illness Evaluation Criteria) revealed Question #1, regarding whether R #2 had a diagnosis or suspected mental illness, was marked No. Further review revealed R #2's diagnosis of depression was not accurately reflected on the PASARR dated 07/29/24. R #5: D. Record review of R #5's face sheet revealed R #5 was initially admitted into the facility on [DATE] with the following diagnosis: Depression. E. Record review of R #5's PASARR Level 1 Identification Screen, dated 01/10/26, revealed staff documented R #5 did not have a diagnosis or suspected mental illness. F. Record review of R #5's Minimum Data Set, dated [DATE], revealed the following: R #5 has a diagnosis of depression, R #5 receives an anti-depressant (medication to relieve the symptoms of depression). R #8: G. Record review of R #8's PASARR Level 1 Identification Screen, dated 02/05/26, revealed R #8 did not have a diagnosis or suspected mental illness. H. Record review of R #8's face sheet, revealed R #8 was admitted into the facility on [DATE] with the following diagnosis: Depression I. Record review of R #8's Minimum Data Set, dated [DATE], revealed the following: R #8 has a diagnosis of depression, R #8 receives an antidepressant medication. R #31: J. Record review of R #31's PASARR Level 1 Identification Screen, dated 08/26/25, revealed R #31 did not have a diagnosis or suspected mental illness. K. Record review of R #31's face sheet revealed R #31 was admitted into the facility on [DATE] with the following diagnosis: Depression. L. Record review of R #31's Minimum Data Set, dated [DATE], revealed the following: R #31 has a diagnosis of depression, R #31 receives an antidepressant medication. M. On 03/12/26 at 2:55 pm, during an interview, the Administrator (ADM) confirmed R #2, R #5, R #8, and R #31 had diagnoses of depression. The ADM stated the facility failed to reflect these mental health diagnoses on the residents' PASARRs, despite the diagnoses requiring inclusion on the PASARRs. The ADM also stated R #2, R #5, R #8, and R #31 should have updated PASARRs to include the diagnosis of depression.

Based on observations, record review, and interviews, the facility failed to properly secure and store medications located in the facility medication cart and medication storage room, when:The facility did not lock a medication cart (moveable equipment used for the storage, transport, and administration of medications) while staff were not present.The facility did not ensure the medication refrigerator temperatures were properly maintained within the appropriate temperature range (36 to 46 degrees Fahrenheit).If the facility fails to secure medication carts or properly store medications, residents may experience unauthorized access to medications and the risk of medications becoming unusable for administration, thereby not receiving the full therapeutic benefit of their medications.The findings are: Medication Cart:A. On 03/09/26 at 1:52 pm, during an observation of the facility medication carts located at the nurse's station, one medication cart was unlocked and left unattended. B. On 03/09/26 at 1:55 pm, during an interview, the Registered Nurse (RN) #1 stated medication carts should always be locked when unattended. He further stated if medication carts are left unlocked, residents and visitors may have access to medications, which could present a serious risk to their health if the medications are taken. C. On 03/11/26 at 2:19 pm, during an interview, the Director of Nursing (DON) stated it is her expectation medication carts are locked at all times while unattended. The DON stated if the medication carts are left unlocked, anyone has access to the medications, and there is always a risk of adverse effects depending on the medication the person would take. Medication Storage Room Refrigerator Temperature:D. Record review of the facility medication storage room's refrigerator temperature logs, dated 01/01/26 through 02/28/26, revealed the following:Dated 01/29/26, a temperature reading of 65 degrees Fahrenheit (F; a scale of temperature on which water freezes at 32 degrees and boils at 212 degrees under standard conditions).Dated 01/31/26, a temperature reading of 48 degrees F.Dated 02/01/26, a temperature reading of 48 degrees F. E. On 03/09/26 at 2:40 pm, during an observation of the medication room, the medication refrigerator temperature was observed to be 50 degrees F on the built-in refrigerator thermometer, and portable thermometer stored in the refrigerator. F. On 03/09/26 at 2:41 pm, during an interview, Certified Medication Aide (CMA) #1 stated the temperature of the refrigerator for medications should be around 42 degrees F, but not more than 46 degrees F. The CMA #1 confirmed both refrigerator thermometers indicated the refrigerator was 50 degrees F. He stated if medications are not stored at proper temperature, they can expire, become ineffective, and be unusable for administration to residents. G. On 03/11/26 at 2:19 pm, during an interview, the Director of Nursing (DON) stated it is her expectation the medication storage room refrigerator temperature should be within appropriate range, and the temperature should be documented on the log daily. The DON confirmed the appropriate medication refrigerator temperature should be 36 to 46 degrees Fahrenheit, and 50 degrees Fahrenheit was too warm. The DON stated if medications aren't stored at the correct temperature, they can become ineffective and unusable for residents.

Based on record review and interviews, the facility failed to ensure resident's medical records contained documentation regarding education, offering, or administration of the COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccination (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 2 (R #4, and R #12) of 5 (R #4, R #6, R #12, R #18, and R #27) residents reviewed. This deficient practice is likely to result in residents not being provided information regarding opportunity for vaccination, and further result in increased risk of infection.The findings are:R #4: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE]. B. Record review of the facility COVID-19 consent and education documentation, provided by the facility on 03/11/26, revealed R #4 did not have a COVID-19 vaccination consent and education form completed, indicating R #4 was not offered a COVID-19 vaccination. R #12:C. Record review of R #12's face sheet revealed R #12 was admitted into the facility on [DATE]. D. Record review of the facility COVID-19 consent and education documentation, provided by the facility on 03/11/26, revealed R #12 did not have a COVID-19 vaccination consent and education form completed, indicating R #12 was not offered a COVID-19 vaccination. E. On 03/11/26 at 10:51 am, during an interview, the Infection Preventionist (IP) stated during the time of the COVID-19 vaccine administrations, R #4 and R #12's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) were unavailable to provide consent to receive the vaccine, but R #4 stated he did not want the vaccination. The IP stated R #4 would be able to sign the consent form declining the COVID-19 vaccine, but that did not happen. The IP confirmed neither R #4 nor R #12 had completed COVID-19 consent and education forms and should have. F. On 03/11/26 at 2:19 pm, during an interview, the Director of Nursing (DON) stated it is her expectation every resident be educated and offered the COVID-19 vaccination. She stated the consents forms are scanned and placed into the resident's chart. The DON stated multiple attempts should be made to contact resident's POA to provide education and offer the vaccination. The DON confirmed neither R #4 nor R #12 had completed COVID-19 consent and education forms and should have.

Based on observation and interview, the facility failed to ensure the outdoor trash bin was covered to minimize odors and prevent pests or rodents. If staff fail to keep outdoor trash bins closed, the environment may become unsanitary, increasing the risk of pest infestation and disease transmission to residents.The finding are:A. On 03/12/26 at 11:37 am, during an observation, the outdoor trash bin was left open, with only one side of the lid able to be closed and the other side broken.B. On 03/12/26 at 11:50 am, during an interview, the Dietary Manager stated the outdoor trash bin lid is broken, and they have been trying to fix the lid for the last six months. She stated pests or rodents can get into the trash and it is a hazard to staff and residents.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #8) of 1 (R #8) resident reviewed, when:The facility staff failed update R #8's plan of care to include an accurate advanced directive code status (a patient's preferences regarding medical interventions in the event of a medical emergency, such as cardiac arrest).This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #8's face sheet revealed R #8 was admitted to the facility on [DATE] with diagnoses:generalized idiopathic epilepsy with status epilepticus, (seizures that happen repeatedly with no identifiable cause),depression (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest),hypertension (HTN; high blood pressure),hypothyroidism (the thyroid is not making enough thyroid hormone), B. Record review of R #8's Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form, dated 02/11/2026, revealed R #8's code status was Do Not Resuscitate (DNR; lifesaving measures are not desired). C. Record review of R #8's current care plan, dated 02/13/2026, revealed R #8's active code status was not included in the care plan. R #8's care plan only stated the facility will educate R #8 and R #8's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) regarding health directives and have the physician complete a MOST form. D. On 03/10/2026 at 2:14 pm, during an interview, the Director of Nursing (DON) stated it is her expectation resident's advanced directives are included in the resident's care plan. The DON confirmed R #8's care plan did not include R #8's advanced directive code status and should have.

Based on record review and interview, the facility failed to ensure a psychotropic medication (medication used to treat mental health conditions) consent form was completed and signed by the resident or resident representative prior to medication administration for 1 (R #4) of 1 (R #4) resident reviewed for unnecessary psychotropic medications. If a resident and/or their representative are not informed of the risks and benefits of the medication, they may not be able to make an informed decision regarding treatment.The findings are:A. Record review of the facility's psychotropic medication use policy, last revised in July 2022, revealed a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Further review revealed anti-psychotics (medications that treat psychosis-related conditions and symptoms), anti-depressants (medications that treat depression), anti-anxiety medications (medications that treat anxiety), and hypnotics (medications used to induce or maintain sleep) were all considered psychotropic medications. B. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] with the following diagnoses: Manic episode (extreme changes in mood),Anxiety disorder (a feeling of worry, nervousness, or unease about something with an uncertain outcome),Post-Traumatic Stress Disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety). C. Record review of R #4's physician orders revealed the following: 8/24/25: Gabapentin (nerve pain medication and anticonvulsant) 100 mg (milligram). Give 1 capsule by mouth three times daily for anxiety/seizure (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) disorder. D. Record review of R #4's psychotropic medication consent forms, dated 03/12/26, revealed the following:A consent form for Gabapentin was not completed nor available. E. On 03/12/26 at 2:00 pm, during an interview, the Director of Nursing (DON) stated any medication listed as a psychotropic should have a consent form. The DON stated R #4 did not have a consent form completed for Gabapentin use, and a consent form should have been completed. The DON stated the lack of a psychotropic consent form affected resident rights, as residents have the right to know what medications they are receiving and to be informed of potential side effects.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 (R #1) of 1 (R #1) resident reviewed when facility staff inappropriately applied physical restraint during the provision of care. If the facility performs inappropriate use of physical restraint during resident care, then residents are at risk for physical injury and psychological harm, including fear or distress related to staff interactions. The findings are: A. Record review of the facility's policy titled Preventing Resident Abuse, revised December 2013, revealed the facility prohibits rough handling of residents and requires staff to manage resident behaviors in a manner that prevents injury, pain, or distress, including monitoring staff practices to identify inappropriate physical handling during resident care. B. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),Alzheimer's disease (a disease which causes irreversible changes in memory, thinking, and behavior). C. Record review of R #1's nursing progress notes dated 12/01/25 at 4:53 p.m., revealed R #1 had a skin tear to her right lower quadrant (right lower abdomen- stomach) and a large bruise to her right hand. D. Record review of R #1's Quarterly Minimum Data Set assessment (MDS; a federally mandated assessment instrument completed by facility staff) dated 12/05/25 revealed R #1's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) revealed a score of 02 (00 to 07 is severe impairment). E. Record review of facility's facility incident report dated 12/01/25, revealed Certified Nurse Aide (CNA) #1 and CNA #2 were attempting to take R #1 to the restroom and R #1 was swinging her arms to hit the CNAs.F. On 12/29/25 at 10:15 a.m., during an interview with CNA #1, she stated on 12/01/25, she attempted to take R #1 to the restroom and she pulled R #1's wheelchair backward several steps from the day room area toward the hallway after R #1 initially resisted going to her room, to go to the restroom. She further stated that during toileting (assistance using the toilet), R #1 became combative and attempted to strike CNA #2. She confirmed she held R #1's hands across R #1's chest, to prevent R #1 from hitting CNA #2. G. On 12/29/25 at 11:24 a.m., during an interview with CNA #2, she stated she assisted R #1 with toileting and confirmed R #1 resisted care, attempted to hit and kick staff. CNA #1 held R 31's hands during care to prevent R #1 from striking staff. She further stated approximately two to two-and-a-half hours later that day on 12/01/25, during another toileting attempt with R #1, she observed bruising to R #1's right hand and identified a skin tear to R #1's right lower quadrant of the abdomen; which she reported to nursing leadership. CNA #2 confirmed she reported her findings to the Director of Nursing (DON). H. On 12/29/25 at 1:17 p.m., during an interview with Assistant Director of Nursing (ADON), he stated he did not believe the staff intentionally attempted to harm the resident, but stated staff should have stepped away and notified nursing staff rather than continuing care during R #1's combative behavior. The ADON stated the facility was notified of bruising to the resident's hand later on 12/01/25 and R #1 also had a superficial (outer layer) skin tear to the right lower quadrant of the abdomen. He stated the skin tear appeared superficial and may have been related to brief (adult-sized disposable diaper designed for incontinence) change, though he could not definitively determine the cause. I. On 12/29/25 at 1:59 p.m., during an interview with the Administrator, she stated she was notified of bruising to R #1's hand following an incident involving CNA #1 and CNA #2 on 12/01/25. She stated she reviewed the available video footage, which showed staff attempting to encourage R #1 to go to the restroom for several minutes prior to entering the resident's room, during which R #1 became increasingly agitated. The administrator stated the facility does not have video monitoring inside resident rooms and therefore could not observe what occurred during toileting, but she immediately suspended CNA #1 and CNA #2 pending investigation. She stated staff reported restraining R #1's hands during care because R #1 was attempting to strike staff. The administrator confirmed it is the facility's expectation, that when a resident becomes combative, staff should step away, redirect, or notify nursing staff rather than continue hands-on care. The Administrator confirmed facility staff rough handling or applying physical restraint to residents during care is not acceptable.

Based on record review and interviews, the facility failed to ensure nurse aides were competent to perform their assigned duties when the facility did not provide adequate orientation and training for new and existing employees. This deficient practice is likely to result in staff not receiving the necessary training to meet the care needs of residents. A. Record review of the facility's policies revealed the facility did not have a formal policy or process in place for the onboarding, orientation, and training of new and existing staff. B. Record review of staff training and competency records for Certified Nurse Aid (CNA) #1, CNA #3, and Registered Nurse (RN) #1 revealed facility was unable to provide the records. C. On 08/14/25 at 1:32 pm, during an interview, the Assistant Director of Nursing (ADON) stated he oversaw training for CNAs. He stated there was not any onboarding process for staff prior to July of this year. D. On 08/14/25 at 1:47 pm, during an interview, the Human Resources Director (HRD) stated she was employed with this facility for three weeks, and the facility did not have a formal onboarding process in place for nursing staff prior to her employment. The HRD stated she was responsible to oversee the facility staff, and she believed the Staffing Coordinator (SC) oversaw the agency staff. E. On 08/14/25 at 2:00 pm, during an interview, the SC stated the ADON was responsible to oversee staff training and competencies. She stated the facility did not have an onboarding process in place until July 2025; however, she contacted the appropriate agency to verify CNA and Nurse licensure. F. On 08/14/25 at 2:23 pm, during an interview, the Director of Nursing (DON) stated when she started working at the facility, they lacked established policies and procedures for onboarding staff as well as for verifying staff competencies. The DON stated the ADON was responsible for all training and competency verification, but the process was still in development. The DON stated a Performance Improvement Plan (PIP) was implemented for the ADON due to failure to complete these required duties. A new MDS (Minimum Data Set) staff member has been hired to address the backlog of staff training.

Based on record review and interview, the facility failed to ensure that all staff received abuse, neglect, and exploitation training prior to providing direct resident care. This deficient practice has the potential to increase the risk for harm to residents due to a lack of knowledge and awareness regarding resident rights and the reporting of abuse. The findings are: A. Record review of staff training and competency records for Certified Nurse Aid (CNA) #1, CNA #3, and Registered Nurse (RN) #1 revealed there was no documentation in the above noted staff records regarding Abuse, Neglect and Exploitation Training. B. On 08/14/25 at 1:32 pm, during an interview, the Assistant Director of Nursing (ADON) stated he was responsible for trainings for Certified Nurse Aides (CNAs). He stated he has been employed with this facility since February 2025 and that prior to July of this year there was not an onboarding process. The ADON stated he verified nursing staff qualifications by checking to see if their license was current and getting them set up with the online training program. He stated it was not his responsibility to verify agency staff qualifications, and he thought it was Human Resources (HR) or the Staffing Coordinator (SC) who oversaw the agency staff. C. On 08/14/25 at 2:00 pm, during an interview, the SC stated the ADON was responsible to oversee staff training and competencies. She stated the facility did not have an onboarding process in place until July 2025; however, she contacted the appropriate agency to verify CNA and Nurse licensure. D. On 08/14/25 at 2:23 pm, during an interview, the Director of Nursing (DON) stated when she started working at the facility, they lacked established policies and procedures for onboarding staff as well as for verifying staff competencies. The DON stated the ADON was responsible for all training and competency verification, but the process was still in development. E. On 08/14/25 at 3:03 pm during an interview, Registered Nurse (RN) #1 stated she had not yet received Abuse, Neglect, and Exploitation training at this facility. RN #1 confirmed that today was her second day of employment, and she had been providing direct resident care. F. On 08/14/25 at 3:15 pm during an interview, Certified Nurse Aide (CNA) #1 stated she had not yet received abuse and neglect training at this facility. The CNA confirmed that she was on her second day of employment and had already been providing direct resident care. G. On 08/14/25 at 3:33 pm during an interview, the Administrator (ADM) stated she was hired a little over a month ago, and she was aware of the issues the facility had with training and competencies. She stated she expected staff to be current on their trainings and the facility was in the process of organizing records and creating and implementing a process for tracking staff trainings.

Based on record review and interview, the facility failed to complete and document a timely and thorough investigation regarding allegations of abuse (knowingly causing physical or mental harm or failing to provide goods and services necessary to avoid physical or mental harm) for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for abuse and neglect allegations when staff failed to complete and submit a thorough follow-up report for an incident involving R #1. If facilities do not submit follow-up reports, then the State Agency (SA) cannot assure the residents are safe and free of abuse. The findings are: A. Record review of R #1's face sheet revealed an admission date of 08/03/24 and included a diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with behaviors. B. Record review of a Facility Reported Incident (FRI), dated 04/06/25, revealed R #1 alleged that she was attacked by a black man on the night shift, resulting in a thumb injury. The resident was unable to provide specific details of the event or the name of the staff member involved. C. Record review of the facility's Five Day Follow-Up Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) revealed it was undated. The facility did not provide a confirmation from the State Agency to show the report was received by the State Agency. D. Record review of the State Agency's Five Day Follow-Up documents revealed the facility's Five Day Follow-up report was received by the State Agency on 06/12/25. E. On 08/07/25 at 3:39 pm during an interview, the Director of Nursing (DON) stated she sent in the five day follow up report to the State Agency on 04/07/25. The DON did not provide a confirmation from the State Agency to show the report was received by the State Agency.

Based on interview and record review, the facility failed to report an unexpected death to the State Survey Agency for 1 (R #1) of 1 (R #1) resident reviewed for clinical decline and death. The facility failed to initiate an internal investigation, submit a reportable event to the State Agency, and document clinical findings in the medical record following the resident's death. If the facility fails to report unexpected deaths, then the State Survey Agency cannot evaluate compliance with Federal regulations.The findings are: A. Record review of R #1's face sheet revealed an admission date of 08/03/24 with the following diagnoses: End-stage renal disease (kidney disease). Chronic respiratory failures with hypoxia (respiratory system is unable to adequately get oxygen into the blood). Diabetes mellitus (DM; a disease in which the body cannot make or properly use insulin). Hypertension (HTN; high blood pressure). B. On 06/25/2025 at 9:26 a.m., during an interview, the Assistant Director of Nursing (ADON) stated R #1 passed away after going to dialysis (a treatment that filters waste, toxins, and extra fluid from the blood) on 05/09/2025. C. Record review of R #1's progress notes, dated 05/09/2025 through 06/20/2025, showed the facility did not conduct an internal investigation regarding R #1's unexpected death, and the facility did not report the resident's death to the State Survey Agency. D. On 06/25/2025 at 10:46 a.m., during an interview, the Administrator stated the facility did not submit a report regarding the resident's unexpected death to the State Survey Agency, and the facility did not conduct a formal review into the resident's unexpected death. She stated they did not complete an incident report (a formal document detailing an event that occurred) or a mortality investigation (a thorough review conducted after a death to determine the cause and contributing factors), because R #1's death happened offsite. E. On 06/26/2025 at 2:26 p.m., during an interview, the Medical Director stated the facility notified her of the resident's death. She stated she expected the facility to notify the State Survey Agency for an unexpected death.

Based on interview and record review, the facility failed to ensure accurate and complete documentation in the medical record for 1 (R #1) of 1 (R #1) resident reviewed for death and discharge status. The facility failed to document the resident's death in the progress notes and inaccurately listed the resident as discharged to home, rather than deceased . If the facility fails to maintain complete and accurate records, then care outcomes cannot be appropriately tracked, regulatory compliance is compromised, and opportunities for review or improvement may be missed. The findings are: A. On [DATE] at 9:26 a.m., during an interview, the Assistant Director of Nursing (ADON) stated R #1 passed away after going to dialysis (a medical treatment which filters waste and excess fluid from the blood) on [DATE].B. Record Review of R #1's progress notes, dated [DATE], showed staff did not document the resident was transported to dialysis and died after arrival at the dialysis center. C. Record review of the facility's Admit/Discharge Report, dated [DATE] through [DATE], revealed R #1 was discharged to home or self-care (routine discharge) on [DATE].D. On [DATE] at 10:12 a.m., during an interview, the Administrator reviewed the facility's admissions and discharges list in which staff documented R #1 was discharged to home instead of deceased . The Administrator stated the document was inaccurate, and the staff should have updated the discharge status.E. On [DATE] at 2:26 p.m., during an interview, the Medical Director stated she expected staff to document resident deaths in the clinical record, and the records should accurately reflect the resident's status.

Based on record review, observation, and interview, the facility failed to assure medications were secured and inaccessible to unauthorized staff. This deficient practice had the potential to affect all 33 residents identified on the facility census list provided by the Administrator on 04/22/25. Improperly stored medications could result in a resident, staff member, or visitor taking the medications not prescribed to them. The findings are: A. Record review of the facility's Medication Storage Controlled Medication Storage policy (any type of chemical that can alter a person's physical or mental state.), dated January 2025, revealed the following: - Only authorized licensed nursing and pharmacy personnel had access to controlled medications. -The access system (key, security codes) used to lock controlled medications (medications or chemicals regulated by the government because they can be easily abused and lead to addiction) and other medications subject to abuse, could not be the same access system used to obtain the non-scheduled medications. - The facility must have a system to limit who had security access and when access was used. B. On 04/22/25 at 1:11 P.M. and 04/23/25 at 12:50 P.M., an observation revealed the facility's supply room was secured by a keypad which required staff to enter a security code to unlock the door. The keypad had an exposed spring near the bottom. Staff could press the exposed spring to open the door and gain access to the supply room without entering a security code into the keypad. The facility's supply room contained various facility supplies to include, isolation gowns, medical gloves, shaving cream, denture cleanser, toothbrushes, shampoo, body wash, and briefs. The room also contained over-the-counter medications and an emergency kit (E-Kit; contains medications which can be provided to residents in an emergency) sitting on top of the locked cabinet. The E-Kit contained a variety of medications, including, but not limited to, morphine oral solution (used to treat pain), Xanax (used for anxiety), Temazepam (a benzodiazepine used to treat insomnia), and various antibiotics (used to treat infections). C. On 04/22/25 at 2:00 P.M., during an interview with the Director of Nursing (DON), she stated staff moved the over-the-counter medications and the E-Kit from the medication room to the supply room after a recommendation from the pharmacist, due to excessive temperatures in the medication room. The DON stated staff utilized the supply room to get personal care supplies for the residents. The DON stated the E-Kit in the supply room posed a potential hazard since the controlled medication in the E-Kit was accessible to unauthorized staff. D. On 04/22/25 at 2:30 P.M., during an observation of the supply room, an unnamed Certified Nurse Aide (CNA) entered the security code into the key pad, entered into the supply room, and came out with briefs. E. On 04/24/25 at 1:07 P.M., during an interview with Maintenance #1, he stated he did not know the exposed spring could be pushed to unlock the supply closet and allow access to the supply room without entering a security code. F. On 04/24/25 at 1:10 P.M., during an interview with the Administrator, she stated staff moved the over the counter medications and the E-Kit into the supply room in March 2025. She stated the room was accessible to all staff in the facility including CNAs since it contained all the facility's supplies. She stated she was not aware staff could bypass the security code by pressing the exposed spring on the keypad.

Based on record review, observation and interviews, the facility failed to sanitize dishes when staff did not maintain the dish washing machine at 120 degrees ( ) Fahrenheit (F), per manufacturer's instructions. This deficient practice was likely to affect all 33 residents of the facility. If the facility fails to ensure the dish machine reached the appropriate temperature, then residents could potentially be exposed to foodborne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites, or toxins.) The findings are: A. Record review of the facility's Dish Washing Policy, dated March 2010, revealed the policy did not address the temperature of the water for sanitizing dishes. B. Record review of the Ecolab Low Temperature (ELT) Dish Machine (low temperature dish washing machines utilize chemicals for sanitation) Manufacturer's Recommendations, dated 2022, revealed the dish machine should be operated at minimum temperatures of 120 F for washing and rinsing. C. On 04/23/25 at 10:26 A.M. during an observation and interview, staff utilized a low-temperature dishwashing machine to wash dishes and the cooking equipment. Kitchen Staff #1 stated the dish machine was broken and did not properly wash the dishes. She stated the old dish washer was replaced in April 2025, and the new dish machine did not reach the proper temperature of 120 F since its installation. D. Record review of the facility's dish washing machine temperature logs, dated April 2025, revealed the following: - On 04/07/25, staff documented wash temperatures as follows: Breakfast 118 F, lunch 112 F, and dinner 118 F. - On 04/08/25, staff documented wash temperatures as follows: Lunch 112 F, and dinner 118 F. - On 04/09/25, staff documented wash temperatures as follows: Lunch 112 F, and dinner 100 F. - On 04/10/25, staff documented wash temperatures as follows: Breakfast 118 F, lunch 96 F, and dinner 95 F. - On 04/11/25, staff documented wash temperatures as follows: Lunch 113 F, and dinner 118 F - On 04/12/25, staff documented wash temperatures as follows: Breakfast 110 F, lunch 103 F, and dinner 103 F. - On 04/13/25, staff documented temperatures as follows: Breakfast wash 110 F, rinse temperature 102 F; lunch wash 110 F; and dinner wash 110 F. - On 04/14/25, staff documented wash temperatures as follows: Breakfast 110 F, lunch 110 F, and dinner 110 F. - On 04/15/25, staff documented temperatures as follows: Breakfast wash 110 F, rinse 102 F; lunch wash 110 F; and dinner wash 110 F. - On 04/16/25, staff documented wash temperatures as follows: Breakfast 110 F. - On 04/17/25, staff documented wash temperatures as follows: Breakfast 110 F, lunch 110 F, and dinner 110 F. - On 04/18/25, staff documented wash temperatures as follows: Breakfast 110 F, lunch 110 F, and dinner 110 F. - On 04/19/25, staff documented wash temperatures as follows: Breakfast 110 F, lunch 114 F, and dinner 115 F. - On 04/20/25, staff documented wash temperatures as follows: Breakfast 110 F, lunch 110 F, and dinner 110 F. - On 04/21/25, staff documented wash temperatures as follows: Breakfast 110 F, lunch 110 F, and dinner 110 F. - On 04/22/25, staff documented wash temperatures as follows: Breakfast 110 F, lunch 110 F, and dinner 110 F. - On 04/23/25, staff documented wash temperatures as follows: Breakfast 118 F. Staff did not document any other temperatures. E. Record review of the Registered Dietician's (RD) kitchen inspection, dated 04/22/25, revealed the RD documented the minimum wash and rinse temperature for the dish machine should be 120 F. She stated at least half of the temperatures documented for the month of April 2025 were less than 120 F. She stated the facility should wash everything in the three compartment sink (a sink with three sections to wash, rinse, and sanitize) until the dishwasher washed and rinsed at the proper temperature of 120 F. F. On 04/23/25 at 10:47 A.M. during an observation and interview, the Lab Technician for an outside company performed maintenance on the facility's dish washing machine. The technician stated the dish machine was a low-temperature, chemical sanitizing machine that depended on the sanitizer (chlorine) to sanitize the dishes. She stated the water temperature for the wash and rinse cycles was also supposed to be 120 F, according to the manufacturer's name plate attached to the machine. She stated the facility needed a boost heater to get temperature of washer at 120 F. G. On 04/23/25 at 12:52 P.M. during an interview with the Dietary Manager (DM), she stated the dishwashing machine was a low-temperature model. She stated the temperature log, dated April 2025, showed staff documented temperature readings between 110 F and 118 F. The DM stated the appropriate temperature was 120 F or above to ensure the dishes were properly sanitized. The DM stated she monitored the temperature logs for the dishwasher, and she was aware of the temperature was not appropriate. The DM stated the RD suggested they wash dishes in the three compartment sink until the dishwasher was repaired. H. On 04/23/25 at 2:00 P.M. during an interview with the Administrator, she stated she was aware the dish machine did not get to the correct temperature. She stated she had staff adjust the chemicals to a higher level to effectively eliminate the germs. She stated she did not know the correct temperature for the dishwasher wash and rinse cycles.

Based on record review and interview, the facility failed to prevent resident to resident sexual abuse for 1 (R #17) of 3 (R #5, #17 and #33) residents reviewed for abuse. This deficient practice likely resulted in psychosocial harm and distress for R #17, as evidence by the resident to become more withdrawn and isolated, experience anxiety and fear, and weight loss. The findings are: A. Record review of R #17's face sheet indicated she was admitted on [DATE] with the following diagnoses: - Cataract extraction (surgery to replace eye lens with an artificial one), - Osteoporosis (low bone mass leading to deterioration of bone tissue) with fracture, - Depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), - Chronic pain. B. Record review of R #17's nursing progress notes indicated the following: - Dated 08/19/24 at 8:05 pm, the Administrator in Training (AIT) notified the Director of Nursing (DON) that the night before R #17 reported to the Charge Nurse that a male resident [R #100] entered R #17's room while she was sleeping and was sexual towards her. The AIT notified Administrator, made a report to the State agency, and initiated an investigation. The DON notified R #17's Power of Attorney (POA; a person who is chosen to make decisions on your behalf when you are unable) on 8/19/24 at 7:27 am of the incident, but R #17 notified the POA yesterday, 08/18/24, that a male resident entered her room. - Dated 08/21/24 at 5:51 pm, R #17 went to the hospital on 08/19/24, and she underwent a computed tomography scan (CT scan; provides a more detailed view of tissues, blood, vessels and bones) on her abdomen. Doctors checked for bruising, screened for a urinary tract infection (UTI), and did bloodwork for possible sexually transmitted disease (STD). A tiny bit of blood was found in R #17's urine from possible tear to her vagina area [inconclusive until a sexual assault nursing exam (SANE) was completed.] Antibiotics were going to be prescribed, but they wanted to wait for the results from the SANE exam. Resident was scheduled for a SANE exam at 1:30 pm today 08/18/24. Resident came back to facility to pick up some of her clothing and belongings. She will stay with her family for the next two or three nights. The POA was provided medications for R #17. Resident and family would like R #17 to be discharged to the facility. Resident voiced she is scared to stay here. Resident's SANE exam went well, and she was released from the hospital on 8/20/24. - Dated 08/26/24 at 2:45 pm, a psychosocial assessment was conducted with R #17. The resident continued to stay in her room and spoke of leaving the facility. The Social Services Director (SSD) let R #17 know the Psychiatrist would come by today to speak with her. The resident stated she was okay with that. The Psychiatrist diagnosed R #17 with acute stress syndrome. R #17 told the Psychiatrist that she had nightmares and was afraid. R #17 stated she wanted to discharge from the facility, and the SSD discussed it further with the resident's POA. C. Record review of R #17's medical record did not include results of the SANE exam. D. Record review of R #17's therapy progress notes, dated 09/25/24, indicated the following: - The Chief Complaint Section: After recent trauma, the patient isolated in her room and sleeps more than usual. Therapy Data, Assessment and Plan Note indicated the following: 08/26/24 Patient confided in her Certified Nursing Assistant (CNA) that another resident came into her room during the night and assaulted her. Plan section: The patient will continue to receive psychotherapy services to address her emotional distress and to monitor for signs of post traumatic stress disorder (PTSD). Resident continues to be seen ongoing for therapy services. E. Record review of a statement made by Nurse #9, the statement revealed the following: Resident Report of Sexual Abuse on Sunday Night:R #17 requested a private meeting with me and CMA #1 to her room at 1900 (7:00 pm) in order to lodge a complaint about an awful encounter with a male resident last night. R #17 alleged at nighttime he entered her room and sat on other bed claiming that is just a friendly visit and only wanted to watch television which she is not comfortable with, so when she is about to sleep she asked him to leave her room which he refused. She later went to bed and five minutes later he came up to her demanding sex which he forcefully pulled her undergarments and had his way with her. She said she did not react because of fear of her life because of his ill behavior. When he left the room she walk to the nurses station and reported to night shift nurse on Sunday and to report to facility authority. She asked for him to be kept away from her in which we provided close monitoring throughout the shift. F. Record review of R #17's care plan indicated the following for psychosocial well-being : - Dated 08/20/24, R #17 was a victim of sexual assault by a male resident and had a diagnosis of acute stress reaction. G. Record review of R #17's hospital record indicated the following: - She was seen in the emergency roiagnom on [DATE] for acute pelvic pain and sexual assault. - Medical Decision Making Section: Present for evaluation of pelvic pain and cramping. Has a history of bladder spasm (having a sensation of needing to urinate) but have been well controlled over the last several years. R #17 denies vaginal bleeding. Abdominal exam is benign (negative) at the time of evaluation. Low suspicion of vaginal tear (an injury to the tissue around your vagina and anus.) Imaging was obtained and somewhat limited but negative for signs of traumatic injuries. H. Record review of the weights for R #17 revealed staff documented the following: - On 09/02/24, 101.8 pounds. - On 10/01/24, 100.6 pounds. - On 11/01/24, 98.6 pounds. - On 12/01/24, 92.0 pounds. I. On 12/16/24 at 3:29 pm, during an interview with R #17, she stated she wanted to go to a different facility. She stated she did not have anyone to talk to here. She stated her roommate was sort of mean, not talkative, and got mad easily. R #17 stated that one night she sat in her room and watched the evening news. She stated she went to bed when the news was over . She stated another resident came into her room and sat on the other bed. R #17 stated he would leave and come back. She stated he told her he was lonely. R #17 stated she told him it had been a long day, and she was ready to go to bed. R #17 stated he left her room, and she went to bed. R #17 stated the resident came back later while she was asleep. She stated he pulled her down to the bottom of the bed and had his way with her. R #17 stated the resident did not bother her before this incident. She stated she was too scared to get out of bed to tell someone, but she did tell someone the next day about what happened to her. R #17 expressed concern the resident might come back to the facility. J. On 12/17/24 at 3:34 pm, during an interview with the Staffing Coordinator, she stated the male resident, who allegedly went into R #17's room, was put on a one-to-one immediately after the incident was reported until he was later discharged from the facility. She stated he had a girlfriend at the facility, and he did not bother anyone else that she was aware. K. Record review of facility investigation report dated 08/23/24 identified that following facility awareness of the incident, local law enforcement was contacted to file a report, R #100 was sent out to PsychER on [DATE] and upon return from the hospital R #100 was provided 30 day discharge notice after an attempt to get an emergency discharge order from tribal court judge failed. L. On 12/18/24 at 10:10 am, during an interview with Social Services Director (SSD), she stated she did not work at the facility at the time of the incident, but she had a lot of concerns about R #17. She stated R #17 lost some weight, she did not leave her room, and self-isolated. She stated she brought her concerns up with management and in a clinical meeting in the morning. The SSD stated she visited R #17 often. She stated R #17 saw a psychiatrist who came to the facility every couple of weeks. The SSD stated R #17's sexual abuse triggered previous issues, and that contributed to her not wanting to leave her room. The SSD stated R #18 was afraid she was going to be shamed by others. The SSD stated she spoke to the resident's daughter a lot, and they discussed interventions like moving rooms, blessing the resident's room, and having a medicine man come out. The SSD stated they would like to remove all triggers for R #17, but R #17 always states she would think about it [offered interventions]. M. On 12/19/24 at 8:44 am, during an interview with Activities Director (AD), she stated R #17 used to be more engaged than she was now. She stated R #17 used to walk up and down the halls to get some exercise, and she would take her lunch tray back to the kitchen after she was finished eating. The AD stated R #17 did not do these things anymore. The AD stated R #17 shut down. The AD stated R #17 will come out of her room with her family when they visit her. N. On 12/20/24 at 12:29 pm, during an interview with the Psychiatrist, she stated R #17 had acute post traumatic stress disorder (PTSD.) The Psychiatrist stated she went to speak with R #17 right after the abuse happened and saw her multiple times after the incident. The Psychiatrist stated R #17 was more withdrawn than she was before the incident. The Psychiatrist stated R #17 used to walk down the halls for exercise, but she did not do that anymore. She stated R #17 slept a lot more now. The Psychiatrist confirmed that she saw R #17 was on 08/26/24, 09/13/24, 09/25/24, 10/21/24, 11/22/24, 12/06/24 and 12/20/24. The Psychiatrist stated R #17 has been awake the last few times she met with her [some visits she was asleep]. She stated the facility has offered R #17 multiple different options, like changing rooms, but the resident has not accepted any of these things yet.

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure staff followed contact precautions (used for individuals with infections that can spread through direct or indirect contact with the patient or their environment) before contact with a resident and his environment for 1 (R #13) of 1(R #13) residents. This practice could likely lead to an increased risk of transmission of the bacteria to other patients and healthcare workers, potentially causing more infections due to direct contact with contaminated surfaces or the infected patient, which could result in serious complications like sepsis (presence of bacteria and infectious organisms in the blood stream) or even death if left untreated. 2. Demonstrate its measures to minimize the risk of Legionella (a type of bacteria that can cause legionellosis; a serious chest infection) and other opportunistic pathogens in the building water systems by not having a documented water management program. This failure to affect all residents in the facility. This deficient practice is likely to increase the risk of exposure to legionella bacteria and potentially outbreaks of legionellosis in the facility. The findings are: Contact Precautions A. Record review of R #13's progress notes, dated 9/27/24, revealed the resident was admitted to the facility on contact precautions due to methicillin resistant staphylococcus aureus (MRSA; bacteria that are resistant to treatment with semi-synthetic penicillin) in coccyx (tail bone located at the end of the spine) wound. B. On 12/18/24 at 10:00 am during observation and interview, Housekeeper #1 did not put on gloves or an isolation gown before she entered R #13's room to pick up trash. Further observation revealed there was a contact precautions sign on the resident's room door which instructed staff and visitors to do the following: 1. Everyone must clean their hands, including before entering and when leaving the room. 2. Providers and staff must also put on gloves and a gown before room entry and discard the gloves and the gown before room exit. C. On 12/18/24 at 10:02 am, during an interview, Housekeeper #1 stated she did not know R #13 was on contact precautions. D. On 12/18/24 at 10:05 am during observation and interview, Certified Nurse Assistant (CNA) #1 entered R #13's room, stayed a few seconds, and exited the room. CNA #1 did not put on gloves or an isolation gown before she entered R #13's room. CNA #1 stated she would only put on gloves and a gown if she had to clean the resident's infected wound. E. On 10/19/24 at 10:32 am during an interview with Nurse #4, she stated Resident #13 was on contact precautions. She stated she expected Housekeeper #1 and CNA #1 to put on gloves and an isolation gown before they entered R #13's room. Water Management Program F. Record review revealed that the facility did not have a documented water management program to minimize the risk of Legionella in the facility's water system. G. On 12/18/24 at 11:46 am during an interview with the Maintenance Technician, he stated the facility did not have a water testing system or any related documents. H. On 12/18/24 at 3:50 pm during an interview with the facility's Administrator, she stated they did not have a system for water testing or water services.

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required dementia and abuse training for 12 (CNAs #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12) of 19 (CNAs #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) CNAs reviewed for dementia and abuse training. This deficient practice could likely result in the nurse aides not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the facility's most current abuse and dementia training list, dated December 2023 to December 2024, revealed 12 CNAs did not receive abuse training, dementia training, or both. B. On 12/18/24 at 10:10 am, during an interview with the Social Services Director, she stated she did not think the staff received dementia. C. On 12/19/24 at 3:30 pm, during an interview with the Interim Administrator, she stated the abuse and dementia training list, dated December 2023 to December 2024, was the most current employees who worked at the facility. She confirmed all nursing staff should complete the trainings. D. On 12/20/24 at 2:50 pm, during an interview with the Nurse Educator, she stated the dementia training on 11/26/24 was for all staff, but the staff who signed the sheet were the only ones who showed up for the training. She stated the other staff who did not come should have reviewed the training, but there was not any documentation to show they did.

Based on interviews and record review, the facility failed to designate one or more individuals as the Infection Preventionist (IP) who was responsible to assess, develop, implement, monitor, and manage the infection prevention and control program (IPCP; a set of practices and procedures that aim to reduce the spread of infections in healthcare facilities and other settings). This practice could likely cause a lack of dedicated oversight and implementation of proper infection control practices across the facility and lead to potential resident harm and a greater risk of outbreaks. The findings are: A. On 12/18/24 at 9:48 am, during an interview with Nurse #4/MDS Nurse, she stated the previous Director of Nursing resigned at the end of November 2024 and did not involve her (Nurse #4) in the process of infection control. She stated the Interim Administrator did not ask her to do any infection control duties, and she did not have any qualifications to perform infection prevention and control duties. B. On 12/18/24 at 10:00 am, during an interview with the facility's Interim Administrator, she stated the previous Director of Nursing handled the infection control reporting. She stated Nurse #4 and the current senior ranking nurse were not officially assigned to any infection control duties.

Based on interviews, and record review, the facility failed to assist a resident in gaining access to vision services when staff failed to make appointments or arrange for transportation for 1 (R #30) of 1 (R #30) residents. This practice could likely lead to an increase in the risk of missing early signs of serious eye diseases like glaucoma (a group of eye conditions that can cause blindness) and macular degeneration (a medical condition which usually affects older adults and results in a loss of vision in the center of the visual field because of damage to the retina), which often have no noticeable symptoms in their early stages, potentially leading to significant vision loss or blindness if left untreated. Additionally, it could likely lead to missing a resident's prescription needs, causing eye strain and difficulties with daily activities. The findings are: A. Record review of R #30's Minimum Data Sets (MDS; a federally mandated assessment instrument completed by facility staff) revealed the following: - Admission MDS, dated [DATE], R #30 had impaired vision. - Quarterly MDS, dated [DATE], R #30 had an impaired vision. B. Record review of R #30's care plan, dated 10/4/24, revealed R #30 had age related impaired vision. The care plan listed a goal aimed to arrange Ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye)/Optometrist (an eye care specialist who examine, diagnose, and treat injuries and health conditions that affect your eyes and vision) consult and to implement recommendations annually and as needed for R #30. C. On 12/16/24 at 12:10 pm, during an interview, R #30 stated she asked a staff to assist her to schedule an eye appointment earlier this year, but she did not get any response from staff. R #30 could not remember the exact date or the staff member's name. D. On 12/19/24 at 3:49 pm during an interview with Nurse #4, she stated staff scheduled R #30 for an eye appointment on 6/14/24. She stated they had to cancel that appointment, because they did not have transportation to take R #30 to her appointment. Nurse #4 stated the facility had to evacuate the building after the cancelation due to a widespread roof leak problem, and nobody rescheduled the appointment after that.

Based on record review and interview, the facility failed to identify hot water as a hazard and implement interventions to reduce the hazard for 1 (R #27) of 1 (R #27) resident reviewed for accidents and hazards when she was provided a hot beverage that spilled on her lap causing severe [CONDITION(S)]. This deficient practice likely resulted in R #27 experiencing second and third degree [CONDITION(S)] (among the most severe of [CONDITION(S)] and destroys two full layers of your skin) on her thighs. The findings are: A. Record review of R #27's face sheet revealed that she was admitted on [DATE] with the following pertinent diagnosis of: [CONDITION(S)] ( a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), adjustment disorder with anxiety (higher levels of stress related to life changing events accompanied by an overwhelmed feeling of anxiety), unspecified mood disorder (symptoms that are similar to depressive disorder), and unspecified pain. B. Record review of a quarterly Hot Liquids Assessment, for R #27, dated 10/19/21, revealed Functional ability: Lacks ability to handle eating equipment (cup, dish, spoon). Demonstrates tremors of arms or hands. Plan of action: Cup with a lid to be provided to resident. Resident to wear liquid resistant clothing protector. Staff to assist with meals. Comments: Resident does not need assistance at all times. C. On 06/05/22 at 2:16 pm, during an interview with the POA (Power of Attorney) of R #27, she stated that R #27 sustained a burn at the facility . She (R #27) had a scalding (to be burnt with hot liquid or steam) on her thigh. It had to have been an exceedingly high temperature of coffee or tea and it caused [CONDITION(S)]. I have complained and met with the board. I have met with the director and the Director of Nursing (DON). A lot of these issues are ridiculous and controllable. D. On 06/08/22 at 3:44 pm, during an interview with the Interim Administrator and the DON, when asked to explain R #27's burn, they explained At dinner [on 04/26/222] she was observed throwing her cup [of hot tea]. The burn was identified the next morning [on 04/27/22] . The nurse [who was observing dinner] said that she didn't believe that it spilled on the resident. She [the resident] threw the cup on the table and the cup and liquid splashed on the ground. At that time, the cup had a lid. When asked if the clothing protector extends over the lap of the resident, they were unsure and stated, The clothing protector may or may not cover the lap. E. On 06/09/22 at 9:40 am, during an interview with Licensed Practical Nurse (LPN) #1, when asked to describe the incident that occurred on 04/26/22, she explained, I was sitting in the dining area and they (the staff) were passing the tea and coffee around. I heard something fall off the table. I got up to look. When I saw the cup on the floor, there was some tea on the floor. Nobody yelled or screamed. I looked at her [R #27] and I asked her if she was ok but she didn't answer me. She is able to voice pain. She said nothing at that time. I picked up her cup. The lid was still on there (plastic lid with a hole (1) centimeter wide to drink from). I took the cup and I put it back by the window. F. On 06/09/22 at 2:03 pm, during an interview with CNA #1, when asked to explain the incident on 04/26/22, she explained, I can't remember who gave her the tea but it was sitting in front of her. She had a double handle cup with a lid. She sits at a table where they need assistance. Two CNA's would sit there to give assistance to four residents. That day, they gave her the hot tea and she can still grab and pull things towards her. From what I heard, the cup did not have a lid on top at the time. There's certain people who pass the drinks and some people who volunteer to pass the drinks while we wait for the food. I think I was passing out trays . but I think when she spilt it we were still bringing residents into the dinning room. Her fingers are kind of contracted and don't open all the way and her hands kind of close so she still tries to grab things. After the cup was thrown, I don't think they took her back to the room to change her or anything. I don't think anybody did anything. I don't know how many days passed, but when we lay her down [after dinner] we have to remove her pants and put a pillow under her legs. The next day another coworker was working with her and she called me and there were bubbles all over her legs. I right away told the DON and she told me to tell the nurse. There were blisters and then after a while they were calling it burn marks. I think she got the blisters from the tea. When asked if her wet clothing would be noticeable during the meal time, she stated, It would not have been noticeable. She usually has a blanket on her lap. It's a thin blanket that kind of looks like a towel but is a blanket- like a throw blanket that is really small. After every meal she is one of the first residents to go lay down. Later, when she had blisters on her thighs she would say like 'ouch, ouch, ouch', because they were not covered. G. On 06/09/22 at 2:26 pm, during an interview with CNA #2, when asked to recall R #27, she stated, I believe she got a burn. I was not there during dinner. I came in at 6 pm. She was scheduled for a shower that night. I didn't know what happened I saw something on her legs. After the shower, I was drying her and I saw some redness. I told the nurse. When I gave her a shower she didn't show any signs of discomfort. Then, the week later I went in and it was blistered. It was pink and like a bubble. Before the shower, she didn't seem in pain. I didn't see any difference in her at all. She was just quiet. She didn't say or point to anything. H. Record review of progress notes, dated 04/27/22, revealed Resident is alert and calm. Assigned CNA drew my attention to some burn like abrasion above her right knee and on her left inner thigh. Pictures taken and sent to [name of physician]. She requested that the wound care nurse take a look at it today. Resident could not answer question to how she feel about this. However, her vitals were stable and resident is not in distress. Will continue to monitor. I. Record review of physician orders revealed the following that on 04/27/22 orders began for treatment of an open blister above left knee and blisters on right inner thigh. J. Record review of wound documentation, date 04/27/22, regarding the wound on right thigh revealed the burn to be 9.4 cm (centimeters) by 3.5 cm with Partial Superficial: painful, no [CONDITION(S)], redness, blanches (white or pale in appearance) with pressure. 3 fluid filled blisters noted, resident denies pain to area. Further review of wound documentation date 04/27/22, revealed the burn on the left knee to be 4.1 cm by 3.7 cm with Partial thickness: redness, blistered, moist, painful. K. Record review of nursing notes, dated 05/02/22, revealed In to assess wounds to residents posterior left knee and right inner thigh. Left posterior knee has a second degree burn. Blister has popped and surrounding tissue is healthy. Wound edges are well identified. Wound bed is moist and red. Moderate amount of yellow drainage is identified. Right inner thigh has a third degree burn with 2 large blisters remaining intact. Small area of eschar (is dead tissue that sheds or falls off from the skin) is noted medially in proximity to the wound bed . L. Record review of the American Burn Association Scald Injury Prevention Educator's Guide, posted 04/25/17, revealed Older adults, like young children, have thinner skin so hot liquids cause deeper [CONDITION(S)] with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Further review revealed that for the skin to receive a third degree burn, hot liquid at the temperature of 155 degrees Fahrenheit needs to make contact with the skin for 1 second. M. Record review of hot beverage temperature log, dated 04/26/22, revealed the hot tea to be 172 degrees Fahrenheit during the dinner meal. N. Record review of facility policy titled Safety of Hot Liquids, last revised October 2014, revealed Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from [CONDITION(S)]. Such interventions may include: . Provide protective lap covering or clothing to protect skin from accidental spills . O. On 06/07/22 at 7:30 am, during an observation, R #27 was observed, sitting at a table, in the dining area without a clothing protector (clothing designed to protect a person from hazards). Observation of other residents wearing a clothing protector revealed that the clothing protector does not extend over the lap or thighs of the residents.

Based on record review and interview, the facility failed to provide the necessary treatment and services to prevent/heal pressure ulcers (areas of damaged skin caused by pressure or friction) for residents whose clinical condition demonstrated they were avoidable for 1 (R #256) of 1 (R # 256) resident reviewed for pressure ulcers. This deficient practice resulted in R #256 developing an unstageable (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) pressure ulcer on his right ankle which required hospitalization and ultimately resulted in his right leg being amputated (removed). The findings are: A. Record review of R 256's Electronic Medical Record revealed he was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. B. Record review of R #256's Nurse's Skin Assessments revealed the following: 1. Skin assessment dated [DATE], indicated a slight skin irritation to the buttock area. No other skin issues were noted. 2. Skin assessment dated [DATE], indicated the skin was intact and no skin issue noted. 3. Skin assessment dated [DATE], indicated an open area on the right lateral (right side) ankle caused by the leg brace, a dark discolored callous-like area to the left heel and a scabbed area to the left posterior (behind) lower extremity. 4. Skin assessment dated [DATE] indicated, Rt. (right) ankle scab. Scab partially lifted off during shower. Wound exposed measuring 0.4 mm (sic) by 1.0 cm (centimeter) in length. Depth (sic) fairly superficial. Wound base white in color. 5. Skin assessment dated [DATE], indicated left heel c (with) a dry callus et (and) right side of ankle c pressure wound approx 1.5 cm healing. no other skin issues noted. 6. Skin assessment dated [DATE], indicated, right side of ankle wound approx. (approximately) 2 cm by 2 cm. Skin scab peeled off. 7. Skin assessment dated [DATE] indicated, Rt (right) outer ankle full thickness skin loss. Area measuring 2.1 cm in width by 1.8 in height. Sm. (small) amt. (amount) exudate (fluid emitted by an organism through pores or a wound) sl. (slightly) bloody. Site covered approx. 50% with black eschar (piece of dead tissue that is cast off from the surface of the skin). 8. Skin assessment dated [DATE] indicated, right ankle lateral c a wound approx. 4.0 diameter in cm, wound c (with) drainage sm (small) amt (amount) reddish brown, noted scant (very little) amt of yellow exudate (fluid emitted by an organism through pores or a wound) et (and) discoloration around wound. C. Record review of R #256's Nurse's Progress note revealed the following: 1. Nurse's Progress note dated 03/14/18 indicated, (Name of Nurse Practitioner) notified on resident right ankle area, noted odor et (and) small amt (amount) drainage reddish brown. (Name of Nurse Practitioner) examined resident ankle . 2. Nurse's Progress note dated 03/15/18 indicated his right ankle wound had a small amount of reddish brown drainage and an odor was noted. 3. Nurse's Progress note dated 03/22/18 (a Thursday) indicated, Right ankle wound has tripled in size from Saturday morning when last observed by this nurse. Malodourous (having a bad odor), with foot below wound red, hot to the touch and swollen. Wound with fair amount of drainage. Day nurse aware. 4. Nurse's Progress note dated 03/22/18 indicated that the Medical Director (MD) was informed of R #256's discomfort to right lower extremity and she examined the resident's ankle wound. It stated the MD placed new orders for pain medication and medication ointment applied to wound. 5. Nurse's Progress note dated 03/24/18 indicated, Per CNA (Certified Nursing Assistant) Resident's right lateral ankle drsg (dressing) no longer in place. Resident declined pain medication prior to wound care. Wound measures 4.0 cm x 5.0 cm with approx 75-80% of wound bed with dark brown eschar (piece of dead tissue that is cast off from the surface of the skin), remainder of wound bed with light yellow slough (layer or mass of dead tissue), sm (small) amt (amount) serosanguinous (containing both blood and serous fluid) drainage, no odor noted at this time. Drsg. (dressing) applied per current order. Approx. 5.0 cm wound area reddened, sl (slightly) warm to the touch. Again spoke with Rsd (resident) RE: (regarding)positioning off of right side to sleep, Rsd did comply and reposition to back. Right leg floated off mattress with soft blanket. S/P (status [REDACTED]. No c/o (complaints) offered at this time. 6. Nurse's Progress note dated 03/26/18 indicated, Wound to outer ankle has increased in dimension over past 24 hours. In addition, when wound is palpated (examined by touch), purulent (containing or discharging pus) fluid oozes out. Amount of sero-sanguineous (containing both blood and serous fluid) drainage has increased and odor also now present. Other aspects of wound unchanged from progress notes of previous days. (Name of Medical Director) ordered rsd (resident) be sent to wound clinic at (Name of Hospital) asap (as soon as possible). All requested information has been faxed to (Name of Hospital) and appt (appointment) details are pending (per medical records.) Drsg (dressing) applied per order x2 (two times) this shift. Will continue to monitor. 7. Nurse Practitioner's progress note dated 03/27/18 indicated, This writer and NP (nurse practitioner) observed wound to Rt. (right) ankle. Obvious increase in size from last week. Approx. 2-3 times in size. Odor from wound. Purulent (containing or discharging pus) appearing drainage. NP request to transport to (Name of Hospital) . D. Record review of R #256's care plan dated 02/28/18 indicated that he had a stage 2 pressure ulcer to his right ankle related to his brace. The only two interventions listed were to administer treatment as ordered and a referral for reassessment of his leg brace. No updates to the care plan were found after 02/28/18. E. On 06/15/18 at 10:30 am, during interview, Licensed Practical Nurse (LPN) #1 stated, that the right ankle was being treated with [MEDICATION NAME] (an antibiotic ointment), then 3 weeks later the Nurse Practitioner ordered for the wound to be cultured (is a test that detects and identifies bacteria that cause infections in a wound). Then it seems they (the physician staff) waited awhile. LPN #1 stated that she was not at work for 4 days, and when she saw the wound again it was getting bigger, she described the wound as, a half-dollar size and the nursing staff was doing the same treatment. About 3 weeks later, when the Medical Director made her rounds and observed the wound, she was accompanied by the Director of Nursing (DON). LPN #1 stated that the wound was swollen, red, and had an odor. She said that the doctor didn't think the wound felt warm. LPN #1 stated that the physician stated, I'll come back the next day, and decide (about the wound). She said that would have been on a Friday, and again the MD looked at the wound. LPN #1 said that later on R #246 was sent to the hospital. LPN #1 stated that she heard from the DON that R #246 had his leg amputated. LPN #1 said that she heard that R #246 was happy, because he didn't hurt so much and that it was the Nurse Practioner (NP) who sent R #246 to the hospital on [DATE].