Every finding on record at Madison Grove Post Acute

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and sanitary environment for two of two sampled residents (Residents 1 and 2), when Residents 1 and 2's shared bathroom was found with approximately 50 dead gnats (term for many species of tiny, two winged flies) on the shower floor, and Resident 1 and 2's shared room had evidence of termites found on the vinyl floorings. This failure has the potential to place Residents 1 and 2's health and safety at risk.Findings: During a review of Resident 1's face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included tracheostomy status (the person has a breathing tube placed through a hole in the neck to help them breathe), hemiplegia (complete paralysis on one side of the body) and hemiparesis (weakness on one side of the body) effecting right dominant side. During a review of Resident 2's face sheet (contains demographic and medical information) indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (damage or malfunction of the brain that alters its structure of function), and tracheostomy status. During a concurrent observation and interview on March 3, 2026, at 2:54 PM, with Certified Nursing Assistant (CNA 1), in Residents 1 and 2's shared bathroom, CNA 1 inspected the bathroom and verified that there were approximately 50 dead gnats on the shower floor. During a concurrent observation and interview on March 3, 2026, at 3:16 PM, with License Vocational Nurse (LVN 1), in Residents 1 and 2's shared bathroom, LVN 1 inspected the bathroom and confirmed that there were approximately 50 dead gnats on the shower floor. LVN 1 stated she found evidence of termites on one of the vinyl floorings in Resident 1's and 2's bedroom. During a concurrent observation and interview on March 3, 2026, at 3:54 PM, with the Maintenance Supervisor (MS 1), in Residents 1 and 2's room, MS 1 inspected the floor close to the sliding door and found that one of the vinyl floorings had cracked and had a missing section. MS 1 stated there was evidence of termites on the missing section of the vinyl flooring. MS 1 stated the missing section of the vinyl flooring was approximately 2 inches wide and 8 inches long. He stated the situation was unacceptable and should have been addressed promptly. During a concurrent telephone interview and record review, on March 4, 2026, at 10:10 AM, with the Director of Nursing (DON), the DON reviewed the facility's Policy and Procedure (P&P) titled, Pest Control, dated May 2008, which indicated, 1. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. The DON acknowledged the policy and stated that residents' rooms should be free from gnats and termites. She further added that it was also their expectation for the building to be in good condition and free from hazards, as outlined in the policy. A review of the facility's P&P titled, Maintenance dated 2015, indicated, a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to maintain eight out of nine shower beds in safe working condition when eight shower beds, which lacked the required locking pins to secure its side rails, were found in three different shower rooms (Shower Rooms at Stations 3, 4, and 1). This failure had the potential to expose 127 out of 230 residents who use the shower bed at risk for falls, or pinching injuries.Findings: During a concurrent observation and interview, on February 9, 2026, at 10:31 AM, with a Certificate Nursing Assistant (CNA 1), at Station 3's Shower Room, three shower beds had plastic bags wrapped around its rails. CNA 1 stated that several locking pins, which were essential for securing the shower bed's side rails, were missing for approximately two weeks. CNA 1 further stated that currently, they were utilizing plastic bags to provide support for the rails while awaiting necessary repairs. During a concurrent observation and interview, on February 9, 2026, at 10:49 AM, with the Maintenance Director (MD 1), at Station 3's Shower Room, the MD inspected the three shower beds and confirmed all three had missing locking pins on its side rails. The MD 1 further stated he should have identified this problem because it was unsafe. During a concurrent observation and interview on February 9, 2026, at 11:00 AM, with the MD 1, at Station 4's Shower Room, the MD 1 inspected the three shower beds and confirmed that all three had missing locking pins on its side rails. During a concurrent observation and interview, on February 9, 2026, at 11:12 AM, with the MD 1, at Station 1's Shower Room, the MD 1 inspected the two shower beds and confirmed had missing locking pins on its side rails. During a concurrent telephone interview and record review, on February 10, 2026, at 12:15 PM, with the Director of Nursing (DON), the [Name of Manufacturer of Polyvinyl Chloride (PVC- a dominant, versatile material)] PVC Healthcare Equipment Owner's Manual dated January 2008 was reviewed. The manual indicated, .The improper use of this equipment or failure to comply with all directions and warnings may result in death or injury. Before use ensure the equipment has been properly assembled. After any adjustments, repairs or service make sure the equipment has been re-assembled properly before use by an individual. The DON acknowledged the shower beds had been utilized prior to its repair, which constituted a breach of the manual's guidelines. A review of the facility's undated policy and procedure (P&P) titled, Maintenance dated 2015, indicated, a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.2. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings and grounds, are maintained in a safe and operable manner.

Based on observation, interviews and record review the facility failed to maintain infection control practices for four of two hundred and twenty-nine residents when: 1. Resident 40's nebulizer (a machine that turns liquid medicine into a mist to be inhaled) . An attached oxygen tubing (a plastic tube that delivers oxygen or misted medicine to the resident) has not been changed since September 1, 2025, (thirteen days past due). 2. For Resident 48, in an Enhanced Barrier Precaution (EBP - an infection control strategy used to reduce the spread of multi-drug-resistant organisms [MDROs] and prevent transmission to other residents and healthcare workers), Restorative Nursing Assistance (RNA 1) did not remove the gloves while providing care and reached out to her pocket and pulled out a walkie talkie to make a call.3. For Resident 154, the oxygen tubing (tubing connected to oxygen to assist breathing) was not labeled and dated as per facility's policy and procedure (P&P).4. For Resident 216, the nasal canula (tubing inserted into the nostrils used to deliver oxygen) was not changed for thirteen (13) days according to facility policy.These failures had the potential to place Resident 40, 48, 154 and 216 at risk for cross-contamination infection, (germs or bacteria from one dirty surface or item get spread to something clean, which can make people sick), infection (when germs enter the body and cause illness), and avoidable illness (sickness that could have been prevented if proper care or precautions were taken).1.During a review of review of Resident 40's admission Record (contains demographic and medical information), it indicated the resident was admitted to the facility on [DATE], with the diagnoses of shortness of breath (trouble breathing or feeling like it is hard to get enough air), wheezing ( a whistling sound when breathing, cause by narrowed or blacked airways) and muscle weakness (when muscles are not strong, making it harder to move or do daily activities) During a concurrent observation and interview on September 14, 2025, at 10:44 AM, inside Resident's 40's room with Licensed Vocational Nurse/ Unit Manager (LVN UM 2), the LVN UM 2 inspected the nebulizer tubing, and it was dated September 1, 2025. The LVN UM 2 then inspected the nebulizer mask, and it was dated September 8, 2025 . The LVN UM 2 stated that the tubing and the mask are part of the same kit and should reflect the same date. The LVN UM 2 explained that the equipment was required to be changed weekly (every Sunday) for infection control purposes and verified that the conflicting dates were inaccurate. The LVN/UM further stated that staff probably wrote the wrong date on the tubbing. During a review of Resident 40's physicians' orders, dated July 30, 2025, it indicated: Albuterol Sulfate Nebulization Solution (a liquid medicine that helps open the airways by relaxing the muscles in the lungs, used for wheezing and shortness of breath), 1.25 mg (MG- unit measured amount of the medicine)/ML (milliliters) inhaled orally via nebulizer every 4 (four) for shortness of breath related to wheezing). During a review of Resident 40's physicians' orders, dated September 14, 2025, it indicated, Changed out nebulizer mask, tubing, and set up bag weekly every night shift every Sun (Sunday). During a concurrent interview and record review on September 17, 2025, at 10:32 AM with the infection Prevention Nurse (IP), the facility's policy and procedure (P&P) titled Respiratory Equipment Change Schedule, undated, was reviewed. The P&P indicted, Disposable equipment must be labeled with the date. Day: Sunday. Shift: Night shift. Supplies/equipment: Change O2 (oxygen) tubing, O2 adaptors, bubble humidifiers and connecting tubing. The IP stated that this policy was not followed by staff and further stated, the date should match. 2.During a review of Resident 48's clinical records, the admission Record, indicated, Patient 48 was admitted on [DATE], with diagnoses which included type 2 diabetes mellitus (a chronic condition where body does resist or not produce enough insulin). gastro-esophageal reflux disease (GERD – a disease in which stomach acid irritates the food pipe lining), and elevated white blood cell count, unspecified (the body is producing more white blood cells to fight an infection or inflammation). During an observation and interview on September 17, 2025, at 10:25AM, with the RNA 1, in Resident 48's room, there was a sign outside the Resident 48's room and indicated, Enhanced Barrier Precautions. Providers and staff must also:. Wear gloves and gown for the following High-Contact Resident Care Activities. Dressing. Bathing/showering. Transferring. Changing Linen. Providing Hygiene. RNA 1 was inside the room, providing care to Resident 48, reached into her pocket and pulled walkie talkie and made a call, RNA1 then put walkie-talkie back in her pocket. RNA 1 stated Sorry, I will go ahead and wash my hands, and I will wipe the Walkie-Talkie. RNA 1 further stated, she will never do it again. During an interview on September 17, 2025, at 10:40 AM, with LVN unit 3 managers (LVN UM) LVN UM, stated, she expects nursing staff to remove the gloves and use hand hygiene after any resident care. During an interview on September 17, 2025, at 10:58 AM, with DON, The DON stated, her expectation is for staff to follow infection control policies and procedures. During a concurrent interview and record review on September 17, 2025, at 12:02 PM, with the Infection Prevention Nurse (IP), the IP reviewed the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised October 2023. The P&P indicated, . 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene, 1.d after touching a resident. The IP stated her expectation of staff is to follow hand hygiene policy and procedure after providing care to a resident. IP further stated RNA 1 did not follow the hand hygiene policy. 3. During a review of Resident 154's admission Record (contains medical and demographic information), Resident 154 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (lung condition that causes ongoing damage to the airways and lungs, making it difficult to breathe), emphysema (chronic lung condition that causes shortness of breath), and shortness of breath (difficulty breathing). During further observation and interview on September 14, 2025, at 8:46 AM with a Registered Nurse Supervisor (RN 1) in resident 154's room, Resident 154 was lying in bed watching television, she was on four liters of oxygen. The oxygen tubing was unlabeled and undated. RN 1 stated oxygen tubing's are changed every Sunday. RN 1 further stated the oxygen tubing should have been labeled and dated. During a review of resident 154's physicians' orders, dated September 16, 2025, the physicians' orders indicated, Oxygen- change oxygen tubing on Sunday NOC (night) shift of every week and date tubing. every night shift every Sunday for oxygen usage. During a concurrent interview and record review on September 17, 2025, at 10:23 AM, with the Infection Prevention Nurse (IP), the facility's policy and procedure (P&P) titled, Respiratory policies & procedures. Section: Infection control.Policy: Change of Disposable Equipment, revised December 7, 2018, was reviewed. The P&P indicated, Disposable equipment is for single resident use only and will be changed as regularly scheduled and on a PRN basis. Disposable equipment must be labeled with the resident's name and date. The IP stated the P&Ps were not followed and should have been followed for proper resident identification and for infection control purposes. 4.During a review of Resident 216's admission Record, it indicated Resident 216 was admitted to the facility with diagnoses that included, emphysema (chronic lung disease), severe persistent asthma (chronic condition where the lungs airways become inflamed and narrow) , hypertension (high blood pressure), and shortness of breath (difficulty breathing). During an observation on September 14, 2025, at 8:38 AM, in Resident 216's room, Resident 216 was lying in bed, wearing a nasal cannula that was attached to an oxygen concentrator (medical device that pulls in surrounding air, separates the nitrogen to concentrate the oxygen and delivers purified oxygen to a patient). The date on the nasal cannula tubing was September 1, 2025 (13 days have passed). During a concurrent interview and observation with Registered Nurse (RN 1) on September 14, 2025, at 9:47 AM, in Resident 216's room, RN 1 inspected Resident 216's nasal cannula and stated the date of the current nasal canula was September 1, 2025. The RN 1 stated the nasal canula tubing should have been changed every week as ordered, and this placed Resident 216 at increased risk for infection.

Based on observations and interview, the facility failed to ensure the resident rights were respected for three (3) of 3 sampled residents (Resident 19, 53 and 54) when there was not contact information of state agencies posted in a manner that was accessible and understandable to residents and resident representatives on the first floor.This failure had the potential to result in Resident 19, 53 and 54 residents and resident representatives being unable to contact pertinent state agencies when needed to file a complaint.During an interview on September 15, 2025, at 8:28 AM, with Resident 19 his room, Resident 19 stated he was not aware of the location of state agency information, in case he needed to file a complaint. Resident 19 further indicated it would require staff assistance to locate the information since it had not been located on the first floor of the two-floor building.During a review of Resident 19's admission Record (contains demographic and medical information), it indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses that included of end-stage renal disease, (ESRD- kidney failure), difficulty walking, absence of right leg below knee, and absence of left leg above knee.During a review of Resident 19's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing home residents) Section C (Cognitive [involving conscious intellectual activity] Patterns), dated September 1, 2025, the MDS Section C indicated, Resident 1 had a BIMS (Brief Interview for Mental Status- a tool used to screen how a resident is functioning cognitively) score of 15 (a BIMS score of 13-15 suggests resident cognitively intact).During an interview on September 15, 2025, at 8:48 AM, with Resident 53's representative outside of Resident 53 room, Resident 53's representative indicated not being ware of the location of the state agency information.During a review of Resident 53's admission Record, it indicated, Resident 53 was admitted to the facility on [DATE], with diagnoses that included, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control, dysphagia (difficulty swallowing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body).During a review of Resident 53's MDS Section C, dated July 8, 2025, the MDS Section C indicated, Resident 53 had a BIMS score of 2 (a BIMS score of 0-7 suggest severe cognitive impairment).During an interview on September 15, 2025, at 12:48 PM, with Resident 54 outside in the designated smoking area, Resident 54 stated he was not aware of the location of state agency information. Resident 54 was asked if it would be possible to locate the state agency information without staff involvement, Resident 54 responded it would not be.During a review of Resident 54's admission Record, it indicated, Resident 54 was admitted to the facility on [DATE], with diagnoses that included of Guillain-Barre syndrome ( condition where the body's immune system mistakenly attacks its own nerves), type 2 diabetes mellitus, and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).During a review of Resident 54's MDS Section C dated July 16, 2025, the MDS Section C indicated, Resident 54 had a BIMS score of 15 (a BIMS score of 13-15 suggests resident cognitively intact).During an observation on September 15, 2025, at 2:00 PM, the first floor was observed to have the Long - Term Care Ombudsman Program posted information in the dinning room, the information for pertinent state agencies was not located on the first floor.During an interview on September 16, 2025, at 12:20 PM, with the Social Services Director (SSD). SSD indicated pertinent information for state agencies is located on the second floor away from the elevator. The SSD stated the information is not posted on the first floor or within the elevator. The SSD stated there were two hallways to go from the entrance to the elevator and the posting is not seen by residents and resident representative.

Based on observation, interview and record review, the facility failed to ensure that two medication storage rooms were free of expired medical supplies.This failure had the potential to result in the use of expired medical supplies during resident care which may increased risk of infection (when germs like bacteria, virus or fungi enter the body, causing illness) to the vulnerable population.During a concurrent observation and interview on [DATE], at 10:11 AM, with Licensed Vocational Nurse (LVN 1), in the Medication Storage Room in Unit 400, there were six (6) Covid-19 Rapid Test with an expiration date of [DATE], and nine (9) Eswab Collection and transport systems (all-in-one device for collecting samples for bacterial testing) with expiration date of [DATE]. LVN 1stated the supplies were past the expiration date and posed a risk for the residents.During a concurrent observation and interview on [DATE], at 11:58 AM, with the Registered Nurse (RN 4), in the Medication Storage Room in Unit 100. There were 171 safety pen needles (specialized insulin or medication device) with expiration date of [DATE]. The RN 4 stated these supplies were expired and posed an infection risk for the residents.During an interview on [DATE], at 2:30 PM, with Director of Nursing (DON), the DON was not able to provide a policy regarding the expired supplies. The DON stated there was no policy in place regarding medication supply or supply storage. When asked if expired supplies pose a risk to residents, the DON agreed.

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 10) when a Certified Nursing Assistant (CNA 1), stood while assisting Resident 10 with breakfast on September 15, 2025.This failure had the potential to negatively affect Resident 10's self-esteem and self-worth. During a review of Resident 10's admission Record (contains demographic and medical information), the admission Record indicated the Resident 10 was admitted to the facility on [DATE], with the diagnoses that included dysphagia (difficulty swallowing), hypertension (high blood pressure) and other abnormalities of gait and mobility (difficulty walking).During a review of Resident 10's physicians' orders, dated June 8, 2025, the physicians' orders indicated, Red Napkin Program (a program that notifies staff that residents need feeding assistance) with meals **1:1 (one-on-one) assist**.During a further review of Resident 10's diet orders, dated September 8, 2025, the diet orders indicated, Fortified (diet that includes foods that have been enriched with additional nutrients, such as vitamins, minerals, or protein) CCHO [Controlled or Constant Carbohydrate] NAS [No added salt] diet, Regular texture, Regular/Thin consistency, No spicy food, Lactose intolerant (inability to fully digest sugar in dairy products), **Red Napkin Program**. During an observation on September 15, 2025, at 8:15 AM in Resident 10's room, Resident 10 was sleeping in bed with a breakfast tray on his bedside table. Resident 10's meal ticket indicated resident requires feeding assistance. There was no documentation that indicated a preference for staff to stand.During further observation and interview on September 15, 2025, at 8:36 AM, in Resident 10's room, a Certified Nursing Assistant (CNA 1) was observed standing at the bedside while feeding Resident 10 for the duration of breakfast. When asked about the expectation when it comes to feeding residents, CNA 1 stated she was supposed to sit down while feeding to show respect.During a concurrent interview and record review on September 17, 2025, at 4:02 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Policy statement, undated, was reviewed. The P&P indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . Policy interpretation and implementation . Residents requiring full assistance: . 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, . The DON stated staff are expected to sit while feeding residents unless the resident has a preference.

Based on observation, interview, and record review, the facility failed to ensure resident care plans (personalized document that outlines healthcare support needs of an individual) for antibiotics (medicine used to treat infections) was developed for two of three sampled residents (Resident 4 and 15) .This failure had the potential to place two residents at risk for lack of planning for adverse side effects to antibiotics and unmet care needs for Residents 4 and 15.1.During a review of Resident 4's admission Record (contains demographic and medical information), it indicated Resident 4 was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (blood flow to the brain is interrupted leading to damage), candidal sepsis (fungal infection in bloodstream), and shortness of breath.During an observation on September 14, 2025, at 11:44 AM, in Resident 4's room, Resident 4 was lying in bed, asleep. Resident 4 had an intravenous site (location on body where a catheter is inserted into a vein) on her right wrist.During a review of Resident 4 physician's order dated September 13, 2025, it indicated Cephalexin (type of antibiotic) Oral Suspension (liquid to give my mouth) . 250mg (milligram- unit of measurement) /5ml (milliliter- unit of measurement) . Give 10 ml via G-tube (gastrostomy tube- tube inserted into stomach to give food or medications) every 12 hours for UTI (urinary tract infection - urine infection) for 5 Days.During a concurrent interview and record review on September 17, 2025, at 12:39 PM, with the Registered Nurse Unit Manager (RN UM), Resident 4's care plan was reviewed. RN UM stated she could not see a care plan for the Cephalexin antibiotic for UTI. RN UM further stated there should have been a care plan because the care plan guides the plan of care.2. During a review of Resident 15's admission Record, it indicated Resident 15 was admitted to the facility on [DATE], with the diagnoses of hemiplegia and hemiparesis following cerebral infarction (weakness or loss of movement on one side of body), elevated white blood cell count (high number of cells that fight infections), and pneumonia (inflammation of the lungs caused by infection).During an observation on September 14, 2025, at 2:58 PM, in Resident 15's room, Resident 15 was lying in bed, awake and staring at the wall. Resident 15 had an intravenous site on his right wrist.During a review of Resident 15's Order Summary Report, dated September 16, 2025, it indicated, Resident 15 had a physician order for Cefoxitin (antibiotic used to treat infections) sodium intravenous (through a vein) solution. 1 GM (gram- unit of measurement) . use 1 gram intravenously every 8 hours for UTI (urinary tract infection - urine infection) for 7 days.During a concurrent interview and record review on September 17, 2025, at 12:45 PM, with the RN UM, Resident 15's care plan was reviewed. RN UM stated she could not see a care plan for the cefoxitin antibiotic for UTI. RN UM further stated there should have been a care plan for Resident 15's antibiotic.During a concurrent interview and record review on September 17, 2025, at 2:32 PM, with the DON, the facility's undated policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team [IDT - a group of professionals from various disciplines who work together to develop a plan of care], undated, was reviewed. The P&P indicated The interdisciplinary team is responsible for the development of resident care plans. 2. Comprehensive, person-centered care plans are based on resident assessment and developed by an interdisciplinary team (IDT) . 3. The IDT includes but is not limited to: . b. a registered nurse with responsibility for the resident; . The DON stated that the care plan is a living document to guide care. The DON further stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure resident food preferences were provided for one of three sampled residents (Resident 37) reviewed for nutrition, when Resident 37 did not receive 8 ounces (oz- unit of measurement) of whole milk for lunch as indicated on Resident 37's meal ticket (a piece of paper indicating allergies, preferences, and likes/dislikes), on September 14, 2025.This failure had the potential to cause nutritional decline and unmet care needs for Resident 37.During a review of Resident 37's admission Record (contains demographic and medical information), it indicated Resident 37 was admitted to the facility on [DATE], with diagnoses that included hypertensive heart disease with heart failure (high blood pressure damages the heart over time), unspecified dementia (group of conditions that cause a decline in memory, problem-solving and language), and dysphagia (difficulty swallowing).During a review of Resident 37's Diet Order, dated September 5, 2025, it indicated fortified diet (added calories), minced and moist (soft, finely cut and well-moistened food, no larger than 4 millimeters) texture, regular/thin consistency.During a concurrent observation and interview on September 14, 2025, at 12:28 PM, in Resident 37's room, Resident 37 was sitting up in bed, lunch was placed on the bedside table over her bed. Resident 37's lunch contained minced meat, vegetables, rice and mashed potatoes, with 4oz of whole milk and 8oz of water. Resident 37 stated her meal tasted very good. Resident 37's meal ticket indicated . 8 fl (fluid) oz milk whole.During a concurrent observation and interview and record review, on September 14, 2025, at 1:04 PM, with Licensed Vocational Nurse Unit Manager (LVN UM), in Resident 37's room, Resident 37's meal and meal ticket were reviewed. LVN UM stated Resident 37 should have been served 8oz of whole milk instead of 4oz, as specified in the meal ticket. LVN UM further stated her expectation was for staff to verify Resident 37 received the correct amount of milk. During a concurrent interview and record review, on September 17, 2025, at 2:30 PM, with the Director of Nursing (DON), the facility's undated policy and procedure (P&P) titled, Food and Nutrition Services, undated, was reviewed. The P&P indicated Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. 5. The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. The DON stated Resident 37's tray was missed, and P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure the medications were administered without errors, for one of 11 residents (Resident 247) observed for medication pass, when LVN 3 was to administer Gabapentin (an anticonvulsant medication used to treat certain types of seizures and specific kinds of nerve pain) and Valproic acid (a medication used to treat seizure disorders, the manic phase of bipolar disorder, and to prevent migraine headaches), according to the physician's orders This failure had the potential for Resident 247 medications not to be administered in the correct prescribed route by the physician and had the potential to increase Resident 247's risk for harm. During a review of Resident 247's clinical record, the admission Record (contains demographic and medical information), indicated Resident 247 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing) and type 2 diabetes mellitus (a chronic condition where body does resist or not produce enough insulin). During a review of Resident 247 's physician order, dated September 3, 2025, it indicated Resident 247 had an order for Gabapentin oral tablet 800 MG (MG - milligrams, unit of measurement) give one tablet by Percutaneous Endoscopic Gastrostomy (PEG tubes - a feeding tube that allows a person to receive nutrition through the stomach), every eight hours for neuropathy (damage or dysfunction of the peripheral nerves, that causes symptoms such as pain, numbness, tingling, and muscle weakness). During a review of Resident 247 's physician order, dated September 15, 2025, it indicated Resident 247 had an order for Valproic acid oral solution 250 mg (milligrams) /5 mL (mL - milliliter unit of measurement) give 20 mL via PEG-tube every eight hours for seizure disorder. During a medication administration observation on September 16, 2025, at 6:21 AM, with Licensed Vocational Nurse (LVN 3), in Resident 247's room. LVN 3 prepared Resident 247's Gabapentin tablet 800 mg and Valproic acid oral solution and proceeded to administered to Resident 247 by mouth. The surveyor intervened and stopped the oral administration. During an interview on September 16, 2025, at 6:42 AM with LVN 3, LVN 3 stated, Resident 247 preferred to have his medication by mouth. LVN 3 further stated, she had administered Resident 247's medications by mouth for the past three days. The LVN 3 further stated, she thought they have changed the order to oral route. The LVN 3 was not able to provide documented evidence of Resident 247's physician orders for to administer Gabapentin and Valproic acid via oral administration. During a concurrent interview and record review, on September 16, 2025, at 8:45 AM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Administering Medication, revised April 2019. The P&P indicated, . 6. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.The DON stated, medication administered by not following the order route, it is considered an error. The DON further stated, LVN 3 should have followed the order.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. There were two medication errors observed out of a total of 27 opportunities for errors, affecting one of 11 observed residents (Residents 247), resulting in an overall medication error rate of 7.41 percent when Resident 247 had an order to receive all medication through Percutaneous Endoscopic Gastrostomy (PEG - a feeding tube that allows a person to receive nutrition through the stomach) and it was to be administered by mouth by a Licensed Vocational Nurse (LVN 3). This failure had the potential for Resident 247 medications not to be administered in the correct prescribed route by the physician and had the potential to increase the Resident 247's risk of harm.During a review of Resident 247's clinical record, the admission Record (contains demographic and medical information), indicated Resident 247 was admitted to the facility on [DATE], with diagnoses which included dysphagia, unspecified difficulty in swallowing) and type 2 diabetes mellitus (a chronic condition where body does resist or not produce enough insulin).During a review of Resident 247 's physician order, dated September 3, 2025, it indicated Resident 247 had an order for gabapentin ( is an anticonvulsant medication used to treat certain types of seizures and specific kinds of nerve pain) oral tablet 800 MG (MG - milligrams, unit of measurement) give one tablet by Percutaneous Endoscopic Gastrostomy (PEG - a feeding tube that allows a person to receive nutrition through the stomach), every eight hours for neuropathy (damage or dysfunction of the nerves, especially the peripheral nerves, that causes symptoms such as pain, numbness, tingling, and muscle weakness). During a review of Resident 247 's physician order, dated September 15, 2025, it indicated Resident 247 had an order for Valproic acid (a medication to treat seizures) oral solution 250 mg/5 mL (mL- milliliter, unit of measurement) give 20 mL via PEG-tube every eight hours for seizures disorder.During a medication administration observation on September 16, 2025, at 6:21 AM, with Licensed Vocational Nurse (LVN 3), in Resident 247's room. LVN 3 prepared Resident 247's Gabapentin tablet 800 mg and Valproic acid oral solution 250 mg/5 mL and proceeded to administered to Resident 247 by mouth. The surveyor intervened and stopped the oral administration. During an interview on September 16, 2025, at 6:42 AM with LVN 3, LVN 3 stated, Resident 247 preferred to have his medication by mouth. LVN 3 further stated, she had administered Resident 247's medications by mouth for the past three days. The LVN 3 further stated, she thought they have changed the order to oral route. The LVN 3 could not provide documented evidence of Resident 247's physician orders for to administer Gabapentin and Valproic acid via oral administration. During a concurrent interview and record review, on September 16, 2025, at 8:45 AM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Administering Medication, revised April 2019. The P&P indicated, . 6. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The DON stated that medication administered by not following the order route, it is considered an error. The DON further stated, LVN 3 should have followed the order.

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of 10 residents (Resident 54) reviewed for smoking, when the rain gutter (a long, hollow channel, often made of metal or plastic, attached to the edge of a roof to collect rainwater and direct it away from the buildings foundation) above the door of the smoking area was not maintained and caused a constant leak to the walkway.This failure had the potential to expose Resident 54 to unsafe walkway conditions when entering the smoking area, due to structural damages and increased the risk for falls.During a review of Resident 54's admission Record (contains demographic and medical information), it indicated, Resident 54 was initially admitted to the facility on [DATE], with the medical diagnosis of Guillain-Barre syndrome (autoimmune condition where the body's immune system mistakenly attacks its own peripheral nerves), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).During a concurrent observation and interview on September 15, 2025, at 12:48 PM in the smoking area with Resident 54, Resident 54 stated that there was a constant drip of water located directly next to the door of the smoking area. There were multiple saturated towels and a yellow caution sign was noted next to the towels.During a concurrent observation and interview on September 16, 2025, at 9:03 AM, in the smoking area with the Director of Maintenance (DOM), the DOM stated the there had been no work order issued for the drip. DOM stated the drip is from a gutter connected to the station three bridge. DOM further indicated there was an unknown black substance on the gutter. DOM indicated the drip is in the walk way of residents. The DOM stated there is no maintenance policy in place.

Based on interview and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident1) when Resident 1, who requires a two-person assist, fell out of bed while one Certified Nursing Assistant (CNA) was repositioning the resident and providing a brief change.This failure resulted in Resident 1 sustaining intertrochanteric (thigh bone) fracture of left hip.Findings:During review of Residents 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes (body has trouble controlling blood sugar), hypertension (high blood pressure), dependance on respirator (difficult to breathe on own, machine dependent). During a review of Resident 1's History and Physical (H&P), dated January 27, 2025, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Seta (MDS - clinical assessment tool used in nursing homes that serves as a comprehensive summary of a resident's functional capabilities, health conditions, and care needs.) Section GG Functional Abilities, dated June 7, 2025, the MDS Section GG Functional Abilities indicated, .Toileting hygiene, Shower/bath self, Roll Left and Right=Dependent= Helper does All of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.During a review of Resident 1's Situation Background Assessment Recommendation (SBAR) notes dated July 29, 2025, at 5:22 AM, the SBAR indicated During rounds resident noted to slide from bed and struck head on oxygen concentrator and was lowered on to the ground by staff. Noted with open area to top of Left eye with scant bleeding. Noted with bruising to cheekbone and cheek. Transfer to acute to rule out fracture.During a review of Resident 1's X-ray (generate images of tissue and structure of body) report, dated July 29, 2025, the X-ray of the left hip shows displaced intertrochanteric fracture. The X-ray report also indicated PLAN: At this time, family is choosing to pursue nonsurgical management for left hip fracture, and they are listing his high propensity (natural tendency) to infections as a deterrent to surgery at this time.During a review of Resident 1's care plan dated June 25, 2024, the care plan indicated Resident 1 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Limited Mobility, Limited ROM. INTERVENTIONS: BATHING/SHOWERING: The resident is totally dependent on (2) staff to provide(bath/shower).and as necessary. BED MOBILITY: The resident is substantial assistance on (2) staff for repositioning and turning in bed (Q2hrs) and as necessary.During an interview on August 27, 2025, at 1:20 PM, with CNA 1, CNA 1 stated, It's always a two (2) person assist to change the residents here in subacute. The CNAs help each other. If it is busy I have to wait, I cannot take the risk of doing the care alone. The nurse also helps if needed.During an interview on August 27, 2025, at 1:38 PM, with CNA 2, CNA 2 stated, In subacute, we always have 2 persons assist with ADLs, we have a buddy with another CNA, but we can always ask the nurses or Respiratory Therapist.During an interview on September 2, 2025, at 10:08 AM, with CNA 3, CNA 3 stated, It was about 1:30 AM. I wanted to see if Resident 1 was wet. He was, so I placed him on his side, he rolled and I tried to catch him, I ran to the other side, he slid down to the floor.I called for the nurses and we got him back to bed. He was not able to help in the repositioning, he is contracted (a shortening or tightening of muscles, tendons, or other tissues). He is a two-person assist after the fall. Now everyone in subacute is two-person assist. I would always provide care for him on my own. I was made aware he had a fracture.During an interview on August 27, 2025, at 2:10 PM, with the Director of Nursing (DON), the DON stated Resident 1 had a fall on July 29, 2025, with femur (thigh bone) fracture. The DON stated that upon their investigation, CNA 3 did not wait for help. The LVN, stated she was in the middle of medication pass, and said to give a couple minutes. CNA 3 was doing patient care, there was no siderails and the residents fell. The DON further stated, Resident 1 requires a two-person assist, CNA 3 should have waited for help as they have a ‘buddy system.During a review of the facility's policy and procedure (P&P) titled, Fall and Fall Risk, Managing, undated, the P&P indicated, Based on previous evaluation and current data, the staff will identify interventions related to the residents specific risk and causes to try to prevent the resident from falling and to try to minimize complications from failing.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents when one of four residents (Resident 2)'s left knee noted with pain and fracture of the proximal left tibia (break in the long bone of the left lower leg). This failure resulted in Resident 2 a clinically compromised resident being sent to the hospital for evaluation and treatment. Findings: During an observation on March 19, 2025, at 12:35 PM, Resident 2 was lying in bed awake and did not respond verbally. During an interview on March 19, 2025, at 12:50 PM, with Certified Nursing Assistant (CNA 2), the CNA 2 stated, He (Resident 2) does not talk. He is total dependent with ADLs (activity of daily living). I usually give him bath, clean and change him, and reposition him every two hours. During an interview on March 19, 2025, at 1:00 PM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated, [Resident 2's name] does not talk. I don't know what happened, but I know he was transferred to the hospital due to pain of his legs and he came back with a diagnosis of fracture. During a review of Resident 2' Admission Record (general demographics) on March 19, 2025, the document indicated Resident 2 was originally admitted to the facility on [DATE], with diagnoses that included quadriplegia (paralysis that affects all four limbs) and contracture other specified joint (a permanent tightening of muscle and tissues leading to a loss of movement). During an interview on March 19, 2025, at 1:50 PM, with the Director of Nursing, she stated, nursing staff used facial grimacing to assess [Resident's name]'s pain since the resident could not speak. A review of Resident 2's care plan dated June 24, 2024, indicated, Focus . has an ADL self-care performance deficit r/t (related to) activity intolerance, confusion, limited mobility. Goal: The resident will maintain current function . Intervention: The resident is totally dependent on (2) staff for repositioning and turning in bed (every 2 hours) and as necessary . A review of Resident 2's Restorative Nursing Assistant Treatment dated January 1, 2025 - January 31, 2025, indicated, RNA (restorative nursing assistant) program passive range of motion to bilateral lower extremities every day shift 3 time a week as tolerated. A review of Resident 2's SNF/NF to Hospital Transfer Form dated January 20, 2025, indicated reason for transfer, S/S of pain in bilateral lower extremity (signs of pain of both lower legs). A review of Resident 2's Clinical Record indicated, EXAMINATION: Left tibia and fibula, 2 views. Indication: Left lower leg pain. Impression: Moderate diffuse osteopenia. Finding suspicious for a fracture of the proximal tibia just below the tibial . Suggestion of a mildly impacted fibular neck fracture is present . A review of facility's undated Policy and Procedure (P&P), titled, Safety and Supervision of Residents, the P&P indicated, Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .

Based on interview and record review the facility failed to prevent a pressure ulcer (damage to area of the skin due to pressure) from developing for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk for potential infection and pain. When the facility failed to prevent the development of a stage 3 pressure ulcer on right trochanter (hip). Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: esophageal cancer (cancer of the tube from throat to stomach), tracheostomy (tube inserted to help oxygen reach lungs), (diabetes type II (body does not produce enough insulin, or resist insulin), hypertension (high blood pressure). During a review concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nurses (ADON and Treatment Nurse (TXT Nurse), reviewed as follows: 1. Skin Pressure Injury Evaluation- Dated June 06, 2024, at 1307: Right Knee Stage 4, measuring 0.5x0.8, depth 0.2. (on admission). 2. Skin non pressure injury evaluation dated June 15, 2024: Right trochanter hip blanchable redness, length 5x4, depth none .Doctor notified, encourage patient to reposition as tolerated, pain management . 3. Skin Pressure Injury Evaluation dated June 19, 2024, at 1430: Right trochanter stage 3, measuring 1.5x1.5, 0.1 depth .Reported by staff of resident with skin break down, noted the following. Right trochanter stage 3 pressure injury, tissue quality 100% granulation, scant serosanguinous drainage noted, wound edges well defined peri wound clean and intact. Resident noted to be noncompliant and is also noted to be favoring right side . 4. Carplan: The resident has pressure ulcer or potential for pressure ulcer development related to, unavoidable factors .Date initiated August 27, 2024. INTERVENTIONS: If the refuses treatment .Interdisciplinary Team (IDT) meeting and family to determine why and try alternative methods to gain compliance. Document alternative methods. (No Careplan regarding resident refusal for repositioning; facility acquired wound started June 19, 2024, no careplan documentation for June 2024, NO IDT meeting in June 2024 regaining wound and repositing refusals). During concurrent interview and record review on August 27, 2024, with the Treatment Nurse (TXT Nurse 1) of medical records, TXT nurse states, the pressure injury developed June 19, 2024, the right trochanter stage 3. The doctor wrote unavoidable factors. We reposition with pillows to keep him from going to right side. He was on air loss mattress. He had foley cath. When asked, should this resident have developed this Pressure injury in facility? States, No, he should have not, we were always repositing him, he was always favoring that side, we would let the CNAs and charge nurses know about repositioning this resident. During concurrent interview and record review on August 27, 2024, with the (ADON) of medical records, ADON nurse states, The family was at bedside, they knew about the wounds. Resident 1 was sent out to hospital a few times; he did come back with wounds. Based on the records he was first sent out June 23, 2024. The wound did develop in facility June 19, 2024, before he was sent out to hospital. (acknowledgement right trochanter developed in facility). During a review of the facility's policy and procedure titled, Wound Care dated January 01, 2024, the policy and procedure indicated, The purpose of this procedure is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. During a review of the facility's policy and procedure titled, Prevention of Pressure Ulcers/Injuries dated January 01, 2024, the policy and procedure indicated, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.

Based on observation, interview and record review the facility failed to protect the resident ' s right to be free from verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of three residents (Resident 1) when staff witnessed a Respiratory Therapist 1 (RT 1, a professional person who is responsible in taking care of patients who has respiratory problems) clapping loudly in Resident 1 ' s face while using foul language. This failure resulted in resident 1 ' s rights being violated and had the potential for Resident 1 to experience psychosocial harm. Findings: During a review of Resident 1 ' s Admission Record (contains demographic information), the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertensive heart disease (number of complications of high blood pressure affecting the heart), chronic kidney disease(disease that cause kidney failure), and chronic respiratory failure (a long term condition that makes difficult to breathe). During a review of a facility provided document titled, Investigation Statements, dated August 3, 2024, by Licensed Vocational Nurse 1 (LVN 1), the Investigation Statements indicated, Resident 1 Vent alarm was going off. RT 2 went in to assess. RT 2 asked for more 02 (oxygen). Needed hyper oxygenated (administration of a higher than usual concentration of oxygen). Resident1 was de-sating (when blood oxygen level drop below a normal range below 90 percent). Grabbed ambu bag (device used to provide respiratory support). CNA (certified nursing assistant) was instructed to get RT. Many responded. All the RT's responded. Resident 1 was being bagged, RT 1 was standing by the head of the bed on the right at the head of the bed. Resident 1 was mouthing things, RT 1 I'll beat your ass, I'll fuck you up RT 1 started clapping loudly in patient face. I told him to STOP! RT1 walked out of the room. We stayed with thee resident to make sure if he would stay stable. Resident 1 was stable. LVN 1 went to find the RN (Registered Nurse). Asked RN if she heard the ruckus. LVN 1 was stopped by RT1 in ' the hallway. RT 1 tried to explain away his behavior. LVN explained that it doesn't matter and that his behavior is abuse. LVN 1 told him this has to be reported. RT1 acted like a small child, put his head down and said he was sorry. RT 1 walked off was very angry . During a subsequent review of a facility provided document titled, Investigation Statements, dated August 3, 2024, by RT 2, the Investigation Statements indicated, .RT 1 went so calmy out of the Resident 1 room and then I saw him in RT charting room and getting ready for last rounds. RT 1 said I'm done with this shit Fuck this shit (he said it calmly), walked towards the computer. Kicked the chair into the desktop, lifted his fist and punched the desktop computer. Picked up the computer and broke it over his knee and threw it at the wall. He said, I'm going to lose my job, threw his Tupperware bowl to the window. Walked out, kicked the wall and made a hole. He was punching walls as he walked out. Tore the kiosk off the wall and threw it on the floor. Headed out threw the station 3 door. They heard a car burning out and drove off . During an interview on August 6, 2024 at 12:20 PM, with the Assistant Director of Nursing (ADON), the ADON stated, On August 3, 2024, around 3:30 AM in room [ROOM NUMBER] B, the RT 1 was verbally abusive toward [name of Resident 1] when [Resident 1] was in distress. The ADON further stated, LVN 1 told RT 1 to step out of room [ROOM NUMBER] B. When RT 1 left the room, was very upset, broke the laptop and made a hole on the wall, by kicking it. During a concurrent interview and record review on August 6, 2024, at 2:20 PM, with the ADON, the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated January 1, 2024, was reviewed. The P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This include but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. The resident abuse, neglect, exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; . The ADON acknowledged and stated the policy was not followed. During a telephone interview on August 8, 2024, at 11:57 AM, with LVN 1, LVN 1 stated, I witnessed the incident when RT1 was verbally abusive towards Resident 1. Resident 1 was bagged; RT 1 was standing by the head of the bed on the right, at the head of the bed. Resident 1 was mouthing things, RT 1 said I'll beat your ass, I'll fuck you up RT 1 started clapping loudly in Resident 1 ' s face. I told him to STOP! RT 1 walked out of the room. We stayed with the resident to make sure if he would stay stable. Patient was stable. During a phone interview on August 8, 2024, at 12:34 PM, with RT2, RT 2 stated, I was shocked by seeing RT 1 verbally abusive and was loud towards Resident 1 when resident 1 was in distress. Even after LVN 1 told RT 1 to stop the aggressive behavior, RT 1 continued. RT 1 went so calmy out of the Resident 1 room and then I saw him in RT charting room and getting ready for last rounds. RT 1 said I'm done with this shit. Fuck this shit. RT 1 walked towards the computer, kicked the chair into the desktop, lifted his fist and punched the desktop computer. Picked up the computer and broke it over his knee and threw it at the wall. He said, I'm gonna lose my job, threw his Tupperware bowl to the window. Walked out, kicked the wall, and made a hole. He was punching walls as he walked out. Tore the kiosk off the wall and threw it on the floor. Headed out threw the station 3 door. We heard a car burning out and drove off.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents when one of seven residents (Resident 1) noted to have swelling of the left thigh and knee. This failure contributed to Resident 1 sustaining an acute distal femur shaft fracture (sudden break in the long part of the thigh bone). Findings: During an observation on May 20, 2024, at 4:15 PM, Resident 1 was lying in bed awake and did not respond verbally. During a review of Resident 4 ' Admission Record (general demographics) on May 20, 2024, the document indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that include traumatic hemorrhage of cerebrum (a condition brain injury), respiratory failure (a condition that makes it difficult to breathe on your own, asthma, seizures (a condition that causes sudden shaking or stiffness), hypertensive (a condition of high blood pressure, and gastrostomy status (a tube inserted through the wall of the abdomen directly into the stomach). A review of Resident 1 ' s care plan dated September 9, 2023, indicated, . has an alteration in musculoskeletal status r/t (related to): bilateral knee contracture. Goal: The resident will remain free of injuries or complications related to contractures . A review of Progress Notes dated, May 15, 2024, at 05:25, indicated, .Outcomes of Physical Assessment . During positioning this morning CN (Charge Nurse) and CNA (Certified Nursing Assistant) noted left thigh/knee appeared to move abnormal and felt odd around kneecap/joint with popping felt. Possible slight swelling to thigh area, hard to determine as resident is contracted at knees to BLE (bilateral lower extremities) . A review of Resident 1 ' s Radiology Result Report, dated May 20, 2024, indicated, . Knee 1 or 2 Views Interpretation: Reason for Study: .Localized swelling, mass and lump, left lower limb . Findings: No comparison study is available. Acute distal femur shaft fracture with displacement seen . Conclusion: Acute distal femur shaft fracture . During an interview on June 5, 2024, at 2:10 PM, with the Registered Nurse Supervisor (RNS), the RNS stated, Staff are expected to check on residents to provide assistance and supervision every two hours and as needed. During an interview on June 5, 2024, at 4:00 PM, with the Administrator, the Administrator indicated staff was not sure of what happened to the Resident 1. He stated, There is no incidents or accidents reported by staff. During a review of the facility ' s P&P, titled, Safety and Supervision of Residents, dated, July 20, 2017, the P&P indicated, Policy Statement Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .

Based on interview, and record review, the facility failed to have the resident, or the responsible party sign the Clothing and Possession ' s sheet (record of personal items) upon admission and discharge for one of three residents (Resident 3). This failure had the potential for Resident 3 ' s personal items to go unaccounted, misplaced or taken while in the facility. Findings: An abbreviated survey was conducted on September 21, 2022, at 1:30 PM to investigate a complaint related to Quality of Care in which the complainant stated. I brought clothes for Resident 3 and they lost all of them. During a review of Resident 3's clinical record, the face sheet (contains demographic and medical information), indicated, Resident 3 was admitted on [DATE], with diagnoses which included: fracture of the right tibia (lower leg), diabetes (high blood sugar) and atrial fibrillation (irregular and often very rapid heart rhythm). This resident was discharged on [DATE]. During a review of the clinical record for Resident 3, the Resident ' s Clothing and Possession ' s sheet indicated: 1. The Admission section indicated Resident 3 was admitted with glasses. This section was not signed by the Resident/Responsible party or by the facility representative and the document was not dated. 2. The Discharge section indicated Resident 3 was not discharge with their belongings. This section was not completed by the facility. During a concurrent interview and record review of Resident 3 ' s Clothing and Possession ' s Sheet with Licensed Vocational Nurse (LVN 1), on January 11, 2023, at 11:36 AM, LVN 1 stated, The inventory sheet should have been filled out. We sign and date it to keep a record of what he or she has in case it gets lost or stolen. During a review of Resident 3 ' s Clothing and Possession ' s Sheet with the Director of Nursing (DON) on January 11, 2023, at 12:11 PM, the DON stated We should have had him sign it. They should have signed it. A review of the facility ' s policy and procedure (P&P) titled Release of a Resident ' s Personal Belongings undated, the P&P indicated, Our facility protects the personal belongings of a resident who has been transferred or discharged from our facility. 1. The personal belongings of a resident transferred or discharged from our facility will be released to the resident or authorized resident representative. 2. Personal belongings of a resident who is temporarily transferred or discharged from the facility will be inventoried and stored by the facility until the resident has returned or such items have been picked up by the resident ' s representative. 3. Individuals receiving the resident ' s personal belongings will be required to sign a release for such items.

Based on interview and record review, the facility failed to notify the Responsible Person (RP) for one of three sampled residents (Resident 3) of a change in medical condition when Resident 3 was found lethargic and transferred to the General Acute Care Hospital. This failure resulted in Resident 3's RP being uninformed and unaware of Resident 3's change of condition and transfer to the hospital. Findings: An abbreviated survey was conducted on September 21, 2022, at 1:30 PM, to investigate a complaint related to Quality of Care. During a review of Resident 3's clinical record, the face sheet (contains demographic and medical information), indicated Resident 3 was admitted on [DATE], with diagnoses which included: fracture of the right tibia (broken bone of lower leg), diabetes (high blood sugar) and atrial fibrillation (irregular and often very rapid heart rhythm). During a review of the Nurses' Progress Notes for Resident 3, dated June 24, 2021, at 6:24 AM, the nurses progress note indicated Resident 3 was found around 5:37 AM by CNA to be very lethargic (very slow to respond) with agonal (struggle) breathing and notified the Registered Nurse (RN). Upon entering the room, RN found Resident 3 unresponsive to chest rub, pupils fixed, unable to obtain pulse and blood pressure .Patient taken to General Acute Care facility by Emergency response paramedics at 6:25 AM. The Nurses Note did not indicate the Responsible Person was informed of the change of condition or the transfer to the hospital. During a concurrent interview and record review of Resident 3 ' s Nurses note with Registered Nurse 1 (RN 1), on September 28, 2022, at 5:54 AM, RN 1 stated, the Responsible Person was not called for this change of condition. The facility could not provide documentation that the RP was called for this change of condition or transfer to the General Acute Care Hospital. During an interview with Director of Nursing (DON) on January 11, 2023, at 12:11 PM, DON stated, The RP was not notified. The facility could not provide documentation that the responsible person was notified of the change of condition or the transfer to the hospital. A review of the facility ' s policy and procedure (P&P) titled, Change of Condition undated, the (P&P) indicated, Change in a Resident ' s Condition or Status. Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status(e.g., changes in level of care .

Based on interview, and record review, the facility failed to ensure the nursing staff provided basic life support in a timely manner for one of three residents (Resident 3) when the blood sugar was checked, insulin (medicine to decrease the sugar in the blood) was given, and emergency medical services (EMS) were called prior to receiving Cardiopulmonary resuscitation (CPR-an emergency lifesaving procedure to support and maintain when breathing or heartbeat has stopped by rescue breathing and chest compressions). This failure resulted in Resident 3 not receiving CPR in a timely manner and could have jeopardized the health and safety of Resident 3. Findings: An abbreviated survey was conducted on [DATE], at 1:30 PM, to investigate a complaint related to Quality of Care. During a review of Resident 3's clinical record, the face sheet (contains demographic and medical information), indicated, Resident 3 was admitted on [DATE], with diagnoses which included: fracture of the right tibia (broken bone of lower leg), diabetes (high blood sugar) and atrial fibrillation (irregular and often very rapid heart rhythm). A review of the Physician Orders for Life-Sustaining Treatment (POLST-indicates the resident's wishes and physician orders for life sustaining medical treatment), dated [DATE], the POLST indicated, Resident 3 was a full code (meaning to attempt Cardiopulmonary Resuscitation (CPR) by providing chest compression and rescue breathing if no pulse and not breathing). The POLST also indicated the resident desired full medical treatment including long term artificial nutrition (tube feeding). During a review of the Nurses' Progress Notes for Resident 3, dated [DATE], at 6:24 AM, the progress note indicated, Resident 3 was found around 5:37 AM by CNA (certified nursing assistant) to be very lethargic (very slow to respond) with agonal (struggle) breathing and notified the RN. Upon entering the room, RN found Resident 3 unresponsive to chest rub, pupils fixed, unable to obtain pulse and blood pressure. Resident 3 was cold to touch. At this time, blood sugar was 482 mg/dl (unit of measure) and 10 units (unit of measure) of insulin was given. Medical Doctor notified. Emergency medical response called at 0540. Respiratory Therapy (RT- specializes in care for the lungs) called to room at 5:45 AM. Code Blue (Cardiac or respiratory arrest or medical emergency) called at 5:45 AM and patient started being bagged (adding air into the lungs during the inspiration phase by using a resuscitation bag.) by Respiratory Therapist. Emergency medical response arrived at 5:50 AM. IO (Intraosseous vascular access placement of a specialized hollow bore needle through the bone for infusion of medical therapy) access and first pulse check done. Asystole (there is no heartbeat) found, done at 6:00 AM. Second and third epi (Epinephrine, to increase blood flow)delivered and Emergency response paramedic able to obtain pulse of 49 bpm (beats per minute) and blood pressure ,d+[DATE] mmHg (unit of measure). Patient taken to General Acute Care facility by Emergency response paramedics at 6:25 AM. This nurses note was documented by Registered Nurse 1. There was no documented evidence of a chest compression was initiated for Resident 3. During a concurrent interview and record review of Resident 3 ' s Nurses note with Registered Nurse 1 (RN 1), on [DATE], at 5:54 AM, RN 1 stated, the Cna told me Resident 3 was lethargic with agonal breathing. I came into the room. She was unresponsive to a chest rub. Her pupils were fixed. Unable to obtain a pulse and blood pressure. The Patient was cold to touch. The Licensed Vocational Nurse checked her blood sugar, and it was 485 mg/dl. She was given 10 units of insulin. Emergency response was called at 5:40 AM and Respiratory therapist (RT) was called at 5:45 AM. A Code blue was called around 5:45 AM. RT came to the room and started bagging at 5:50 AM. Emergency response paramedics arrived at 5:50 AM. Paramedics provided IO access. They drilled into the bone to get an IV (intravenous device for delivering medicines) and first pulse check was asystole and that was done at 6:00 AM. Second and third dose of epinephrinedelivered. Emergency response paramedics were able to obtain a pulse of 49 bpm and blood pressure of ,d+[DATE] mmHg. It does not say anything about chest compressions. The code blue should have been called immediately after she was found unresponsive. During a concurrent interview and record review of Resident 3 ' s Nurses notes with RN 2, on [DATE], at 9:32 AM, RN 2 stated, when a resident is unresponsive, we start CPR and call the medical doctor. RN 2 then stated, as soon as you see them unresponsive, you call a code blue, start CPR, get crash cart, put the board (hard board used for chest compressions) under them. You call 911 at the same time. The nurse should have started CPR when the patient was unresponsive. The MD should have been called simultaneously as everyone is doing CPR. The MD should have been called after he called the code blue. During an interview and concurrent record review of Resident 3 ' s nurses note written on [DATE], with the Director of Nursing (DON), on [DATE], at 12:11 PM, DON stated, Code blue should have been called within a minute or two of 5:37 AM. The DON confirmed there was a delay in treatment. A review of the facility ' s policy and procedure (P&P), titled Advanced Directives undated, the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy h. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form - a form designed to improve care by creating a portable medical order form that records patients ' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency .

Based on observation, interview and record review, the facility failed to initiate a care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) for a resident at risk for elopement (resident with cognitive challenges who wanders or runs away) for one of three residents (Resident 3). This failure had the potential to result in deficient care and treatment which could have resulted in an elopement. Findings: An abbreviated survey was conducted on September 21, 2022, at 1:30 PM, to investigate a complaint related to Quality of Care. During a review of Resident 3's clinical record, the face sheet (contains demographic and medical information), indicated, Resident 3 was admitted on [DATE], with diagnoses which included: fracture of the right tibia (broken bone of lower leg), diabetes (high blood sugar) and atrial fibrillation (irregular and often very rapid heart rhythm). During a review of the clinical record for Resident 3, the nurses note dated June 4, 2021, at 9:05 AM, indicated, CNA (Certified nursing assistant) informed the charge nurse that resident 3 was in the parking lot. Unable to redirect resident. Psychiatric Physician and Primary Physician notified. Resident moved to secure unit for safety precautions. During a review of the clinical record for Resident 3, the Wandering Elopement Risk assessment dated [DATE], indicated, Resident 3 was a moderate (medium) risk for elopement. During a review of the clinical record for Resident 3, the care plan for Elopement dated June 22, 2021, indicated, The resident is an elopement risk/wanderer. The care plan did not list goals or interventions that would be in place to stop or deter Resident 3 from eloping/leaving the facility. During a concurrent interview and record review of Resident 3 ' s Care plan with Licensed Vocational Nurse 1 (LVN 1), on January 11, 2023, at 11:36 AM, LVN 1 stated, The care plan for elopement is missing a goal and the interventions which tell us what we can do to prevent the elopement from happening again. It is incomplete. During an interview and concurrent record review of Resident 3 ' s Care plan for elopement with the Director of Nursing (DON) on January 11, 2023, at 12:11 PM, DON stated All they have is the focus but no goal or intervention. They should have an intervention and goal to drive the plan of care. So, we know what ' s the goal and how we will obtain the goal. A review of the facility ' s policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered undated, the P&P indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident ' s highest physical, mental, and psychosocial well-being .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident ' s conditions change .

Based on observations, interviews, and record reviews, the facility failed to ensure resident ' s rights were honored for Justice Involved Residents (residents in custody) when six of six residents (Residents 1,2,3,4, 5 and 6) were denied the same rights and privileges to move freely about the facility and participate in activities of their choosing due to the criminal justice system making their decisions, instead of the facility following federal regulations related to resident rights This failure resulted in Residents 1, 2, 3, 4, 5 and 6 to be shackled by one ankle to the bed frame except for therapy, toileting or showering and denied the right to move around their room, participate in activities which had the potential for severe psychosocial (having to do with the mental, emotional, social, and spiritual effects) harm. All decisions were made by the correction officers (COs) present with each justice involved resident and superseded the federal regulations to be followed by the facility. Findings: During review of Residents 1 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 1 was initially admitted to the facility on [DATE], with diagnosis (DX) which included: urinary tract infection (infection of the bladder), diabetes (high blood sugar), [CONDITION(S)] ([CONDITION(S)] does not produce enough hormones), [CONDITION(S)] (high levels of fat in the blood), [CONDITION(S)] (a thought disorder characterized by hallucinations and delusions), Gastro-[CONDITION(S)] reflux disease (gastric fluid backflow into the esophagus) and high blood pressure. During a concurrent observation and interview of Resident 1 on September 22, 2022, at 12:10 PM, Resident 1 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the right ankle. Resident 1 stated, The nurses don ' t do anything to me. The correctional officer checks my shackles every hour to two hours. During an observation on September 23, 2022, at 5:18 PM, Resident 1 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] attached to the right ankle. During a review of the clinical records for Resident 1, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion (being apart from human beings or of being cut off from one's usual associates) strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). During review of the care plans for Resident 1 on September 22, 2022, at 3:02 PM, with the Medical Records Director, the Medical Records Director stated the facility did not have a care plan related to Resident 1 ' s [NAME]/restraint. During a review of the clinical record for Resident 1, the Wandering/Elopement Risk assessment dated [DATE], at 7:05 PM, indicated the Resident was a low risk for elopement/wandering. During a review of the clinical record for Resident 1, the Restraint Physical assessment dated [DATE], at 1:24 PM, indicated Reasons for use of Physical Restraint . C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Residents 2 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 2 was initially admitted to the facility on [DATE], with diagnosis (DX) which included: [CONDITION(S)] (damaged area of the brain), pneumonia (infection of the lungs), chronic obstructive pulmonary disease ([MEDICATION(S)] of the airway and difficulty breathing), obesity (overweight), [CONDITION(S)] (high levels of fat in the blood), [CONDITION(S)] (mood disorder characterized by hallucinations and delusions), Gastro-[CONDITION(S)] reflux disease (gastric fluid backflow into the esophagus), high blood pressure, pressure induced tissue damage of the left ankle, and [CONDITION(S)] (thin and weakened bones). During a concurrent observation and interview of Resident 2 on September 22, 2022, at 12:10 PM, Resident 2 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the left ankle. Resident 2 stated he does not know how often the nurses come in to check his shackles. During an interview with a Correctional Officer (CO 1) on September 22, 2022, at 12:10 PM, CO 1 stated We switch the shackles every two hours. We switch the shackles between the two legs. The only time we take the shackles off is when staff are showering the Justice involved residents (JIR). When the CO was asked why the JIR ' s are shackled, CO 1 stated, They are (name of state hospital) patients. They have committed crimes and not mentally capable of going to court. CO 1 stated further, The Activity department will come in since they (JIR ' s) are not allowed to go play bingo. CO 1 then stated, Typically, with the shackles on they can walk a steps length away from the bed. The chain is about 3 feet. I put the restraint/[NAME] on to keep them from running. It ' s ([NAME]) just long enough for them to step or stand by the bed. CO 1 stated, the three activities that the JIR does when outside of their room are: walk with physical therapy, therapy (occupational), and showers. During a review of the clinical records for Resident 2, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 [name of State Hospital] contract). During a review of the clinical records for Resident 2, the Care plans indicated, 1. Focus: Resident 2 is unable to participate in group or out of room recreational or leisure activities related to (name of state hospital) and Correction Officer guidelines. Undated. 2. Focus: Resident 2 is at risk for decline in psychosocial wellbeing related to need for restraint and bedside corrections officer to be in place. Resident 2 is a (name of state hospital) resident and restraint/officer must be in place in this setting per (name of state hospital) and Corrections guidelines for safety of self and others. Undated. 3. Focus: Resident 2 requires shackles to extremity due to under custody of California department of Corrections and (name of State Hospital) Patient. Undated. During a review of the clinical record for Resident 2, the Wandering/Elopement Risk assessment dated [DATE], at 7:45 PM, indicated the Resident was a low risk for elopement/wandering. During a review of the clinical record for Resident 2, the Restraint Physical Assessment (Initial Evaluation) dated September 15, 2022, at 1:59 PM, indicated Reasons for use of Physical Restraint. C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Residents 3 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 3 was admitted to the facility on [DATE], with diagnosis (DX) which included: stroke affecting the right side, seizures (uncontrolled electrical disturbance in the brain), lack of coordination, abnormalities of gait and mobility, high blood pressure, [CONDITION(S)] (high levels of fat in the blood), [CONDITION(S)] (low activity of [CONDITION(S)] gland), [CONDITION(S)] (prostate enlargement), dysphagia (difficulty swallowing), [CONDITION(S)] (bulge or swelling in the main blood vessel that runs from the heart) and [CONDITION(S)] (brain disorder that leaves one with trouble speaking or understanding people speaking). During observation of Resident 3 on September 22, 2022, at 12:28 PM, Resident 3 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the left ankle. Resident 3 did not respond to questioning. During an interview with Correctional Officer (CO 2) on September 22, 2022, at 12:28 PM, CO 2 stated, Resident 3 is wearing the [NAME] because its ' s (name of state hospital) policy. It can be removed every two hours. The [NAME] is removed when JIR goes to physical therapy or for a shower. If Resident 3 is lying there for a while, we switch the [NAME] to the other ankle. Resident 3 can move while in the shackles. Resident 3 can stand. CO 2 stated further, I don ' t think Resident 3 does any activities. No, he has not done any activities while I ' ve been here. During an interview with Certified Nursing Assistant (CNA 2) on September 22, 2022, at 1:07 PM, CNA 2 stated, Resident 3 has shackles because he is a prisoner. The Shackles come off when we change, shower, or reposition him or when he goes to Therapy. Nothing else. If they go to the restroom (located in his room) then the shackles come off. CNA 2 stated that he does not go to activities. Resident 3 just goes to therapy. During a review of the clinical records for Resident 3, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract. During a review of the clinical records for Resident 3, the Care plans indicated, 1.Focus: Resident 3 has limited ability to participate in Activities program Related to (name of state hospital) and corrections protocol. Needs in room activities visits. Goal: will accept one to one visit of interest for 15 minutes for 3 days a week. Interventions: Before giving anything to Resident 3 get consent from bedside corrections officer per (name of state hospital) instruction. Only provide writing materials that are provided by (name of state hospital) Social Worker. Dated September 6, 2022. 2.Focus: Resident 3 is at risk for decline in mood and psychosocial wellbeing related to history that led to admission at (name of state hospital), the need for restraint at all times with guard present related to (name of state hospital) and corrections protocol. Dated June 29, 2022. 3.Focus: Resident 3 requires shackles to extremity due to under custody of California department of Corrections and (name of state hospital) Patient. Dated August 19, 2022 During a review of the clinical record for Resident 3, the Wandering/Elopement Risk assessment dated [DATE], at 6:05 PM, indicated the Resident was a low risk for elopement/wandering. During a review of the clinical record for Resident 3, the Restraint Physical Assessment (Initial Evaluation) dated August 18, 2022, at 8:11 AM indicated Reasons for use of Physical Restraint . C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Residents 4 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 4 was admitted to the facility on [DATE], with diagnosis (DX) which included: [CONDITION(S)] (blood poisoning), abnormalities of gait, muscle wasting and atrophy (thinning or loss of muscle), [CONDITION(S)] (thought disorder characterized by hallucinations and delusions), depression, arthritis (swelling) of left knee, [CONDITION(S)] (tissues in the joint breakdown over time), [CONDITION(S)] (thin and weakened bones), disorder of kidney and ureter (blockage in one or more of the tubes leading to the kidneys). During a concurrent observation and interview of Resident 4 on September 22, 2022, at 12:34 PM, Resident 4 was observed lying in bed without shackles. A correctional officer was standing beside Resident 4 ' s bed. Resident 4 was asked about the shackles, and she stated, It ' s ok. Every day, I see nursing staff. Everyday. I don ' t have any coloring books. In the hospital I colored and did stuff like that. They don ' t give me things like that. Resident 4 stated further, I cannot walk. I don ' t get physical therapy. I don ' t leave the room and I don ' t like the shackles. During an interview with Correctional Officer (CO 3) on September 22, 2022, at 12:34 PM, CO 3 stated, The shackles are switched from one ankle to another ankle every two hours. The right ankle is swollen, and the left ankle is bandaged up. So, Resident 4 can ' t tolerate the shackles right now. She is allowed to go without them. Resident 4 does not wear them when taking a shower. When CO 3 was asked why Resident 4 has to wear the shackles, CO 3 stated, She is incarcerated. She is in the custody of (name of state hospital). Anywhere she goes custody must go. CO 3 stated further, Resident 4 goes to therapy and baths. During concurrent observation of Resident 4 and interview with a licensed vocational nurse (LVN 1) on September 23, 2022, at 5:30 PM, Resident 4 was observed to be in her room without shackles. LVN 1 stated, Resident 4 is bedridden, and does not get up. LVN 1 stated the activities assistant goes to her room and Resident 4 does not participate in group activities. During a review of the clinical records for Resident 4, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). During a review of the clinical records for Resident 4, the Care plans indicated, 1. Focus: Resident 4 is unable to participate in group or out of room recreational or leisure activities related to (name of state hospital) and Correction Officer guidelines. Goal: Resident 4 will need in room activity visits during stay at this facility. Interventions: Do not give any item without Corrections officer at bedside and approval. Only give the writing implements provided by (name of state hospital.) Undated. 2. Focus: Resident 4 is at risk for decline in psych-social wellbeing related to need for restraint and bedside corrections officer to be in place. Resident 4 is a (name of state hospital) resident and restraint/officer must be in place in this setting per (name of state hospital) and Corrections guidelines for safety of self and others. Undated. 3. Focus: Resident 4 requires shackles to the extremity due to under custody of California department of Corrections and (name of State Hospital) Patient. Undated. During a review of the clinical record for Resident 4, the Wandering/Elopement Risk assessment dated [DATE], at 7:50 PM, indicated Resident 4 was a low risk for elopement/wandering. During a review of the clinical record for Resident 4, the Restraint Physical Assessment (Initial Evaluation) dated September 21, 2022, at 2:27 PM, indicated Reasons for use of Physical Restraint . C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Residents 5 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 5 was admitted to the facility on [DATE], with diagnosis (DX) which included: Pyelonephritis (infection of both kidneys), mycoses (skin disease caused by a fungus), diabetes (high blood sugar), lack of coordination, abnormality of gait, [CONDITION(S)] (thought disorder characterized by hallucinations and delusions), high blood pressure, hydronephrosis (swelling of a kidney due to a build-up of urine), obstructive [CONDITION(S)] (urine cannot drain through the urinary tract), and acute kidney failure (abrupt decrease in kidney function.) During a concurrent observation and interview of Resident 5 on September 22, 2022, at 12:44 PM, Resident 5 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the right ankle. Resident 5 stated he was not sure how often nursing staff was coming in to check the shackles. Resident 5 then stated, I don ' t remember how often they come. They did come a couple of times yesterday. During a review of the clinical records for Resident 5, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). During a review of the clinical records for Resident 5, the Care plans indicated, 1. Focus: Resident 5 is unable to participate in group or out of room recreational or leisure activities related to (name of state hospital) and Correction Officer guidelines. Goal: Resident 5 will allow and participate in room/bedside activity visits. Interventions: Do not give any item without Corrections officer at bedside and approval. Only give the writing implements provided by (name of state hospital.) Dated September 19, 2022. 2. Focus: Resident 5 is at risk for decline in psychosocial wellbeing related to need for restraint and bedside corrections officer to be in place in this setting per (name of state hospital) and Corrections guidelines. Dated September 19, 2022. 3. Focus: Resident 5 requires shackles to extremity d/t under custody of California department of Corrections and (name of State Hospital) Patient. Dated September 19, 2022. During a review of the clinical record for Resident 5, the Wandering/Elopement Risk assessment dated [DATE], at 11:15 PM, indicated the Resident was a low risk for elopement/wandering. During a review of the clinical record for Resident 5, the Restraint Physical Assessment (Initial Evaluation) dated September 19, 2022, at 11:39 AM, indicated Reasons for use of Physical Restraint . C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Residents 6 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 6 was initially admitted to the facility on [DATE], with diagnosis (DX) which included: [CONDITION(S)] (skin cancer), diabetes (high blood sugar), [CONDITION(S)] ((damaged area of the brain), [CONDITION(S)] (though disorder characterized by hallucinations and delusions), anxiety disorder, high blood pressure, [CONDITION(S)] (infection in a bone), abnormality of gait and mobility, lack of coordination. During a concurrent observation and interview of Resident 6 on September 22, 2022, at 12:44 PM, Resident 6 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the left ankle. Resident 6 stated, Every day, I see nursing staff. The shackles, they just leave them on the left foot. There is a sore on the right foot. During an interview with Correctional Officer (CO 4) on September 22, 2022, at 12:44 PM, CO 4 stated, JIR ' s wear the shackles for security. CO 4 then stated regarding the shackles, I ' m responsible for them. The shackles are on until they must go to the bathroom and/or go to therapy. We do not take them off any other times. Nursing has nothing to do with the shackles. During an interview with a Certified Nursing Assistant (CNA 1) on September 22, 2022, at 12:53 PM, CNA 1 stated, the (name of state hospital) residents are allowed to leave for therapy and to shower. Activities? I think activities comes to the room and gives them coloring books. I have not seen (name of state hospital) residents going to activities. The only time JIR ' s leave the room is for therapy and showers. JIR ' s have restraints because they are correctional inmates. CNA 1 stated further, If I were restrained and not allowed to leave my room like the (name of state hospital) residents. I would feel restrained and anxious if I had shackles and could not leave the room. During a review of the clinical records for Resident 6, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). During a review of the clinical records for Resident 6, the Care plans indicated, 1. Focus: Resident 6 has limited ability to participate in Activities program related to (name of state hospital) and corrections protocol. Goal: Resident 6 will participate actively in bedside activities. Interventions: Do not give any object to Resident 6 without consent of Corrections officer at bedside per (name of hospital) interdisciplinary team. Only give Resident 6 the writing implements that (name of state hospital) social worker has given and clear with correction officer prior to giving. Provide room visits three times a week. Dated September 6, 2022 2. Focus: Resident 6 is at risk for decline in mood related to need for cuff/restraint to be in place while in this setting per (name of state hospital) and Department of Corrections. Cuff/restraint is required while off (name of state hospital) grounds for safety of self and others. Dated August 18, 2022. 3. Focus: Resident 6 requires shackles to extremity due to under custody of California department of Corrections and (name of State Hospital) Patient. Dated August 18, 2022. During a review of the clinical record for Resident 6, the Wandering/Elopement Risk assessment dated [DATE], at 8:45 PM, indicated the Resident was a low risk for elopement/wandering. During a review of the clinical record for Resident 6, the Restraint Physical Assessment (Initial Evaluation) dated August 18, 2022, at 12:55 PM, indicated Reasons for use of Physical Restraint . C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: Conservator. During an interview with Director of Nursing (DON) on September 22, 2022, at 1:26 PM, when asked why do the JIR ' s wear restraints the DON stated, That is part of (name of state hospital) policy. When they are in this type of post-acute care, a non-locked facility. It ' s their policy, practice that they have to be shackled. I know inmates are shackled for security reasons. JIR ' s are shackled because they reside in a locked psychiatric facility and JIR ' s are not in a locked facility. Being shackled here is for the safety of the patient. So, that they don ' t get out and get harmed. During an interview with Registered Nurse (RN 1) on September 22, 2022, at 2:07 PM, RN 1 stated, (name of state hospital) residents? Occasionally, I admit them. We have special orders for (name of state hospital) patients because they have shackles. They come with shackles, and they keep them on. It is the correctional officer ' s decision to have the restraints off or on. It is their policy to have the shackles on. We do not to take the shackles off at any time. I have requested for the shackles to be taken off to go to the restroom. Other than that, they continuously wear the shackles. They rotate the sites, but they continue to wear the shackles. RN 1 stated further why the JIR ' s wear shackles, Like I said it is the policy of (name of state hospital). So, we have to follow it. It is for the protection of the other residents. RN 1 then stated, All of the JIR ' s participate in activities. They don ' t participate in public areas. They do activities in their room. They don ' t do group activities. In a follow up interview with the DON on September 22, 2022, at 3:06 PM, When the DON was asked can the shackles be removed the DON stated, Like I said its controlled by the Correctional Officer ' s. They have the keys, and they can remove them. The correctional officers completely control that. Its upon their discretion. When asked can the JIR ' s be without the shackles, the DON stated, No, they are used for security and for protection of the (name of state hospital) resident. During an interview with Activities Director (AD 1) on September 22, 2022, at 3:37 PM, AD 1 stated, for JIR ' s we do our visits a tiny bit different. One on one, three times a week but with (name of state hospital) we are not really doing a lot with them. AD 1 stated further, JIR's do not participate in group activities. They won ' t let us take them out of the room. I see JIR's only inside of their rooms. I have never seen them outside. Unless I see a guard walking them. I have seen that twice in two months. When AD 1 was asked, why do the JIR ' s wear restraints? AD 1 stated, I just don ' t think they put people in (name of state hospital) that don ' t have a good reason to be there. I believe they have a altered mental status and they are a criminal too. AD 1 then stated, They ' re criminally insane. During an interview with Administrator on September 22, 2022, at 6:20 PM, Administrator stated, the prisoners are not in restraints for discipline. They are here because they are criminals with medical issues. They leave their rooms. They don ' t participate in group activities. Where does it say that they have to participate in group activities? They are prisoners. In a follow up interview with the Administrator on September 26, 2022, at 2:57 PM, Administrator stated, The restraints, it was for the safety of others based on their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator stated the JIR ' s were able to leave the room for therapy, and appointments. I determined the use of a restraint was because they come from (name of state hospital) for the criminally insane. So, the reason you would be at (name of state hospital) is because you would be deemed criminally insane. I just know that if you are there you are deemed mentally ill. You are incarcerated. I don ' t know the parameters. I just know that you are there because you are criminally insane. Administrator was asked did the Policy and procedure titled, Residents Rights pertain to the (name of state hospital) residents and the Administrator stated, Yes. During an interview with the Medical Director (MD) on September 26, 2022, at 3:24 PM, when asked why (name of state hospital) residents were wearing shackles. MD stated, I assume they have a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD stated, if there is a policy that requires that they not have shackles. MD then stated, I am saying then they didn ' t follow their policy. When the MD was asked about the policy and procedure titled, Residents ' Rights for the JIR ' s, MD stated, Based on the policy and procedure if they (facility) did something else, they violated it. MD stated the facility did not follow their policy and procedure in relation to restraints and residents ' rights. During random interviews of residents on September 28, 2022, between 7:29 AM and 9:48 AM, when asked how they would feel if shackled to the bed and to not be able to participate in activities or move freely around their room or the facility, when other residents were not shackled, they responded as follows: a. 7:29 AM Resident 7 stated, I would feel wronged, and I would not be happy about it. b. 7:32 AM Resident 8 stated, I ' d feel like I was in jail. It would make me feel sad. I was like that when I had a broken hip. It didn ' t feel very good. It depressed me. No group activities too. c. 7:36 AM Resident 9 stated, That would not be good. I would feel helpless and abandoned. d. 9:48AM Resident 10 stated, Let ' s say they took my rights away. I ' d be mad as the devil. During a review of the facility ' s policy and procedure titled, Residents Rights,revised December 2016, the policy and procedure indicated, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident ' s right to: a. dignified existence; b. be treated with respect, kindness, and dignity; d. be free from corporal punishment (punishment which is intended to cause physical pain to a person) or involuntary seclusion, and physical or chemical restraints not required to treat the resident ' s symptoms; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; I. exercise his or her rights without interference, coercion, discrimination or reprisal (act of retaliation) from the facility; m. exercise rights not delegated to a legal representative. During a review of the facility ' s policy and procedure titled, Use of Restraintsrevised April 2017. The policy and procedure indicated, Restraints shall only be used for the safety and well-being of the residents(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident ' s medical symptom (s) and never for discipline or staff convenience . When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary. 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one ' s body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident ' s physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, the device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints .4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted. 10. Orders for restraints will not be enforced for longer than twelve hours unless the resident ' s condition requires continued treatment. 13. Seclusion, which is defined as the placement of a resident alone in a room, shall not be employed. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom (s), but the underlying problems that may be causing the symptom(s). 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. An immediate jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F550 on September 22, 2022, at 6:14 PM in the presence of the Administrator and Director of Nursing. A corrective action plan was requested [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure their policy and procedure for physical restraints was followed for Justice involved residents (JIR; residents under the care of law enforcement, in custody, held involuntarily through operation of law enforcement authorities) when six of six residents (Residents 1, 2, 3, 4, 5, and 6) were denied the right to be treated with respect and dignity including the right to be free from any physical restraint imposed for the purpose of discipline and not required to treat the resident ' s medical condition. The facility instead imposed the policies and procedures of the California Department of Corrections and Rehabilitation (CDCR), which maintained the custody of public offenders (inmates) to always be shackled at the ankle and to the bedrail. These failures had the potential to place clinically compromised Residents (Resident 1, 2, 3, 4, 5 and 6) at risk of serious injury and psychosocial harm resulting from the continuous use of shackles/restraints to include the involuntary seclusion of these 6 residents. Findings: During review of Resident 1 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 1 was initially admitted to the facility on [DATE], with diagnosis (DX) which included: urinary tract infection (infection of the bladder), diabetes (high blood sugar), [CONDITION(S)] ([CONDITION(S)] does not produce enough hormones), [CONDITION(S)] (high levels of fat in the blood), [CONDITION(S)] (thought disorder characterized by hallucinations and delusions), Gastro-[CONDITION(S)] reflux disease (gastric fluid backflow into the esophagus) and high blood pressure. During a review of the clinical record for Resident 1, the Nurses Note dated September 21, 2022, at 7:44 PM, indicated, Admission Summary Note. Resident 1 can make needs known . (Resident 1) arrives with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview of Resident 1 on September 22, 2022, at 12:10 PM, Resident 1 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the right ankle. Resident 1 stated, The nurses don ' t do anything to me. The correctional officer checks my shackles every hour to two hours. During an interview with Correctional Officer (CO 1) on September 22, 2022, at 12:10 PM, CO 1 stated, We switch the shackles every two hours. We switch the shackles between the two legs. The only time we take the shackles off is when staff are showering the Justice involved residents (JIR). When the CO was asked why the JIR ' s are shackled, CO 1 stated, They are (name of state hospital) patients. They have committed crimes and not mentally capable of going to court. CO 1 stated further, The Activity department will come in since they (JIR ' s) are not allowed to go play bingo. CO 1 then stated, Typically, with the shackles on they can walk a steps length away from the bed. The chain is about 3 feet. I put the restraint/[NAME] on to keep them from running. It ' s ([NAME]) just long enough for them to step or stand by the bed. CO 1 stated, the three activities that the JIR does when outside of their room are: walk with physical therapy, therapy (occupational), and showers. During an observation on September 23, 2022, at 5:18 PM, Resident 1 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] attached to the right ankle. During a review of the clinical records for Resident 1, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. During a interview and concurrent record review of the care plans for Resident 1 on September 22, 2022, at 3:02 PM, with the Medical Records Director, the Medical Records Director stated the facility did not have care plans related to Resident 1 ' s [NAME]/restraint. During a review of the clinical record for Resident 1, the Wandering/Elopement Risk assessment dated [DATE], at 7:05 PM, indicated Resident 1 was a low risk for elopement/wandering. During a review of the clinical record for Resident 1, the Restraint Physical assessment dated [DATE], at 1:24 PM, indicated Reasons for use of Physical Restraint. Shackles needed to protect the patient and staff and to prevent elopement. B. History Alternatives Attempted: Resident 1 requires [NAME] per (name of state facility) protocol. C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Resident 2 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 2 was initially admitted to the facility on [DATE], with diagnosis (DX) which included: [CONDITION(S)] (damaged area of the brain), pneumonia (infection of the lungs), chronic obstructive pulmonary disease ([MEDICATION(S)] of the airway and difficulty breathing), obesity (overweight), [CONDITION(S)] (high levels of fat in the blood), [CONDITION(S)] (thought disorder characterized by hallucinations and delusions), Gastro-[CONDITION(S)] reflux disease (gastric fluid backflow into the esophagus), high blood pressure, pressure induced tissue damage of the left ankle, and [CONDITION(S)] (thin and weakened bones). During a concurrent observation and interview of Resident 2 on September 22, 2022, at 12:10 PM, Resident 2 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the left ankle. Resident 2 stated he did not know how often the nurses came in to check his shackles. During a review of the clinical records for Resident 2, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 [name of State Hospital] contract). During a review of the clinical records for Resident 2, the Care plan indicated, 1. Focus: Resident 2 is unable to participate in group or out of room recreational or leisure activities related to (name of state hospital) and Correction Officer guidelines. Goal: Resident 2 will need in room activity visits during stay at this facility. Interventions: Do not give any item without Corrections officer at bedside and approval. Only give the writing implements provided by (name of state hospital.) Undated. 2. Focus: Resident 2 is at risk for decline in psychosocial wellbeing related to need for restraint and bedside corrections officer to be in place. Resident 2 is a (name of state hospital) resident and restraint/officer must be in place in this setting per (name of state hospital) and Corrections guidelines for safety of self and others. Undated. 3. Focus: Resident 2 requires shackles to extremity d/t under custody of California department of Corrections and [NAME] State Hospital Patient. Goal: Resident 2 will not have discomfort while [NAME] is on resident. Interventions: Rotate [NAME] as needed. Prevent elopement. Shackles needed to protect the patient and staff. Undated. During a review of the clinical record for Resident 2, the Wandering/Elopement Risk assessment dated [DATE], at 7:45 PM, indicated Resident 2 was a low risk for elopement/wandering. During a review of the clinical record for Resident 2, the Restraint Physical Assessment (Initial Evaluation) dated September 15, 2022, at 1:59 PM, indicated Reasons for use of Physical Restraint. Describe resident behavior prompting restraint use: Shackles needed to protect the patient and staff and to prevent elopement . 14. Explain how the above behaviors/issues impact this resident ' s or other resident ' s safety: Resident 2 is under custody of California Department of Corrections (name of state hospital). B. History Alternatives Attempted: Describe why these alternatives did not work, prompting need for a restraint: per (name of state hospital) protocol. C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Resident 3 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 3 was admitted to the facility on [DATE], with diagnosis (DX) which included: stroke affecting the right side, seizures (uncontrolled electrical disturbance in the brain), lack of coordination, abnormalities of gait and mobility, high blood pressure, [CONDITION(S)] (high levels of fat in the blood), [CONDITION(S)] (low activity of [CONDITION(S)] gland), [CONDITION(S)] (prostate enlargement), dysphagia (difficulty swallowing), [CONDITION(S)] (bulge or swelling in the main blood vessel that runs from the heart) and [CONDITION(S)] (brain disorder that leaves one with trouble speaking or understanding people speaking). During observation of Resident 3 on September 22, 2022, at 12:28 PM, Resident 3 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the left ankle. In a concurrent interview with Resident 3, Resident 3 did not respond to questioning. During an interview with Correctional Officer (CO 2) on September 22, 2022, at 12:28 PM, CO 2 stated, Resident 3 is wearing the [NAME] because its ' s (name of state hospital) policy. It can be removed every two hours. The [NAME] is removed when JIR goes to physical therapy or for a shower. If Resident 3 is lying there for a while, we switch the [NAME] to the other ankle. Resident 3 can move while in the shackles. Resident 3 can stand. CO 2 stated further, I don ' t think Resident 3 does any activities. No, he has not done any activities while I ' ve been here. During an interview with Certified Nursing Assistant (CNA 2) on September 22, 2022, at 1:07 PM, CNA 2 stated, Resident 3 has shackles because he is a prisoner. The Shackles come off when we change, shower, or reposition him or when he goes to Therapy. Nothing else. If they go to the restroom (located in his room) then the shackles come off. CNA 2 stated that he does not go to activities. Resident 3 just goes to therapy. During a review of the clinical records for Resident 3, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). This physicians order did not indicate the medical necessity for the shackles/restraint. During a review of the clinical records for Resident 3, the Care plan indicated, 1. Focus: Resident 3 has limited ability to participate in Activities program Related to (name of state hospital) and corrections protocol. Needs in room activities visits. Goal: will accept one to one visit of interest for 15 minutes for 3 days a week. Interventions: Before giving anything to Resident 3 get consent from bedside corrections officer per (name of state hospital) instruction. Only provide writing materials that are provided by (name of state hospital) Social Worker. Dated September 6, 2022. 2.Focus: Resident 3 is at risk for decline in mood and psychosocial wellbeing related to history that led to admission at (name of state hospital), always need for restraint with guard present related to (name of state hospital) and corrections protocol. Dated June 29, 2022. 3.Focus: Resident 3 requires shackles to extremity due to under custody of California department of Corrections and (name of state hospital) Patient. Goal: Resident 3 will not have discomfort while [NAME] is on resident. Interventions: Rotate [NAME] as needed. Shackles used to protect (name of state hospital) patient, staff and to prevent elopement. Dated August 19, 2022. During a review of the clinical record for Resident 3, the Wandering/Elopement Risk assessment dated [DATE], at 6:05 PM, indicated Resident 3 was a low risk for elopement/wandering. During a review of the clinical record for Resident 3, the Restraint Physical Assessment (Initial Evaluation) dated August 18, 2022, at 8:11 AM, indicated Reasons for use of Physical Restraint. Restraint use is only mandated if the resident is in imminent danger of injuring him/herself or others. Describe resident behavior prompting restraint use: Shackles is to protect (name of state hospital) patient and staff and to prevent elopement .14. Explain how the above behaviors/issues impact this resident ' s or other resident ' s safety: Resident 3 is under custody of California Department of Corrections and (name of state hospital) patient. B. History Alternatives Attempted: Describe why these alternatives did not work, prompting need for a restraint: per (name of state hospital) protocol. C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Resident 4 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 4 was admitted to the facility on [DATE], with diagnosis (DX) which included: [CONDITION(S)] (blood poisoning), abnormalities of gait, muscle wasting and atrophy (thinning or loss of muscle), [CONDITION(S)] (thought disorder characterized by hallucinations and delusions), depression, arthritis (swelling) of left knee, [CONDITION(S)] (tissues in the joint breakdown over time), [CONDITION(S)] (thin and weakened bones), disorder of kidney and ureter (blockage in one or more of the tubes leading to the kidneys). During an observation and interview of Resident 4 on September 22, 2022, at 12:34 PM, Resident 4 was observed lying in bed without shackles. A correctional officer was standing beside Resident 4 ' s bed. Resident 4 was asked about the shackles, and she stated, Its ok. Every day, I see nursing staff. Everyday. I don ' t have any coloring books. In the hospital I colored and did stuff like that. They don ' t give me things like that. Resident 4 stated further, I cannot walk. I don ' t get physical therapy. I don ' t leave the room and I don ' t like the shackles. During an interview with Correctional Officer (CO 3) on September 22, 2022, at 12:34 PM, CO 3 stated, the shackles are switched from one ankle to another ankle every two hours. The right ankle is swollen, and the left ankle is bandaged up. So, Resident 4 can ' t tolerate the shackles right now. She is allowed to go without them. Resident 4 does not wear them when taking a shower. When CO 3 was asked why Resident 4 must wea the shackles, CO 3 stated, She is incarcerated. She is in the custody of (name of state hospital). Anywhere she goes custody must go. CO 3 stated further, Resident 4 goes to therapy and baths without the shackles/restraints. During observation of Resident 4 and concurrent interview with a licensed vocational nurse (LVN 1) on September 23, 2022, at 5:30 PM, Resident 4 was observed to be without shackles. LVN 1 stated, Resident 4 was bedridden, and does not get up. LVN 4 stated the activities assistant goes to Resident 4 ' s room and Resident 4 does not participate in group activities. During a review of the clinical records for Resident 4, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). This physicians order did not indicate the medical necessity for the shackles/restraint. During a review of the clinical records for Resident 4, the Care plan indicated, 1. Focus: Resident 4 is unable to participate in group or out of room recreational or leisure activities related to (name of state hospital) and Correction Officer guidelines. Goal: Resident 4 will need in room activity visits during stay at this facility. Interventions: Do not give any item without Corrections officer at bedside and approval. Only give the writing implements provided by (name of state hospital.) Undated. 2. Focus: Resident 4 is at risk for decline in psych-social wellbeing related to need for restraint and bedside corrections officer to be in place. Resident 4 is a (name of state hospital) resident and restraint/officer must be in place in this setting per [NAME] and Corrections guidelines for safety of self and others. Undated. 3. Focus: Resident 4 requires shackles to the extremity due to under custody of California department of Corrections and (name of State Hospital) Patient. Undated. Goal: Resident 4 will not have discomfort while [NAME] is on resident. Interventions: Rotate [NAME] as needed. Shackles used to protect (name of state hospital) patient, staff to prevent elopement. Undated. During a review of the clinical record for Resident 4, the Wandering/Elopement Risk assessment dated [DATE], at 7:50 PM indicated Resident 4 was a low risk for elopement/wandering. During a review of the clinical record for Resident 4, the Restraint Physical Assessment (Initial Evaluation) dated September 21, 2022, at 2:27 PM indicated Reasons for use of Physical Restraint. Restraint use is only mandated if the resident is in imminent danger of injuring him/herself or others. Describe resident behavior prompting restraint use: Shackles are to protect (name of state hospital) patient and staff and to prevent elopement .14. Explain how the above behaviors/issues impact this resident ' s or other resident ' s safety: Resident 4 is under custody of California Department of Corrections and (name of state hospital) patient. B. History Alternatives Attempted: Describe why these alternatives did not work, prompting need for a restraint: per (name of state hospital) protocol. C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State hospital) patient. During review of Resident 5 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 5 was admitted to the facility on [DATE], with diagnosis (DX) which included: Pyelonephritis (infection of both kidneys), mycoses (skin disease caused by a fungus), diabetes (high blood sugar), lack of coordination, abnormality of gait, [CONDITION(S)] (thought disorder characterized by hallucinations and delusions), high blood pressure, hydronephrosis (swelling of a kidney due to a build-up of urine), obstructive [CONDITION(S)] (urine cannot drain through the urinary tract), and acute kidney failure (abrupt decrease in kidney function.) During a concurrent observation and interview of Resident 5 on September 22, 2022, at 12:44 PM, Resident 5 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the right ankle. Resident 5 stated he was not sure how often nursing staff was coming in to check the shackles. Resident 5 then stated, I don ' t remember how often they come. They did come a couple of times yesterday. During a review of the clinical records for Resident 5, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). During a review of the clinical records for Resident 5, the Care plans indicated, 1. Focus: Resident 5 is unable to participate in group or out of room recreational or leisure activities related to (name of state hospital) and Correction Officer guidelines. Goal: Resident 5 will allow and participate in room/bedside activity visits. Interventions: Do not give any item without Corrections officer at bedside and approval. Only give the writing implements provided by (name of state hospital.) Dated September 19, 2022. 2. Focus: Resident 5 is at risk for decline in psychosocial wellbeing related to need for restraint and bedside corrections officer to be in place in this setting per (name of state hospital) and Corrections guidelines for safety of self and others. Dated September 19, 2022. 3. Focus: Resident 5 requires shackles to extremity d/t under custody of California department of Corrections and (name of State Hospital) Patient. Dated September 19, 2022. Goal: Resident 5 will not have discomfort while [NAME] is on resident. Interventions: Prevent elopement. Shackles needed to protect the patient and staff. During a review of the clinical record for Resident 5, the Wandering/Elopement Risk assessment dated [DATE], at 11:15 PM indicated Resident 5 was a low risk for elopement/wandering. During a review of the clinical record for Resident 5, the Restraint Physical Assessment (Initial Evaluation) dated September 19, 2022, at 11:39 AM indicated Reasons for use of Physical Restraint Describe resident behavior prompting restraint use: Shackles needed to protect the patient and staff and to prevent elopement . 14. Explain how the above behaviors/issues impact this resident ' s or other resident ' s safety: Resident 5 is under custody of California Department of Corrections (name of state hospital). B. History Alternatives Attempted: Describe why these alternatives did not work, prompting need for a restraint: per (name of state hospital) protocol. C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: under the custody of California Department of Corrections and (name of State Hospital) patient. During review of Resident 6 ' s Admission Record (general demographics) on September 22, 2022, the document indicated Resident 6 was initially admitted to the facility on [DATE], with diagnosis (DX) which included: [CONDITION(S)] (skin cancer), diabetes (high blood sugar), [CONDITION(S)] (damaged area of the brain), [CONDITION(S)] (affect ability to think, feel and behave clearly), anxiety disorder, high blood pressure, [CONDITION(S)] (infection in a bone), abnormality of gait and mobility, lack of coordination. During a concurrent observation and interview of Resident 6 on September 22, 2022, at 12:44 PM, Resident 6 was observed lying in bed with one end of the [NAME] attached to the bed and the other end of the [NAME] connected to the left ankle. Resident 6 stated Every day, I see nursing staff. They do everything. The shackles, they just leave them on the left foot. There is a sore on the right foot. During an interview with Correctional Officer (CO 4) on September 22, 2022, at 12:44 PM, CO 4 stated, JIR ' s wear the shackles for security. CO 4 then stated, the shackles, I ' m responsible for them. The shackles are on until they (JIR ' s) must go to the bathroom and/or go to therapy. We do not take them off any other times. Nursing has nothing to do with the shackles. During an interview with Certified Nursing Assistant (CNA 1) on September 22, 2022, at 12:53 PM, CNA 1 stated, the (name of state hospital) residents are allowed to leave for therapy and to shower. Activities? I think activities comes to the room and gives them coloring books. I have not seen (name of state hospital) residents going to activities. The only time JIR ' s leave the room is for therapy and showers. JIR ' s have restraints because they are correctional inmates. CNA 1 stated further, If I were restrained and not allowed to leave my room like the (name of state hospital) residents. I would feel restrained and anxious if I had shackles and could not leave the room. During a review of the clinical records for Resident 6, the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). During a review of the clinical records for Resident 6, the Care plan indicated, 1. Focus: Resident 6 has limited ability to participate in Activities program related to (name of state hospital) and corrections protocol. Goal: Resident 6 will participate actively in bedside activities. Interventions: Do not give any object to Resident 6 without consent of Corrections officer at bedside per (name of hospital) interdisciplinary team. Only give Resident 6 the writing implements that (name of state hospital) social worker has given and clear with correction officer prior to giving. Provide room visits three times a week. Dated September 6, 2022 2. Focus: Resident 6 is at risk for decline in mood related to need for cuff/restraint to be in place while in this setting per (name of state hospital) and Department of Corrections. Cuff/restraint is required while off (name of state hospital) grounds for safety of self and others. Dated August 18, 2022. 3. Focus: Resident 6 requires shackles to extremity due to under custody of California department of Corrections and (name of State Hospital) Patient. Goal: Resident 6 will not have discomfort while [NAME] is on resident. Interventions: Rotate [NAME] as needed. Prevent elopement. Shackles used to protect (name of state hospital) patient, staff and prevent elopement. Dated August 18, 2022. During a review of the clinical record for Resident 6, the Wandering/Elopement Risk assessment dated [DATE], at 8:45 PM, indicated Resident 6 was a low risk for elopement/wandering. During a review of the clinical record for Resident 6, the Restraint Physical Assessment (Initial Evaluation) dated August 18, 2022, at 12:55 PM indicated Reasons for use of Physical Restraint. Restraint use is only mandated if the resident is in imminent danger of injuring him/herself or others. Describe resident behavior prompting restraint use: Shackles needed to protect the patient and staff and to prevent elopement . 14. Explain how the above behaviors/issues impact this resident ' s or other resident ' s safety: Resident 6 is under custody of California Department of Corrections (name of state hospital). B. History Alternatives Attempted: Describe why these alternatives did not work, prompting need for a restraint: Patient requires shackles per protocol. C. Decision to restrain: 1b. State who made the decision to apply the restraint and why: Conservator. During an interview with Director of Nursing (DON) on September 22, 2022, at 1:26 PM, when asked why do the JIR ' s wear restraints the DON stated, That is part of (name of state hospital) policy. When they are in this type of post-acute care, a non-locked facility. It ' s their policy, practice that they must be shackled. I know inmates are shackled for security reasons. JIR ' s are shackled because they reside in a locked psychiatric facility and JIR ' s are not in a locked facility. Being shackled here is for the safety of the patient. So, that they don ' t get out and get harmed. During an interview with Registered Nurse (RN 1) on September 22, 2022, at 2:07 PM, RN 1 stated, (name of state hospital) residents? Occasionally, I admit them. We have special orders for (name of state hospital) patients because they have shackles. They come with shackles, and they keep them on. It is the correctional officer ' s decision to have the restraints off or on. It is their policy to have the shackles on. We do not to take the shackles off at any time. I have requested for the shackles to be taken off to go to the restroom. Other than that, they continuously wear the shackles. They rotate the sites, but they continue to wear the shackles. RN 1 stated further why the JIR ' s wear shackles, Like I said it is the policy of (name of state hospital). So, we must follow it. It is for the protection of the other residents. RN 1 then stated, All of the JIR ' s participate in activities. They don ' t participate in public areas. They do activities in their room. They don ' t do group activities. In a follow up interview with the DON on September 22, 2022, at 3:06 PM, When the DON was asked can the shackles be removed the DON stated, Like I said its controlled by the Correctional Officer ' s. They have the keys, and they can remove them. The correctional officers completely control that. Its upon their discretion. When asked can the JIR ' s be without the shackles, the DON stated, No, they are used for security and for protection of the (name of state hospital) resident. During an interview with Activities Director (AD 1) on September 22, 2022, at 3:37 PM, AD 1 stated, for JIR ' s we do our visits a tiny bit different. One on one, three times a week but with (name of state hospital) we are not really doing a lot with them. AD 1 stated further, JIR ' s do not participate in group activities. They won ' t let us take them out of the room. I see JIR ' s only inside of their rooms. I have never seen them outside. Unless I see a guard walking them. I have seen that twice in two months. When the AD 1 was asked, why do the JIR ' s wear restraints? AD 1 stated, I just don ' t think they put people in (name of state hospital) that don ' t have a good reason to be there. I believe they have an altered mental status, and they are a criminal too. AD 1 then stated, They ' re criminally insane. During an interview with Administrator on September 22, 2022, at 6:20 PM, Administrator stated, the prisoners are not in restraints for discipline. They are here because they are criminals with medical issues. They leave their rooms. They don ' t participate in group activities. Where does it say that they have to participate in group activities? They are prisoners. In a follow up interview with the Administrator on September 26, 2022, at 2:57 PM, Administrator stated, The restraints, it was for the safety of others based on their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator stated the JIR ' s were able to leave the room for therapy, and appointments. I determined the use of a restraint was because they come from (name of state hospital) for the criminally insane. So, the reason you would be at (name of state hospital) is because you would be deemed criminally insane. I just know that if you are there you are deemed mentally ill. You are incarcerated. I don ' t know the parameters. I just know that you are there because you are criminally insane. During an interview with the Medical Director (MD) on September 26, 2022, at 3:24 PM, when asked why (name of state hospital) residents were wearing[TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide monitoring and supervision for one of twelve residents (Resident 1) who was disoriented (having lost one's sense of direction) with wandering behaviors eloped (a dependent resident leaving the facility without observation or knowledge of departure) from the facility through an unlocked gate without staff's knowledge. This failure resulted in Resident 1 suffering from head trauma and serious lacerations to his face and head according to hospital records. An Immediate Jeopardy (IJ a situation that has threatened or is likely to threaten the health and safety of a Resident) was called under 483.5, Quality of Life (refer to F 689 Free of Accident Hazards/Supervision) on May 27, 2021 at 10:41 AM, and verbally notified in the presence 0f the Administrator. Resident 1 was admitted and assessed as a moderate elope risk and the facility failed to provide monitoring and supervision for Resident 1who was disoriented with wandering behaviors eloped through an unlocked gate without staff's knowledge which resulted in serious bodily injuries. The Corrective Action Plan (CAP): Was accepted on May 27, 2021 at 1:20 PM in the presence of the Administrator. Ordered. The CAP steps consisted of Immediate in service for all License Nurses (LN's) and Certified Nurse's Assistant (CNA's). Immediate Intervention for any residents showing any signs and symptoms of wandering/elopement not in lock unit. Ongoing in service to LN's and CNA's are re educated. Update policy and procedure for Wandering/Elopement. All 23 Resident's with Dementia diagnosis not in memory care unit will be re-assessed. All new admission/re admissions will be assessed immediately for signs and symptoms of wandering/elopement. Assistant DON/Unit Managers will be reviewing Change of Condition's (COC) daily for episodes of wandering/elopement. All resident's that have exit seeking behavior will be reassessed. Assisted Director of Nurses (ADON)/ Unit Manager (UM) will review monthly to make sure high risk are addressed for part of Quality Assurance (QA) All Change of Conditions (COC's) with behavior of wandering/elopement will be reported monthly to QA. When all steps of the CAP were reviewed, staff interviews were conducted, observations were made and record reviews were completed, on May 30, 2021 at 1:00 PM the IJ was lifted in the presence on the Administrator. Findings: During a review of Resident 1's facility document entitled, Pre-Admission Record, dated May 18, 2021, indicated, Resident 1 has a diagnosis of cognitive communication deficit (occurs after a stroke among other possible reasons which results in difficulty thinking and how someone uses language.) During a review of the medical record for Resident 1 the document entitled, Admission Record, (shows resident's demographics) indicated, Resident 1 admitted to the facility on [DATE], with diagnoses of intracerebral hemorrhage (bleed in the brain that can cause deficits in attention, verbal and nonverbal learning, short term and working memory, visual and auditory processing, problem solving, processing speed, and motor functioning), hypertension (high blood pressure), heart failure (your heart muscle doesn't pump blood as well as it should), and type 2 diabetes (an impairment in the way the body regulates and uses sugar as a fuel). Resident 1 was assigned to unit 1. During a review of the physician notes from the hospital, dated May 23, 2021, the History of Present Illness indicated, Resident 1 was at the hospital for evaluation due to ALOC (Altered level of consciousness). He was found altered by the police wandering away from the facility [Name of Facility] with a bag containing his belongings .he presents with abrasions to the right cheek. Under Social History his smoking status is listed as Never Smoker. During a review of Resident 1's physician notes from [Name of Hospital], dated May 23, 2021, the record of other imaging indicated, Computerized Tomography (CT uses computers and rotating x ray machines to create cross sectional images of the body) head .radiologist impression: small acute bilateral subdural hematoma (bleeding on both sides of your brain). During a review of the facility list of recent discharges, undated, the list of discharges indicated Resident 1 was listed as discharged AMA (Against Medical Advice when a resident leaves the facility without a physician's consent) to home with no home health service on May 24, 2021. During a review of Resident 1's admission Wandering/Elopement Risk Assessment (scores a resident for low, moderate to high risk based on indicators such as orientation (aware of one's environment to place, time, and people), behavior/mood, etc.), dated May 21, 2021, the wandering/Elopement risk assessment for Resident 1 indicated, a Score of 5 indicating a moderate risk for elopement. Under the Orientation section, the resident is entered as forgetful/short attention span. Under Behavior/mood section, it indicates Resident 1 does not understand surroundings. During a review of Resident 1's admission Fall Risk Assessment, dated May 21, 2021, the Fall Risk Assessment indicates, under level of consciousness/mental status as disoriented. During a review Resident 1's Nursing Progress Note, dated May 22, 2021, at 7:39 PM, the Nursing Progress Note indicated, Resident 1 is Alert, confused and verbally responsive with clear speech. Steady gait and constantly ambulating per hallways aimlessly stating he is looking for a family member and has to be redirected frequently and constantly. During a review of Resident 1's physician progress notes, dated May 21, 2021 to May 24, 2021, indicated no documentation that the physician was notified of Resident 1's disorientation or wandering behavior prior to his elopement. During a review of Resident 1's Nursing Progress Note, dated May 23, 2021, at 7:19 PM, the Nursing Progress Note indicated, Received phone call from family member stating resident is found outside of [Name of Facility] at 1900 (7PM) from [name of city] police department and taken to [Name of Hospital]. Last saw resident was at 1600 (4 PM) walking around unit. Notify .the DON and . The administrator at 1919 (7:19 PM). Both are aware of the situation. During a review of Resident 1's Social Services Note, dated May 24, 2021, at 12:21 PM, the Social Services Note indicated, Resident 1 left AMA on May 22, 2021. Social Services reported incident to Ombudsman and APS (Adult Protective Services). During a review of Resident 1's admission care plans, dated May 12, indicated no care plans (C/P's) were initiated for Resident 1 being at risk for wandering and elopement risk. During an interview on May 26, 2021, at 11:26 AM, with the Director of Nursing (DON), the DON confirmed if any residents were considered wanderers/elopement risks, we would place them in our locked memory care unit (Unit 2). During an interview on May 26, 2021, at 2:06 PM, with the DON, the DON stated on May 23, 2021 Resident 1 did elope from the facility without staff's knowledge's and did not leave AMA as documented by the SSW but, does not know how he got out. . During an interview on May 26, 2021, at 2:06 PM, with the Administrator (ADM), the ADM stated if residents are not exit seeking then we do place them in our locked memory care unit. The ADM stated, We have 72 hours to validate a resident 's behavior. The ADM stated he is unsure how Resident 1 got out of the facility, it mayhave3 been through the courtyard and up the ramp through an unlocked gate. During an interview on May 27, 2021, at 12:15 PM, with the ADM, he stated he did not know if the doors on unit 1 are locked 24 hours a day/ 7days a week but did know the main entrance was locked at 8pm. During an interview on May 27, 2021, at 1:40 PM, with the ADM, the ADM stated Resident 1 left AMA on evening of May 23, 2021. The ADM stated any Resident not housed on Unit 2 (locked Memory Unit) can leave any time they want, and they have the right to decline to sign the AMA form. When asked if staff should be responsible to know where Residents are always for their safety, the ADM stated, Yes, we should, and I will take responsibility for the fact we did not know that Resident 1 had left the facility. The ADM confirmed the facility did not notify California Department of Public Health (CDPH) when Resident 1 left facility on May 23, 2021 because, Resident 1 had a right to leave. During an interview on May 27, 2021, at 4:40 PM, with Licensed Vocational Nurse (LVN 1), LVN 1 stated, since Resident 1's admission on May 21, 2021 she felt he was confused and really wanted to leave. He would not stay in his room after redirection. He wanted to go to the smoking area often. LVN 1 stated Resident 1 was an elopement risk and notified the ADM regarding her concerns about Resident 1 at risk for eloping. LVN 1 further stated when one of the Certified Nurse's Assistant (CNA) went to lunch, Resident 1 was seen in the smoking area at around 4:00 PM. During a concurrent observation/Interview on May 27, 2021, at 4:40 PM, with LVN 1 of unit 1, the alarm on the door to the smoking area was not set. The door from unit 1 to the smoking area is near the nurse's station. LVN 1 confirmed, by pointing out the door that staff were unable to observe residents outside in the smoking patio unless staff are in the patio area. The unlocked gait from the smoking patio leads to the parking area. Also, there is another exit at the end of the hallway opposite of nurse's station. This exit has an inactivated alarm that leads to a courtyard with a wheelchair ramp that leads to the parking lot. LVN 1 further confirms these are doors are always unlocked. During an interview on May 30, 2021, at 11:50 AM, with the Registered Nurse Supervisor (RNS), the RNS stated, if I admitted a resident with cognitive communication deficit and nursing progress notes indicating resident was confused x2 (orientation is assessed for self, place, time and situation), then that resident should be monitored for possible elopement risk. The RNS stated there are two doors (smoking and courtyard) on unit 1 where residents can leave but must knock to get back in. The RNS stated the doors are locked at 11:00 PM. During an interview on May 30, 2021, at 12:30 PM, with the ADM, the ADM stated for unit 1 staff do not have to supervise residents when they go out to smoke. The ADM confirmed staff cannot see residents in smoking area. He stated the residents can go to the smoking area at any time. He stated staff check residents every two hours. When asked if this was safe for resident's to be unsupervised, the ADM asked, Should I assign staff to supervise the smoking are. During an interview on June 1, 2021, at 4:20 PM, with CNA 1, CNA 1 stated Resident 1's bed was empty when he arrived on unit 1 for evening shift (3pm to 11pm) on May 23, 2021. CNA 1 stated there were no belongings in his room except a sheet and a pillow. He stated at the time, he thought Resident 1 was outside in the smoking area or with family. During shift change, CNA 1 was told Resident 1 walked out the door to the back patio/smoking area. During an interview on June 1, 2021, at 5:08 PM, with LVN 6, LVN 6 stated Resident 1 needed to be redirected here and there. LVN 6 stated Resident 1 would go to the smoking area and then staff would redirect him to go back inside often. LVN 6 stated his last sighting was between 4 and 4:15 PM on May 23, 2021. Resident 1 was looking for his girlfriend and staff would tell Resident 1 she wasn't at facility. LVN 6 stated she was waiting for the facility to send Resident 1 to unit 2 (locked unit memory care). LVN 6 stated she suggested to RN supervisor Resident 1 may need to go to locked unit. LVN 6 stated she can't remember who the RN Supervisor was. During a review of the facility's policy and procedure titled, Wandering, Revised March 2019, indicated under Policy Statement ., The facility will identify residents who are at risk of unsafe wandering, risk for wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Also, under Policy Interpretation and Implementation, 1. If identified as at risk for wandering, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner .; c. inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises, and c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies. During a review of the facilities policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, Revised March 2019 indicated under Policy Statement,5. Residents will have minimal complications associated with the management of altered or impaired behavior. Under Policy Interpretation and Implementation, Assessment .3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition including a. Onset, duration, intensity and frequency of behavioral symptoms. 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Under Management, 1. The interdisciplinary team will evaluate behavioral symptoms in resident to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately unnecessary, to protect the resident and others from harm.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were implemented when 16 heads of potentially contaminated romaine lettuce were found inside the facility's walk-in refrigerator readily available for resident consumption. The facility received a food safety alert notice from their food vendor not to consume romaine lettuce due to Escherichia coli (E. coli, a harmful bacteria usually found in the gut, if it is infectious cause severe abdominal cramps, nausea, diarrhea) infections. This failure had the potential to cause food borne illness (food poisoning caused by contaminated food consumption) for a medically compromised (residents with weak immune system) population of 174 residents who received food from the kitchen in the universe of 228. An Immediate Jeopardy (IJ, a crisis situation in which the health and safety of individual(s) are at risk) was called on (MONTH) 26, (YEAR) at 6:36 PM, when romaine lettuce was available for use in the kitchen's walk- in refrigerator and was served to the residents on (MONTH) 23, (YEAR), despite a food safety alert advisement received on (MONTH) 20, (YEAR). The IJ was called in the presence of the Administrator (ADMIN), the Director of Nursing (DON) and the Regional Director Clinical (RDC). A Corrective Action Plan (CAP) was requested. A record review was conducted on (MONTH) 27, (YEAR) at 3:00 PM, and indicated corrective action plan that included multiple posters with bold letters regarding the romaine lettuce alert in the kitchen's refrigerator door and dining area, monitoring the residents for signs and symptoms of E.coli infections, immediately throw out the recalled food, and any other foods stored with it and any instances of potential contamination will be reported immediately California Department of Public Health (CDPH) . An acceptable corrective action plan was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on (MONTH) 27, (YEAR) at 3:32 PM, in the presence of the ADMIN, DON and the RDC. Findings: During an initial tour of the kitchen on (MONTH) 26,2018, at 8:20 AM, with the facility's Dietary Service Supervisor (DSS), there were 16 heads of romaine lettuce observed stored inside a plastic tub in the bottom rack of the walk in refrigerator. During a concurrent interview with the DSS, he verified there were 16 heads of romaine lettuces in the kitchen's walk in refrigerator. He stated they purchased 24 heads of romaine lettuce on (MONTH) 20, (YEAR), and eight heads of romaine lettuce were used and been served to the residents with their salad. The DSS stated he received a food safety alert from their food vendor and Centers for Disease Control and Prevention(CDC) on (MONTH) 20, (YEAR). The DSS verified there were no other kind of lettuces stored inside facility's walk in refrigerator. During an interview with the DSS on (MONTH) 26, (YEAR) at 10:10 AM, the DSS stated It is my fault, I would have tossed it. The DSS stated romaine lettuces were used on (MONTH) 23,2018, and served to the residents with their salad. The DSS provided a copy of the purchase order and the food safety alert issued by their food vendor, dated (MONTH) 20, (YEAR). The DSS stated he received CDC food safety alert about a recall on romaine lettuce on for potential E. Coli contamination on (MONTH) 20, (YEAR). During an interview with the DSS on (MONTH) 26, (YEAR) at 4:45 PM, he stated although he received the romaine lettuce food safety alert on (MONTH) 20, (YEAR), he did not notify the dietary staffs about the food safety alert until (MONTH) 22, (YEAR). A review of the facility's menu titled, GOOD FOR YOUR HEALTH MENUS, indicated the following: 1. (MONTH) 21, (YEAR) Week 3 Lunch: Italian Green Salad 2. (MONTH) 23, (YEAR) Week 3 Lunch: Tossed green salad 3. (MONTH) 27,2018 Week 4 Lunch: Tossed Green Salad 4. (MONTH) 30, (YEAR) Week 4 Lunch: Mixed Greens Salad 5. (MONTH) 1, (YEAR) Week 4 Lunch: Italian Green Salad A review of the facility's recipe book by RD's for Healthcare, Inc. indicated the following: 1. TOSSED GREEN SALAD WITH DRESSING: Ingredients: Lettuce of choice: Romaine, . 2. ITALIAN GREEN SALAD: Ingredients: Lettuce of choice: Strongly suggest portion of lettuce be romaine, . 3. MIXED GREENS SALAD: Ingredients: Romaine, . A review of the facility's purchase order invoice by (NAME OF THE COMPANY) dated (MONTH) 20, (YEAR), indicated . LETTUCE RMN FRESH REF 24 EA . A review of the facility provided letter titled (NAME OF FOOD SUPPLIER) dated (MONTH) 20, (YEAR) indicated the following: .Effective immediately, (NAME) has put a national hold on ALL romaine lettuce products in response to the (MONTH) 20, (YEAR) CDC FOOD SAFETY ALERT. The CDC and Food Drug administration (FDA) are investigating a multistate outbreak of Shiga toxin- producing E. coli infections linked to romaine lettuce . A review of the facility provided record titled, Outbreak of E. coli infections Linked to romaine Lettuce, Food Safety Alert issued by CDC posted on (MONTH) 20, (YEAR) at 2:30 PM indicated the following: Advice to Consumers, Restaurants, and Retailers; CDC is advising that U.S. customers not eat any romaine lettuce, and retailers and restaurants not serve or sell any, until we learn more about the outbreak . Consumers who have any type of romaine lettuce in their home should not eat it and should throw it away, even if . Restaurants and retailers should not serve or sell any romaine lettuce, including salad and salad mixes. The facility policy and procedure titled, STORAGE OF FOOD AND SUPPLIES, by (Name of healthcare), Inc. (YEAR) indicated POLICY: Food and supplies will be stored properly and in a safe manner.

Based on observation, interview, and record review, the facility failed to ensure temperature sensitive medications were properly monitored and stored when medications were found to have been stored at or below 35 degrees Fahrenheit (F) and not within an acceptable temperature range between 36 degrees Fahrenheit (F) to 46 degrees F, according to the facility's policy and procedure and medication safe storage guidelines, affecting five of 57 sampled residents (Residents 329, 537, C, D, and E) in a universe of 228 residents. This failed practice could result in medication losing their potency (effectiveness) which could cause residents not getting the full benefits of their medications. Immediate Jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a Resident) was called on (MONTH) 28, (YEAR) at 3:58 PM, under medication storage and labeling, in the presence of the Administrator (Admin), Director of Nurses (DON), and a Nurse Consultant (Consultant 3). The IJ was called and the Administrator, Director of Nurses and Nurse Consultant were made aware of a medication refrigerator containing temperature sensitive medications that were found and kept inside an out of safe range (36 degrees Fahrenheit (F) to 46 degrees F) refrigerator. There was a temperature log sheet being kept on the outside of the refrigerator with temperatures being checked twice a day. The staff were aware of the out of range temperatures below 36 degrees Fahrenheit but failed to report and fix the refrigerator. The temperature log indicated, there were five days in (MONTH) (YEAR) and 27 days out of 28 days in (MONTH) of (YEAR) that the medication refrigerator temperature were out of range, below 36 degrees Fahrenheit. The staff verified the medications being stored in the out of temperature range refrigerator were administered to the residents. A corrective action plan was requested. The Corrective Action Plan (CAP) was provided and verified to be implemented. The CAP indicated all of the medications being stored inside the out of range refrigerator (the temperatures ranged from 30 degrees F to 35 degrees F) in Nursing Station 4 were disposed, a log sheet was posted on every refrigerator to remind staff to monitor the refrigerator temperature two times a day with the correct safe temperature range indicated on the log. Training of staff was provided on how to correctly take refrigerator temperatures and what to do if they are out of range. The old refrigerator was replaced, temperatures on all refrigerators were verified in a safe range, five of 57 residents will be revaccinated. The IJ situation was lifted on (MONTH) 30, (YEAR) at 11:45 AM in the presence of the Admin, DON, and the Consultant 3. Findings: During an inspection of the medication room in Nursing Station 4, with Registered Nurse (RN 1) on (MONTH) 28, (YEAR), at 8:25 AM, the refrigerator temperature was 35 degrees Fahrenheit (F) (normal range is 36 degrees F to 46 degrees F). RN 1 verified the refrigerator temperature was out of range. RN 1 stated she was aware that the refrigerator was out of temperature range but did not notify anyone. Review of the Refrigerator Log indicated out of range temperatures from (MONTH) 13 to (MONTH) 18, (YEAR) and for the month of November, (YEAR). The medication refrigerator contained the following medications. 1. Quadrivalent- (vaccine given in (YEAR)-2019 to prevent getting the Influenza Flu) nine of 10 prefilled syringes, one dose was missing. 2. Flusaval Quadrivalent- (vaccine given in (YEAR)-2019 to prevent getting the Influenza Flu) 14 of 16 (3 milliliters-ML Unit of measure) vials. One vial opened on (MONTH) 22, (YEAR), one opened on (MONTH) 22, (YEAR), Expired: May, 2019, Lot #5GBPRF2XGG. 3. Flucelvax Quadrivalent- (vaccine given in (YEAR)-2019 to prevent getting the Influenza Flu) one of two, one vial opened on (MONTH) 12, (YEAR), Expired: (MONTH) 30, 2019, Lot# 3. 4. Colistimethate- (antibiotic that fights bacteria)150 milligram (MG-unit of measure) vial-date Filled-[DATE], (YEAR)- Seven of seven {Quantity six}. 5. Colistimethate- (antibiotic that fights bacteria) dry vial 150 mg vial-date filled: (MONTH) 26,2018, Unopened for {Quality six}. 6. [MEDICATION NAME]- (hormone that works by lowering levels of sugar) 100-unit vial, date filled: (MONTH) 19, (YEAR), Expired: (MONTH) 2020, Unopened. 7. [MEDICATION NAME]- (hormone that works by lowering levels of sugar) 100 units/ml vial, date filled: (MONTH) 25, (YEAR), Expired: (MONTH) 2020, unopened. 8. Humalog- (hormone that works by lowering levels of sugar) 100 units/ml, date filled: (MONTH) 24, (YEAR), expired: (MONTH) 2019, unopened. 9. [MEDICATION NAME]- (hormone that works by lowering levels of sugar) 100 units/ml, dated filled: (MONTH) 6, (YEAR), expired: (MONTH) 2020, unopened. 10. [MEDICATION NAME] - ([MEDICATION NAME] (TB) purified protein derivative PPD used in a skin test to diagnose TB ( infection in persons at increased risk of developing active disease))-five units/o,1 ml, date filled: (MONTH) 26, (YEAR), expired: (MONTH) 2020, unopened. House supply. 11. [MEDICATION NAME]- (used to treat anxiety disorder)2 mg/ml vial, date filled: (MONTH) 7, (YEAR), Expired: (MONTH) 2020, Six of Six. 12. [MEDICATION NAME]-R- (hormone that works by lowering levels of sugar) 100 units/ml vial, date filled: (MONTH) 26, (YEAR), Expired: (MONTH) 2020. 13. [MEDICATION NAME] (vaccine indicated for active immunization for the prevention of pneumococcal disease) 23 vials, date filled: (MONTH) 23, (YEAR), expired (MONTH) 10 2020, unopened. 14. [MEDICATION NAME]- (used to treat anxiety disorder)2 mg/ml vial, date filled: (MONTH) 20, (YEAR), expired (MONTH) 19, 2019, unopened one of one. 15. [MEDICATION NAME]- (used to treat anxiety disorder)2 mg/ml, date filled: (MONTH) 21, 2021, expired: (MONTH) 2021 unopened two of two. 16. [MEDICATION NAME]- (used to treat anxiety disorder) 20 mg/10 ml, ,[DATE], date filled: IV (MONTH) 1, (YEAR), Expired (MONTH) 21, 2019, unopened. 17. Acetyzcyetine - (used for the treatment of [REDACTED]. Box #,[DATE] unopened, 1 opened, 1 missing. 18, [MEDICATION NAME]- (used for the treatment of [REDACTED]. Box #1- three bottles unopened-30 ml each. 19. [MEDICATION NAME]- (used for the treatment of [REDACTED]. 20. E-Kit-Expired (MONTH) 31, 2020, date filled: (MONTH) 26, (YEAR) L 31 for Station 4. a. [MEDICATION NAME] R-(hormone that works by lowering levels of sugar) 3 ml 100 units/ML, expire: ,[DATE]- unopened. b. [MEDICATION NAME]- (used to treat anxiety disorder) 2 mg/ml 100 units/ml, expired: (MONTH) 2020, Lot # 3, unopened. c. [MEDICATION NAME]- (used to treat anxiety disorder) 2 mg/ml expired: (MONTH) 2021, Lot # 1, unopened. d. [MEDICATION NAME] N- (insulin-a manmade form of a hormone produced in the body that lowers blood sugar) 3 ml 100 units/ml, Expired: October. 2020, unopened. During an interview and record review with Registered Nurse (RN 2) on (MONTH) 28, (YEAR), at 8:35 AM, the medication refrigerator's temperature log sheet from (MONTH) 1 through 28, (YEAR) at Nursing Station 4 indicated, the medication refrigerator was out of temperature range between 30 degrees F to 35 degrees F. RN 2 verified temperature sensitive medications were kept inside the out of range refrigerator. There was a reminder note for the staff that indicated, Acceptable temperatures should be between 36 degrees Fahrenheit (F) to 40 degrees. The temperature log did not reflect what to do if the medication refrigerator temperature was out of range. RN 2 stated she was aware the temperature log sheet and medication refrigerator in Nursing Station 4 was out of range but did not report it. RN 2 stated, The refrigerator temperatures being out of range would change the potency of the medications administered to the residents and vaccines would not have been as effective. RN 2 verified all of the medications that were found in the refrigerator. RN 2 stated, I did not notify maintenance regarding the refrigerator temperatures being out of range. During an interview and record review with RN 1 on (MONTH) 28, (YEAR), at 8:53 AM, RN 1 stated the medication refrigerator temperatures get checked twice a day and the normal range should be between 36 degrees to 40 degrees F. The medication refrigerator log sheet for the month of (MONTH) (YEAR) was reviewed with RN 1. RN 1 confirmed for 28 days the temperatures were out of range. RN 1 verified the medications found stored in the refrigerator with out of range temperatures and the potential of reduced potency of the medications. RN 1 verified the medications were administered to Residents 329, 537, C, D, and E, which could leave them susceptible to illnesses. RN 1 stated, I did not notify anyone regarding the refrigerators being out of range. During an interview with the Infection Control Prevention Nurse (ICP), on (MONTH) 28, (YEAR), at 10:00 AM, the ICP verified the medication temperature log sheet for the medication room on Station 4 was out of range for 28 days in (MONTH) (YEAR). The ICP verified there was temperature sensitive medications being stored in a refrigerator with out of range temperatures. The ICP also verified that would affect the potency of the vaccines that were being stored in that refrigerator that were administered to Resident 329, 537, C, D, and E. During a review of the October's Refrigerator Log sheet for the medication room on Nursing Station 4, it indicated temperatures were out of range and revealed: [DATE], at 6 AM, the temperature is documented as 32 degrees F. [DATE], at 8 AM, the temperature is documented as 34 degrees F. [DATE], at 8 AM, the temperature is documented as 34 degrees F. [DATE], at 8 AM, the temperature is documented as 33 degrees F. [DATE], at 9 AM, the temperature is documented as 30 degrees F. [DATE], at 6 PM, the temperature is documented as 30 degrees F. A review of the November's Refrigerator Log sheet for the medication room on Nursing Station 4, indicated temperatures were out of range and revealed: [DATE], at 9 AM and at 3 PM, the temperature is documented as 32 degrees F. [DATE], at 9 AM and at 8 PM, the temperature is documented as 32 degrees F. [DATE], at 9 AM and at 8 PM, the temperature is documented as 32 degrees F. [DATE], at 9 AM and at 8 PM, the temperature is documented as 32 degrees F. [DATE], at 9 AM and at 3 PM, the temperature is documented as 32 degrees F. [DATE], at 8 AM and at 5 PM, the temperature is documented as 32 degrees F. [DATE], at 8 AM and at 6 PM, the temperature is documented as 31 degrees F. [DATE], at 9 AM and at 8 PM, the temperature is documented as 31 degrees F. [DATE], at 9 AM and at 8 PM, the temperature is documented as 31 degrees F and 32 degrees F. [DATE], at 9 AM and at 3 PM, the temperature is documented as 32 degrees F. [DATE], at 9 AM and at 3 PM, the temperature is documented as 31 degrees F. [DATE], at 9 AM and at 4 PM, the temperature is documented as 31 degrees F. [DATE], at 9 AM and at 5 PM, the temperature is documented as 31 degrees F. [DATE], at 9 AM and at 10 PM, the temperature is documented as 31 degrees F. [DATE], at 7 AM and at 8 PM, the temperature is documented as 30 degrees F and 31 degrees F. [DATE], at 6 AM and at 6 PM, the temperature is documented as 31 degrees F. [DATE], at 8 AM and at 6 PM, the temperature is documented as 31 degrees F. [DATE], at 9 AM and at 6 PM, the temperature is documented as 34 degrees F and 31 degrees F. [DATE], at 10 AM and at 7 PM, the temperature is documented as 34 degrees F and 31 degrees F. [DATE], at 6 AM and at 8 PM, the temperature is documented as 32 degrees F. [DATE], at 6 AM and at 8 PM, the temperature is documented as 32 degrees F. [DATE], at 8 AM and at 6 PM, the temperature is documented as 32 degrees F. [DATE], at 8 AM and at 6 PM, the temperature is documented as 32 degrees F. [DATE], at 11:10 AM and at 9 PM, the temperature is documented as 32 degrees F and 33 degrees F. [DATE], at 8 AM and at 5 PM, the temperature is documented as 32 degrees F. [DATE], at 8:15 AM and at 5 PM, the temperature is documented as 33 degrees F and 32 degrees F. [DATE], at 8:15 AM and at 7 PM, the temperature is documented as 33 degrees F and 34 degrees F. [DATE], at 8 AM and at 7 PM, the temperature is documented as 35 degrees F and 32 degrees F. During a review of maintenance log for the months of September, October, and (MONTH) (YEAR), there were no entries from the staff indicating medication refrigerator in Station 4 was out temperature range. During an interview and a review of the refrigerator log with the DON, on (MONTH) 28, (YEAR), at 12:30 PM, the DON confirmed there were five days in (MONTH) (YEAR) and 28 days in (MONTH) (YEAR) the medication refrigerator temperature in Station 4 was out of range. The DON verified the refrigerator contained temperature sensitive medications and medications were administered to the residents where the potency could have been affected. During a review of the clinical record Immunization report, dated (MONTH) 1, (YEAR) to (MONTH) 30, (YEAR), Type of Immunization: Influenza, it revealed five residents from Station 4 were vaccinated from vaccines that were stored in a refrigerator with documented temperatures out of range. A phone call was made to the Pharmacy Consultant (PC), on (MONTH) 28, (YEAR), at 2:18 PM. The PC stated he would have to call back. A review of the inserts of the medications that were being stored and were administered and available for use in the refrigerator indicated the following: 1. Quadrivalent, should be stored in a refrigerator with temperature ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. If the vaccine has been exposed to inappropriate conditions/temperatures discard. 2. Flusaval Quadrivalent, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. If the vaccine has been exposed to inappropriate conditions/temperatures discard. 3. Flucelvax Quadrivalent, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. If the vaccine has been exposed to inappropriate conditions/temperatures discard. 4. Colistimethate, should be stored at room temperature (59 degrees F- 86 degrees F) for full potency of medication use when in seven days. 5. [MEDICATION NAME], should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. Do not freeze. 6. [MEDICATION NAME], should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. 7. Humalog, should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. 8. [MEDICATION NAME], should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. 9. [MEDICATION NAME], should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. 10. [MEDICATION NAME], store in a refrigerator and protect from light. [MEDICATION NAME] should be stored at 36 degrees F to 46 degrees F. 11. [MEDICATION NAME], should be stored in a refrigerator with temperatures ranging 35 degrees F-46 degrees F. Do not freeze. Discard if the vaccine has been frozen. If the vaccine has been exposed to inappropriate conditions/temperatures discard. 12. Acetylcsteine, store unopened vials at room temperature 68 degrees F to 77 degrees F. Store at 36 degrees F to 46 degrees F after opening. During an interview with the Maintenance Director Of Operations (MDO), on (MONTH) 28, (YEAR), at 2:55 PM, the MDO stated he is in-charge of the facility maintenance for the building. The MDO confirmed no one had reported any refrigerator with temperatures out of range for the past two months. The MDO verified each nursing station had a log book to record any maintenance issues and it gets checked twice a day. The MDO also verified he carries a radio and can be reached at all times when he is at the facility. When asked about the procedure for a refrigerator with temperatures that are out of range, the MDO stated, The staff should report it right away and I will check with my laser gun (a device used to check refrigerator temperatures). The MDO stated the medication rooms are locked and only licensed nurses go in them and should report any problems to me. A phone call was made to the Pharmacy Consultant (PC), on (MONTH) 28, (YEAR), at 3:01 PM, there was no answer. During a phone interview with the PC, on (MONTH) 29, (YEAR), at 9:25 AM, the PC confirmed he is the Pharmacy Consultant for {Name of Facility}. The PC stated he comes to facility twice month and he does Drug Regimen Reviews, reviews any potential medication problem, and does a reconciliation on the cubex (automated medication and supply management). The PC stated he delegates the medication storage to the nurse consultant but everything is supposed to be reported to him. The PC confirmed medication refrigerator temperatures should be monitored by staff and maintained at a safe range for medications around 36 degrees F to 46 degrees F. The PC stated if a medication refrigerator temperatures were out of range and they contained temperature sensitive medications like vaccines and insulin, I would not administer them because they would not be affective anymore. Review of the facility's Pharmacy Services Agreement For: {Name of Facility}, dated (MONTH) 1, (YEAR), indicated Handling, Storage and Distribution. Pharmacy will assist the Facility in complying with the federal and state regulations regarding drug handling, storage, control and distribution. Review of the facility policy and procedure titled, Medication Refrigerator Storage, Revised (MONTH) (YEAR), indicated,1. Temperature Control-Drugs requiring refrigeration shall be stored on a refrigerator between 36 degrees F and 46 degrees F. 2. A daily medication refrigerator temperature log will be kept to assure that the temperature is maintained. 3. Adjustments will be made to the thermostatic control as needed. 4. If the temperature is found to be outside acceptable range then monstrance will be alerted. Review of the facility policy and procedure titled, Maintenance Services, revised (MONTH) 2009, indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure to implement their infection control and prevention program as evidenced by the following: 1. A Glucometer (device used to check blood sugar) was not disinfected according to the manufacturer's guidelines and adhere to facility's policy and procedure to use specified Environmental Protection Agency (EPA) approved disinfectant (a chemical agent that destroy bacteria, virus, and fungi) before and after residents' use for four of 39 sampled residents (Residents B, 170, 45, and 57) in a universe of 228 residents. A. For Resident B, the Licensed Vocational Nurse (LVN 12) used alcohol wipes instead of facility approved disinfectant. B. For Resident 170, LVN 3 used the glucometer without disinfecting the glucometer before and after use. C. For Residents 45 and 57, LVN 9 did not disinfect the glucometer before and after obtaining the blood sugar checks between these two residents. 2. A Biohazard waste container was found in the conference room with a sharps container filled with used syringes, trash, and a towel. 3. LVN 3 did not perform hand washing before and after medication administration for Residents 170 and 199. 4. LVN 3 used tap water from the bathroom faucet for Gastrostomy tube (a feeding plastic tube used to administer medication and liquid nutrition through a surgical opening in the stomach) medication administration for Resident 199. 5. The Respiratory Therapist (RT) did not label the incentive spirometer (breathing machine to help the lungs) for Resident 153. 6. Three oxygen tubings and concentrators were found unlabeled for Residents 9, 28, and 31. 7. The Cubex (automated drug dispensing machine) was inside the storage room with piles of residents' personal clothing, water bottles, dry food, radios, and staff personal belongings. 8. Resident 176's wheelchair was found with multiple white spots, dry food, and dust at the foot board and arm rests. 9. Multiple plastic food warming lids and food warming bases were stacked and stored wet in the kitchen. These failures created an overall danger of transmission of infection to vulnerable residents and had the potential for all residents who shared the potentially contaminated glucometer to develop blood borne infection (disease that can be spread through contaminated blood and other body fluids). The failure to follow the manufacturer's guidelines and adhere to the facility's policy and procedure to disinfect their glucometer with EPA approved disinfectant in between resident' use resulted in an Immediate Jeopardy (IJ, immediate danger of harm). An IJ was called on (MONTH) 28, (YEAR), at 3:58 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON were informed of the findings related to the glucometer and were asked to provide a corrective action plan. On (MONTH) 28, (YEAR) at 5:16 PM, a corrective action plan was provided by the facility. Observation, staff interviews, and record reviews were conducted to ensure the corrective action plan was implemented. The facility's corrective action plan included, providing in-service training of all staffs to perform hand hygiene before and after resident's care, using clean technique while performing blood sugar checks, and disinfecting glucometer properly before and after use with EPA approved disinfectant, new glucometers were provided, and EPA approved wipes (BRAND NAME) were made available for disinfecting on all medication carts. The IJ was lifted on (MONTH) 30, (YEAR), at 11:45 AM, in the presence of the ADMIN and DON after the survey team ensured the corrective action plan had been implemented. Findings: 1. A review of Resident B's clinical records indicated she was admitted on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. During a medication pass observation on (MONTH) 28, (YEAR), at 6:11 AM, LVN 12 wiped the glucometer with alcohol wipes after performing blood sugar testing for Resident B. During a concurrent interview with LVN 12, he stated he used one glucometer machine to check for blood sugar test on multiple residents in his unit and used alcohol wipes to disinfect the glucometer in between residents use. LVN 12 stated he normally uses (BRAND NAME) wipes to disinfect the glucometer machine at midnight and at the end of the shift, otherwise, he used alcohol wipes to disinfect the glucometer before and after resident's use. LVN 12 stated he never received in service training on disinfecting the glucometer machine. A review of the in-service training record sign-in log for the glucometer machine dated (MONTH) 28, (YEAR), (MONTH) 6, (YEAR), and (MONTH) 26, (YEAR), indicated LVN 12 did not attend the in service provided by the facility. B. A review of Resident 170's clinical records indicated Resident 170 was admitted on (MONTH) 4, (YEAR) with [DIAGNOSES REDACTED]. During an observation on (MONTH) 28, (YEAR), at 6:11 AM, LVN 3 used the glucometer without disinfecting the glucometer prior to and after use during the blood sugar check for Resident 170. During an interview with LVN 3 on (MONTH) 28, (YEAR), at 6:22 AM, she stated, I forgot to clean the glucometer before and after checking the blood sugar for Resident 170. During an interview with LVN 1 on (MONTH) 28, (YEAR), at 6:43 AM, LVN 1 stated, The night shift nurses will disinfect with (BRAND NAME) wipes and I use alcohol wipes before and after use of glucometer, right now I don't have any disinfectant wipes (BAND NAME) in my medication cart. During an interview with the Director Staff Development (DSD 1) on (MONTH) 28, (YEAR), at 6:58 AM, the DSD 1 stated it (the glucometer) should be disinfected before and after use with disinfectant wipes (BRAND NAME). During an interview with the Infection Control Preventionist Nurse (ICP Nurse) on (MONTH) 28, (YEAR) at 7:00 AM, he stated, We have to clean our glucometer with certain wipe's (BRAND NAME) that should be available on every medication cart and our glucometer must be disinfected before, after, and in between resident use. During an interview with the Assistant Director of Nursing (ADON 1) on (MONTH) 28, (YEAR) at 7:04 AM, the ADON stated that the glucometer machine should be cleansed with disinfectant wipes (BRAND NAME) before and after checking the blood sugar of the residents. During an interview with the Director of nursing (DON) on (MONTH) 28, (YEAR) at 7:21 AM, the DON stated that the nurse must disinfect the glucometer before and after using our approved disinfectant wipes (BRAND NAME) for disinfecting our equipment's used for resident care. C. A review of Resident 45's clinical record, indicated Resident 45 was admitted on (MONTH) 24, (YEAR) with [DIAGNOSES REDACTED]. During an observation on (MONTH) 28, (YEAR), at 6:41 AM, LVN 9 was observe not to disinfect the glucometer before use on Resident 45. LVN 9 left the glucometer on Resident 45's bed and performed the blood sugar check on the resident. LVN 9 did not perform hand hygiene nor did he disinfected the glucometer after the blood sugar test on Resident 45. LVN 9 proceeded to perform another blood sugar test on Resident 57 without disinfecting the glucometer. A review of Resident 57's clinical record, indicated Resident 57 was admitted on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. During an observation on (MONTH) 28, (YEAR), at 6:42 AM, LVN 9 continued to check the blood sugar for Resident 57 without performing hand hygiene nor disinfecting the glucometer before and after use for Resident 57. During a concurrent interview with LVN 9, he verified he did not disinfect the glucometer or perform hand hygiene. He stated, I forgot. LVN 9 stated he usually uses alcohol wipes to disinfect the glucometer before and after residents' use. During an interview with the DON on (MONTH) 28, (YEAR), at 8:30 AM, the DON stated the glucometer should be disinfected between residents use with facility approved disinfectant (BRAND NAME) wipes to prevent the transmission of infection. The DON further stated alcohol wipes should not be used to disinfect the glucometer. During an interview with the Pharmacy Nurse Consultant (Consultant) on (MONTH) 28, (YEAR), at 3:46 PM, she stated the glucometer should be disinfected with EPA approved disinfectant in between resident use and alcohol wipes are never to be used as a disinfectant for glucometer. A review of facility's policy and procedure titled, Blood Sampling and Disinfectant- Glucometer, dated (MONTH) 2014, indicated wash hands before and after the procedure and Equipment and supplies; 6. Approved EPA registered disinfectant for cleaning of sampling device such as (BRAND NAME), General Guidelines; 1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses with disinfectant such as (BRAND NAME) disinfecting. A review of facility's form titled, Medication Administration Licensed Nurse Skills Competency Worksheet, dated (YEAR), indicated the glucose machine should be disinfected. 2. During an observation on (MONTH) 26, (YEAR) at 8:36 PM, a red plastic container labeled with a Biohazard Wastes (any waste contaminated with potentially with infectious agents or materials) was found inside the conference room/chapel room. The biohazard waste container had a plastic sharps container with used syringes, trash, and a towel. During an interview with the Director of Nursing (DON) on (MONTH) 26, (YEAR) at 8:45 PM, she stated the biohazard wastes should be stored inside the biohazard wastes storage located in Unit 1, on the first floor of the facility. During a concurrent observation and interview with the DON, she verified the biohazard waste was in the conference room /chapel room. She opened the biohazard waste container and confirmed it contained a sharps container filled with used syringes, trash, and towel. The DON stated the biohazard wastes container should have been stored in the bio hazard wastes storage room in Unit 1, on the first floor. During an interview with Infection Control Preventionist Nurse (ICP Nurse) on (MONTH) 27, (YEAR) at 9:50 AM, he stated that the RN (Registered Nurse) Supervisor and himself had the key to the biohazard storage room. The ICP Nurse stated he was responsible for leaving the biohazard wastes container in the conference room. He stated it should have been removed and stored in the biohazard storage room. A review of the facility policy and procedure titled, Biohazard Waste Storage, revised (MONTH) 2012, indicated, Policy Interpretation and Implementation: 3. Containers of medical waste will be stored in the following location (s): Station I - Labeled Biohazard room. 8. Medical wastes storage room will be locked and access to medical waste will be to the limited to the following personnel: ADON, RN Supervisor, Charge Nurse, Infectious Control Preventionist, and Maintenance Supervisor. 3. A review of Resident 170's clinical record, indicated Resident 170 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Residents 199 's clinical record indicated, Resident 199 was admitted on (MONTH) 12, (YEAR) with a [DIAGNOSES REDACTED]. During a medication pass observation on (MONTH) 28, (YEAR), at 6:11 AM, LVN 3 did not wash her hands before and after medication administration. During a concurrent interview with LVN 3, she verified and stated, I forgot to wash my hands before and after medication administration. During an interview with the Director Staff Development (DSD 1) on (MONTH) 28, (YEAR) at 6:58 AM, he stated that the staff should always perform hand hygiene before and after resident care and during medication administration. During an interview with Director of Nursing (DON) on (MONTH) 28, (YEAR) at 7:21 AM, she stated staff should follow and implement their policy and procedure to observe hand hygiene practices to prevent transmission of infection. The facility policy and procedure titled, Handwashing/Hand Hygiene, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections; . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situation b. before and after contact with residents, before preparing or handling medications . l. after contact with objects (e.g., medical equipment. Applying and Removing Gloves; . 1. Perform hand hygiene before applying non-sterile gloves. The facility policy and procedure titled, Medication Administration Licensed Nurse Skills Competency Worksheet, dated (MONTH) 27, (YEAR), indicated, Procedure steps: wash hands prior to passing medication, invasive procedures, before and after gloves, after touching resident or their items. 4. During a review of Resident 199's clinical record indicated, Resident 199 was admitted on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. During a medication pass observation on (MONTH) 28, (YEAR), at 6:16 AM, LVN 3 used tap water from the bathroom faucet for medication administration via [DEVICE] for Resident 199. During an interview with LVN 3 on (MONTH) 28, (YEAR), at 6:22 AM, she stated, I think I'm allowed to get water from the bathroom faucet but usually our water pitcher was always filled from the kitchen. During an interview with the DSD 1 on (MONTH) 28, (YEAR), at 6:58 AM, he stated the drinking water for the residents and [DEVICE] medication administration and GT flushes should come from the kitchen. During an interview with Infection Control Preventionist Nurse (ICP Nurse) on (MONTH) 28, (YEAR) at 7:00 AM, he stated that they use water from the kitchen for medication administration. During an interview with (ADON 1) on (MONTH) 28, (YEAR) at 7:04 AM, she stated, We don't get water from the resident bathroom water faucet for medication administration. During an interview with the Director of Nursing (DON) on (MONTH) 28, (YEAR) at 7:21 AM, she stated that the water from the bathroom faucet cannot be use for medication administration. The policy and procedure was requested from Medical Records Director (MRD) for water to use for medication administration but a policy and procedure was not provided during the survey. 5. A review the clinical record for Resident 153 indicated the resident was admitted on (MONTH) 20, (YEAR) with a [DIAGNOSES REDACTED]. During an observation on (MONTH) 26, (YEAR) at 10:40 AM, Resident 153 was in his bed watching TV. On top of the bedside table were a water pitcher, a drinking glass and an incentive spirometer (a medical device used to help patients improve the functioning of their lungs) with no label. During an interview with Resident 153 on (MONTH) 26, (YEAR) at 10:48 AM, Resident 153 stated, This thing is mine, I use it sometimes and yes the Respiratory Therapist forget to put my name I guess. During an interview on (MONTH) 26, (YEAR) at 10:55 AM, LVN 19 stated, All equipment's used by residents were usually labeled with their names. During an interview on (MONTH) 26, (YEAR) at 10:58 AM, with the Respiratory Therapist (RT), the RT stated, I haven't noticed that there was no name on it. During an interview on (MONTH) 26, (YEAR) at 11:08 AM, the Director of Staff Development (DSD 1) stated that they have instructed all staff to write the name of the resident on the items belonging to each resident such as their incentive spirometer, oxygen tubing, water pitcher, drinking glass and more. The policy and procedure titled, Standard Precautions, dated (MONTH) 2007, indicated standard precautions include the following practices: 5. Resident-Care-Equipment; Ensure that reusable equipment is not used for the care of another resident after it has been appropriately cleaned. 6a. A review of Resident 9's clinical record indicated, the resident was admitted to the facility on (MONTH) 22, (YEAR) with [DIAGNOSES REDACTED]. During a review of Resident 9's physicians orders dated (MONTH) 30, (YEAR), an order for [REDACTED]. During an observation on (MONTH) 26, (YEAR) at 9:46 AM, Resident 9 was observed with oxygen (O2-a gas essential to life) at 2 Liter (L-unit of measure)/minute via nasal cannula (N/C- used to deliver oxygen when low to medium concentration is required) via a concentrator (a medical device used to deliver oxygen) that was unlabeled, without a date and time of when it was last changed. During a concurrent interview with LVN 13, LVN 13 verified the oxygen tubing and concentrator were not labeled with the date and time of when it was last changed and acknowledged it should be labeled. 6b. A review of Resident 31's clinical record indicated, the resident was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. During a review of Resident 31's physician's orders dated (MONTH) 29, (YEAR), indicated a physician order for [REDACTED]. During an observation on (MONTH) 26, (YEAR), at 10:17 AM, Resident 31 was observed with O 2 at 2L/minute per N/C via a concentrator, which was found unlabeled with no date and time of when it was last changed. During a concurrent interview with LVN 13, LVN 13 confirmed oxygen tubing and concentrator were not labeled and should be labeled. 6c. A review of Resident 28's clinical record indicated, Resident 28 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 28's physician's orders dated (MONTH) 30, (YEAR), indicated the physicians order for O 2 at 2/minute continuously for shortness of breath. During an observation on (MONTH) 26, (YEAR), at 10:48 AM, Resident 28 was observed to have O 2 in-place at 2 L/ minute per N/C via concentrator was found unlabeled. Resident 28 stated the O 2 does help her breathe. During a concurrent interview with LVN 13, LVN 13 confirmed oxygen tubing and concentrator were not labeled and should be labeled with date and time when it was last changed. The facility schedule titled, Terracina Respiratory Equipment Change Schedule, Undated, indicated' . Sunday Night Shift-Oxygen tubing, tubing mask, and [MEDICATION NAME]. Change as needed. 7. During an observation of the facility's Cubex (automated drug dispensing machine) located inside the medication room on (MONTH) 28, (YEAR), at 7:17 AM, with the Licensed Vocational Nurse (LVN 10), there were piles of residents' personnel clothes, water bottles, dry food, radios, and staffs' personnel belongings. During a concurrent interview with LVN 10, she stated she was not sure why the residents and staff belongings were stored inside the Cubex medication dispenser area. During an interview with the Social Worker (SW) on (MONTH) 28, (YEAR), at 7:20 AM, she stated these clothes belonged to transferred residents. During an interview with the RN 1, on (MONTH) 28, (YEAR), at 7:30 AM, she stated, Only licensed staff had the access to Cubex medication room and should not be used as a storage. During an interview with the Activity Assistant (AA), on (MONTH) 28, (YEAR), at 7:30 AM, she verified the radios belonged to the activity department. During an interview with Director of Nursing (DON), on (MONTH) 28, (YEAR), at 2:19 PM, she stated the Cubex medication room should not be used for storage of personal belongings and etc. but for medication storage. A review of facility's policy and procedure titled, Storage of Medication, dated Revised (MONTH) 2007, indicated 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 8. During an observation on (MONTH) 26, (YEAR) at 10:56 AM, Resident 176 was sitting in a wheel chair (WC) with multiple white spots, dried food and dust at the foot board, and both arm rests. During an interview with a Certified Nursing Assistant (CNA 4) on (MONTH) 26, (YEAR) at 11:07 AM, CNA 4 stated. It looks dirty. During an observation on (MONTH) 27, (YEAR) at 9:30 AM, Resident 176 was observed sitting in a wheel chair with multiple white spots, dried food particles at the foot board and the both arm rests. During an observation on (MONTH) 28, (YEAR) at 2:00 PM, Resident 176 was sitting in the same wheel chair with multiple white spots and dried food particles on the foot board and the both arm rests. During an interview with the House Keeping Supervisor (HK Sup) on (MONTH) 28, (YEAR) at 2:25 PM, he stated morning housekeepers usually clean the wheelchairs in the unit. The HK Sup stated the facility had a wheelchair cleaning schedule, however the HK Sup can not provide the cleaning schedule log for wheelchair. During an observation on (MONTH) 29, (YEAR) at 9:00 AM, Resident 176 was sitting in a same wheelchair with multiple white spots and dried food particles at the arm rests and foot board, in the activity room. During a concurrent observation and interview on (MONTH) 30, (YEAR) at 8:44 AM, along with the Housekeeping 1 (HK 1) he verified and stated, It is a dirty wheelchair. During an interview with CNA 3, on (MONTH) 30, (YEAR) at 8:50 AM, she stated, It looks dirty to me. CNA 3 stated housekeeping/maintenance usually cleaned the wheel chair once a week. The facility policy and procedure titled, Standard Precautions, revised (MONTH) 2007, indicated the following: Standard precautions include the following practices: 6. Environmental Control a. Ensure that environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned. 9. During a kitchen observation on (MONTH) 26, (YEAR) at 3:15 PM, multiple plastic food warming lids were found stacked and stored wet in the kitchen rack readily available for resident's use. During an interview with the Dietary Aide/Dishwasher (DA) on (MONTH) 26, (YEAR) at 3:15 PM, the DA verified the lids were stored and stacked wet. He further stated, It takes more time to dry, there is no time to dry it. During an interview with the Dietary Service Supervisor (DSS) on (MONTH) 26, (YEAR), at 3:17 PM, the DSS verified the food warming lids were stacked and stored wet in the kitchen rack and were ready for resident's use. The DSS stated all food warming lids should be completely air dry before stacking and storing. During a tray line observation on (MONTH) 28, (YEAR) at 7:00 AM, 13 plastic food warming bases were stacked and stored wet and ready to use in the kitchen. During a concurrent interview with the DSS, he confirmed that there were 13 counts of plastic food warming bases that were stacked and stored wet and was readily available for resident's use. A review of the facility policy and procedure titled, DISH WASHING (NAME OF THE HEALTHCARE GROUP), Inc. (YEAR), indicated: Procedure 5. Dishes are to be air dried in racks before stacking and storing.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided the necessary protection and interventions in accordance with the facility's abuse policy and procedure. This failure resulted in Resident 1 experiencing verbal abuse, which caused psychological harm and emotional distress. Findings: An unannounced visit was conducted to the facility on (MONTH) 6, (YEAR), at 3:45 PM, to investigate a facility reported incident (FRI) regarding an allegation of resident abuse (Resident 1). A review of the written statement signed by the MDS 2 Coordinator (Minimum Data Set), dated (MONTH) 5, (YEAR), indicated Resident 1 was upset and demanded that something be done in regards to the staff awakening her (on (MONTH) 4, (YEAR)) and calling her Coo Coo. During an observation on (MONTH) 6, (YEAR), at 5:05 PM, in Resident 1's room, she was lying in bed, awake, alert and anxious. She stated she was upset with the abuse she had received from the staff on (MONTH) 4, (YEAR). During an interview with Resident 1, on (MONTH) 6, (YEAR), at 5:10 PM, she stated she could not stop thinking about the treatment she had received on (MONTH) 4, (YEAR). She stated the Certified Nurse Assistant (CNA 1) had scared her by standing over her and clapping her hands loudly. Resident 1 stated, She was making fun of me. Resident 1 stated after she had awakened, CNA 1 laughed at her and called her Coo, Coo Resident 1 further stated CNA 1 had gone into her room, on (MONTH) 6, (YEAR), and said, Hello to her roommates. Resident 1 stated her voice just gave me chills. She further stated she did not understand the reason CNA 1 treated her so badly. Resident 1 stated she felt CNA 1 would retaliate against her. A review of Resident 1's clinical record indicated she was admitted to the facility on (MONTH) 28, (YEAR), with [DIAGNOSES REDACTED]. During an interview with the staffing coordinator (SC 1), on (MONTH) 6, (YEAR), at 5:35 PM, she stated CNA 1 had worked (MONTH) 6, (YEAR), on day shift (7:00 AM-3:00 PM) and was assigned to Station 1 where Resident 1 resides. A review of the Daily Station Assignment dated (MONTH) 6, (YEAR), indicated CNA 1 had been assigned to Resident 1's room. CNA 1 had further signed in on the assignment sheet dated (MONTH) 6, (YEAR). During an interview with the Director of Nursing (DON), on (MONTH) 6, (YEAR), at 6:01 PM, she stated she was aware Resident 1 had made an abuse allegation, on (MONTH) 5, (YEAR), and the facility was in the process of investigating the allegation. She stated CNA 1 had not been suspended. A review of the written statement signed by LVN 1, undated, indicated Resident 1 began to scream and yell saying that CNA was yelling and clapping in my face. She is a racist. You don't have to wake me up by clapping in my face. A review of the facility's physician's history and physical for Resident 1, dated (MONTH) 11, (YEAR), indicated, Resident 1 does have the capacity to understand and make her own decisions. During an interview with MDS 1, on (MONTH) 7, (YEAR), at 9:15 PM, she reviewed the clinical record for Resident 1 and stated her BIMS (Brief Interview for Mental Status-given by the healthcare team that helps determine a patient's mental understanding. A BIMS score of 13-15 indicates mental status intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment) score is fifteen (15). She further stated Resident 1 has the capacity to understand and responds appropriately most of the time. During an interview with CNA 1, on (MONTH) 10, (YEAR), at 4:05 PM, she stated she had received a phone call, on (MONTH) 5, (YEAR), from the facility. CNA 1 stated she was asked about the incident that had occurred with Resident 1. She further stated, At no time did anyone say I was suspended or I could not return to my normal run (station or unit). CNA 1 stated she was not feeling well, on (MONTH) 5, (YEAR), and called the facility to request the evening off. She stated the staff coordinator asked if she could work the following morning (September 6, (YEAR)), she could have the requested night off. CNA 1 stated she had agreed to the terms. CNA 1 stated she reported to her normal run, on (MONTH) 6, (YEAR). She further stated she had worked the entire shift and had gone into Resident 1's room, on (MONTH) 6, (YEAR), to provide care for Resident 2 and Resident 3, but she did not talk to Resident 1 or attempt to provide care for her. She stated, on (MONTH) 7, (YEAR), she had been re-assigned to another station. During an interview with the Administrator and the DON on (MONTH) 11, (YEAR) at 5:20 PM, he stated the facility did not suspend CNA 1 and they allowed her to return to her regular duty. The facility acknowledged they did not follow their abuse policy and procedure. A review of the facility's policy and procedure titled, Abuse Investigation and Reporting dated (MONTH) (YEAR), indicated the following: 2. In the event the employee is not present at the time allegation is made, we will contact the employee by phone and notify the employee of their suspended employee status. 4. In the event an allegation is deemed unsubstantiated, accused employee and/or visitor will be instructed and monitored by facility leadership to avoid contact with alleging resident ( .remain away from the resident's station). 5. All facility leadership involved in assigning accused employee's work (whether substantiated or unsubstantiated), will be instructed by the Administrator or Designee of the employee's modified status. A review of the facility's policy and procedure titled, Preventing Resident Abuse with a review date of (MONTH) (YEAR), indicated: Policy Statement: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems . to assist in preventing resident abuse .

Based on interview, and record review, the facility failed to ensure that all tests and medications ordered at the time of admission were transcribed and administered to one of three sampled residents (Resident 1), when insulin (Insulin [MEDICATION NAME]- controls blood sugar) and finger stick blood sugars were missed for a total of 10 days. This failure resulted in Resident 1 experiencing hyperglycemic hyperosmotic non- ketoti[DIAGNOSES REDACTED] (HHNS) (a complication of high blood sugar state causing severe dehydration, increases in osmolality (relative concentration of solute) and a high risk of complications, coma and death. It is diagnosed with [REDACTED]. Findings: An unannounced on-site visit was conducted on June 1, 2017, for an abbreviated survey to investigate a complaint regarding Resident 1 being admitted to a GACH with a blood sugar greater than 900 (normal 70-110 milligram per deciliter (mg/dl)). During a review of Resident 1's electronic clinical record (e-record) the Face sheet (a document which provides the demographic data of the resident) indicated Resident 1 was admitted to the facility on [DATE], at 7:45 PM, from a General Acute Care Hospital (GACH 1), with [DIAGNOSES REDACTED]., insulin resistance, and relative lack of insulin) and has a gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach). A review of the discharge orders from the transferring facility (GACH 1) dated May 17, 2017, for Resident 1, included, Insulin [MEDICATION NAME], subcutaneous (under the skin) injection, units sliding scale (insulin dosed based on finger stick blood sugar readings), if BS (blood sugar) < (less than) 50 milligram per deciliter (mg/dl) (a unit of measurement), critical value, notify MD (physician). If BS < 61, see D50 (50% [MEDICATION NAME] solution given to raise blood sugar) order. If BS 150 to 200, give 3 units (insulin). If BS 201 to 250, give 5 units (insulin). If BS 251 to 300, give 7 units (insulin). If BS 301 to 350, give 9 units (insulin). If BS 351 to 400, give 11 units (insulin). If BS > (greater than) 400, Notify MD. If BS >450,critical value Notify MD. First dose (order initiated) 4/6/17(April 6, 2017) 0600 (6 AM), y Q6H (every six hours), last dose 5/17/17 ( May 17, 17) 7:08 AM. A review of Resident 1's Order Summary Sheet, dated May 17, 2017, did not include the transfer order to continue the finger stick blood sugars with the sliding scale dose of insulin, as prescribed in the discharge orders from the transferring facility (GACH 1). During an interview with the Registered Dietician (RD) on June 13, 2017, at 2:10 PM, she stated that she was not informed about Resident 1's diabetic diagnosis. During an interview with a Registered Nurse (RN 1) on June 13, 2017 at 3:08 PM, she reviewed the e-record and was unable to find documentation of the medication verification with the physician upon admission for Resident 1. RN 1 described the admission order verification process as follows: when a new admission comes it is the licensed nurses' responsibility to call the physician and verify orders and document the verification in the residents' e-record. An interview was conducted on June 13, 2017 at 3:14 PM, with the Licensed Vocational Nurse (LVN 1) who had entered the transfer orders into Resident 1's electronic clinical record. LVN 1 stated that she verified with Resident 1's physician regarding the admission orders [REDACTED]. LVN 1 reviewed Resident 1's e-record and was unable to find any documentation of medication verification, or the order for the finger stick blood sugars nor insulin as ordered on the discharge transfer form from the GACH 1. A review of Resident 1's physician progress notes [REDACTED].continue present discharge orders(from GACH 1). During a telephone interview with Physician 2, on June 16, 2017 at 11:55 AM, he stated that he did not receive any call or text regarding Resident 1's admission orders [REDACTED]. During an interview with the Director of Nurses (DON), on June 13, 2017 at 2:22 PM, he stated that when a new admission comes into the facility, more than one licensed staff, and the physician review the orders. He was unable to explain how this medication order had been missed. A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's clinical record titled SBAR(Situation Background Assessment Recommendations)/ Acute Care Transfer dated May 27, 2017, indicated that Resident 1 required a transfer to the acute care hospital (GACH 2) due to shortness of breath. A review of the admission assessment from GACH 2 dated May 27, 2017, indicated that Resident 1 was admitted for [MEDICAL CONDITION] (high blood sugar). Further review of the clinical record indicated that Resident 1 was in a state of severe dehydration due to HHNS. Resident 1 was being treated in GACH 2 with a continuous insulin drip (intravenous administration of insulin) for [MEDICAL CONDITION]. A review of the of the clinical laboratory results for Resident 1, from GACH 2, dated May 27, 2017, indicated that the blood sugar level was 949 mg/dl where the normal range was 70-110 mg/dl.(unit of measure). A review of the skilled nursing facility's policy and procedure titled Reconciliation of Medication on Admission, revised December 2012, indicated: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission. The policy further indicated that licensed nurses were required to communicate with the physician for medication reconciliation and document that in the residents' medical record on admission.

Based on observation, interview, and record review, the facility failed to have a system in place to monitor the water temperatures in 47 of 106 resident rooms, three of three private showers, and one of four community shower rooms, which resulted in the potential for scalding burns (3rd degree-full thickness burns can occur during exposure to water temperatures of 120 degrees Fahrenheit for five minutes) to 218 residents due to water temperatures above 120 degrees Fahrenheit. An immediate jeopardy (IJ) was called under 483.25, Quality of Care, on November 9, 2015 at 4:35 PM, in the presence of the Administrator, Director of Nursing, and Director of Clinical Operations. The corrective action plan was reviewed by the team and based on observation, interview, and record review the immediate jeopardy was removed on November 9, 2015 at 7:15 PM in the presence of the Administrator, Director of Nursing, and Director of Clinical Operations. Findings: During initial tour on November 9, 2015 from 8:35 AM to 10:30 AM, the following temperatures were obtained throughout the facility: Room 118 sink- 125.7 degrees Fahrenheit Room 119 sink- 125 degrees Fahrenheit Room 120 sink- 130 degrees Fahrenheit Room 105 sink- 139.3 degrees Fahrenheit Room 124 sink- 130 degrees Fahrenheit Room 125 sink- 126 degrees Fahrenheit Room 126 sink- 130 degrees Fahrenheit Room 110 sink- 130.9 degrees Fahrenheit Room 113 sink- 136.2 degrees Fahrenheit Room 201 sink- 121 degrees Fahrenheit Room 235 sink- 130.1 degrees Fahrenheit These rooms had hot water temperatures 5 to 9.3 degrees Fahrenheit above the safe hot water temperature of 120 degrees Fahrenheit. During an interview with Social Worker (SW), provided by the facility as a tour guide, in room 120, on November 9, 2015 at 8:47 AM, she verified the temperature of the bathroom sink water was 130 degrees Fahrenheit. During a concurrent interview with Resident B, he stated the water temperature gets hot and that it has been like that for a few weeks. When asked if he reported it to anybody, Resident B stated, No. No one here listens anyway. During an interview with Resident 19, in room 105, on November 9, 2015 at 9:05 AM, Resident 19 stated, The water temperature in the bathroom is too hot. I have not hurt myself but I'm afraid someone will. I reported it yesterday (November 8, 2015) and before to the people in charge of taking care the building (Maintenance Supervisor). It is the same (the water temperature), I don't have much feeling in my hands, but I know it is hot. During a concurrent interview with the Unit Manager (UM), she confirmed the temperature in room 105 was 139.3 degrees Fahrenheit. During an interview with Resident 27, in room 235, on November 9, 2015 at 10:30 AM, she stated the water temperature in the bathroom was too hot. During an interview with the Maintenance Supervisor (MS) and the Maintenance Worker (MW), on November 9, 2015 at 4:07 PM, the MS stated, the water temperatures had to be between 105-140 degrees Fahrenheit. He further stated, there was an anti-scalding device and it was set at 140 degrees Fahrenheit. The MS stated the water temperatures are only checked, when we get a complaint and no one has complained. During additional observation of hot water temperatures on November 9, 2015 at 4:00 PM, the following hot water temperatures were obtained from a sampling of residents' rooms throughout the facility: a.) The bathroom sinks in rooms 148, 159, 203, and 204 had water temperatures tested to be 129.9 degrees Fahrenheit (9.9 degrees above the safe water temperature of 120 degrees Fahrenheit). b.) The bathroom sink in room 207 had a water temperature of 129.5 degrees Fahrenheit (9.5 degrees above the safe water temperature of 120 degrees Fahrenheit). c.) The bathroom sink in room 209 had a water temperature of 133.9 degrees Fahrenheit (13.9 degrees above the safe water temperature of 120 degrees Fahrenheit). d.) The bathroom sink in room 210 had water temperature of 135.1 degrees Fahrenheit (15.1 degrees above the safe water temperature of 120 degrees Fahrenheit). e.) The bathroom sink in room 213 had a water temperature of 130.1 degrees Fahrenheit (10.1 degrees above the safe water temperature of 120 degrees Fahrenheit). f.) The bathroom sinks in rooms 218, 219, 220, and 221 had water temperatures of 129.9 degrees Fahrenheit (9.9 degrees above the safe water temperature of 120 degrees Fahrenheit). g.) The bathroom sink in room 223 had a water temperature of 130.1 degrees Fahrenheit (10.1 degrees above the safe water temperature of 120 degrees Fahrenheit). h.) The bathroom sink in room 228 had a water temperature of 129.8 degrees Fahrenheit (9.8 degrees above the safe water temperature of 120 degrees Fahrenheit). i.) The bathroom sink in room 230 had a water temperature of 129.9 degrees Fahrenheit (9.9 degrees above the safe water temperature of 120 degrees Fahrenheit). j.) The bathroom sink in room 231 had a water temperature of 122 degrees Fahrenheit (2 degrees above the safe water temperature of 120 degrees Fahrenheit). k.) The bathroom sink in room 232 had a water temperature of 129 degrees Fahrenheit (9 degrees above the safe water temperature of 120 degrees Fahrenheit). l.) The bathroom sink in room 233 had a water temperature of 124.5 degrees Fahrenheit (4.5 degrees above the safe water temperature of 120 degrees Fahrenheit). m.) The bathroom sink in room 237 had a water temperature of 134.1 degrees Fahrenheit (14.1 degrees above the safe water temperature of 120 degrees Fahrenheit). n.) The bathroom sinks in rooms 238, 239, 240, 241, 244, 245, 248, 250, 251, 252, 253, 254, 255, 257, 259, 260, and 261 had water temperatures tested to be 129.9 degrees Fahrenheit (9.9 degrees above the safe water temperature of 120 degrees Fahrenheit). o.) The private shower in room 213 had a water temperature of 136 degrees Fahrenheit (16 degrees above the safe water temperature of 120 degrees Fahrenheit). p.) The private shower in room 236 had a water temperature of 130.6 degrees Fahrenheit (10.6 degrees above the safe water temperature of 120 degrees Fahrenheit). q.) The private shower in room 237 had a water temperature of 130.2 degrees Fahrenheit (10.2 degrees above the safe water temperature of 120 degrees Fahrenheit). r.) The community shower room on Station 4 had a water temperature of 124.2 degrees Fahrenheit (4.2 degrees above the safe water temperature of 120 degrees Fahrenheit). During an interview with Certified Nurse Assistant 1 (CNA 1), on November 9, 2015 at 4:10 PM, she stated that she tests the water temperature with her elbow. She verified the sink water in room 237 was 134.1 degrees Fahrenheit. She further stated, It (the water) is too hot. It is usually like that. During an interview with Certified Nurse Assistant 2 (CNA 2), on November 9, 2015 at 4:15 PM, she stated she checks the temperature of water using the back of her hand and then adjusts it to the correct temperature by adding cold water. CNA 2 verified the sink water in room 209 was 133.9 degrees Fahrenheit. During an observation on November 9, 2015 at 4:20 PM, in room 236, an attempt to turn on the cold water of the private shower was made and no cold water came out. During a concurrent interview with CNA 1, when CNA 1 attempted to turn on the cold water she stated, Oh, it is not working. During an interview with the Director of Staff Development (DSD), on November 10, 2015 at 7:00 AM, she was asked to provide in-service records for training the CNAs on how to check shower temperatures. The DSD stated, the in-service for the Certified Nurse Assistants (CNAs) on how to check for water temperatures was done verbally and there was no documentation. During a review of Showers as per Schedule Turn In Shower Sheets to the Unit Manager to Forward to DSD, dated November 10, 2015, the form indicated an in-service training conducted by the DSD instructed staff on shower schedules, skin assessment sheets, and linen changes. There was no documented evidence the staff had been trained on how to determine if water temperatures were safe before providing a shower to prevent scalding. The facility policy and procedure titled Safety of Water Temperatures, dated December 2009, indicated: Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by residents should attain a hot water temperature not less than 105 degrees Fahrenheit (40.5 degrees Celsius) and not more than 120 degrees Fahrenheit (49 degrees Celsius). Maintenance staff should conduct periodic tap water temperature checks and record water temperatures in a maintenance log.Direct-care staff shall be informed of risk factors for scalding/burns related to hot water There was no documented evidence water temperatures were being monitored by the facility to prevent scalding of residents as per their policy and procedure. According to the State Operations Manual (SOM) 483.25 (h) Accidents indicated, Water may reach hazardous temperatures in hand sinks, showers, and tubs .Many residents in long-term care facilities have conditions that put them at increased risk for burns caused by scalding. These include decreased skin sensitivity, peripheral neuropathy (decreased circulation), and decreased agility (reduced reaction time) . The SOM further indicated at only a four (4) degree increase in temperature to 124 degrees Fahrenheit a 3rd degree burn can occur in three minutes.

Based on observation, interview, and record review, the facility failed to provide the necessary services to four (4) of 31 sampled residents (Residents 4, 9, 20 and 12) and 15 unsampled residents (Residents H, I, J, K, Q, R, S, O, P, T, U, V, W, Y and Z) as follows: 1. Failure to ensure insulin (medication that lowers blood sugar) vials were removed to prevent administration after their expiration dates to Residents 4, Y and Z. An immediate jeopardy (IJ) was called under 483.25, Quality of Care, on November 13, 2015 at 6:20 PM, in the presence of the Administrator, Director of Nursing, and Director of Clinical Services. 2. Failure of the licensed nurses to check the fingerstick blood sugar using the glucometer (a portable monitor used to measure blood sugar levels) for three (3) sampled residents (Residents 9, 20 and 12) and 13 unsampled residents (Residents H, I, J, K, Q, R, S, O, P, T, U, V, and W). 3. Failure to provide [MEDICATION NAME] (medication used to treat severe memory loss - dementia) to Resident 12 for treatment of [REDACTED]. These failures had the potential to adversely affect the resident's health and safety for all residents in a universe of 221 residents. Findings: 1. During a medication storage observation, on November 13, 2015 at 2:30 PM, in Station 4 front hallway with a Licensed Vocational Nurse (LVN 9), four expired multi-dose vials (containers of medication that can be used more than one time) of insulin were found. The following insulin vials were labeled by the pharmacy to discard 28 days after opening: a. Resident 4- [MEDICATION NAME] dated as opened on October 2, 2015, which expired October 30, 2015, and Humalog ([MEDICATION NAME]) insulin dated opened on October 8, 2015, which expired November 5, 2015. b. Resident Y- [MEDICATION NAME] R insulin (Insulin Regular) dated opened September 13, 2015, which expired on October 11, 2015. c. Resident Z- Humalog insulin ([MEDICATION NAME])dated opened October 10, 2015, which expired on November 7, 2015. During a concurrent interview with LVN 9, he stated usually the night shift checks the expiration of insulin at least one time a month. He further stated, But, I should have checked. During an interview with the Clinical Care Coordinator (CCC), on November 13, 2015 at 4:45 PM, in the medication room, the CCC verified the [MEDICATION NAME] with date opened of October 2, 2015, [MEDICATION NAME] R with date opened September 13, 2015, and [MEDICATION NAME] with date opened October 10, 2015 were expired. A review of Resident 4's Medication Administration Record (a document indicating when a medication was given to a resident; MAR) , dated for the months of October and November 2015, indicated Resident 4 received [MEDICATION NAME] at least once a day on October 31, 2015 and on November 1 through November 13, 2015. The [MEDICATION NAME] expired on October 30, 2015, and was administered to Resident 4 a total of 14 days after expiration. Resident 4 received [MEDICATION NAME]on November 13, 2015. The [MEDICATION NAME]expired on November 5, 2015, and was administered a total of one day after expiration. A review of Resident Y's MAR, dated for the months of October and November 2015, indicated Resident Y received Insulin Regular ([MEDICATION NAME] R), at least once a day on October 17, 19, 20, 22, 23, 24, 25, 29, 30, 2015 and November 2, 5, 6, 2015. The Insulin Regular ([MEDICATION NAME] R), had expired on October 11, 2015, and was administered to Resident Y a total of 12 days after expiration. A review of Resident Z's MAR, dated for the months of October and November 2015, indicated Resident Z received Humalog insulin, at least once a day on October 10, 11, 12, 15, 16, 19, 22, 27, 29, 30, 2015 and November 3, 4, 6, 10, 11, 12, 2015. The Humalog insulin had expired on November 7, 2015 and was administered to Resident Z a total of 16 days after expiration. The facility policy and procedure titled, Facility Auditing and Removal of Expired and Discontinued Medications, (not dated), indicated, The medication nurse will remove expired medications from the drug storage areas so that they are not administered to residents. The facility staff will remove expired medications from the medication storage areas on a regular schedule and when encountered .Prior to each use the nurse administering the medication will verify that the medication is not expired At least once monthly the nurse responsible for the medication cart for each station will inspect the medication cart and medication room for expiring medications . An immediate jeopardy (IJ) was called under 483.25, Quality of Care, on November 13, 2015 at 6:20 PM, in the presence of the Administrator, Director of Nursing, and Director of Clinical Services. On November 13, 2015, the corrective action plan submitted was reviewed. The implementation action, which included the insulin medications being discarded and a new delivery from pharmacy, provided to the team by the facility was observed to be in place. The immediacy was removed on November 13, 2015 at 7:05 PM. 2 a. During a review of the clinical record for Resident 9, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 1, 2015, noted an order for [REDACTED]. Notify MD if the blood sugar (BS) is less than (<) 70 or greater than (>)180. A review of Resident 9's Medication Administration Record (MAR- a form on which the licensed nurses log medications that have been given) beginning on August 1, 2015 and continuing through November 12, 2015, showed there was no documented evidence that the Accuchecks were performed by the licensed nurses as ordered by the physician to include the BS results to indicate the BS had not been <70 or >180 which requires physician notification. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident 9's MAR's for the months of August, September, October and November of 2015, which included the physician's order for Accuchecks. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS as ordered by the physician. b. During a review of the clinical record for Resident 20, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 10, 2015, noted an order for [REDACTED]. Notify MD if BS is less than (<) 80 or greater than (>) 300. A review of Resident 20's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) beginning on August 11, 2015 and continuing through November 12, 2015, showed no BS results for the following dates for morning Accucheck BS: On August 22, 2015, September 3, 2015, October 8, 2015, October 15, 2015 and November 3, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident 20's MAR's for the months of September, October and November of 2015, with the physician's order for Accuchecks. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS's as ordered by the physician. c. During a review of the clinical record for Resident H, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 1, 2015, noted an order for [REDACTED]. Notify MD if BS is less than (<) 60 or greater than (>) 200. A review of Resident H's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) beginning on August 1, 2015 and continuing through November 12, 2015, showed no indication Accuchecks were performed by the licensed nurses as ordered by the physician. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident H's MAR's for the months of August, September, October and November of 2015, with the physician's order for Accuchecks. The CCC verified and confirmed there was no indication that the licensed nurses had performed Accucheck BS as ordered by the physician. d. During a review of the clinical record for Resident I, the facesheet (form containing diagnostic and demographic information), indicated, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders showed an order for [REDACTED]. Review of the start date on the physician's order was noted to be August 3, 2015, (one year and seven months after the date of the original order). The physician's order was for Accucheck's two times a day every Monday, Wednesday and Friday. Notify MD if BS is less than (<) 60 or greater than (>) 250. A review of Resident I's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) beginning on August 1, 2015 and continuing through November 12, 2015, showed no indication Accuchecks were performed by the licensed nurses as ordered by the physician. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident I's MAR's for the months of August, September, October and November of 2015, with the physician's order for Accuchecks. The CCC verified and confirmed there was no indication that the licensed nurses had performed Accucheck BS as ordered by the physician. e. During a review of the clinical record for Resident J, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 1, 2015, noted an order for [REDACTED].@ 0630 ( at 6:30 AM). If FSBS (fasting blood sugar) is <70 or > 200 notify MD before meals. A review of Resident J's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) beginning on August 1, 2015 and continuing through November 12, 2015, showed no indication Accuchecks were performed by the licensed nurses as ordered by the physician. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident J's MAR's for the months of August, September, October and November of 2015, with the physician's order for Accuchecks. The CCC verified and confirmed there was no indication that the licensed nurses had performed Accucheck BS as ordered by the physician. f. During a review of the clinical record for Resident K, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 1, 2015, noted an order for [REDACTED].< 60 or >200 in the morning every Monday. A review of Resident K's Medication Administration Record beginning on August 1, 2015 and continuing through November 12, 2015, showed no indication of Accuchecks performed as ordered by the physician. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident K's MAR's for the months of August, September, October and November of 2015, with the physician's order for Accuchecks. The CCC verified and confirmed there was no indication that the licensed nurses had performed Accucheck BS as ordered by the physician. g. During a review of the clinical record for Resident Q, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 1, 2015, noted an order for [REDACTED]. Notify MD if BS is greater than (>) 200 before meals every Monday and Friday. A review of Resident Q's Medication Administration Record (MAR) beginning on August 1, 2015 and continuing through November 13, 2015, and the Blood Sugar Summary form (a form with all of the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for the following mornings: On August 3, 2015, August 21, 2015, September 21, 2015 and October 23, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident Q's MAR's for the months of August, September, October and November of 2015, with the physician's order for Accuchecks. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS's on the dates documented above, as ordered by the physician. h. During a review of the clinical record for Resident R, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 10, 2015, noted an order for [REDACTED]. Call MD if FSBS (fasting blood sugar) is < 60 or > 250. A review of Resident R's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) and the Blood Sugar Summary form (a form with all of the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for the following mornings: On August 19, 2015, August 21, 2015, September 9, 2015, September 18, 2015, September 30, 2015, October 9, 2015, October 14, 2015 and October 23, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident R's MAR for August 2015 with the physician's order for Accuchecks and her BS Summary form for September, October and November of 2015. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS on the dates documented above, as ordered by the physician. i. During a review of the clinical record for Resident S, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 9, 2015, noted an order for [REDACTED]. Call MD if BS result is below 60 or above 200. A review of Resident S's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) and the Blood Sugar Summary form (a form with the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for the following mornings: August 12, 2015, August 21, 2015, September 30, 2015, October 1, 2015, October 14, 2015, October 23, 2015 and November 4, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident S's MAR for the months of August, September, October and November of 2015 with the physician's order for Accuchecks and the BS Summary form for August, September, October and November of 2015. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS on the dates documented above, as ordered by the physician. j. During a review of the clinical record for Resident O, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 18, 2015, noted an order for [REDACTED]. A review of Resident O's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) and the Blood Sugar Summary form (a form with the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for September 28, 2015 and October 21, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident O's MAR for the months of August, September, October and November of 2015 with the physician's order for Accuchecks and the BS Summary form for August, September, October and November of 2015. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS on the dates documented above, as ordered by the physician. k. During a review of the clinical record for Resident P, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated July 28, 2015, noted an order for [REDACTED].< 60 or > 200 in the morning every Tues and Fri for DM. A review of Resident P's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) and the Blood Sugar Summary form (a form with the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for the morning Accuchecks on August 11, 2015, August 21, 2015, October 6, 2015, October 23, 2015 and November 3, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident P's MAR for the months of August, September, October and November of 2015 with the physician's order for Accuchecks and the BS Summary form for August, September, October and November of 2015. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS on the dates documented above, as ordered by the physician. l. During a review of the clinical record for Resident T, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 10, 2015, noted an order for [REDACTED].< 60 or > 200 (DM). A review of Resident T's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) and the Blood Sugar Summary form (a form with the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for the morning Accuchecks on August 22, 2015, September 3, 2015, September 9, 2015, September 21, 2015, October 8, 2015, October 15, 2015 and October 23, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident T's MAR for the months of August, September, October and November of 2015 with the physician's order for Accuchecks and the BS Summary form for August, September, October and November of 2015. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS on the dates documented above, as ordered by the physician. m. During a review of the clinical record for Resident U, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated August 9, 2015, noted an order for [REDACTED].< 60 or > 400 DM. A review of Resident U's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) and the Blood Sugar Summary form (a form with the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for the morning Acuchecks on August 22, 2015, September 3, 2015, October 6, 2015, October 8, 2015, October 15, 2015 and November 3, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident U's MAR for the months of August, September, October and November of 2015 with the physician's order for Accuchecks and the BS Summary form for August, September, October and November of 2015. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS on the dates documented above, as ordered by the physician. n. During a review of the clinical record for Resident V, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders for November 2015 showed a physician's order dated May 14, 2012 for Accucheck in the morning for DM, call MD if blood sugar is 200 or above or below 60. The start date of the order was July 30, 2015. A review of Resident V's Medication Administration Record (MAR - a form on which the licensed nurses log medications that have been given) and the Blood Sugar Summary form (a form with the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for the morning Accuchecks on August 2, 2015, August 3, 2015, August 22, 2015, September 3, 2015, September 5, 2015, September 9, 2015, September 21, 2015, October 8, 2015, October 15, 2015, October 23, 2015, November 3, 2015 and November 4, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident V's MAR for the months of August, September, October and November of 2015 with the physician's order for Accuchecks and the BS Summary form for August, September, October and November of 2015. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS on the dates documented above, as ordered by the physician. o. During a review of the clinical record for Resident W, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders for November 2015 showed a physician's order dated September 24, 2014 for Accucheck in the morning every Mon, Wed, and Fri for DM, call MD if blood sugar is < 60 or > 250. The start date of the order was August 1, 2015. A review of Resident W's Medication Administration Record (MAR -a form on which the licensed nurses log medications that have been given) and the Blood Sugar Summary form (a form with the dates of the Accuchecks performed and the BS results), showed no Accucheck BS results for the morning Accuchecks on September 28, 2015 and October 21, 2015. During an interview with the Clinical Care Coordinator (CCC) on November 13, 2015 at 12:00 PM, she was shown Resident W's MAR for the months of August, September, October and November of 2015 with the physician's order for Accuchecks and the BS Summary form for August, September, October and November of 2015. The CCC verified and confirmed there was no indication the licensed nurses had performed Accucheck BS on the dates documented above, as ordered by the physician. During an interview with LVN 3 on November 16, 2015 at 8:45 AM, in reference to the three (3) sampled residents (Residents 9, 20 and 12) and the 13 unsampled residents (Residents H, I, J, K, Q, R, S, O, P, T, U, V, and W), LVN 3 stated, he was not really sure where to document Accucheck BS's, if the resident does not receive insulin (medication to lower blood sugar). He further stated that he would enter it under the progress notes. During a review of the progress notes for Residents 9, 12, 20, and unsampled Residents H, I, J, K, Q, R, S, O, P, T, U, V, and W there was no documented evidence found to indicate the results of prescribed Accucheck blood sugars for these residents. During an interview with LVN 4 on November 16, 2015 at 9:00 AM, in reference to the three (3) sampled residents (Residents 9, 20 and 12) and the 13 unsampled residents (Residents H, I, J, K, Q, R, S, O, P, T, U, V, and W), LVN 4 stated there is a place on the MAR where the specific Accucheck BS's results are entered only for residents who receive insulin on a sliding scale (increased dosage increments are given based on specific ranges of blood sugar). There were only check marks listed on residents who received oral hyperglycemic medications (medications used to lower the blood sugar). LVN 4 was unable to explain how the physician would be notified of the out of parameter blood sugar results, if the results were not documented on the MAR. A review of the facility policy titled, Obtaining a Fingerstick Glucose Level, Revised April 2008, under Documentation, number 4: Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on a sliding scale coverage, and/or physician intervention is need to adjust insulin or oral medication dosages) . 3. During a review of the clinical record for Resident 12, the facesheet (form containing diagnostic and demographic information), indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 12's nursing care plans (a nursing care plan outlines the nursing care to be provided to a patient) dated August 30, 2015 revealed a nursing care plan that noted, The resident has impaired cognitive function/dementia (a person's ability to process thoughts. Including things like memory and speech). Documentation under the interventions section of the care plan showed, Administer [MEDICATION NAME] a/o (as ordered) for dementia. Review of the physician's orders dated September 1, 2014 indicated, there was an order to change the resident's dosage of [MEDICATION NAME] from 10 mg (milligrams) BID (two times a day) to [MEDICATION NAME] XR 7 mg one tablet PO (orally) BID. During a review of the Medication Administration Record (MAR- a form on which the licensed nurses log medications that have been given) for July 1, 2015 through July 31, 2015, showed the licensed nursing staff's initials that indicated Resident 12 had received the [MEDICATION NAME] XR 7 mg one tablet medication two times a day every day during the month of July 2015. A review of the Pharmacy's packing slips (a form that documented the receipt of the medication that was delivered to the facility with the signature of the licensed staff who received it from the pharmacy) showed a delivery dated June 9, 2015, of 28 capsules of the [MEDICATION NAME] XR 7 mg caps. Resident 12 was to receive the medication BID (two times a day), the 28 capsules of the medication would have lasted 14 days, or until June 23, 2015. During a review of the Pharmacy's packing slips showed a delivery, dated June 25, 2015 of 28 capsules of the [MEDICATION NAME] XR 7 mg caps (If Resident 12 was receiving the medication BID, the 28 capsules of the medication would have lasted 14 days or until July 9, 2015). No other pharmacy packing slips or deliveries of Resident 12's [MEDICATION NAME] medication had been made to the facility, as verified by the pharmacy during a telephone interview. A review of the Progress Notes (notes that have been entered into the computer by the licensed nursing staff) was conducted and reflected entries for the months of August, September and October of 2015. The following entries documented and dated by LVN 6, indicated the reason she did not administer the medication to Resident 12, was documented as the medication not available on: August 5, 6, 9, 10, 11, 12, 17, 18, 21, 22, 23, and 25, 2015. In September the medication was not available on September 3, 8, 14, 15, 16, 17, 21, 22, 23, 26, 2015, 28, In October, the medication was not available on October 3, 2015. Review of the MAR's for the months of July, August and September of 2015 indicated, the licensed nursing staff administered the [MEDICATION NAME] medication as ordered by the physician, two times a day, as evidenced by the licensed nursing staff 's initials and a check mark, which indicated the licensed nurse had given the medication. The only licensed nurse that did not administer the medication was LVN 6, with the dates shown above and LVN 6's documentation that the medication was not available. Review of Physician's orders showed a verbal physician's order dated September 29, 2015 and received by LVN 6; [MEDICATION NAME] XR Capsule Extended Release 24 Hour 7 MG, give 1 (one) capsule by mouth one time a day for Dementia. Review of the Pharmacy's packing slips (the receipt of the medication that is delivered to the facility with the signature of the licensed staff who received it from the pharmacy) showed a delivery, dated October 3, 2015 of 30 capsules of the [MEDICATION NAME] XR 7 mg caps. Resident 12 received the medication one time a day during the month of October. During an interview with the Clinical Care Coordinator (CCC) on November 12, 2015 at 12:30 PM, a request was made to interview Licensed Vocational Nurse (LVN) 6. The CCC stated that LVN 6 no longer worked for the facility, she was terminated. During an interview with the Clinical Care Coordinator (CCC) on November 12, 2015 at 4:30 PM. She was shown the progress notes documented by LVN 6 and the MAR's for Resident 12 from July, August and September of 2015. The CCC was unable to offer an explanation for the discrepancy as to how the licensed nursing staff administered the [MEDICATION NAME] medication (as e

Based on observation, interview, and record review, the facility failed for 1 of 3 sampled Residents (Resident 1), to ensure that Resident 1 was free from physical abuse, when Certified Nurse Aide (CNA 1) slapped Resident 1 in the face. This failed practice resulted in contusions (when the blood vessels under the skin are broken, and blood collects, usually caused by a [MEDICATION NAME] trauma, causing discoloration, swelling, and significant pain) on the right side of Resident 1's chin and face. Findings: A record review revealed, that Resident 1 was admitted to the facility on [DATE]. Resident 1 was [AGE] years old with [DIAGNOSES REDACTED]. The diseases are progressive, resulting in the inability to care for self and eventual death), [MEDICAL CONDITION] (a loss of contact with reality), and [MEDICAL CONDITION] (unable to sleep). A review of the documentation titled, "Patient Change of Condition Notification and Documentation", dated June 20, 2013, at 3 AM, and signed by Licensed Vocational Nurse 1 (LVN 1) revealed, "Discoloration under right eye, as stated by two NOC (NOC = shift from 11 PM to 7 AM) CNAs. The area has become bigger and the discoloration has become darker with mild swelling...". A review of LVN 1's progress note, dated June 21, 2013, at 7:30 AM, revealed, "Entry for June 20, 2013, at 3:00 AM clarification...At 2:00 AM (on June 20, 2013) two NOC CNAs reported (Resident 1) had swelling and discoloration to her right eye." A review of documentation titled, "Interdisciplinary Team Conference Record", revealed, "June 20, 2013, Resident noted to have area of discoloration and swelling to below right eye, also upon reassessment Resident had also area of discoloration to chin area on right side as well...Resident does not recall event...". During an interview with the Administrator, on June 25, 2013, at 1:30 PM, she stated that on the morning of June 20, 2013, around 2:30 AM to 3 AM, it was discovered that Resident 1 had redness to the right side of the face. She stated that on the morning of June 20, 2013, at 2 AM, Resident 1 had [MEDICAL CONDITION] and was out in the hallway in a wheelchair. She further stated that CNA 1 was monitoring Resident 1 in the hallway, from 2 AM to 2:30 AM. The Administrator further stated CNA 1 confirmed that, during the time she was monitoring Resident 1, on June 20, 2013, from 2:00 AM to 2:30 AM, she slapped Resident 1 on the right side of the face with the back of her hand. During an interview with CNA 1, on June 25, 2013, at 3:20 PM, she stated that on the morning of June 20, 2013, from 2:00 PM to 2:30 PM, she monitored Resident 1. She stated that Resident 1 was awake in the hallway, in a wheelchair. CNA 1 stated Resident 1 had a behavior of sliding down in the wheelchair and required frequent repositioning. CNA 1 stated that Resident 1 kept sliding down in the wheelchair and she had to continuously reposition Resident 1. CNA 1 stated that at first she used her right foot to tap Resident 1 on the lower part of her right leg and told her to stop sliding down. CNA 1 also stated, "I felt overwhelmed and slapped (Resident 1's) face with the back of my hand." A review of a written statement that was signed by CNA 1, dated June 20, 2013, revealed, "Last night on the night of 6/20/13 (June 19, 2013, the date that the NOC shift began) out of frustration I did something unspeakable, I abused a patient." An observation on June 25, 2013, at 3:50 PM (five days after the abuse incident occurred) Resident 1 was observed. The right side of her face had dark purple, red, and yellowish discoloration covering almost the entire right side of her face. The discoloration was under and around the right eye, on the right cheek bone, and on the right side of the mouth and chin. A review of the facility's policy and procedure titled, "Abuse Prevention and Elder Justice Program, Version: 02.2013", revealed, "This facility recognizes that each resident has the right to be free from all forms of abuse...all forms of abuse are strictly prohibited by the facility. Abuse means the willful infliction of injury...physical abuse includes hitting, slapping, pinching and kicking." During an interview with the Administrator, on June 25, 2013, at 1:30 PM, she confirmed that physical abuse was inflicted upon Resident 1, when CNA 1 slapped Resident 1 on the right side of the face, which resulted in a contusion to the right eye, cheek, and chin.

Based on observation, interview and record review, the facility failed to ensure that 4 of 30 sampled residents (Resident 11, 6, 19, 14) were provided the nutritional care and services necessary to maintain acceptable parameters of nutritional status as evidenced by: 1. For Resident 11: The facility failed to consistently provide weekly weights as recommended by the Interdisciplinary Team (IDT) and failed to ensure that the weights obtained were accurate and that all weight discrepancies were addressed timely. The registered dietitian (RD) failed to establish a baseline of the usual weight during the comprehensive nutritional assessment on admission. The RD failed to address the discrepancy between the estimated calories needed and what the tube feeding intake provided, considering the resident's poor by mouth intake. The RD also failed to provide timely reassessment of the resident's nutritional needs after the resident developed pressure ulcers starting on 10/11/12 and after the resident was below the RD established low end goal weight of 105 pounds. These failures did not allow for weight gain to increase the resident body mass or to increase the resident's nutritional status to regain a healthy weight, prevent pressure ulcer formation and promote wound healing. 2. For 19, the significant weight loss of greater than 5 % weight loss in one month was not addressed. This had the potential for the resident to continue unplanned weight loss which could adversely affect the resident nutritional status. 3. For Resident 6, the facility failed to identify and address unintentional, severe weight loss. According to the American Family Physician, a peer reviewed journal of the American Academy of Family Physicians, this failure had the potential to result in "higher risk for infection, depression and death." 4. For Resident 14, the facility failed to ensure that an appropriate diet was ordered. This failure had the potential to result in unnecessary weight loss of Resident 14. Findings: 1. On 1/29/13, Resident 11's medical record was reviewed. It noted that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). A review of the Minimum Data Set (MDS a comprehensive assessment of the resident) completed on 11/15/12, noted that at times, the resident was able to make her needs known. She required extensive assistance for transfer, bed mobility, feeding and activities of daily living. On 1/28/13, at approximately 1:35 PM, Resident 11 was observed lying in bed with the tube feeding off. The resident responded to name but refused all food and fluid offered by staff. On 1/29/13 at 9:00 AM, the resident refused breakfast. The resident did not open her mouth and moved her head around when the staff tried to feed her. Certified Nursing Assistant (CNA) 10, who was assigned to provide care for the resident, stated that the resident continued to refuse all food and fluids offered. On 1/29/13 at approximately 9:35 AM, during observation of the wound treatment, the resident was awake, alert and responded appropriately to questions. The resident appeared to be thin with bony prominences of the back, hips and feet. She was depended on staff for transfer, positioning and all care needs. The staff stated that the resident was currently bedfast (stayed in bed at all times). An interview was conducted on 1/29/13, at 2:15 PM, with Licensed Vocational Nurse (LVN) 1, the floor supervisor and Resident 11's nutritional needs were discussed. LVN 1 stated that she was aware of the resident's poor intake, the resident was being medicated to stimulate her appetite and that the resident continued on tube feeding. A review of the "Vital Signs and Weight Record" for Resident 11, noted the following weights: 8/9/12 = 105.6 lbs (pounds) 8/12/12 = 106 lbs 8/19/12 = 112.6 lbs 8/26/12 = 114 lbs 9/10/12 = 116.6 lbs 9/16/12 = 112.1 lbs 9/23/12 = 112 lbs 9/30/12 = 112.1 lbs 10/7/12 = 112.1 lbs Further review of the "Vital Signs/Weight Record" noted a weight of 116.6 lbs. on 9/10/12, approximately 30 days after admission. A review of the "Nutrition at Risk" , progress record by the Interdisciplinary team (IDT), dated 9/13/12, noted a weight of 123.2 lbs., which indicated a weight gain of 18.2 lbs. in 30 days since admission. The resident meal intake was 0-50 % with poor overall appetite. A review of the IDT meeting notes, dated 9/13/12, noted that the RD was present at the IDT meeting. The recommendation was to decrease the [MEDICATION NAME] 1.2 (a liquid formula for tube-fed patients which provides increased protein and calories) to 60 cc/hr for 10 hours to provide 600 cc/720 calories/day and to continue weekly weights. There was no documentation on the "Weight Record" that noted a weight of 123.2 pounds, 30 days after admission. There was no documented evidence in the IDT meeting notes of where the IDT obtained a weight of 123.2 lbs. There was no documented evidence that the IDT follow-up on the weight discrepancy noted on 9/13/12 and there was no documentation how the discrepancy in the weight was resolved. Further review of the "Vital Signs and Weight Record", noted that on 9/16/12, the weight was 112.1 lbs., a weight loss of 4.5 lbs. in 1 week. On 9/20/12, the RD recommended the same diet. There were no weekly weights recorded between 10/7/12 and 11/3/12. On 11/3/12, the resident weighed 101.1 lbs., a loss of 11 lbs. from 10/7/12, which was below the admission established goal weight of 105 -115 lbs. and also below a usual weight for a person of 68 inches. A review of the facility policy titled, "Weight monitoring " , dated 6/1/09, included the following: "1. All residents should be weighed at the following intervals: c. Monthly thereafter if stable, and/or d. As otherwise directed by the physician, dietitian, director of nursing services or the interdisciplinary team. " " 6. Staff members obtaining weights should notify the licensed nurse of any unusual or significant weight variances immediately. These variances should be confirmed by reweighing prior to taking other action " . Section under " Weight Variance Committee " : " 2. The Committee will meet weekly to review residents with significant weight variances. The committee will also review residents with pressure ulcers or other skin integrity problems that are impacted by nutritional risk factors. " " 4. Recommendations of the weight Variance Committee and/or dietitian should be reported to the physician in a timely manner and implemented within 3 working days " . An interview was conducted on 2/1/13, at approximately 9:00 AM, with the Consultant Dietary Services Supervisor (DSS) and the "Vital Signs and Weight Record" along with the IDT notes were reviewed. The DSS stated that she could not explain the discrepancy between the weight gain in the "Nutrition at Risk"progress notes dated 9/13/12 of 123.2 pounds, which showed a weight gain of 18.2 pounds in 1 month and the "Vital Signs and Weight Record" which noted a weight of 112.1 pounds on 10/7/12 and then a weight of 101.lbs on 11/3/12. Also, she confirmed that there were no weekly weights documented between 10/7/12 and 11/3/12. The DSS stated that she began covering the dietary department in December of 2012 and was currently transitioning the new DSS and was not sure of what occurred in the past. A review of the initial comprehensive "Nutrition Screening Form" completed by the RD on 8/13/12, noted: "Height 68 inches, weight 105.6 pounds/48 kilograms (kg), BMI (body mass index - uses height and weight to calculate healthy weight) 16.1 (BMI of less than 18.5 represents underweight or unhealthy weight), no [MEDICAL CONDITION] (retention of fluids in the legs) and had no pressure ulcers (intact skin with no localized discoloration). Goal weight was 105 - 115 pounds. (Usually a person with a height of 68 inches, ideal weight would be between 126 - 140 lbs.) Estimated Nutritional Needs were evaluated at 1440-1680 calories at 30 -35 kcal/kg; resident was receiving Tube feeding of [MEDICATION NAME] 1.2 at 50 ml an hour for 20 hours which provided 1200 calories at 25 cal/kg, protein 55.5 at 1.15 gm/kg, RDI (required dietary intake) is adequate. The resident was on a pureed diet with thickened liquids with poor by mouth intake; left 25 % or more of food uneaten at meals. A review of the RD dietary progress notes completed on 9/20/12, noted a weight of 116.6 lbs. The weight of 116.6 lbs. was recorded on the " Vital Signs and Weight Record " on 9/10/12 but on 9/16/12, the weight recorded was 112.1 lbs. Per the Certified Nursing Assistant (CNA) the resident was refusing to eat and intake ranged from 0 -75 %. The RD questioned the weight difference but recommended the same diet with GT feeding. The RD did not document how the resident was obtaining the difference of 240 calories from the initial daily requirement of 1440 to 1680 calories assessed on admission, when the GT feeding was only providing 1200 calories a day and the resident by mouth intake was poor. A review of Resident 11' medical noted that on 10/11/12, a pressure ulcer to the right lateral 5th. Metatarsal (little toe), 1.5 x 1 cm, there was also a pressure ulcer to the left lateral 5th. Metatarsal, 1.0 x 0.7 cm,. Also, identified was an unsteagable area to the left lateral foot. The dietary, family and physician were notified on 10/11/12. Additionally, on 11/3/12, a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with pink wound bed) 3.1 x 1.2 cm was observed to the coccyx area. On 11/15/12, the area increased to Stage III (full thickness tissue loss) 2.0 x 1.7 x 0.2 cm,. On 11/3/12, noted re-occurrence of a deep tissue injury to the right 5th. Metatarsal plantar aspect 2.0 x 2.0 cm. On 11/3/12, a stage II area was noted to right ischium (1.0 x 1.0 cm). The dietary, family and physician were notified on 11/3/12 and again on 11/15/12. A review of the RD progress notes dated 10/22/12, noted a weight of 112 lbs., a decrease of 4.5 pounds and dinner intake of 0 -100%. This weight of 112.1 lbs. was noted on the "Vital Signs and Weight Record" dated 10/7/12. The weekly weights were not completed per the IDT recommendation dated 9/13/12. The resident had a history of [REDACTED]. Trials supplement was ordered with meals for 4 ounces of health shakes three times a day (TID) with meals; weekly weights for 4 weeks. There was no documentation in the RD progress notes that addressed the resident's increased nutritional needs relating to the development of pressure ulcers noted on 10/11/12 and the resident continued poor food intake. There was no documentation in the RD progress notes to indicate if the resident was drinking the health shakes. According to the "Wound/Skin Healing Record" dated 10/11/12, the pressure ulcer to the right and left lateral 5th. Metatarsals and the unstageable area to the left lateral foot were reported to the RD on 10/11/12. Also, the RD was notified on 11/3/12 of new Stage II pressure ulcers to the coccyx and right ischium. The RD did not address the pressure areas until 11/21/12. A review of the IDT notes dated 11/8/12, noted weight of 101.5 lbs. a weight loss of 10 lbs. in 30 days. It noted that the resident had a history of [REDACTED]. The resident had new healing areas and new orders on 11/7/12 for Pro Stat and 2 Cal. Recommended same GT feedings and supplements. A review of the RD progress notes dated 11/21/12 noted the following: " Seen at weight meeting 11/15/12, secondary to weight loss, weight 103 lbs. on 11/18/12. 11/7/12, Pro Stat sugar free (protein intended for the dietary management for persons with wound/pressure ulcers) 30 ml daily & 2 Cal (high-calorie liquid food) 90 cc tree times daily via [DEVICE] for wound healing and provides 640 additional calories. 11/12/12, Stage III pressure ulcer to the coccyx. 11/12/12, Stage II pressure ulcer to right ischium. 11/12/12, Deep Tissue injury to right 5th. Metatarsals, (2x2 cm, unable to determine (UTD). 11/19/12, [DEVICE] feeding of [MEDICATION NAME] 1.2 increased to 60 cc/hr. for 18 hours (1080 ml/1296 calories). On diet but not eating meals. 11/18/12, GT pulled out but replaced. A review of the RD progress notes dated 12/17/12, noted a weight of 103 lbs. on 12/2/12,. The RD did not address that the resident was below the goal weight of 105 lbs. noted on admission. A review of the RD progress notes dated 12/27/12, noted the following "... Pureed diet with thick liquids, 4 ounces health shakes 3 times daily with meals, Resident refused breakfast, lunch and snacks but dinner intake for 3 days was at 33%. Resident has poor intake and [DIAGNOSES REDACTED]." An interview was conducted on 1/31/13 at 9:05 AM with the RD. She stated that in her role as the Dietary Consultant, she visited the facility 2 times a week. Her duties included completion of a comprehensive assessment of new residents; participation in the weight and pressure ulcer meetings and monthly assessment of residents on tube feedings. The RD was asked how she calculated Resident 11's nutritional needs on admission. The RD responded that since she did not know what the resident's usual body weight was and that she calculated her caloric needs based on her admission weight of 105.6 lbs and her experience. The RD was asked to show how she calculated Resident 11's caloric needs. The RD stated that she last assessed the resident on 12/17/12 and that she planned on assessing the resident today (1/31/13). The resident was seen by a different RD on 12/27/12. A subsequent interview was conducted on 1/31/13 at approximately 3:00 PM, with the RD. She stated that she calculated the caloric needs of the resident at 35 cal/kg and proteins at 1.3 -1.5 gm/kg and that formula provided adequate nutritional needs for the resident. It was brought to RD's attention that Resident 11's weight was still less than her weight on admission, that Resident 11 had pressure ulcers and the poor nutrition status contributed to their development. 2. On 1/31/13, Resident 19 ' s medical record was reviewed. It noted that the resident was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. It affects memory, thinking, language, judgment, and behavior), Alzheimer ' s disease (most common form of dementia) and dysphagia (difficulty swallowing). A review of the MDS completed on 11/6/12, noted that the resident was able to make her needs known and required set up and supervision for meals. The resident weighed 100 pounds. A review of the "Vital Signs and Weight Record" included the following: 6/6/12 =109 pounds 7/4/12 = 106 9/1/12 = 107 10/1/12 = 106 11/1/12 = 100 (5.6% in 1 mth) 1/7/13 = 100 A review of the medical record was conducted on 2/1/13 at approximately 8:45 AM, with the Consultant Dietary Services Supervisor (DSS). She confirmed that the weight loss on 11/1/12 was not addressed, when the weight loss was over 5% in 1 month and that the resident was below the established goal weight of 105 pounds. A review of the facility policy titled, " Weight Monitoring " , version 6/1/09, included: " 7. Weight loss or gain will be calculated to determine significant variances as follows: a. Unintentional gain or loss of 5 pounds or 5% on a monthly or weekly weight ... " " 8. A licensed nurse will notify the physician and responsible party of any significant weight changes and will document the notification in the clinical record. " " 9. The care plan will be revised to address unplanned significant weight variances " . 3. Resident 6 was readmitted to the facility on [DATE], with the following diagnoses, muscle weakness, difficulty in walking, diabetes mellitus (a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, which causes the blood sugar level to rise), [MEDICAL CONDITION] (stroke) and [MEDICAL CONDITION] reflux disease (stomach acid or, bile flows back (refluxes) into food pipe) A clinical record review, on 1/29/13, indicated on the History and Physical form, dated 5/30/12, that Resident 6 "has fluctuating capacity to understand and make decisions." During an interview with the Administrator on 1/30/13, at 7:40 AM, when asked about who makes decisions for Resident 6 she stated, "The resident's family member comes in mostly every day." The clinical record for Resident 6 was reviewed on 1/29/13. A document titled "Vital Signs and Weight Record" dated 9/5/2011 to 1/28/13 indicated that Resident 6 underwent a severe weight loss of 49 pounds (loss of 27.2% of total body weight) between February 2012 and February 2013. Resident 6's documented weights are as follows: 2/7/12 180.0 lbs (pounds) 3/25/12 168 lbs (weight loss of 12 lbs since the previous weight) 5/7/12 162 lbs (weight loss of 6 lbs since the previous weight) 6/5/12 159 lbs (one month weight loss of 3 lbs) 7/1/12 154 lbs (one month weight loss of 5 lbs) 9/1/12 150 lbs (two month weight loss of 4 lbs) 10/1/12 145 lbs (one month weight loss of 5 lbs) 12/7/12 139.5 lbs (two month weight loss of 5.5 lbs) 1/7/13 130 lbs (one month weight loss of 9.5 lbs) 1/28/13 131 lbs Severe weight loss occurred at one month between the dates of 12/7/12 and 1/7/13, when Resident 6 experienced a 6.8% decrease in body weight (139.5 lbs to 130 lbs). Severe weight loss occurred at three months between the dates of 10/28/12 and 1/28/13, when Resident 6 experienced a 9.02% decrease in body weight (144 lbs to 131 lbs). Severe weight loss occurred at six months between the dates of 7/29/12 and 1/28/13, when Resident 6 experienced a 14.37% reduction in body weight (153 to 131 lbs). During clinical record review on 1/29/13, a document titled "Progress Report on Nutrition at Risk" dated from 3/15/12 to 1/10/13, revealed multiple entries regarding Resident 6 declining meal intake and desired weight loss. Entries are as follows: 03/15/12 entry by Registered Dietician (RD) documented, "Weight 175", "Weekly weights initiated, Weight above target weight." Target weight indicated at 165-180 lbs. 3/29/12 entry by RD documented, "Weight 168", "...does not like facility food. She desires weight loss and set goal for 160-165 lbs." 5/3/12 entry by RD documented, "Weight 162", Resident 6 "desires weight loss." 07/19/12 entry by RD documented, "Weight 152", "She desires weight loss but she is now below her set goal." Trial of ice cream shakes recommended. 10/11/12 entry by RD documented, "weight 141", Dislikes food offered here. Refuses ice cream shakes. Husband brings in TV/frozen dinners. RD adds Resident 6 "likes weight loss." 1/10/13 entry by RD documented, "Weight 130", "She had wanted weight loss, recommendation: provide what she will accept." During a clinical record review on 1/29/13, an Interdisciplinary Team Conference Record, dated 1/17/13, signed by the RD, and titled "Weight" was reviewed. Under the section "Weight Review" it lists Resident 6's weight at 130 lbs. It further reveals that, "Resident desires weight loss target of 160 - 165 lbs. The only intervention indicated on this form was a vitamin supplements. A review on 1/29/13 of Resident 6's clinical record revealed a "Nursing Assistant Flow Sheet" dated January 2013, in which there was documentation that out of 84 meals offered during the month of January, 30 meals were charted as refused. During an interview on 1/29/13 at 1:30 PM, Resident 6 stated, "I don't like the food here, I don't like the substitutes either," Resident 6 further went on to state, "I would like some soup, my family member brings me soup, but it is expensive." During an interview with the Social Services Director (SSD) on 1/30/13, at 8:25 AM, she stated, "I know that Resident 6 had desired to lose some weight." She further stated that she did not know what the weight goal was that Resident 6 wanted to achieve. The SSD acknowledged that she had seen Resident 6's family member bring in food. The clinical record for Resident 6 was reviewed on 1/30/13. A document titled Care Plan "Nutrition," initiated 3/27/09, continued to list Resident 6's goal weight to be 160-165 lbs. The last intervention to be listed on the form was dated 2/16/11. During an interview with the Director of Nurses (DON), on 1/30/13, at 9:50 AM, she stated that she could not find any documentation of Resident 6's medical doctor (MD) being notified of severe weight loss of 14.37% at three months. The DON did state that "according to regulations, we have to address it." During an interview with the Dietary Services Supervisor Consultant (DSSC), on 1/30/13, at 10:00 AM, she stated that, "It is not documented what foods have been offered to Resident 6." After reviewing Resident 6's "Weight Record" the DSSC stated, "It shows slow progressive weight loss." During a telephone interview with Resident 6's family member on 1/30/13, at 10:20 AM, he stated, "I bring her food, but I am concerned about the expense." He further stated that he feels that Resident 6 has been "wasting away lately, and that it is affecting her mentally." He also stated that Resident 6, "cannot sit up for long periods of time, because she has no padding on her butt." During an interview with the Registered Dietician (RD), on 1/31/13, at 9:00AM, the RD stated that Resident 6, "wanted weight loss." RD could not show specific dietary interventions on Resident 6's Nutritional Care Plan. She further went on to state, "We (the facility) are very limited in what we can do." After a review of the meal percentage flow sheets, the RD stated, this is "something we need to work on." During an interview on 1/31/13, at 1:30 PM, with Resident 6's Medical Doctor (MD), he stated that resident should be down to 108 lbs because it is her Ideal Body Weight (IBW). When informed of family member's comment of Resident 6 "wasting away" the MD stated, "No, I would like her to stay where she is (weight wise)." According to the American Family Physician, a peer reviewed journal of the American Academy of Family Physicians: "Unintentional weight loss can lead to muscle wasting, decreased immunocompetence, depression and an increased rate of disease complications. Various studies have demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of [DIAGNOSES REDACTED]." The facility policy and procedure titled "Weight Monitoring," undated, indicates 8. A licensed nurse will notify the physician and responsible party of any significant weight changes... 9. The care plan will be revised to address unplanned significant weight variances. 4. During a clinical record review on 1/28/13 of the "Record of Admission" indicated that the Resident 14 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further record review on 1/28/13 of the "History and Physical" (an assessment of a patient's medical history and current physical status) dated 1/16/12 indicated that Resident 14 "does not have the capacity to understand and make decisions" regarding her medical care. Further review of the clinical record on 1/28/13 of the "Resident-Data Collection" upon admission indicated that Resident 14's admitting weight was 153 pounds. During a clinical record review on 1/28/13 of the "Admission Telephone Orders/Physician Orders " dated 1/16/12 at 1:45 PM indicated that Resident 14 was admitted to the facility with a mechanical soft (special diet people who have trouble chewing) NAS (No added salt), NCS (No concentrated sweets) diet upon admission. Further review of the clinical record review on 1/28/13 of the initial "Nutrition Screening Form" dated 1/18/12 indicated that Resident 14 was on a mechanical soft diet NAS, NCS. This record also indicated that Resident 14 had her own teeth and did not have any concerns "in chewing or swallowing." Further review of the clinical record on 1/28/13 of the "Vital Signs and Weight Record" indicated that between 5/1/12 and 11/7/12, Resident 14 had lost a total of 16.5 pounds in weight. During an interview on 1/31/13 at 10:00 AM with the Registered Dietician (RD), the RD confirmed that Resident 14 was admitted to the facility on [DATE] with a mechanical soft diet NAS, NCS. The RD confirmed that Resident 14 had her own teeth and did not have any chewing or swallowing problems. The RD stated that the mechanical soft diet "never got changed" and could not provide documented evidence as to why the resident required a mechanical soft diet. The RD also stated that "nobody questioned it (why the resident was on a mechanical soft diet)."

Based on observation, interview and record review, the facility failed to immediately notify the resident's attending physician of a significant change in condition for 1 of 28 sampled residents (Resident 6) which resulted in delayed physician intervention and deterioration of the resident condition. For Resident 6, facility staff failed to notify the physician of abnormally high blood sugar levels greater than 400 (care plan goal was to have a blood sugar level of 60 - 200 mg /dL). This resulted in the deterioration of the resident's level of consciousness when the resident became lethargic and had the potential to result in ketoacidosis (increase of waste products and acid in the blood), diabetic coma and eventually death. Findings: During the initial tour observation with Licensed Vocational Nurse (LVN 3) on 3/12/12, at approximately 7:30 AM, Resident 6 was in bed awake, alert and unable to respond verbally. Resident 6 responded with a smile during communication. Resident 6 had a gastrostomy tube (GT- a flexible tube surgically placed into the stomach used to provide nutrition) and had been receiving tube feedings. A review of Resident 6's medical record on 3/12/12 indicated that the resident had [DIAGNOSES REDACTED].) and status [REDACTED]. The physician's orders [REDACTED]. (relief and prevention of suffering) care without prolonging life, yes to antibiotics via enteral tube (GT) and no transfer to acute hospital." The physician's orders [REDACTED]. The sliding scale was as follows: 200- 249 mg/dL = administer 2 units (amount of regular insulin) 250- 299 = 4 units 300- 349 = 6 units 350- 400 = 8 units Greater than (>) 400 = 10 units and call MD (physician). A review of the licensed nurses progress notes dated 2/11/12, at 5:50 AM -showed Resident 6's blood sugar level was 558 mg/dL and that regular insulin coverage of 10 units per sliding scale was given. The nurses progress note at 11:30 AM on the same day showed that the resident's family member who was at the bedside had complained to LVN 1 that Resident 6 "looks very lethargic" (very drowsy) and requested that her (Resident 6) blood sugar be checked. LVN 1 checked the resident's blood sugar with a result that registered at "HI" (a blood sugar level that was beyond what the device could register) . LVN 1's progress notes showed that LVN 1 called the hospice nurse for advice and was given instructions to give the maximum regular insulin coverage of 10 units per sliding scale and to recheck the blood sugar in one hour. The licensed nurses progress notes showed that Resident 6's blood sugar level results remained persistently and abnormally high as follows: 2/11/12, at 1 PM- 469 mg/dL, "gastrostomy tube feedings was hooked (up) and started ... " 2/12/12, at 5:35 AM- 570 mg/dL, "10 units of regular insulin given." There was no documentation found in Resident 6's medical record to show that the physician was promptly notified of the resident's significant changes of condition which included lethargy and persistently and abnormally high blood sugar levels on 2/11/12 & 2/12/12. Documentation showed that the physician was not notified until 2/15/12, when Resident 6's blood sugar level test registered at "HI". At this time the physician had ordered an extra dose of 20 units of regular insulin, and on 2/17/12 increased the resident's [MEDICATION NAME] from 25 to 40 units. In an interview with LVN 1 on 3/14/12, at about 2:45 PM, he stated, "...my understanding is that when a resident is on hospice, we only call the hospice and not the physician. "LVN 1 reviewed Resident 6's medical record and acknowledged that the physician was not notified on 2/11/12 and 2/12/12 of the resident's persistently high blood sugar levels and lethargy.

Based on observation, interview and record review, the facility failed to ensure that necessary care and services were provided to 2 of 28 sampled residents (Residents 6 and 4) in accordance with the comprehensive assessment, plan of care and facility policies and procedures. 1. For Resident 6, the facility failed to monitor signs and symptoms of [MEDICAL CONDITION] (extremely high blood sugar) and notify the physician. This failure caused Resident 6 to become lethargic and had the potential to result in ketoacidosis (increase of waste products and acid in the blood), diabetic coma and eventually death. 2. For Resident 4, the facility failed to follow their policies and procedures regarding Informed Consents and Preferred Intensity of Treatment when they allowed the resident to make decisions regarding psychoactive medications and end of life treatment when the resident did not have the capacity to make these decisions. This failure put the resident at risk for adverse reactions to the medication and not receiving appropriate intervention in the event of a change of medical condition. Findings: A Review of the POS [REDACTED]. The [MEDICAL TREATMENT] nurse further commented, "Please check catheter, patient said that he is bleeding ... " 1. During an observation with Licensed Vocational Nurse (LVN 3) on 3/12/12, at approximately 7:30 AM, Resident 6 was in bed awake, alert and was unable to respond verbally. Resident 6 responded with a smile during communication. A review of Resident 6's medical record on 3/12/12, the minimum data set (MDS) comprehensive assessment dated [DATE] indicated that she had [DIAGNOSES REDACTED]. Resident 6 was on hospice (focuses on relief of pain and prevention of suffering) care with orders that included, "yes" to palliative (relief of pain and prevention of suffering) care without prolonging life, "yes" to antibiotics via enteral tube (GT) and no transfer to acute hospital. A review of the resident's plan of care for diabetes dated 2/7/12 showed that the resident's goal was to have a blood sugar level between 60- 200 milligrams per deciliter (mg/dL). The care plan interventions included monitoring for signs and symptoms of hyperglycemic reaction such as lethargy (extreme drowsiness) and stupor, and to notify the physician as needed. A review of the licensed nurses progress notes showed that on 2/11/12, at 5:50 AM, Resident 6 had an abnormally high blood sugar level of 558 mg/dL (care plan goal was to have a blood sugar level of 60- 200 mg/dL). On 2/11/12, at 11:30 AM, a resident's family member at bedside complained to LVN 1 that Resident 6 "looks very lethargic" (extremely drowsy) and had requested that Resident 6's blood sugar be checked. LVN 1 checked the resident's blood sugar with a result registered at "HI" (extremely high blood sugar level). The licensed nurses progress notes further showed that Resident 6's blood sugar level results remained persistently and abnormally high as follows: 2/11/12, at 1 PM- 469 mg/dL, "gastrostomy tube feedings was hooked up and started ..." 2/12/12, at 5:35 AM- 570 mg/dL, "10 units of regular insulin given." On 3/16/12 a review of the facility policy and procedure titled "Change of Condition version 3.7.12" defined a change of condition as "...any emergent or non-emergent deviation from the resident's normal health, mental status and/or psychosocial status that requires a physician's intervention and significant alterations in the treatment plan." There was no documentation found in the resident's medical record to show that staff had consistently monitored Resident 6 for signs and symptoms of hyperglycemic reaction such as lethargy (extreme drowsiness) and stupor (lack of consciousness, unresponsive), and to promptly notify the physician of the resident's change of condition until a family member complained that the resident had been lethargic. Documentation showed that the physician was not notified until 2/15/12, (4 days later) when Resident 6's blood sugar level registered "HI" at 7:45 AM. In an interview with LVN 1 on 3/14/12, at about 2:45 PM, he stated, "...my understanding is that when a resident is on hospice, we only call the hospice and not the physician. LVN 1 reviewed Resident 6's medical record and acknowledged that there was no documentation to show that staff had consistently monitored Resident 6 for signs and symptoms of hyperglycemic reaction and that the physician was notified promptly of the resident's persistent high blood sugar levels and lethargy according to the plan of care. 2. On 3/14/12 at 9:00 AM, the medical record for Resident 4 was reviewed and showed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's yearly H and P (history and physical) dated 3/11/12 showed that Resident 4 did not have the capacity to understand and make healthcare decisions. The H and P dated 3/12/11 also noted that the resident did not have the capacity to understand and make healthcare decisions. Further review of the resident's medical record showed that the resident was prescribed [MEDICATION NAME] 500 mg PO (per Oral) TID (three times a day) for cyclothymia (a mood disturbance disorder characterized by mood swings) manifested by mood swings began on 11/16/11. The resident signed the informed consent for "[MEDICATION NAME] 250 mg PO (orally) TID" (three times per day) on 5/11/11. Further review of the resident's medical record revealed [REDACTED]. During an interview with the IDT nurse on 3/14/12 at 9:23 AM, the nurse stated that she wasn't sure if the resident had been referred to the bioethics committee (a committee used to determine a residents capacity for health care decision making). The IDT nurse stated that if a resident is referred to the bioethics committee, two physicians will determine the resident's decision making capacity and if the bioethics committee determines the resident does not have the capacity to make decisions (and the resident has no designated responsible party identified) the bioethics committee can appoint the interdisciplinary team to act on the resident's behalf. The nurse confirmed that the H and P for this year and last year showed that the resident did not have decision making capacity. During a concurrent interview with the SSD (Social Service Designee), the SSD stated that the facility is placing the resident under the Bioethics Committee due to her lack of capacity and having no family around to be the responsible party. Both the SSD and the IDT nurse confirmed that the resident had signed her POLST and consent for the medication after it was determined that she did not have capacity. A concurrent review of the SSD notes indicated that the resident was scheduled to have a Bioethics Committee meeting regarding her ability to make health decisions on 2/8/12. The meeting had to be rescheduled due to the inability of the hospice chaplain to attend. There was no further documentation indicating a new date for the meeting. As of 3/14/12 there was no evidence the Bioethics Committee meeting was conducted for Resident 4. Review of the facilities policy and procedure titled, "Informed Consent" dated 12/20/11 documents, "For residents who do not have a legally responsible party or involved family member, the physician may obtain informed consent by providing the material information to the interdisciplinary team who has been appointed under the supervision of the Bioethics Committee to act on behalf of the resident's best interest."