Every finding on record at Mayers Memorial Hospital

Based on interview, record review, and policy review the facility failed to ensure appropriate discharge (the safe release of a patient from a hospital, or medical facility when they are medically stable, able to manage self-care, or have arranged support) for one of two residents sampled (Resident 1) when:1. Resident 1 was transferred out of the skilled nursing facility (SNF - are places for people to live temporarily or permanently while they are getting rehabilitation and medical treatments after hospitalization for an illness or injury) to the acute care hospital (a healthcare facility where patients are treated for brief but severe episodes of illness or injury) due to a medical emergency and did not receive information regarding a 7-day bed hold form (a document that is signed by the resident or their representative which validates the resident's or their representative's agreement to the facility holding or reserving the resident's bed while the resident is absent from the facility for therapeutic leave [resident absences for purposes other than required hospitalization] or hospitalization) nor was she educated about her right to appeal her discharge (a resident's legal right to challenge a healthcare facility's decision to send them home or to another facility if they feel they are being inappropriately discharged ) from the facility.2. No discharge physician's orders (the official directive from a doctor to a healthcare facility that a patient no longer requires inpatient care and can safely transition to another level of care, such as home) was found in Resident 1's record nor was there documentation of a conversation about Resident 1's discharge with Resident 1 or her representative.3. No change in condition assessment was completed after Resident 1 was transferred out of the skilled nursing facility.4. Resident 1's care plan was not updated with changes in her health status when she was transferred out of the skilled nursing facility.These failures violated Resident 1's right to be involved and prepared for discharge as well as the right to appeal the discharge and could potentially result in emotional distress for Resident 1.Findings:Review of Resident 1's medical record indicated that she was admitted to the facility on [DATE] with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs) and Chronic Obstructive Pulmonary Disease (COPD -a chronic lung disease causing difficulty in breathing).Review of Resident 1's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 2/13/26 and completed by the Minimum Data Set Nurse (MDS) indicated a score of 15 out of 15 indicating good decision making ability.Review of Resident 1's record titled, Alert Charting Note dated 3/11/26 at 2:12 am and written by Licensed Nurse (LN A) indicated that Resident 1 was sent to the acute care hospital due to shortness of breath (difficulty breathing) and confusion.1. Review of a facility policy titled Bed Hold - SNF dated 2/4/16 indicated 1. For transfer to acute for illness, testing, or procedure, including surgery: c. Signature is required to acknowledge the resident, family, guardian, or Power of Attorney (POA - is a legal document that appoints someone to make healthcare decisions if the document's signer is unable to do so). If unable to get a signature; the nurse can do a telephone call to the responsible party (medical decision maker) verified by two nurses.During a concurrent interview and record review on 4/1/26 at 1:53 pm, with the Director of Nursing (DON), reviewed Resident 1's record titled Bed-Hold Information for SNF Residents Going to Acute Status undated, the DON acknowledged that this document did not include the signature of Resident 1, nor her responsible party. The DON confirmed that since the document was not signed by Resident 1 or her responsible party that it should have been signed by two nurses validating if Resident 1 or her responsible party agreed verbally (such as in person or over the phone) with the facility holding her bed.During a phone interview on 4/3/26 at 4:09 pm, with Family Member (FM), FM indicated that Resident 1 did not receive the Bed-Hold Information for the SNF Resident Going to Acute Status form or received any information about appealing her discharge from the facility. FM indicated that the only communication she has gotten had been that Resident 1's belongings are packed and ready to be picked up. FM indicated that Resident 1 was still at the acute care hospital and had not been able to come back home to the skilled nursing facility in her community.2. Review of a facility policy titled, Transfer and Discharge of Residents dated 5/5/22 indicated, Discharge Procedure: 1. Obtain, implement, and sign off Physicians orders.a. Time and date of discharge order, b. Resident destination, c. Disposition of medications (the finalized plan for managing a patient's prescriptions, including reconciliation [comparing hospital/home or other facility medications], prescribing new medications, and scheduling pharmacy pickups). And 8. Complete the Resident Transfer/Discharge Summary/Plan form and go over these instructions with resident &/or family member.During a concurrent interview and record review on 4/1/26 at 1:53 pm, with the DON, reviewed Resident 1's Orders Summary, the DON confirmed that there was no discharge physician's order for Resident 1. Reviewed Resident 1's Progress Notes, the DON confirmed that there was no documentation of a conversation with Resident 1 or her responsible party regarding Resident 1's discharge from the facility.3. Review of a facility policy titled Charting and Documentation revised 3/5/25 indicated, All skilled and unskilled services will be recorded, including but not limited to: Any significant change in condition.During a concurrent interview and record review on 4/1/26 at 4:05 pm, with the DON, reviewed Resident 1's progress notes from 3/11/26 to 4/1/26. The DON confirmed that no Change in Condition assessment had been completed.4. Review of a facility policy titled, Care Plans LTC revised 3/27/25 indicated The planning for care, treatment and services will include the following: Review and revision of the care plan, treatment, and services.During a concurrent interview and record review on 4/1/26 at 4:05 pm, with the DON, reviewed Resident 1's record titled, Care Plan date initiated 11/22/22. The DON confirmed that there were no updates to the care plan regarding Resident 1's transfer to the acute care hospital due to respiratory issues on 3/11/26.

Based on observation, interview, and record review the facility failed to ensure 2 of 7 sampled residents (Residents 17 and 19) were treated with dignity and respect when the facility did not have portable oxygen tanks (can be taken anywhere) available and the residents had no choice but to use oxygen concentrators (a large, noisy, and not portable machine that requires electricity).This failure resulted in preventing Resident 2 and 7 from going anywhere there was not an electrical outlet, such outdoors, to appointments and out on pass with their family. This caused Resident 2 and 7 to feel embarrassed, confined, angry and anxious, which resulted in mental aguish and loss of dignity. During a record review of Facility's Resident Rights, undated, the resident's rights indicated, The resident has the right.(11) To be treated with consideration, respect and full recognition of dignity and individuality.A review of Resident 17's medical record indicated that Resident 17 was admitted on [DATE] with diagnoses that included, Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), Heart Failure (heart muscle does not pump blood well), and Anxiety Disorder (feelings of unease to intense fear). A review of Resident 17's Minimum Data Set (MDS, a tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score, dated 7/18/2025, indicated Resident 17 rated 6/15, which equates to a severe cognitive impairment. Resident 17 was not their own representative (RP), does not make their own medical decisions, but is able to verbalize needs and preferences.A review of Resident 19's medical record indicated that Resident 19 was admitted on [DATE] for diagnoses that included, Dementia (loss of memory, language, problem-solving, and other thinking skills that are severe enough to interfere with daily life), Heart Failure, and Anxiety Disorder. A review of Resident 19's MDS, the BIMS score, dated 7/11/2025, indicated Resident 19 rated15/15, which equates to cognition intact. Resident 19 was their own RP, made their own medical decisions, and was able to verbalize needs and preferences.During an observation and interview on 8/5/25 at 12:00 pm, in the hall in front of the nurse's station with Resident 17, who stated, the portable oxygen tanks are not being filled because the machine is broken again, so we have to drag these bulky things around wherever we go, if you want to be out of your room. Some people stay in their rooms because they don't want to be tied to this machine; you must sit by a wall plug-in. It is embarrassing and I don't like it.During an observation and interview on 8/5/25 at 12:45 pm, in the dining room with Resident 19, who stated, we use these (concentrators) when they can't fill the other ones (portable oxygen tanks), the machines are bulky and have to be plugged in, and you have to have help. It can be troublesome.During an interview on 8/6/25 at 07:45 am, with Certified Nursing Assistant (CNA) E, in the lobby, CNA E stated, the oxygen concentrators are oftentimes not working to fill portable tanks. We have had them fixed a lot but they keep on breaking. I have heard we may be going to a different company. We do have to help the residents take the concentrators with them to travel around, so residents are not stuck in their rooms. The cords can be a safety concern sometimes, like in the dining room.During an interview on 8/6/25 at 08:45 am, with [NAME] Clerk (WCL) G at the nurse' station, WCL G stated, I have been here since 6/11/25 and I know I have called the oxygen service provider to send a technician out at least 6 times since I started. It is frequent. They were supposed to come out on Friday 8/1/25, and just did not show up. I had to call on Monday 8/4/25, the provider was not aware that the technician did not show up. A lot of our residents go out of the facility with their families. When no portable oxygen tank is available, the family activities are curtailed, and some residents stay in their rooms because they do not want to drag the concentrators around.During an interview on 8/6/25 at 9:00 am, with Assistant Director of Nursing (ADON) B, outside the facility by the laundry building, ADON confirmed the concentrators have had to be fixed multiple times in addition to problems with operator errors. We have had technicians out quite a bit to fix different issues with the large concentrators. When the concentrators don't work the portable tanks cannot be filled, so the residents have to use either their room oxygen, or concentrators which must be plugged in to the electric outlets to work. Residents do need assistance to take the concentrator machine unit where there is an electrical outlet. This can be a problem for the residents because of the machine's size, and the potential safety concern with the cord.

Based on observation, interview, and record review, the facility failed to provide a homelike environment when 6 out of 8 resident bathrooms observed were found to have unsanitary conditions around the toilets and floors.This was unsightly with the potential to cause health issues due to bacteria and cause the residents psychological stress and depression.During a review of the facility’s, “Resident [NAME] of Rights”, undated, the [NAME] of Rights indicated, (e ) The facility shall be clean, sanitary, and in good repair at all times.” During an observation and interview on 8/5/25 at 3:30 pm, while in resident room [ROOM NUMBER] with Family Member (FM) H. FM H stated, “Have you looked at the bathroom? It is disgusting.” Resident restroom [ROOM NUMBER] was observed to have a gap around the toilet base and the linoleum where the caulking (a waterproof filler or sealant used to seal cracks or gaps to prevent buildup and water damage), was torn and missing, grime had collected in the gap resulting in discolored buildup, which appeared to be dirty with the resemblance of urine or fecal matter buildup. In general, the linoleum was old, scratched up, and in disrepair. FM H stated, “I want it to be homelike here, and I would never allow my home restroom to look like this.” During an observation on 8/5/25 at 4:30 pm, in resident restroom [ROOM NUMBER], there was a gap between the linoleum and the toilet base with torn or missing caulking. The discolored buildup in the gap resembled dried urine or fecal matter. During an observation and interview on 8/6/25 at 9:30 am, with Assistant Director of Nursing (ADON) B, in resident restroom [ROOM NUMBER], the linoleum gap around the toilet with torn caulking and discolored buildup was observed, as well as the condition of the linoleum on the floor. ADON B confirmed the bathroom was is not in acceptable condition. During an interview on 8/6/25 at 11:45 am, with Environmental Services Manager (EVM) in ADON B's office, EVM stated,We know there are issues with floor disrepair and are working on them. During a review of the facility’s document titled, Housekeeping Principles,” with an effective date of 4/25/19, indicated the facility, “promotes a sanitary environment by incorporating infection control principles into housekeeping practices”. In the section titled, Procedure: Frictional Cleaning”, indicated, “Thorough scrubbing is used for all environmental surfaces that are cleaned in patient care areas”. The policy continues in the section, “Routine Cleaning of Horizontal Surfaces”, “…cleaning of non-carpeted floors and other horizontal surfaces is done daily and or frequently if spillage or visible soiling occurs”. During an observation on 8/4/25 at 1:44 pm, in resident restroom [ROOM NUMBER], the base of the toilet had dark grime collected resulting in discolored buildup on the caulking, which appeared to resemble dried urine. During an observation on 8/4/25 at 2:20 pm, in resident restroom [ROOM NUMBER], the base of the toilet was missing caulking, and had dark grime and loose dirt debris that encircled the base of the toilet. The floor had grime buildup, loose dirt debris, and a black scuff mark. During an observation on 8/4/25 at 2:25 pm, in resident restroom [ROOM NUMBER], the caulking at the base of the toilet was chipped and had yellow staining, which appeared to resemble dried urine. Caulking was partially missing from the base of the toilet and had a buildup of grime and loose dirt debris. The floor had dark grime buildup, loose dirt debris, and black scuff marks. During an observation on 8/4/25 at 2:27 pm, in resident restroom [ROOM NUMBER], the base of the toilet had grime collected resulting in discolored buildup on the caulking, which appeared to resemble dried urine. The floor had dark grime buildup and loose dirt debris. During an interview in the hallway with Licensed Vocational Nurse (LVN) I on 8/6/25 at 7:36 am, when asked about the resident restrooms on the unit, LVN I confirmed the condition of the restrooms on the unit were, “not good and are unsanitary. My bathroom would not look like this”. During an interview with the Assistant Director of Nursing (ADON) B in the office on 8/6/25 at 10:14 am, when asked about the condition of the resident restrooms, the ADON B confirmed the restrooms had, “inadequate maintenance and they need to be addressed”.

Based on interview, observation, and record review, the facility failed to meet this requirement when three of five sampled residents (Residents 3, 5, and 29) with dementia (a brain problem that affects memory and behavior), received antipsychotic medications (drugs that regulate or control thinking and behaviors) without an adequate indication for use (target symptom or behavior) when: 1. Specific, measurable, behaviors that are not subjective;2. Non-pharmacologic (non- drug) interventions were tried to address residents' behaviors prior to administering antipsychotic agents, and;3. A physician's response to the pharmacist's recommendations for use of these medications was not done. These failures had the potential for unwanted and adverse medication side effects including; motor and sensory instability (unreliable thinking and ability to move), dizziness, drowsiness, increased risk of falls and fractures, and death caused by heart problems. Findings: Review of the facility's policy titled, Residents with Dementia Antipsychotic Medication indicated: 1a.: The physician in conjunction with the interdisciplinary team (IDT) will add resident-specific, non-pharmacological (non drug) interventions upon admission, and routinely throughout therapy when needed and; 1b.: The IDT will continue to follow the specific non-pharmacological interventions to make sure they are the best fit for the resident. This will be done at least monthly. and;2. Upon initiation of an antipsychotic medication for a resident with a diagnosis of dementia [age-related decline in brain function], the Charge LVN will obtain from the physician an approved diagnosis for the antipsychotic medication and specific behaviors for its use. Whenever there is a change in the resident's medical condition or medical status, the consultant pharmacy, at the bequest of the facility, will review the resident's current medications. The consultant pharmacist will then recommend to the physician any specific dose reductions, additions/changes, and or discontinuations, based on need, labs, and the current dose.Clinical record review indicated Resident 3 was admitted for medical conditions that included unspecified dementia, chronic kidney disease, and emphysema (loss of ability of lungs to expand). Review of resident 3's physician orders indicated that on 6/17/25, his physician ordered Rexulti (brexpiprazole, an antipsychotic medication) for agitation, (undefined) related to unspecified dementia, unspecified severity, with other behavioral disturbances, which were also further undefined. Resident 3's physician orders indicated that he first received Rexulti on 5/10/25 for agitation which had not specified the specific target behavior or symptom.Review of Resident 3's care plan dated 5/12/25, indicated that resident had, an alteration in mood and behavior related to dementia as evidenced by physical aggression toward staff and peers, including verbal aggression and agitation toward staff/peers. The terms aggression and agitation were undefined, without example, creating a potential for subjective interpretation by various staff assessing Resident 3's behavior. Resident 3's care plan indicated an absence of non-pharmacologic approaches other than general statements such as anticipate the resident's needs, and approach the resident in a calm manner. Review of Resident 3's electronic medication administration record (eMAR) dated 5/11/25, indicated that Behavior Monitoring was constituted by verbal aggression, and agitation without further definition or examples of aggressive or agitated acts. Review of Interdisciplinary Team (IDT, a group of facility managers who oversee resident care) notes dated 7/1/25, had not addressed Resident 3's use of Rexulti. There was no discussion of what target symptoms the antipsychotic medication was prescribed for or what the expected risks and benefits were for Resident 3 by using this medication.Review of progress notes entered by Charge LVN (LN C) on 6/05/25 at 8:42 am, indicated only broad examples of aggression, which were mainly toward staff. LVN C indicated in that progress note that Rexulti may have been an inappropriate medication for Resident 3, Resident continues to have aggressive behaviors towards staff and peers. This morning resident got agitated that another resident was calling out to go to the restroom. Making threatening statements towards nursing staff stating he was going to fight the nurse and take care of him. These behaviors seem to continue to worsen and is becoming a safety issue for not only other residents but staff as well. Rexulti seems to be ineffective at this time.During a concurrent interview and observation on 8/5/25 at 9:15 am, of Resident 3 stated that he had problems with roommates he has had and, the alarms that were going off all the time. He appeared unkept, had long uncombed hair, and had difficulty communicating clearly. He currently had no roommate. In an interview on 8/6/25 at 10:57 am, LVN C stated that she couldn't recall any non-pharmacologic interventions for Resident 3. LVN C stated that Resident 3 was new, and that she was the charge nurse helping staff contact the medical provider about the resident's behaviors of throwing objects and threatening his roommates. She stated the as she recalls it, the provider just put in the order, but she couldn't recall what staff might have tried otherwise before starting an antipsychotic drug. LVN C stated that Resident 3 had received a dose of Clonidine (a blood pressure medicine) that was abruptly stopped; Resident 3's provider suspected it could have had an interaction with other medication and caused Resident 3's agitation. LVN C stated that Rexulti was ordered and started around the same time as stopping Clonidine, which made it difficult to asses what the Rexulti was actually contributing to the medication mix. LVN C confirmed that using the antipsychotic was aggressive, adding, there were other things that staff could try before aggressive treatment.Record review indicated Resident 5 was admitted to the facility for medical conditions that included a history of stroke, unspecified dementia, nerve pain, weakness, and need for assistance. Review of Resident 5's physician orders indicated that her physician ordered Rexulti 0.5 milligrams (mg, a unit of measure) by mouth once daily, on 1/22/25, for agitation related to dementia. No further definition of agitation was described. Resident 5's physician orders indicated that on 3/26/25 Resident 5's dose of Rexulti was increased to 1 mg, and that the medication was discontinued 5/14/25, and restarted as 0.5 mg on 5/28/25, at the recommendation of the resident's daughter.Review of IDT notes had not addressed Resident 5's use of Rexulti. There was no discussion of what target symptoms the antipsychotic medication was prescribed for or what the expected risks and benefits were for Resident 5, by using this medication.Resident 5's record titled, Order Summary dated 5/28/25 indicated, Monitor for the following behaviors: A) Verbal aggression toward staff and others; B) Physical aggression toward staff and others. There were no defining characteristics of verbal or physical aggression. Review of Resident 5's care plan dated 1/22/25 through 7/21/25, indicated Rexulti as the first intervention for the Resident 5's behavior of, Aggressive documented episodes with her roommates, Anger, Poor impulse control, and Attempt at leaving the facility unassisted. No nonpharmacologic approaches were included on the care plan. In an interview and observation on 8/4/25 at 3:30 pm, Resident 5 was observed to be socializing in activities and stated she doesn't need any medication, she's fine.In an interview on 8/5/25 at 12:44 pm, LVN B stated that Resident 5 received Rexulti after she had episodes of aggression toward others and staff, mostly consisting of threatening her roommate, hostility toward her granddaughter, and refusing showers and washing hair. In an interview and concurrent review on 8/5/25 at 3:21, with the Director of Nursing (DON), the DON confirmed that behaviors listed as aggressive could be more specific. DON confirmed that Resident 3 and 5's IDT notes had not addressed the use of Rexulti or included specific target behaviors, non-pharmacological interventions to be tried, and what the expected risks and benefits were for the use of the antipsychotic medication in accordance with the facility's policy, and should have.Review of Resident 29's clinical record indicated that he was admitted to the facility for conditions that included dementia and a need for staff assistance in carrying out activities of daily living. A review of Resident 29's physician's orders indicated that on 4/28/25 an order was entered by his physician for Zyprexa (olanzapine, an antipsychotic drug), Oral Tablet 5 mg, once daily at bedtime for aggressive behaviors related to dementia. A review of 29's e-MAR from January to July 2025, indicated that the facility had not monitored any behaviors for the use of Zyprexa for Resident 29.A review of Resident 29's pharmacist drug regimen review (DRR) dated June 2025, indicated the Pharmacist's (PHARM) documented, Contacted provider.Resident has no charted behaviors for at least 120 days at time of review. OBRA F329 (federal Omnibus Reconciliation Act, a federal act that impacts use of antipsychotics) states that the lowest effective dose of antipsychotics should be used to control symptoms. Please evaluate a trail of a lower dose would be indicated. If dose not reduced, please work with nursing staff on targeted behaviors. The record further indicated that this was the pharmacist's fourth month in a row this recommendation was made without Resident 29's physician responding. The PHARM DRR also included that Buspar (an antianxiety medication) had no behavior monitoring and documented, Resident has had minimal behaviors charted for Buspar in May. None in June at time of review. Please evaluate. If dose reduction not indicated, please work with nursing staff to target behaviors. The DRR indicated Resident 29's physician had not responded to this review since May 2025, a period of three months.In an interview DON on 8/6/26 at 2:46 pm, and concurrent review of Resident 29's care plan , DON stated, Non-pharmacologic approaches appears to be none. She confirmed that the documentation was not adequate for justification of using an antipsychotic, and that there should be more specific about behaviors.In an interview and concurrent record review on 8/7/25 at 9:00 am, PHARM confirmed that he had reviewed all of the above medications. PHARM stated that Rexulti is a medication specific to agitation and aggressiveness in patients with dementia. Pharmacist stated, When I reviewed these orders, I looked at specific instances of agitation and aggression that could be harmful to the resident or others. PHARM confirmed that he reminded the DON and nursing staff that the documentation of behaviors over the last 120 days of his review needed to be more specific to meet the standard of using an antipsychotic in a skilled nursing setting. PHARM confirmed that his request to consider Gradual Dose Reduction (GDR) for Resident 29 had carried over four months in a row unaddressed by Resident 29's physician. PHARM stated that Resident 29 was declining as would be expected with his disease, but at this point Resident 29 was almost nonverbal (unable to speak), so many of the behaviors he may have had in the past may not be continuing as he becomes more incapacitated. PHARM added that the use of antipsychotic medications in the elderly has been associated with falls and poor clinical outcomes, and that doses should be continuously evaluated throughout their disease progression.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 69 when the controlled drug (medication that may be abused or cause addiction) record form was not filled out and signed accurately. This failure could result in diversion of the residents' unused controlled medications.During an inspection of the controlled medication bin located in the medication room on 8/4/25 at 1:22 p.m., the controlled medication bin was observed to be locked and sealed with a numbered zip tie, 9973377, which was different than the recorded tag number, 9973375, on the controlled count sheet.During an interview on 8/4/25 at 1:25 p.m. with Charged Nurse (CN) A, CN A confirmed that the number stated on the numbered zip tie was not the same as the number recorded and signed by her on the controlled count sheet. CN A acknowledged it was a mistake.During an interview on 8/4/25 at 1:32 p.m. with the Director of Nursing (DON), the DON stated, I see the potential that someone can come and switch out the tag. The code on the lock should match with the record to minimize the risk of drug diversion.Review of the facility policy and procedure titled, discontinued Medications and Controlled Substance Disposal, dated 4/24/25, indicated, [NAME] Memorial Hospital District's Skilled Nursing Facility handles discontinued medications in a secure, safe, and legal manner.

This regulation was not met when pharmacy recommendations were not followed or responded to by the Physician, Director of Nursing or nursing staff for three of six sampled residents (Residents 3 ,5, and 29), for periods of up to six months (120 days).This had the potential for residents to remain on unnecessary medication and potentially exposing them to unnecessary unwanted and adverse side effects of those medications, which included falls, confusion and death by heart related problems. Findings: Review of the facility's policy titled, Residents with Dementia Antipsychotic Medication, dated 6/18/24, indicated, Whenever there is a change in the resident's medical condition or medical status, the consultant pharmacy, at the bequest of the facility, will review the resident's current medications. The consultant pharmacist will then recommend to the physician any specific dose reductions, additions/changes, and or discontinuations, based on need, labs, and the current dose. The physician will review the dosage recommendations and determine at such time if a dose adjustment is medically indicated or clinically contraindicated [not necessary]. The reason for the medication to continue to be medically indicated will be answered in the response section on the consultant's recommendation or in the physicians' progress note.Clinical record review indicated Resident 3 was admitted for medical conditions that included unspecified dementia, chronic kidney disease, and emphysema (loss of ability of lungs to expand).Review of resident 3's physician orders indicated that on 6/17/25 his physician ordered Rexulti (brexpiprazole, an antipsychotic medication that alters thinking or behavior disturbances) for agitation. Review of Resident 3's monthly Pharmacy Medication Regimen Review (MRR) records dated 1/25 to 7/25/25, indicated no signature or response to the Pharmacist's recommendations from Resident 's physician, from 3/25/25 to present, a period of five months. Clinical record review indicated Resident 5 was admitted to the facility for medical conditions that included a history of stroke, unspecified dementia, nerve pain, weakness, and need for assistance with activities of daily living.Review of Resident 5's physician orders indicated that her physician ordered Rexulti 0.5 milligrams (mg, a unit of measure) by mouth once daily on 1/22/25, for agitation related to dementia.A review of the, Beers Criteria for Potentially Inappropriate Medications, a set of guidelines developed by the American Geriatrics Society, indicated Antipsychotics as a class of medications that have the potential to be unsafe in patients greater than [AGE] years old. Review of Resident 5's MRR's dated 1/25 to 7/25/25 indicated that in January, PHARM indicated to the provider, The combination of gabapentin [a nerve pain medicine] and an opioid (a strong narcotic pain medicine), was a high risk combination per the Beers list. Please document a risk benefit analysis that addresses risk of fall/fracture and respiratory depression. Gabapentin is ordered for nerve pain in back. Is it effective? Nerve pain in back is an off-label use. Resident 5's physician had not responded to PHARM's recommendations for 10 months. Review of Resident 29's clinical record indicated that he was admitted to the facility for conditions that included dementia and a need for assistance in his activities of daily living.A review of Resident 29's orders indicated that on 4/28/25 an order was entered by his physician for Zyprexa (olanzapine, an antipsychotic medication), Oral Tablet, 5 mg per day, for aggressive behaviors related to dementia.A review of Resident 29's MRR dated June 2025, indicated the Pharmacist's (PHARM) comments: Contacted provider.Resident has no charted behaviors for at least 120 days at time of review. OBRA F329 (federal Omnibus Reconciliation Act, a federal act that impacts use of antipsychotics) states that the lowest effective dose of antipsychotics should be used to control symptoms. Please evaluate a trail of a lower dose would be indicated. If dose not reduced, please work with nursing staff on targeted behaviors. The record further indicated that this was the pharmacist's fourth month in a row this recommendation continued. Resident 29's June 2025 MRR also indicated concerns for behavior documentation for the use of Buspar (an antianxiety medication), Resident has had minimal behaviors charted for Buspar in May. None in June at time of review. Please evaluate. If dose reduction not indicated, please work with nursing staff to target behaviors. No response was indicated in the physician's signature line.In an interview and concurrent record review on 8/7/25 at 9:00 am, PHARM confirmed that he had reviewed all of the above medications for Resident 29. PHARM confirmed that he reminded the DON and nursing staff that the documentation of behaviors for antipsychotics needed to be more specific to meet the standard of using an antipsychotic in a skilled nursing setting. PHARM confirmed that his request to consider Gradual Dose Reduction (GDR) for Resident 29 had carried over four months in a row unaddressed by the Physician, DON, and nursing staff.

Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 2 of 6 sampled residents (Resident 40 and 4).1. For Resident 40, a licensed nurse was unable to administer Resident's 40's doxycycline, a medication to treat and prevent infections, with the rest of resident's morning medications when doxycycline was not available to be administered per Physician Orders.2. For Resident 4, a licensed nurse did not administer Resident 4's omeprazole, a medication to treat certain conditions where there is too much acid in the stomach, as ordered by the physician.As a result, 2 errors were identified out of 31 opportunities for error during the observation of medication administration; the facility medication error was 6.45%.1. During an observation of medication administration on 8/5/25 at 7:05 a.m., Licensed Nurse (LN) B was observed to prepare and administer Resident 40's morning medications which did not include Resident 40's doxycycline. During an interview on 8/5/25 at 7:10 a.m. with LN B, LN B stated, doxycycline was not available. Resident ran out short somehow, and I don't know why. Reconciliation of the observation of medication administration with Resident 40's current Physician Orders indicated an order, dated 7/30/25, doxycycline oral tablet, 100 mg (milligram, unit of measurement) by mouth two times a day for bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs) until 8/8/25. During an interview on 8/5/25 at 7:35 a.m. with the Charge Nurse (CN), the CN stated, RX [prescription] got extended by the provider, but the medication was still not received from the pharmacy. During another interview on 8/5/25 at 7:38 a.m. with LN B, LN B stated, the dose was just taken out of the emergency medication box and administered.During another interview on 8/5/25 at 11:59 a.m. with the CN, the CN stated, the pharmacy was contacted to follow up on the missing doses of doxycycline. During an interview on 8/5/2025 at 12:07 p.m. with the Director of Nursing (DON), the DON stated, the expectation is to have the full dose of medication available for medication administration. If short [the quantity], the pharmacy needs to send the remaining quantity in a timely manner. A review of facility policy titled, Administering Medications, dated 9/2023, indicated Medications and treatment shall be administered as prescribed.retrieve medication from patient medication drawer.2. During an observation of medication administration on 8/5/25 at 7:58 a.m., LN B was observed to prepare and administer Resident 4's morning medications which included Resident 4's omeprazole. All medications were given together. Breakfast was already served and Resident 4 had consumed approximately 1/2 of his breakfast. Reconciliation of the observation of medication administration with Resident 4's current Physician Orders indicated an order, dated 5/17/25, for omeprazole oral capsule delayed release 20 mg, give 1 capsule by mouth two times a day for GI (gastrointestinal) protection give on empty stomach before breakfast. During an interview on 8/5/25 at 11:55 a.m. with LN B, the LN B stated according to the Physician Orders, Resident's omeprazole should have been given on empty stomach to protect Resident's stomach. Omeprazole was given to Resident after breakfast. LN B stated the order summary on the MAR (Medication Administration Record) did not match with the prescription label.During an interview on 8/5/25 at 12:10 p.m. with the DON, the DON stated, the nurses are expected to follow the Physician Orders. The nurses should make sure the MAR and Physician Order match. The MAR should have been updated to administer Resident's omeprazole to 7 a.m. allowing the nurse to have enough time to administer the medication before breakfast.A review of facility policy and procedure (P&P) titled, Administering Medications, dated 9/2023, the P&P indicated Medications and treatment shall be administered as prescribed.The 6 rights.the Right drug: read re-read med [medication] orders and drug label.the Right Time: times given are correct .recheck EMAR [Electronic Medication Administration Record] and medication bottle labels to insure patient name, medication, and directions match.

Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when:1. An expired 3 ml (milliliter, unit of measure) insulin lispro pen, medication used to treat high blood sugar levels, was found in the medication cart. 2. An expired 5 ml multidose vials of Tuberculin purified protein derivative testing agent, a solution used in a skin test to diagnose latent lung infection, was found in the medication room B's refrigerator. These failures had the potential for medication error, misuse, or administering expired and ineffective medications to the residents.1. During an inspection of medication cart Hall #2 with Licensed Nurse (LN) A on 8/4/25 at 1:19 p.m., an expired insulin lispro pen was found with an expiration date of 7/22/25 on the label. During an interview on 8/4/25 at 1:20 p.m. with LN A , LN A acknowledged that the insulin pen was expired and needed to be removed from the refrigerator. LN A stated, “expired medications will have reduced efficacy.” During a review of insulin lispro’s Provider Information (PI), last revised 9/2023, the PI indicated, “Do not use insulin lispro past the expiration date printed on the label .Throw away all opened vials after 28 days of use, even if there is insulin left in the vial.” During an interview on 8/4/25 at 1:35 p.m. with the Director of Nursing (DON), the DON stated, the nurses should be checking for outdates every time they take over the cart. The insulin pens should be dated and replaced when they are expired. expired medications will not be effective. Review of the facility policy and procedure (P&P) titled, “Medication Procurement, Storage & Security” dated 3/2025, the P&P stated, “Drugs and biologicals are stored under the conditions recommended by the manufacturer…medications with shortened expiration dates are labeled with the new expiration date after first use. Example include insulin…outdated medications are removed from drug storage areas monthly…outdated, mislabeled, recalled, or otherwise unusable drugs and biologicals are not available for patient use and are stored separately…” 2. During an inspection of medication room B’s refrigerator on 8/4/25 at 8:43 a.m. with Assistant Director of Nursing (ADON) B, an expired 5 ml multi-dose vial of tuberculin purified protein derivative testing agent was found with “open date of 5/22/25” and “discard after 6/21/25” on the label. A review of the label on the product box indicated, “Discard opened product after 30 days.” During an interview on 8/4/25 at 8:54 a.m. with ADON B, ADON B confirmed that the tuberculin purified protein derivative testing agent was expired and needed to be removed from the refrigerator. ADON B stated, “It should have been removed from the active medication storage. The expired medication could be less effective and dangerous for a resident.” Review of the facility P&P titled, “Medication Procurement, Storage & Security” dated 3/2025, the P&P stated, “Drugs and biologicals are stored under the conditions recommended by the manufacturer…outdated, mislabeled, recalled, or otherwise unusable drugs and biologicals are not available for patient use and are stored separately…”

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when a blood pressure monitor (device used to measure blood pressure) was not disinfected according to manufacturer's instructions after being used during medication pass observation. This failure had the potential to transmit blood-borne pathogens or bodily fluids between residents.During a medication pass observation with Licensed Nurse (LN) A on 8/5/25 at 8:30 a.m., LN A used a blood pressure monitor to measure Resident 40's blood pressure inside the resident's room. The blood pressure monitor was then taken out of resident room's and placed on the medication cart without being cleaned and disinfected.During a medication pass observation with LN A on 8/5/25 at 7:28 a.m., LN A used the same blood pressure monitor to measure Resident 13's blood pressure inside the resident's room. The blood pressure monitor was then taken out of resident's room and placed on the medication cart without being cleaned and disinfected.During a medication pass observation with LN A on 8/5/25 at 7:45 a.m., LN A used the same blood pressure monitor to measure Resident 2's blood pressure inside the resident's room. The blood pressure monitor was then taken out of resident's room and placed on the medication cart without being cleaned and disinfected.During an interview with LN A on 8/5/25 at 8:25 a.m., LN A acknowledged that the blood pressure monitor and cuffs were not cleaned and sanitized between patients. LN 1 stated, ideally blood pressure monitor and cuffs could be wiped to reduce risk of infection.During an interview with Director of Nursing (DON) on 8/5/25 at 12:12 p.m., the DON stated, the blood pressure monitor and cuffs needed to be sanitized and disinfected between each resident to reduce risk of infection.During a review of the facility's policy and procedure (P&P) titled, Cleaning, disinfecting, and Sterilization, dated 5/2021, the P&P indicated, The following guidelines are general rules for ensuring that supplies and equipment are adequately cleaned, disinfected or sterilized. Specific policies for high-level disinfection or sterilization are maintained by the respective department.personal must have proper training on processing instruments (through either sterilization or high level disinfection) with competency testing upon hire, annually and periodically as needed.During a review of facility provided document by the DON on 8/5/25 t 4:36 p.m., untitled, the document stated, cleaning recommendations for your [brand name] wrist blood pressure monitor are important to maintain its hygiene.Monitor Casing: use a soft, dry cloth or a cloth dampened with water and a mild detergent to clean the monitor's exterior surface.Cuff: similar to the monitor casing, clean the cuff with a soft, moistened cloth and a mild, neutral detergent.regularly clean your blood pressure monitor to maintain accuracy and hygiene.

Based on interview, record review, facility policy review and video surveillance review, the facility failed to ensure that the pharmacist was responsible for establishing a system of records of receipt and disposition of all controlled medications (medications that have a high potential for abuse and addiction) in sufficient detail to enable an accurate reconciliation, and to ensure that these drugs were handled and administered in a safe and secure manner. This failure allowed narcotic medications to be diverted (stolen or misused) without detection, compromising the facility's ability to ensure the safe and effective use of medications. Residents were placed at potential risk of unrelieved pain, undertreatment, and harm from diverted medications. Findings: A review of the facility's policy titled, Controlled Substance Storage, Receiving, Tracking and Documenting dated 6/25/09, indicated, Receiving and tracking of controlled substances is done in a consistent manner to prevent and detect diversion. An interview with the Director of Nurses (DON) and Director of Safety and Security (DSS) on 6/19/25 at 11:13 am, revealed that the facility identified a narcotic reconciliation issue on 2/14/25 when a Licensed Vocational Nurse (LVN) had requested additional narcotics for Resident 1 when the medication was too soon to be refilled. Video surveillance on 2/4/25 showed the LVN in the locked medication room putting cassetts of narcotics in her jacket. The facility immediately terminated the LVN's employment on 2/18/25 and made the proper agency referrals. The DSS indicated that a detailed narcotic audit was done from August 2024 to February 2025 and reflected that 2550 narcotic tablets and 2 vials of Morphine (a narcotic) liquid were missing. DSS stated, we audited only back to August and determined that there was missing paperwork [yellow control sheets] on 85 narcotic cassettes and 2 vials of liquid morphine. According to the DSS, the facility had identified numerous contributing factors to the theft and loss of narcotic medications to, lack of overflow accountability and pharmacy not tracking yellow control sheets. The DSS stated, the root cause analysis was processes were not followed as we had lots of leadership changes. In an interview with the Pharmacist on 6/19/25 at 12:15 pm, he stated that he was alerted by the DEA (Drug Enforcement Agency, a government agency that enforces the prevention of narcotic diversion and drug trafficking) software system that it was too soon when he tried to refill Resident 1's narcotic pills. He then notified the DON and DSS to begin an investigation. The Pharmacist stated, According to the DEA, once I fill the narcotic and it goes to nursing I am no longer responsible. The Pharmacist confirmed he had no knowledge of his responsibilities according to the Federal regulations and confirmed he had not established and maintained records of receipt and disposition of all controlled medications, performed routine audits to reconcile narcotic drug usage, identify narcotic use discrepancies, or collaborated with facility staff to ensure safe, secure, and appropriate use of narcotic/controlled medications.

Based on interview and record review, the facility failed to implement care planned fall prevention interventions (a set of proactive measures designed to minimize the risk of falls in individuals) for 2 of 4 residents sampled for falls who had been identified as high risk for falls (Resident 1 and 2) when: 1. Resident 1's care planned intervention for staff to follow Resident 1 to his room and assist him with toileting or lying down was not followed. 2. Resident 2's care planned intervention to ensure that Resident 2 was wearing non-skid socks or footwear was not followed. These failures resulted in avoidable falls with broken hips for both Resident 1 and 2 which and rehospitalizations for surgical repairs. This had the potential to negatively impact the residents' physical and emotional well-being and subject them to further falls with injuries. Findings: A review of the facility's policy titled, FALLS-SNF (Skilled Nursing Facility) dated 5/22/23, indicated that a fall is an unplanned descent to the floor which may either be observed or unobserved. The policy indicated the facility is committed to maintaining resident safety by identifying those residents who are at risk for falls, at high risk of injury from falls and implement evidence-based interventions to prevent falls and injury. For residents identified as at risk for falls, the policy indicated that the facility would implement fall prevention measures such as addressing fall risks on the residents' care plan and providing non-skid footwear or shoes. A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included dementia (memory and decision-making problems), rheumatoid arthritis (arthritis that deforms joints), prostate cancer, vision problems, and high blood pressure. A review of Resident 1's Morse Fall Scale (a fall risk assessment with scores of High Risk-45 or higher, Moderate Risk-25 to 44, and Low Risk- 0 to 25), dated 1/18/24, 3/19/24, 8/24/24, and 10/4/24, was conducted. Resident 1 was at a high risk for falls with a score of 90, due to a history of falls, severe cognitive impairment (ability to remember and make sound decisions), impulsiveness (acts before thinking about the consequences), poor safety awareness, poor vision, and balance problems while sitting and walking. A review of Resident 1's post fall Nursing Notes indicated that on: 4/19/24, Resident 1 was found in his room by a Certified Nursing Assistant (CNA), after breakfast on the floor between his recliner and bathroom. 8/10/24, Resident 1 was found on the floor in his room when a CNA heard a thump after lunch. 8/12/24, Resident 1 was found on the floor in his room next to his wheelchair, after supper. 8/24/24, Resident 1 was found on the floor in his room after sliding out of his wheelchair while trying to get into bed at 2 pm. 9/16/24, Resident 1 was found on the floor in his room after attempting to transfer himself from his wheelchair to bed at 4:20 pm. On 10/24/24, Resident 1 was seen by a CNA from the hallway attempting to transfer himself from his wheelchair to his bed and fell on the floor, which resulted in a broken right hip. A review of Resident 1's Nursing Note dated 10/31/24 at 11:10am, written by the Interdisciplinary Team (IDT, a group of facility managers who discuss resident problems and find solutions), indicated that on 10/24/25 at 11:30 am, Resident 1 had a witnessed (observed by another person) fall in his room when he attempted to transfer himself from his wheelchair to his bed. The wheelchair alarm was sounding but the CNA could not reach him in time to prevent the fall. Resident 1 was then transferred to the emergency room (ER) where it was determined he had sustained a right hip fracture that required surgery to be repaired. A review of Resident 1's care plan titled, The Resident is at High Risk for Falls created 9/29/20, included the following interventions: Resident is not to be left alone in room sitting in wheelchair, he enjoys lying in bed. When [Resident 1] is heading toward his room follow him and assist him to the bathroom or to bed. During an interview with the Director of Nursing (DON) on 6/13/25 at 2 pm, the DON confirmed that the facility failed to implement Resident 1's care planned interventions by not following him to his room and assisting him back to bed or to the bathroom, which resulted in an avoidable fall with a right broken hip on 10/4/24. 2. Resident 2 was admitted on [DATE] with diagnoses that included dementia, depression, anxiety, insomnia (difficulty sleeping), repeated falls, chronic pain, heart failure, lung disease, some loss of bowel and bladder control, arthritis, osteoporosis (bone loss), and fractures of the upper spine. A review of Resident 2's Morse Fall Scale, dated 6/23/24, indicated that Resident 2 was at high risk for falls with a score of 90. Resident 2's risk factors included, unsteady on her feet, balance problems, cognitive impairments, and prior falls with injuries and a broken hip. Resident 2 had sustained 11 falls on 4/3/24, 4/8/24, 5/19/24, 8/9/24, 8/27/24, 9/6/24, 9/9/24, 9/20/24, 9/24/24, 10/8/24 which resulted in a broken right hip, and on 1/6/25 which resulted in a broken left hip. A review of Resident 2's At High Risk for Falls care plan, created 6/28/23, included the following interventions: Ensure that the resident is wearing appropriate non-skid footwear when ambulating or mobilizing in a wheelchair. Make sure shoes are comfortable and not slippery. A review of a statement written by CNA 1 on 1/6/25 at 11:15 am, who witnessed Resident 2's fall on 1/6/25 indicated, I had just got done cleaning the resident from a loose bowel movement and she was placed in her wheelchair. While cleaning up the bathroom, the resident made an attempt to get to her recliner, I was not aware she intended to self-transfer to the recliner. During the self-transfer I turned around and saw her slippers slide out from underneath her. She fell from the standing position on her side and landed on her left hip. She hit her left hip first and then her head on the floor. A review of the Interdisciplinary Post Fall committee meeting note dated 1/8/25 at 1:20 pm, indicated the root cause of Resident 2's fall was due to, resident's footwear inappropriate and that Resident 2 was transferred by ambulance to the ER at 11:30 am on 1/6/25, and admitted for surgical repair of a broken left hip. During an interview with Licensed Vocational Nurse (LVN) 1 on 6/17/25 at 1:45 pm, LVN 1 indicated that she was on duty when Resident 2 fell on 1/6/25. LVN 1 confirmed that Resident 2 was wearing slippers that were not non-skid footwear or shoes, and that Resident 2's care plan was not followed. LVN 1 stated she, threw them [the slippers] out after Resident 2 fell.

Based on interview and record review, the facility failed to prevent physical and verbal abuse for two of six sampled residents (Resident 3 and Resident 4) when Certified Nursing Assistant (CNA) A was rough with Resident 3 and CNA H cursed and threw personal care items toward Resident 4. These failures violated Resident's 3 and 4's right to be free from abuse and caused Resident 4 to fear CNA H. These failures and had the potential to subject residents to physical harm, mistreatment and negatively impact their emotional and psychosocial well-being. Findings: Review of the facility ' s policy and procedure titled, Abuse, Resident dated 3/2/2023 indicated that the facility, .ensure that each patient has the right to be free from abuse (verbal, sexual, physical and mental) and The facility prohibits mistreatment . Review of admission records for Resident 3 indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory and ability to make sound decisions), chronic pain (pain that lasts longer than three months), and weakness. Review of Resident 3 ' s Annual Minimum Data Set (MDS an assessment tool), dated 1/30/25, indicated Resident 3 had a Brief Interview for Mental Status (BIMS, an assessment of a resident's memory and decision-making skills with a score from 0 to 15), score of 3 out of 15 which is a severe impairment. Review of a nursing note by Licensed Nurse (LN) C dated 10/30/24 at 2:20 PM, indicated that Resident 3 was, .emotional and distraught during conversation . after the abuse by CNA A. During an interview on 4/25/25 at 12:32 PM, with Resident 2, who was Resident 3 ' s roommate, Resident 2 indicated that she saw CNA A push at and be rough with Resident 3. Review of admission records for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included dementia. Review of Resident 4 ' s Quarterly BIMS, dated 4/6/25, indicated Resident 4 scored 3 out of 15, a severe impairment. During an interview on 4/24/25 at 1:48 PM, with CNA I, CNA I stated that she was in the room when CNA H pushed Resident 4 and said, [F***] it, I ' m done and threw a clean brief (adult diaper) and a container of wet wipes on Resident 4 ' s chest and left the room. CNA I indicated that after CNA H left Resident 4's room, and that Resident 4 said he didn ' t like CNA H taking care of him because she can get aggressive, and it scared him. During an interview on 4/24/25 at 3:48 PM, with CNA H, CNA H stated that she tossed the brief and wipes to CNA I, not Resident 4, and left the room. During an interview on 5/27/25 at 12:56 PM, with the Director of Nursing (DON), the DON confirmed that both CNA A and CNA H were terminated and and stated that her expectations for staff were that they, need to treat the residents with respect, dignity, and care as if they are in their own home.

Based on interview and record review, the facility failed to ensure a thorough investigation of an allegation of staff to resident abuse was conducted for one of six sampled residents (Resident 3). This failure had the potential to put all residents of the facility at risk for staff to resident abuse. Findings: Review of a facility policy titled, Abuse, Resident dated 3/2/2023 indicated that, 5. a) The facility will investigate all suspected incidents .i) Obtain written statements by all persons involved while facts are fresh in their minds. Review of a facility policy titled, Guidelines for Conducting Investigation Accidents/Incidents dated 10/8/2019, indicated that, 1. The Licensed Nurse on duty at the time an accident or incident occurs will .a. i. Conduct staff/resident interviews. Review of Resident 3 ' s Annual Minimum Data Set (MDS an assessment tool) dated 1/30/25, reflected that Resident 3 scored 3 out of 15 possible points on a Brief Interview for Mental Status (BIMS, an assessment of memory and decision-making skills), which indicated severely impaired cognition. During an interview on 4/25/25 at 12:32 PM, with Resident 2, who was Resident 3 ' s roommate, Resident 2 indicated that she saw Certified Nursing Assistant (CNA) A push at and be rough with Resident 3, and confirmed that the facility had not interviewed her about the incident. During a review of the facility ' s investigation of alleged abuse of Resident 3, no records were found of an interview with Resident 3 ' s roommate, Resident 2. During an interview on 5/27/25 at 12:56 PM, the Director of Nursing (DON), the DON confirmed that there was no interview conducted with Resident 2 regarding Resident 3 ' s abuse allegation, and there should have been since Resident 2 witnessed the incident.

Based on interview and record reviews, the facility failed to ensure Resident 4 was monitored specifically for any problems resulting from the abuse he experienced when Certified Nursing Assistant (CNA) H was rough with Resident 4 and threw personal care items at him on 1/10/25, when they did not complete change in condition charting (documentation done just after an unexpected incident occurs that had a negative effect on a resident to communicate the resident's condition to other healthcare providers), and alert charting (ongoing documentation of monitoring for 72 hours after an accident, injury, or incident to reassess if any problems occurred over time resulting from the accident, injury, incident), was initiated late. These failures had the potential for staff to not be fully informed and intervene if Resident 4's mental and medical status declined which could result in delays in care and a decline in Resident 4's physical and emotional well-being. Findings: Review of a facility policy titled, Charting and Documentation dated 3/5/2025, indicated that, All skilled and unskilled services will be recorded .Any significant change in condition and Narrative entries are required for all changes in condition .abuse/unusual occurrences. Review of a facility policy titled, Abuse, Resident dated 3/2/2023, indicated that the facility will, (7) Monitor patient and assess if abusive behavior could be repeated and (10) Chart the occurrence in nurse ' s notes. Review of admission records for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory and ability to make sound decisions). During a review of Resident 4's progress notes after the reporting of abuse of Resident 4 by staff on 1/10/25, no Change in Condition charting was found. During a review of Resident 4's progress note by Licensed Nurse (LN) D, dated 1/12/25 at 12:42 PM, indicated that alert charting was added for Resident 4 two days after he experienced abuse by CNA H. During a concurrent interview and record review on 4/24/25 at 2:49 PM, the Assistant Director of Nursing (ADON) confirmed Resident 4's documentation was missing Change in Condition documentation and that alert charting documentation should have been started on Resident 4 right away after he experienced abuse by CNA H on 1/10/25.

Based on interview and record review the facility failed to ensure their abuse reporting policy was followed for six of 14 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) sampled for abuse when: 1. Resident 1 had an altercation with Resident 6 and the follow-up investigation was not sent to California Department of Health (CDPH) as per facility policy. 2. Resident 4 was accused of an altercation with Resident 3 and Resident 5 and the follow-up investigation was not sent to the CDPH as per facility policy. 3. Resident 2's family member (FM) was accused of verbally abusing Resident 2 and the facility did not report the alleged abuse to the CDPH withing 24 hours per facility policy. This failure had the potential to subject residents to mistreatment, neglect or abuse. Findings: 1.A review of the facility's policy and procedure (P&P) titled Abuse, Resident revised 3/2/23, indicated Results of investigation are reported to, with documentation of dates and times, as appropriate . State Survey, Certification Agency and any other agency according to state law. DHS (Department of Health Services or CDPH) Licensing and Certification. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with other behavioral disturbance (a type of dementia [memory, thinking and cognitive abilities are affected] caused from a lack of blood flow to the brain, leading to damage and eventual loss of brain cells with mood changes, agitation, and aggression.) Resident 1 made her own health care decisions. A review of Resident 6's Admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, and chronic pain. A review of an Entity Reported Incident (a federally required report sent to CDPH concerning an alleged abuse) dated 9/13/24, indicated Resident 1 abused Resident 6. No other details were provided. A review of the facility's document titled Investigation Tool dated 9/16/24, indicated Resident 1 threw a cheese and crackers plate at Resident 6 on 9/13/24. During a concurrent interview with the Director of Nursing (DON) A and document review on 3/28/25 at 2:01 pm, the Investigation Tool for the altercation between Resident 1 and Resident 6 was reviewed. The DON confirmed that the result of the investigation should have been sent to the CDPH, but the DON was unable to provide proof that the results were sent. 2. A review of Resident 4's Admission Record indicated Resident 4 was admitted on [DATE] with diagnoses that included dementia, stroke (blood supply is blocked to the brain leading to brain damage) and dysphagia (difficulty swallowing). A review of Resident 3's Admission Record indicated Resident 3 was admitted on [DATE] with diagnoses that included weakness, pain, depression and heart failure. A review of Resident 5's Admission Record indicated Resident 5 was admitted on [DATE] with diagnoses that included lung disease, depression, and chronic pain. A review of the facility's Entity Reported Incident dated 11/18/24, indicated Resident 4 slapped Resident 3 on the wrist on 11/17/24. A review of the facility's document titled Investigation Tool dated 11/19/25, indicated an investigation was conducted for the altercation between Resident 4 and Resident 3 but there was no documentation that the report was sent to the CDPH. A review of the facility's Entity Reported Incident dated 1/13/25, indicated Resident 4 yelled at Resident 5 on 1/12/25. A review of the facility's Investigation Tool dated 11/13/25, indicated an investigation was conducted for the altercation between Resident 4 and Resident 5 but there was no documentation that the report was sent to the CDPH. During a concurrent interview with the DON A and document review on 4/1/25 at 11:29 am, Investigation Tool for the altercations between Resident 4 and Resident 3, and between Resident 4 and Resident 5 were reviewed. The DON A confirmed that there was no record that the investigations for these incidents were reported to the CDPH, and they should have been. 3.A review of the facility's policy and procedure (P&P) titled Abuse, Resident revised 3/2/23, indicated Call Department of Health Services (DHS) Licensing and Certification [CDPH] no later than 2 hours after allegation is made, if the events that cause the allegations involves abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. A review of Resident 2 Admission Record indicated Resident 2 was admitted to the facility on [DATE] with the diagnoses that included dementia, mood disturbance and anxiety. A review of Resident 2's progress note dated 9/22/24 at 12:12 pm, by Registered Nurse (RN) C, indicated resident had distressing visit with [Family Member, FM] today. A written review of the interaction with Resident 2 and her FM by RN C dated 9/22/24 (Sunday) at 12:00 pm, indicated Today at lunch time [Resident 2's FM name] came for a visit. I was notified by a CNA [Certified Nursing Assistant] that they were concerned about conversations heard in room. I went and stood outside room since door was open a little along with a CNA. We overheard [FM] cussing at patient letting her know how much of a [NAME] she was and the fact that no one knew she would live this long. [FM] said F* about every other word and continued to belittle resident for quite some time. A review of the facility's Entity Reported Incident received by the CDPH on 9/24/24 at 9:44 am (Tuesday), indicated that on 9/22/24 at 12:00 pm .Resident 2's (FM) visited, and the CNA and Nurse overheard him verbally abusing her about living so long and used profanity. During a concurrent interview with the Assistant Director of Nursing (ADON) and review of the Entity Reported Incident on 3/28/25 at 3:20 pm, the interaction between Resident 2 and FM was reviewed. The ADON indicated the incident was reported 46 hours after the incident and should have been reported to CDPH withing 24 hours but was not.

Based on interview and record review, the facility failed to prevent verbal abuse for one of three sampled residents (Resident 1) when Registered Nurse (RN) A yelled and cursed at Resident 1 and told Resident 1 to not use her call light. This mistreatment caused Resident 1 distress and feelings that her needs were not met and had the potential to affect all residents under the care of RN A and negatively impact their quality of life and emotional well-being. Findings: Review of the facility's policy and procedure titled, Abuse, Resident dated 3/23/2023, indicated that the facility .ensure that each patient has the right to be free from abuse (verbal, sexual, physical and mental) and The facility prohibits mistreatment . Review of admission records for Resident 1, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Age related cognitive decline (difficulty thinking and making decisions), insomnia (difficulty sleeping), diabetes (high sugar in the blood), depression, and hypertension (HTN-high blood pressure). Resident 1 had a BIMS score (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 14 out of 15, which indicated she had good memory and decision making skills. Review of the facility document titled, Resident Abuse Investigation Questionnaire dated 8/12/24, showed that Resident 1 indicated that RN A had yelled and sworn at her. Review of facility's document titled, Investigation Tool Form SNF indicated that Resident 1 accused RN A of verbally abusing her on 8/11/24, that Resident 1 was upset by how she was talked to, and that Resident 1 didn't want RN A to be her nurse again. During an interview on 1/28/25 at 3:08 PM, Resident 1 stated that she liked it at the facility very much. Review of a written witness statement from Certified Nursing Assistant (CNA) C dated 8/13/24, showed that CNA C indicated Resident 1 stated RN A, gave her nothing but trouble and that Resident 1 stated she wanted another nurse to bring her medication. Review of a written witness statement from CNA D dated 8/14/24, indicated that RN A showed frustration with Resident 1 due to Resident 1 using the call light a lot. CNA D indicated that every time Resident 1 used her call light RN A went down and turned it off. CNA D stated RN A told her, This is bull**** your not going down there just ignore her. CNA D indicated that RN A told her to come to Resident 1's room with her. When they entered Resident 1's room, RN A started yelling at Resident 1 and told CNA D, for the rest of the night, she is not allowed to touch her call light unless it was an emergency and this is why all the residents f****** hate her and no one is gonna to come back down to help her including any CNAs. CNA D indicated that RN A told Resident 1, this is bull**** you keep pushing your button for little stupid bull**** and it's gonna f****** stop. CNA D indicated that Resident 1 asked RN A if she was the boss and RN A replied, You're damn straight I'm the boss so stop your sh**. CNA D indicated that later on that night Resident 1 requested her inhaler, and RN A told CNA D, She's [Resident 1] is being f****** ridiculous, if she's wearing oxygen then she can breathe. RN A did take Resident 1 her inhaler and slammed the inhaler down on Resident 1's bed side table and stated, Here, take it and hurry up. Two attempts to contact RN A for an interview were made on 1/29/25 and 1/30/25, RN A did not return the calls. A review of an email RN A sent to the facility dated 10/30/24, indicated, That the particular patient [Resident 1] was difficult to work with .Looking back I would definitely slow down and take a little more time with her. During an interview on 1/28/25 at 3:24 PM, with the Director of Nursing (DON), the DON confirmed that the facility investigation substantiated that RN A had verbally abused Resident 1 and the facility terminated their relationship with RN A.

Based on interview and record review, the facility failed to ensure five of seven sampled residents (Resident 1, 2, 3, 4 and 5) were free from verbal abuse when Certified Nurse Assistant (CNA) 1 verbally abused Residents 1, 2, 3, 4, and 5. This failure had the potential to negatively impact Resident 1, 2, 3, 4, and 5's sense of security, increased loss of dignity, and humiliation and emotional, and psychological well-being. Findings: During a review of Resident 1 ' s clinical record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss), anxiety (fear of the unknown), Spinal stenosis (a narrowing of the spinal canal in the lower part of your back), and high blood pressure. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 3/27/24, indicated, Resident 1 was cognitively intact (able to think and reason). During an interview on 5/24/24, at 9:30 a.m., with Resident 1, Resident 1 stated, I have a hard time sitting up due to pain. CNA 1 told me she would not give me my food if I didn ' t sit up. I let her know I was unable to sit up due to the pain in my back. CNA 1 turned and walked out of the room without giving me my food. CNA 1 was not kind and shouldn ' t be working in this profession. During an interview on 5/24/24, at 2:14 p.m., with CNA 2, CNA 2 stated, I was sitting at the nurses station charting, when I heard CNA 1 tell Resident 1, she was not going to give him his tray because he would not sit up. CNA 1 was very rude and disrespectful. During a review of the facility ' s Progress Notes (PG), type, Event Note, dated 5/13/24, at 3:50 p.m., the PG indicated, Activities Aide reported, I observed when I was charting on 5/11/24 approximately 5:30 p.m., a traveling CNA, CNA 1, was working the front she was in the room with Resident 1 and she was refusing to give him his meal because he would not sit up, her tone was very rude, and another CNA ended up giving Resident 1 his tray. During a review of the facility ' s PG, type, Nursing Note, dated 5/15/24, at 2:03 p.m., the PG indicated, CNA 1 put Resident 1 ' s dinner tray on his table, told him to sit up or she would take his tray away. Resident 1 said he eats in this position all the time. CNA 1took his tray away. Resident 1 stated he had a horrible night because of CNA 1. During a record review of a facility document titled, Report od Suspected Dependent Adult/Elders Abuse (SOC 341), dated 5/31/24, the SOC 341 indicated CNA 2 stated, CNA 1 was in Resident 1 ' s room refusing to give him his tray because he would not sit up. During a review of Resident 2 ' s clinical record, Resident 2 was admitted to the facility on [DATE] with diagnoses that included stroke, obesity, hearing loss, and arthritis. The most recent MDS dated [DATE], indicated Resident 2 was cognitively intact. During interview on 5/24/24, at 2:45 p.m., with RN, RN stated, CNA 1 came out of Resident 2 ' s room and yelled down the hall, Resident 2 is too big for me. During a review of the facility ' s PG, type, Event Note, dated 5/13/24, at 3:50 p.m., the PG indicated Activities Aide reported I heard her telling Resident 2 she was to big and could not get her tray closer to her, then CNA 1 walked out in to the hallway and was yelling I need help Resident 2 is a Hoyer and to big for me it ' s a 2 man job. During a review of the facility ' s PG, type, Nursing Note, dated 5/15/24, at 2:10 p.m., the PG indicated, the CNA 1 told Resident 2 she was too big to have her dinner tray while in her recliner. The CNA 1 was heard yelling down the hall to another coworker, I cannot do Resident 2 by myself; she is too heavy. During a record review of a facility document titled SOC 341, dated 5/31/24, the SOC 341 indicated, CNA 2 heard CNA 1 telling Resident 2 she was too big and could not get her tray close to her, then CNA walked out into the hallway and was yelling, I need help Resident 2 is a Hoyer and to big for me. During a review of Resident 3 ' s clinical record, Resident 3 was admitted to the facility on [DATE] with diagnoses that included obesity, Fibromyalgia (Widespread musculoskeletal pain accompanied by fatigue and trouble sleeping), and diabetes. The most recent MDS dated [DATE], indicated Resident 3 was cognitively intact. During an interview on 5/24/24, at 12:00 p.m., with Resident 3, Resident 3 stated, CNA 1 is a bad CNA and very abrupt. During an interview on 5/20/24, at 2:50 p.m., with RN, RN stated, Resident 3 stated CNA 1 is a bad CNA. During a review of the facility ' s PG, type, Event Note, dated 5/13/24, at 5:50 p.m., the PG indicated Resident 3 reported to RN CNA 1 is a bad CNA During a review of the facility ' s PG, type, Nursing Note, dated 5/15/24, at 2:15 p.m., the PG indicated Resident 3 had an alleged abuse on 5/11/24 on night shift. Nursing Description: CNA 1 is a bad CNA. This is what Resident 3 had to say about CNA 1, but Resident 3 would not elaborate. When asked what happened Resident 3 just said, nothing would be done anyway. During a record review of a facility document titled, SOC 341, dated 5/31/24, the SOC 341 indicated, RN reported Resident 3 stated CNA 1 is a bad CNA. During a review of Resident 4 ' s clinical record, Resident 4 was admitted to the facility on [DATE] with diagnoses that included Parkinson ' s disease (uncontrollable shaking), Cancer, and history of falling. The most recent MDS dated [DATE], indicated Resident 4 was cognitively intact. During an interview on 5/20/24, at 10:00 a.m., with Resident 4, Resident 4 stated, CNA 1 is unprofessional, not respectful, and made me feel pretty small. CNA 1 snapped at me and Resident 1 and said this is not my first rodeo. During a review of the facility ' s PG, type, Event Note, dated 5/13/24, at 3:50 p.m., the PG indicated Resident 4 reported to RN that he never wants CNA 1 to take care of him. Stated, She doesn't listen to me and told Resident 4, This is not my first rodeo. During a review of the facility ' s PG, type, Nursing Note, dated 5/14/24, at 1:00 p.m., the PG indicated Resident 4 stated this am that he never wants CNA 1 to take care of him. CNA 1 doesn't listen and would state, This is not my first rodeo. Resident 4 stated he'd rather lay in urine than to be cared for by CNA 1. During a record review of a facility document titled, SOC 341, dated 5/31/24, the SOC 341 indicated, Resident 4 reported to RN that he never wants CNA 1 to take care of him again. CNA 1 doesn ' t listen and would state, this is not my first rodeo. Resident 4 stated he would rather lay in his own urine than be cared for by CNA 1. During a review of Resident 5 ' s clinical record, Resident 5 was admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s (memory loss), hip replacement, anxiety, and arthritis. The most recent MDS dated [DATE], indicated Resident 5 was cognitively intact. During an interview on 5/24/24, at 11:30 a.m., with Resident 5, Resident 5 stated, CNA 1 doesn ' t treat people well. CNA 1 is bossy, and she was the worst. CNA 1 continued to rush her and made her feel terrible. Resident 5 doesn ' t want CNA 1 to ever take care of her again and she should not be allowed to take care of people. During a review of the facility ' s PG, type, Event Note, dated 5/13/24, at 3:50 p.m., the PG indicated Resident 5 reported to RN that a CNA 1 rushes me and refused to help me to the toilet. During a review of the facility ' s PG, type, Nursing Note, dated 5/13/24, at 3:50 p.m., the PG indicated Resident 5 had an alleged abuse on5/11/24 on night shift: Nursing Description: CNA 1 rushes me and refused to help me to the toilet. I would rather have anyone but CNA 1 care for me, stated, Resident 5. During a record review of a facility document titled SOC 341, dated 5/31/24, the SOC 341 indicated, RN reported that Resident 5 stated, CNA 1 rushes me and refuses to help me to the toilet. I would rather have anyone but her care for me. During a review of the facility ' s policy and procedure (P&P) titled, [Facility Name] Policy and Procedure Abuse, Resident, dated 3/2/2023, the P&P indicated, verbal abuse is defined as, the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or with in hearing distance, regardless of age, ability to comprehend, or disability. Policy, It is [Facility Name] intent to ensure that each patient has the right to be free from abuse (verbal, sexual, physical, and mental) including corporal punishment and involuntary seclusion. Residents must not be subjected to any of the above by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers and other agencies that service the resident, family, staff members, legal guardians, friends or other individuals

Based on observation, interview, and record review, the facility failed to ensure two of two residents (Resident 1 and Resident 2), sampled for unsafe wandering (a random, aimless or repetitive search for an exit that is non-goal-directed), and elopement (a resident leaves the premises or a safe area without the facility's knowledge and supervision) was assessed and monitored for unsafe wandering and elopement. Resident 1 and Resident 2 eloped from the facility and had no wander/elopement risk assessments at the time of their elopements. These failures resulted in Resident 1 eloping from the facility from an unknown exit at an unknown time and being found in the facility ' s parking lot by a staff member who happened to go out to the parking lot. And Resident 2 eloping from the facility and being found by law enforcement at a gas station four-tenths of a mile away, in the middle of the night. Findings: A review of the facility ' s policy titled, Elopement Policy, dated 5/8/24, indicated that the facility must Complete an elopement risk assessment upon admission ., and Identify residents who wander and/or who are at risk for elopement . A review of the facility ' s policy titled, Wandering Resident Protocol, dated 12/21/22, indicated that, Each new patient should be evaluated as to whether or not he/she presents a wandering risk. All patients, at any time, should be observed and evaluated as being a wandering risk, and If evaluation indicates the patient is at risk for wandering, use of the Wanderguard signaling device [a device that alarms and alerts staff when the resident exits through a facility door] as recommended. Review of Resident 1 ' s face sheet indicated that he was admitted to the facility on [DATE] with a diagnosis of anoxic brain injury (when the brain does not get oxygen causing brain cell death and problems with thinking and decision making). Record review of Resident 1 ' s Brief Interview for Mental Status (BIMS, a screening tool used to identify cognitive conditions) indicated a score of 3 (a score of 0-7 suggests severe cognitive impairment). Record review of Resident 1 ' s progress notes for 8/18/24 indicated he was found unharmed in the parking lot of the facility at 1:35 PM, the facility did not know when or through which door he exited, he stated to staff that he was looking for a cigarette. The progress note indicated that Resident 1 was wearing a Wander Guard and that the Wander Guard was functioning that day. Review of Resident 1 ' s Wandering Risk Assessment indicated that the assessment was completed on 8/18/24 at 1:38 pm, and the elopement risk assessment for Resident 1 was completed on 8/18/24 at 1:39 pm, after he eloped from the facility and was returned to the facility by staff. Review of Resident 2 ' s face sheet indicated that she was admitted to the facility on [DATE] with medical diagnoses including cancer, depression, and anxiety. Review of Resident 2 ' s BIMS, indicated a score of 11 (a score of 8-12 suggests moderate cognitive impairment). Review of Resident 2 ' s progress notes for 4/2/24 indicated that she was missing from her room at 12:40 AM on 4/2/24 and was found 3:14 AM at a gas station (four-tenths of a mile away from the facility, by law enforcement. The record indicated that at 8:20 AM on 4/2/24, a Wander Guard was placed on Resident 2. Review of Resident 2 ' s Elopement Risk Assessment indicated the assessment was completed on 8/22/24 at 9:43 am, and Resident 2 ' s Wandering risk Assessment was completed on 8/22/24 at 9:44 am, nearly 5 months after she eloped from the facility and was returned to the facility by law enforcement. During an in interview with Licensed Vocational Nurse (LVN 2), LVN2 stated that there was some previous wandering in the halls with Resident 2 but, not outside to her knowledge. During an interview with Assistant Director of Nursing (ADON) on 8/28/24 at 4:09 PM, in the ADON ' s office, she confirmed that Resident 1's Wandering Risk Assessment and Elopement Risk Assessment was not done until he actually eloped, two months after he was admitted . The ADON confirmed that Resident 2's Wandering Risk Assessment and Elopement Risk Assessment was not done until she actually eloped, 5 months after she was admitted .

Based on observation, interview, and record review, the facility failed to meet the required daily Registered Nursing (RN) hours for Payroll Based Journaling (PBJ) staffing information submitted to the Centers for Medicare and Medicaid Services (CMS). Failing to meet the required hours the facility did not ensure an adequate level of staff is working at a given time, potentially leading to inadequate care of residents and adverse clinical outcomes. FINDINGS During a concurrent record review and interview on 05/09/24 at 12:33 PM, the Quality Manager (QM) confirmed the required RN coverage was not met for 20 days of the first Federal Quarter of 2024 (The first Federal Fiscal Quarter begins October 1st of the prior year, in this case, October 1st, 2023). The QM stated, It is all here and matches the PBJ report on these dates. We did not have an RN present on the schedule. We do have them in other roles and we encourage them to clock in when they are giving resident care. Referring to the XML template (computer staffing sheet) the QM stated, It is the 7 group (designation) only which are RN's and these are the days they worked and will show a deficit on the PBJ. The QM provided and reviewed with the surveyor a copy of the XML Submission Form. Gaps in RN Coverage were pointed out by the QM and are as follows: 10/2, 10/3, 10/4, 10/10, 10/16, 10/1,7 10/18, 10/23, 10/23, 10/24, 10/31, 11/01, 11/06, 11/13, 11/14, 11/20, 11/27, 11/28, 11/29, 12/11, 12/18, 12/26 and 12/28/2023. The QM read the list aloud and confirmed the dates no RN's were listed for resident care as required by CMS.

Based on interview and record review, the facility failed report abuse allegations on 4/8/24 and unknown date for Resident 10 and reported late for Resident 50 and 278 when: 1. One of three sampled residents (Resident 10) was verbally and physically abused. 2. Two of three sampled residents (Resident 50 and 278) were reported late. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Abuse, Resident, dated 7/15/2022, included the following statement, For all intents and purposes, the word patient(s) refers to all customers receiving health care services in our facilities, including inpatients, outpatients, residents, and clients, the P&P indicated, each patient has the right to be free from abuse (verbal, sexual, physical and mental) including corporal punishment and isolation. Patients must not be subjected to any of the above by anyone, including, but not limited to, facility staff, other patients, consultants, volunteers, and other agencies that service the patient, family members, legal guardians, friends, or other individuals. Procedure: 5. Investigation: b) any person who becomes aware of a report of potential physical or mental abuse will inform the licensed nurse on duty. The licensed nurse will: ix) notify Chief Nursing Officer (CNO) - Skilled Nursing Facility (SNF) and Director of Quality (DIQ). X) notify ombudsman. Xi) call Department of Health Services Licensing and Certification no later than two hours after allegation is made. C) i) complete form State of California 341 (SOC 341). During a review of Resident 10's clinical record, Resident 10 was admitted to the facility on [DATE] with diagnoses that included high blood pressure, intellectual disability (limits to a person's ability to learn at an expected level and function in daily life), need for assistant at home and no other household member able to render care, and traumatic brain injury (sudden trauma causes damage to the brain). The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 02/12/24, indicated, Resident 10 was cognitively intact (able to think and reason.) During an interview on 5/7/24, at 11:00 a.m., with Confidential Informant (CI)1, CI1 stated the DON has a problem when anyone makes too much noise, including residents. The DON yells at people constantly. Resident 10 was hit by a car and has had a stroke and Resident 10's right side extremities are too weak to use adequately. Resident 10 has to wheel herself backwards to get around. About a month ago Resident 10 was wheeling herself down the hall and accidently bumped into another resident. The other resident yelled out. This was close to the DON's office and nurses station. DON came out of her office yelling at Resident 10 about the incident. DON stated she cannot keep wheeling backwards. DON grabbed Resident 10's wheelchair and physically shook it and turned her around to try to make her steer to her frontwards. Resident 10 was so embarrassed and in tears. CI1 stated I am afraid for my job. I did not know who else to report it to but the DON. During an interview on 5/7/24, at 11:45 a.m., with CI2, CI2 stated Resident 10 told her the DON was yelling or speaking to her in a very loud manner and grabbing Resident 10's wheelchair. CI2 stated, I did not know this was a reportable incident. During an interview on 5/8/24, at 10:00 a.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated, I do no know who the abuse coordinator is or if there is an abuse coordinator. During a concurrent interview and record review on 5/8/24, at 3:30 p.m., with Social Service (SS), Resident 10's Progress Note (PN), dated 4/8/24 was reviewed. The PN indicated, Resident 10 filled a grievance regarding her roommate and feeling unsafe. Resident 10 reported not being able to sleep and being scared to sleep as her roommate has thrown things at her in the middle of the night. Social Services report to the charge nurse on duty and DON. SS stated, when she returned to work the next day, she found the grievance note from Resident 10 and reported it to the Charge nurse and Director of Nursing (DON). 2. During a review of Resident 50's clinical record, Resident 50 was admitted to the facility on [DATE] with diagnoses that included conduct disorder, high cholesterol, and Dementia (forgetful). The most recent MDS dated [DATE], indicated, Resident 50 was severely cognitively impaired. During a review of Resident 278's clinical record, Resident 278 was admitted to the facility on [DATE] with diagnoses that included behavioral disturbances, high cholesterol, and sleep apnea. During a record review of state of California-Health and Human Services Agency. Unusual Incident/Injury Report (SOC 342), dated 4/22/24, at 2:35 p.m., the SOC 342 indicated, during a chart review from the weekend, a nursing note was discovered stating that on 4/19/24 at 4:57 p.m. a CNA witnessed Resident 278 hitting Resident 50 while walking in the hallway. DON During a concurrent interview and record review on 5/7/24, at 10:00 a.m., with DON, Resident 278's PN was reviewed. The PN indicated, on 4/19/24, at 4:57 p.m., Resident 278 hit Resident 50's head while walking on the hallway. During a concurrent interview and record review on 7/7/24, at 12:00 p.m., with Director of Staff Development (DSD), the RELIAS (education for abuse for all staff) dated 2022, was reviewed. DSD confirmed in the RELIAS program Section 3: Screening and Reporting Abuse, Staff are educated to report suspected abuse with in two hours to the abuse coordinator, DON, law enforcement, and the state of California Health and Human services. 40204 2. On 5/09/2024 at 12:15 PM during a concurrent interview and record review regarding abuse reporting with the Quality Manager (QM) the QM stated, I interviewed the resident and she gave a real detailed account and it was virtually the same as staff. Staff didn't want to report it and we have to change that culture. Maybe a good thing can come out of this now that we know and they feel comfortable reporting. It should be a just culture and people shouldn't be afraid to say something if they see it. The QM confirmed the staff witness did not report the abuse of Resident 10 when the Director of Nursing yelled and shook her wheelchair because there was not a culture that supported reporting. As to a written report the QM stated, I looked and didn't find anything. On record review there was no regulatory required documentation that the facility reported the incident to the California Department of Public Health.

Based on observation, interview, and record review, the facility failed to ensure staff had the knowledge and resources (cleaning supplies or cleaning materials), required to provide a safe and sanitary environment which promoted the prevention of the spread of infections when 2 of 2 sampled residents (Resident 1 and 2) had C-Diff infections, (C-Diff, a highly contagious bacteria in the intestines that could cause severe diarrhea, inflammation of the colon, abdominal discomfort, lack of appetite, weight loss, isolation, extended hospital stays, and/or death) and resided in a locked memory care unit for dementia (an enclosed living space for residents with dementia, a disease that caused an inability to think, reason, or remember) and; 1. Licensed Nurses (LN) and Certified Nurse Assistants (CNA) used cleansing wipes, with the brand name of, CaviWipes 1 to disinfect (cleaning with a chemical liquid that destroyed bacteria) on objects that were used for resident care on infected and non-infected residents as well as on surfaces touched by infected residents and staff did not know that this product did not kill C-Diff.; and 2. Residents 1 and 2) were not provided with dedicated (used by one resident) medical equipment such as blood pressure cuffs, thermometers, and stethoscope (a device used to listen to a pulse or heartbeat), when they had C-Diff. (according to the Centers for Disease Control (CDC), C-diff bacteria produced spores that could live on surfaces for months and years); and 3. Cleaning and disinfecting supplies that were approved to kill C-Diff were not available for use to clean the rooms of Resident 1 and 2 or the shower which was shared by 18 other residents. These failures resulted in an Immediate Jeopardy (IJ, situation in which the provider's noncompliance with one or more requirements of participation was likely to cause serious injury, harm, impairment, or death to a resident), when 2 out 2 sampled residents (Resident 1 and Resident 2) had C-Diff. and precautions were not taken to kill this bacteria, which had the potential to infect 18 other residents who resided in that memory care unit. An IJ was declared on 12/8/2023 at 2:40 pm, at F880, in the presence of the facility Director of Quality (DOQ) and Interim (temporary) Director of Nurses/Infection Preventionist (DON/IP), when the facility staff lacked adequate cleaning supplies, knowledge, and practices that were required to prevent the spread of C-Diff that included use of dedicated medical equipment such as; blood pressure cuff, thermometer, and stethoscope, and adequate cleaning and disinfection procedures had not been followed when cleaning resident rooms or a shared resident shower room. The facility DOQ provided an acceptable immediate action plan, (a plan to correct these deficient practices immediately) on 12/8/2023 at 4:47 pm. The actions to remove the IJ situation included training/education for facility staff that included the facility ' s C-Diff policy and procedure (P&P), use of dedicated medical equipment for residents that were positive for C-Diff, and aquiring approved cleaning and disinfectant supplies (use of a cleaning products that contained bleach) that were approved to kill C-Diff. The IJ was removed onsite by surveyors on 12/13/2023 at 1:22 pm, when the facility was able to demonstrate the immediate plan of action had been implemented, facility staff were knowledgeable on the C-Diff policy and procedures, dedicated medical equipment was present in the facility, and approved cleaning and disinfectant supplies for residents who had C-Diff were available for staff use. 4. LN A and CNA B were observed touching a contaminated blood pressure cuff that had been exposed to COVID and C-Diff, without wearing gloves. 5. CNA C was observed providing direct resident care to two separate residents and touching CNA C ' s own body in between direct resident care, without performing hand hygiene (HH, cleansing hands with an alcohol-based gel rub or washing hands with soap and water). These failures had the potential to spread infection to all 20 residents who resided in the memory care unit, staff and visitors and result in a serious infectious disease outbreak and negatively impact the residents' ability to attain or maintain their highest practicable level of physical and emotional well-being. Findings: 1. During a review of the facility ' s P&P titled, Infection Prevention Plan, dated 5/17/22, indicated, facility staff would be educated about infection prevention and control guidelines and methods. During a review of the facility ' s undated P&P titled, Clostridium Difficile C. difficile, indicated, facility staff would be educated on the prevention of the spread of C-Diff. A review of Resident 1 ' s undated Admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnosis of unspecified dementia (Inability to think, remember, or recall information) and was not her own responsible party (RP). A review of Resident 1 ' s Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/12/23, indicated Resident 1 did not have good cognition (ability to think or be understood). A review of Resident 1 ' s Order Details, dated 11/25/23, indicated, Stools for PCR (test to determine if a person had C-Diff) had been ordered. A review of Resident 1 ' s Physician ' s Note, dated 11/29/23, indicated Resident 1 was diagnosed with C-Diff. During an interview on 12/6/23 at 1:10 pm, CNA D stated, Resident 1 was positive for C-Diff and was on contact isolation precautions. CNA D stated, a cleansing wipe with the brand name of CaviWipes 1 was used to clean Resident 1 ' s commode (a portable toilet that looked like a chair), after Resident 1 ' s use. CNA D incorrectly stated, CaviWipes 1 required a five-minute wet time (the amount of time a disinfectant was required to remain wet on a surface to kill specific bacteria or viruses), and stated CNA D did not know if CaviWipes 1 was an effective cleaning agent in the prevention of the spread of C-Diff. A review of Resident 2 ' s undated Admission Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of unspecified dementia and was not her own RP. A review of Resident 2 ' s Quarterly MDS, dated [DATE], indicated Resident 2 did not have good cognition. A review of Resident 2 ' s Order Details, dated 11/30/23, indicated the facility suspected Resident 2 had C-Diff and the physician had ordered a stool sample. A review of Resident 2 ' s Immunology-Serology (type of laboratory test) report, dated 11/30/23, indicated Resident 2 tested positive for C-Diff. During an interview on 12/6/23 at 1:24 pm, LN E stated Resident 1 and Resident 2 had tested positive for C-Diff. LN E stated, CaviWipes 1 had been used to clean the vital sign cart (portable medical equipment used to check the blood pressure, temperature, and pulse) in-between each resident use and the vital sign cart was used for all 20 residents that resided in the facility ' s memory unit. LN E incorrectly stated, when cleaning objects touched by residents, a five-minute wet time was required for the disinfectant to be effective and stated CNA E did not know if CaviWipes 1 killed C-Diff. During an interview on 12/6/23 at 1:30 pm, CNA F stated, CaviWipes 1 was used to clean high touch resident areas (areas that were touched often by residents). CNA F confirmed using CaviWipes 1 to clean door handles, resident bed rails, and handrails (rails attached to the wall for residents to hold while walking). CNA F stated CNA F, assumed CaviWipes 1 killed C-Diff and did not know if CaviWipes 1 killed C-Diff. During an interview on 12/7/23 at 7:45 am, LN A stated, CaviWipes 1 was used to clean the electronic blood pressure cuff in-between each resident use and LN A liked to spray Lysol on the electronic blood pressure cuff, directly after using the CaviWipes 1 LN A stated that the use of a cleaning product that contained bleach would be effective in prevention of the spread of C-Diff, but did not know if Lysol or CaviWipes 1 contained bleach. LN A stated she did not know if Cavi Wipes 1 killed C-Diff. During an interview on 12/7/23 at 3:44 pm, CNA H stated, CNA H used CaviWipes 1 to clean and disinfect objects the residents touched and did not know if CaviWipes 1 killed C-Diff. During a concurrent observation and interview on 12/8/23 at 7:47 am, CNA B was observed cleaning the electronic blood pressure cuff. CNA 1 stated the electronic blood pressure cuff was cleaned with CaviWipes 1 after each resident use and did not know if CaviWipes 1 killed C-Diff. During a review of the CaviWipes 1 label, the label did not include C-Diff as a bacteria that the product killed. During an interview on 12/8/23 at 8:31 am, DON/IP confirmed bleach wipes were not available for facility staff to clean and disinfect with on the memory unit during the C-Diff outbreak. DON/IP stated, she had not ordered bleach wipes, though she knew that use of bleach for cleaning and disinfecting C-Diff was the preferred cleaning agent in order to kill C-Diff spores. 2. During a review of the facility ' s undated P&P titled, Clostridium Difficile C. difficile, indicated, Dedicated patient care equipment shall be used. During a review of the facility ' s P&P titled, Isolation Precautions, dated 9/29/16, indicated, residents that were suspected for or tested positive for C-Diff would be placed on Contact Precautions and Dedicated patient-care equipment should be considered for the patient. The P&P included a chart that indicated a residents placed on Contact Precautions would be provided with Dedicated Equipment. During an interview on 12/6/23 at 1:39 pm, CNA F stated, there was no dedicated vital sign equipment being used for Resident 1 or Resident 2, confirmed Resident 1 and Resident 2 had tested positive for C-Diff, and that there was one portable vital sign cart that was used for all 20 residents that resided in the memory unit. (Resident 1 was on contact isolation for C-Diff precautions for 12 days, and Resident 2 was on contact isolation for C-Diff for seven days). A review of Resident 1 ' s Order Details, dated 11/25/23, indicated, Stools for PCR (test to determine if a person had C-Diff) had been ordered. Resident 1 was on contact isolation for C-Diff precautions for 12 days without dedicated medical equipment. A review of Resident 2 ' s Immunology-Serology report, dated 11/30/23, indicated Resident 2 tested positive for C-Diff. Resident 2 was on contact isolation for C-Diff precautions for seven days without dedicated medical equipment. During a concurrent observation and interview on 12/7/23 at 7:45 am, LN A was observed walking out of Resident 1 ' s room carrying an electronic blood pressure cuff (small battery-operated blood pressure cuff that wrapped around the resident ' s wrist). LN A confirmed there was no dedicated vital sign equipment for Resident 1 or Resident 2 and stated the electronic blood pressure cuff was used for all residents. During an interview on 12/8/23 at 8:31 am, DON/IP stated use of disposable (dedicated for one person then thrown away) vital sign equipment was ideal and should be used for residents that had C-Diff. DON/IP stated, staff did not notify her that they needed dedicated vital sign equipment for Resident 1 or Resident 2, and indicated it was the staff's responsibility to do so. A review of the undated record titled, Job Description, Department: Infection Control, indicated, the Infection Control Nurse (IP), Confers with medical and nursing staff to determine appropriate implementation of isolation precautions. 3. During a review of the facility ' s P&P titled, Housekeeping Principles, Infection Control, dated 11/27/23, indicated, the facility promoted a sanitary environment by incorporating infection control practices into housekeeping practices. The P&P indicated housekeeping, Personnel are oriented and trained in proper .techniques regarding infection control. During a review of the facility ' s undated P&P titled, Clostridium Difficile C.difficile indicated, An Environmental Protection Agency (EPA)-registered sodium hypochlorite-based disinfectant shall be used for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (i.e., household chlorine bleach), also may be appropriately diluted and used (diluted 1:10 with water). Contact Precautions shall be used for patients with known or suspected C. difficile-associated disease. During an interview on 12/6/23 at 1:10 pm, CNA D stated, CaviWipes 1 were the only cleaning supplies available for CNAs to use when cleaning Resident 1 ' s commode. CNA D stated CaviWipes 1 were used to clean Resident 1 ' s commode after each use, and then housekeeping staff would deep clean Resident 1 ' s room, including Resident 1 ' s commode daily. During an interview on 12/6/23 at 1:30 pm, CNA F stated, CaviWipes 1 were the only cleaning supplies available for staff to use when cleaning resident door handles, wheelchair handles, and handrails. During an observation on 12/6/23 at 3:31 pm, CNA D was observed wiping down the handrails on the memory unit with CaviWipes 1 while residents wandered in the hallway utilizing the handrails to walk. During a concurrent observation, interview, and record review on 12/7/23 at 1:34 pm, with Housekeeper (HSK) 1, the housekeeping closet located in the facility ' s memory care unit was observed. HSK 1 stated for normal, everyday cleaning, E23 was used to clean resident rooms and the shower. HSK pointed to a clear plastic container on the wall that had E23 written on a label. A description of the cleaner was printed on paper an attached the wall near the clear plastic container. HSK reviewed the paper on the wall and confirmed the paper on the wall indicated, E23 was a neutral disinfectant to be used for cleaning the floors inside and outside of bathrooms and could be used to spray and wipe inside and outside restrooms, but did not kill C-Diff. HSK 1 stated on 12/2/23, five days after Resident 1 and 2 tested positive for C-Diff, a bottle of household bleach had been provided for housekeeping staff to use when cleaning and disinfecting the isolation rooms with C-Diff. HSK 1 stated bleach was not being used in the shower room for daily cleaning by housekeeping staff and stated the housekeeping staff was using E23 to clean the shower room. HSK 1 stated HSK 1 did not know bleach should be used when cleaning the shower room, located in the facility ' s memory unit. During an interview on 12/7/23 at 1:44 pm, with CNA L, CNA L stated, the housekeeping staff cleaned the shower room in the memory unit once a day. CNA L stated there was not a specific time that housekeeping staff cleaned the shower room, sometimes housekeeping staff cleaned the shower in the morning and sometimes housekeeping staff cleaned the shower in the afternoon. CNA L stated, in between each resident shower, the CNA who provided the shower, would clean the shower room with CaviWipes 1. During a review of the CaviWipes 1 label, the label indicated that this producte did not contain bleach or kill C-Diff. During a concurrent observation, interview, and record review, on 12/7/23 at 1:55 pm, with Environmental Services Manager (EVSM), a green contact isolation sign was observed outside of Resident 2 ' s door and EVSM stated the contact isolation sign should have been yellow. EVSM stated the green contact isolation sign indicated housekeeping staff did not need to clean the resident ' s room with bleach. EVSM stated the housekeeping staff relied on the isolation signage to determine how the room would be cleaned and disinfected. EVSM stated there was a yellow contact isolation sign that indicated, special considerations were needed. EVSM stated the yellow contact isolation sign was housekeeping ' s cue to clean with bleach and not with E23. EVSM confirmed the housekeeping staff was not provided with bleach for cleaning the special consideration contact isolation rooms until 12/2/23, seven days after the facility knew they had positive C-Diff infections. During an interview on 12/7/23 at 2:14 pm, DON/IP stated, after a resident on contact isolation used the shower room, LNs or CNAs (who ever provided the shower) were expected to call the housekeeping staff to clean and disinfect the shower room. DON/IP stated, when the housekeeping staff was not available to clean and disinfect the shower room, it was the responsibility of LNs and CNAs to clean and disinfect the shower room with the appropriate cleaner. DON/IP stated the shower room needed to be cleaned and disinfected with bleach after Resident 1 and Resident 2 used the shower room and confirmed bleach was not made available to staff until 12/2/23, seven days after the facility knew they had positive C-Diff infections. During an interview on 12/7/23 at 3:40 pm, CNA L stated all 20 memory care unit residents utilized the shower room located on the memory care unit. CNA L stated the shower room was cleaned after each resident use by the CNA who gave the resident a shower. CNA L stated use of CaviWipes 1 was available to staff for cleaning the shower. CNA L confirmed, there was no bleach available for CNA L to clean the shower room. CNA L stated that CNA L did not call housekeeping to clean or disinfect the shower room with bleach after providing showers to residents that were on contact isolation. During an interview on 12/7/23 at 3:48 pm, with CNA M, CNA M stated in between each resident shower, CNA M cleaned the shower room with CaviWipes1. CNA M stated they provided Resident 1 and Resident 2 with a shower on 12/6/23, was aware both residents had been diagnosed with C-Diff, and stated they had not called housekeeping to clean the shower room with bleach after Resident 1 or Resident 2 were showered. CNA M stated the housekeeping staff had cleaned the shower room that morning and CNA M did not know whether or not the shower room had been cleaned after CNA M had showered Residents 1 and 2, that same morning. During an interview on 12/8/23 at 8:31 am, DON/IP stated when a resident had symptoms and was suspected (to think that someone might have an illness without laboratory testing results), to have C-Diff, the resident would be placed on contact isolation. DON/IP stated reviewing the CaviWipes 1 label, with the DOQ, on 12/7/23, that the CaviWipes 1 label did not indicate CaviWipes 1 killed C-Diff. DON/IP confirmed that facility staff were using CaviWipes 1 for cleaning objects touched by residents with C-Diff, including high touch areas, for 13 days, before they were given bleach wipes, and that housekeeping was not provided bleach to clean the C-Diff rooms for 7 days, after the facility was aware that there were C-Diff infections. A review of the undated record titled, Job Description, Department: Infection Control, indicated, the Infection Control Nurse (IP) Monitors proper use of germicides, cleaning products, antiseptics, and disinfectants throughout the facility and indicated the IP Monitors methods of asepsis, sterilization, and disinfection employed throughout the facility. 4. During a review of the facility ' s undated P&P titled, Clostridium Difficile (C. difficile), indicated, Full barrier precautions (gowns and gloves) shall be worn when staff is in contact with patients with CDI During a review of the facility ' s P&P titled, Infection Prevention Plan, dated 5/17/22, indicated, a goal of limiting the transmission of infections associated with procedures. The P&P indicated a component of prevention of the spread of infection was hand hygiene (washing hands with soap and water or use of an alcohol-based hand gel). During a review of the facility ' s P&P titled, Isolation Precautions, dated 9/29/16, indicated, After glove removal and hand hygiene, hands should not touch potentially contaminated environmental surfaces or items. During a concurrent observation and interview on 12/7/23 at 7:45 am, LN A was observed entering Resident 1 ' s room with medication and an electronic blood pressure cuff. LN A was observed placing the electronic blood pressure cuff onto Resident 1 ' s wrist and then placing the electronic blood pressure cuff onto Resident 1 ' s table, next to Resident 1 ' s breakfast tray. LN A was observed carrying the electronic blood pressure cuff to the counter next to Resident 1 ' s sink and placing it on a paper towel. LN A removed LN A ' s gown and gloves and washed hands with soap and water. LN A picked up the uncleaned electronic blood pressure cuff with bare hands, held the electronic blood pressure against LN A ' s chest area of the uniform top, walked into the nurse ' s station room, and placed the uncleaned electronic blood pressure cuff onto the medication cart (a cart on wheels that contained all resident medication). Approximately 7-10 minutes later, at 8:02 am, LN, A was observed wiping the electronic blood pressure cuff with a CaviWipes 1 and immediately spraying the electronic blood pressure cuff with Lysol and left the nurse ' s station room with the electronic blood pressure cuff. LN A returned to the nurse station room and confirmed LN A touched the uncleaned electronic blood pressure cuff with bare hands, directly after use on a resident with C-Diff, and placing the electronic blood pressure cuff on the medication cart. LN A confirmed LN A should have worn gloves and not placed the electronic blood pressure cuff on the medication cart prior to cleaning and disinfecting and did not know that Cavi Wipes 1 did not kill C-Diff. During a concurrent observation and interview on 12/8/23 at 7:47 am, CNA B was observed standing outside of an isolation room cleaning the electronic blood pressure cuff with CNA B ' s bare hands. CNA B stated the resident was positive for COVID and confirmed CNA B should have had on gloves and did not. 5. During a review of the facility ' s P&P titled, Infection Prevention Plan, dated 5/17/22, indicated the, Infection Prevention Plan was designed to ensure the safety of patients, staff, and visitors within its healthcare environment by reducing the risk of acquiring a healthcare-associated infection (HAI). The P&P indicated, all residents .will be considered potentially infectious, and standard precautions are indicated for all patients. The P&P indicated Hand hygiene procedures were required when coming into direct contact with all residents and resident items. During a concurrent observation and interview on 12/8/23 at 8:06 am, CNA C was observed for 10 minutes assisting Resident 3 and Resident 4 to eat breakfast in the hallway of the facility ' s memory unit. CNA C was observed placing bare hands onto Resident 4 ' s shoulder and arm. CNA C provided Resident 4 with a bite of food and then walked over to Resident 3. CNA C was observed to touch Resident 3 ' s arm and rub Resident 3 ' s back. CNA C provided Resident 3 a bite of food and walked over to Resident 4. CNA C was observed touching CNA C ' s own arms and hair. CNA C touched Resident 4 ' s arm, provided Resident 4 a bite of food and while walking back to Resident 3, CNA C rubbed CNA C ' s eyes with bare fingers and provided Resident 3 a bite of food. CNA C had not performed hand hygiene for the entirety of the observation. CNA C confirmed not performing hand hygiene before or after assisting Resident 3 and Resident 4 with eating breakfast or when touching Resident 3 or Resident 4 ' s body. CNA C confirmed touching CNA C ' s own arm, face, and rubbing own eyes with CNA C ' s fingers, not performing hand hygiene before or after touching self, and stated CNA C should have. CNA C stated the facility expectation was to perform hand hygiene before and after resident care or touching self. CNA C stated the purpose of hand hygiene was to prevent the spread of infection to residents, self, and staff. During an interview on 12/8/23 at 8:31 am, DON/IP stated facility staff should not touch uncleaned medical equipment with bare hands and expectations for cleaning medical equipment after resident use, was to wear gloves while cleaning medical equipment. DON/IP stated uncleaned medical equipment should not be placed against the body and staff were expected to perform hand hygiene before and after resident care or touching themselves with their bare hands.

Based on interview and record review the facility did not ensure Staff were adequately trained in the use of the transport van liftgate resulting in two resident falls. The falls resulted in resident injuries which caused pain and suffering which could lead to additional adverse clinical outcomes. Findings: On 10/29/2021 and 11/29/2021, Facility staff were transporting residents to appointments using the facility transport van with liftgate. On both occasions facility staff erred in the use of the liftgate resulting in injuries to one resident on each occasion. Resident 1 was injured during the 10/29/21 incident and Resident 2 was injured during the 11/29/2021 incident. During a concurrent interview and record review on 1/13/2022 at 9 am, the Quality Manager stated, We had two falls about a month apart. After the second one we realized there was more training needed so we worked on that and competency assessments too. Before this we did not have any formal education of the transport staff. Documentation of the incident in Resident 1's medical record has the following statement from the van driver. The Driver states that he got out of the van, went around back, opened it up, put the ramp down, walked around the side of the van got in, unbuckled the wheelchair, walked around him, unbuckled the back of the wheelchair, started walking backward, and they both fell off the ramp . Somehow during (Resident 1's) fall he sustained a larger laceration to the head. Documentation reflects 31 staples were used to close the laceration. Resident 1 was admitted to the facility 11/30/2018 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/20/2021 Resident 1 scored a perfect 15 on a test of his mental function (Brief Interview for Mental Status- BIMS) indicating no memory or functional problems. Resident 1 stated, He (Transporter 1) got out of the van and went to the back and lowered the lift to the picking up position. Then he came inside and unbuckled my chair and went around the back and pulled me towards the rear of the van. The next thing I know he is falling backwards and holding onto my chair which pulled me down with him. I didn't feel much pain at the time, but I remember touching my head and seeing blood all over my hand. On 11/29/2021 Resident 2 was involved in a transport related incident with Transporter #2 (T2), falling from the transport lift in the same manner. Staff documentation in the records indicate the same mechanism of fall and injury. Resident 2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 has a BIMS Test score of 14 on 10/27/21 which shows very good mental function and memory. Resident 2 stated, I was in my chair, and she went around after helping another patient and got in. She went back to the back behind me and the next thing I heard was her saying 'no no no.' She was grabbing ahold of my chair and back we went. The next thing I know I'm on the ground on top of her and bumped my head on the ground. Resident 2 complains of neck and shoulder pain during the interview. Resident 2's wife was present and confirmed the complaints of pain. On 1/13/22 at 12:00 pm, Noon Transporter 2 was interviewed and stated, I stepped off the back of the van because the lift wasn't up, and I fell , and he landed on top of me. Regarding training after the incident Transporter 2 stated They now give a return demo and check off. They also are confirmed they know how to do the transfers. Before the incidents that was not done. On 2/7/22 at 1:44 pm, Transporter 1 (T1) was interviewed. T1 was asked about training for use of the ramp and safety. T1 replied, No, I mean they show us how to use the lift and all but no real big training. It was clarified that this was before both incidents. T1 was fired after the accident and is not aware of any additional training that has been instituted to increase the safe transport of residents. The facility's job description titled Activities Van Driver/Aide for transportation drivers was obtained and reviewed. The job description requires the van operator to be responsible for .transportation of residents/patients safely . The medical records of Residents 1 and 2 indicate the facility staff did not meet the job description requirements when Residents 1 and 2 were injured in the transportation incidents.

Based on observation, interview, and record review, the facility failed to implement prevention of skin break down protocols (actions and/or interventions), per facility policy, for two of 17 sampled residents (Resident 58 and Resident 24) when the residents were identified for risk for skin breakdown and pressure related wounds. These failures resulted in the development of a new pressure wound for Resident 58 on her left heel, and the potential for the worsening of a pressure wound for Resident 24 on her right ankle. Findings: The facility provided policy and procedure titled Skin Tears, Abrasions and Other Wounds, undated, was reviewed and read: The person who first discovers a skin problem will notify the licensed nurse The licensed nurse will thoroughly assess area, noting type of wound, location, measurements, depth, and amount of drainage . notify physician of problem, request wound care dressing, if appropriate, and/or other interventions. Chart that the physician has been notified. Notify the family or responsible party Chart notification and family response Licensed nurse is responsible for checking dressing for cleanliness and integrity each shift, recording initials on treatment sheet as verification. Problems and/or dressing changes will be documented in Nurse's Notes A complete head-to-toe assessment will be done every 'Weekly Update' Areas of concern must be care planned The Skin Tears, Abrasions and Other Wounds, policy and procedure was reviewed and included a section titled, Prevention/treatment of [REDACTED]. Reposition the resident every two hours. Use pillows or foam wedges to keep bony prominence's from direct contact. Use devices that totally relieve pressure on heels Use a written plan Inspect skin at least twice a day and on change of condition Institute a turning program. Monitor and document interventions and outcomes Risk will be assessed on admission, on change of condition, and at least quarterly. Care should be modified according to the level of risk. Frequency of reassessment depends on residents status. 1. Resident 58's medical record was reviewed. Resident 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Insulin is a hormone that helps cells use sugar for energy), and diabetic [MEDICAL CONDITION] (a condition that can cause numbness, tingling and/or pain in the feet and hands). Resident 58's record included a Nursing Note, dated 1/28/18 at 1:20 am, that read a Certified Nursing Assistant (CNA) had notified the Licensed Nurse (LN) that Resident 58 had a wound to her left heel. The wound was described as her heel has eschar (dead tissue), skin peeling, and area is dark purple in color. There is some bleeding. It measures 3.5 centimeters (cm). Took a picture Heels are now being floated (the use of a device to relieve all pressure from the heels while a resident is in bed). Resident 58's admission Minimum Data Set (MDS - a comprehensive resident assessment), dated 1/3/18, was reviewed and identified that she was at risk for pressure related wounds, but did not have any pressure wounds on admission. A care plan for mobility was initiated, but did not address the risks for skin breakdown or pressure related wounds. There was no turning program or pressure reduction devices instructed to be used in Resident 58's care plans. Resident 58's admission MDS assessment identified that she needed extensive assist to turn in bed. During an observation and interview, on 1/30/18 at 11:53 am, Resident 58 was observed in her wheelchair sitting next to her bed. She had a soft foam boot on her left foot. She stated, I think there is a wound there. Resident 58 was unable to provide any details as to how her heel wound developed. She did not appear to have heel pain and did not report that her heel hurt. During a concurrent interview and record review, with the Assistant Director of Nursing (ADON) on 1/31/18 at 12 pm, she stated that Resident 58's left heel wound appeared to be a pressure related wound and that the wound met the criteria of a Suspected Deep Tissue Injury (DTI). The facility skin assessment document defined a DTI as a Purple or maroon localized area of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. ADON stated that Resident 58's heel wound was awaiting evaluation by the facility wound consult nurse. ADON stated that she was unable to find any documented evidence that the facility had developed a skin integrity care plan that included the facility policy and protocol interventions for Resident 58 to avoid pressure related skin injuries, prior to the development and the identification of the DTI on 1/28/18. ADON acknowledged that Resident 58 was at risk for skin breakdown and should of had interventions in place to prevent the development of the pressure wound. The records reviewed included LN weekly summary reports done by registry staff (temporary staff), that did not identify any heel redness or injury on 1/17/18 and 1/24/17. ADON stated that the facility does not utilize any documented communication system such as shower skin sheets to document the check of a resident skin during showers or bed baths, but CNA's know to report changes to the LNs. During an interview on 1/31/18 at 5:02 pm with CNA L, who first identified Resident 58's heel injury, he stated that he was reluctant to keep the facility non-slip socks on the residents at night, while in bed, because they seem to restrict circulation for some residents. CNA L stated he had put Resident 58 to bed on the eve of 1/28/18 when her heel injury was discovered and did not notice any heel injury at that time. He stated that later in the evening Resident 58 had sat up on the side of her bed and he noticed some spots on the sheet of the bed that appeared to be blood and when he investigated he found the heel wound. He stated that he did not see blood on Resident 58's socks that he had removed earlier that eve. CNA L stated he had not worked with Resident 58 for over a month prior to the eve of the wound discovery, but that he had not noticed any redness or problems with her heels before seeing the blood spots on the sheets. During an interview and record review with CNA N, on 2/1/18 at 9:10 am, she stated that she had assisted Resident 58 with her documented showers on 1/18/18 and 1/26/18 and that she (CNA N) washed Resident 58's feet and between her toes during the showers. She stated that she had not identified any heel injury or redness during the care, but that she may have missed the injury. CNA N stated that Resident 58 wore a urine catheter leg bag when up during the day so she did not need to be taken to the toilet as frequently as other residents. CNA N stated that she checked the urine catheter bag at least every four hours. CNA A stated that she had not done any pressure reliving measures for Resident 58's heels prior to her injury being discovered. During an interview, on 1/31/18 at 2:54 pm, the facility Chief Nursing Officer (CNO) stated that she had looked at the picture of Resident 58's wound. CNO stated that she was disappointed with the outcome of Resident 58's care, and that the facility needed to do more frequent and complete skin assessments and better documentation to prevent pressure wounds from developing. During an interview with the facility wound consultant licensed nurse (LN) E, on 1/31/18 at 3:16 pm, she stated that Resident 58's left heel was boggy (abnormal texture of tissue characterized by sponginess, usually because of high fluid content) and has a deep tissue injury wound present. LN E stated that Resident 58 had slow healing due to her diabetes, and had poor circulation and [MEDICAL CONDITION] (swelling of soft tissues as a result of excess fluid accumulation) in her lower leg that could have contributed to the wound developing. LN E stated that Resident 58 should have had preventative measures in place to prevent the pressure related injury. LN E's assessment documentation, dated 1/31/18 at 2:15 pm, described a DTI to the left heel that measured 2.1 cm in length by 1.8 cm width by 0.1 cm depth and 4.2 cm diagonal. There was minimal drainage from the wound. The assessment identified that 40% of the wound was dried eschar, 50% was deep purple and 10% stable adherent tissue. 2. A review of a facility provided policy, titled Pressure Ulcer Care, SNF, approved 1/28/16, indicated that the Licensed Nurse would notify the physician of the wound and request wound care orders. The Licensed Nurse would thoroughly assess the area, ensure the area was cleaned and perform treatment per protocol or physician's orders [REDACTED]. A review of Resident 24's record indicated that she was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated that Resident 24 was cognitively intact (able to think and reason) and she did not have any pressure injuries. During an observation on 1/29/18 at 4:17 pm, a wound was observed on Resident 24's right outer ankle. The wound had a dressing dated 1/29 that was partially covering the wound. A review of Resident 24's Weekly Assessment, dated 1/19/18, indicated that Resident 24 had an abrasion on her right outer ankle. During an interview on 1/31/18 at 4:12 pm, LN F stated that she identified Resident 24's right outer ankle wound on 1/19/18. LN F stated that Resident 24 had a wound in the same location previously that had healed. LN F confirmed that she did not initiate a care plan due to Resident 24's room changed at the same time and she was no longer Resident 24's nurse. During a concurrent observation and interview on 1/31/18 at 4:47 pm, LN C observed the wound on Resident 24's right outer ankle. LN C confirmed that Resident 24's wound had no dressing on it. The wound appeared as non-blanchable [DIAGNOSES REDACTED] (redness that does not fade when pressed) with dry flaky skin in the middle that measured 1.6 cm wide by 1.1 cm long. LN C confirmed the wound was a Stage 1 pressure injury, it was identified on 1/19/18 and the MD was not notified, the care plan was not updated and no orders were received for the treatment of [REDACTED].

Based on interview and record review, the facility failed to provide annual influenza vaccinations in a timely manner for one of 17 sampled residents (Resident 51) and two residents outside of the sample (Residents 3 and 67). This failure resulted in Residents 3 and 67 not being vaccinated and becoming ill with influenza and had the potential for Resident 51 to become ill with influenza. Findings: 1. A review of Resident 3's record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 3's influenza vaccine consent dated 1/15/18. indicated that the consent was signed by Resident 3's Responsible Party (a person the facility can call about the care needs or finances of a resident) on 1/15/18. 2. A review of Resident 67's record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 67's influenza vaccine consent dated 1/12/18. indicated that the consent was signed by Resident 3's Responsible Party (a person the facility can call about the care needs or finances of a resident) on 1/12/18. During an interview with Licensed Nurse (LN) A, on 2/1/18 at 8 am, LN A stated that some the residents (3 and 67) did not get the flu vaccination because the usual process the facility used had changed and the staff in the facility were no longer giving the vaccinations to the residents. A record review of the facility's line listing (list of residents who became ill with influenza and other relevant data) indicated Resident 3 became ill with influenza on 12/26/17 and Resident 67 became ill on 1/10/18. A review of Resident 51's record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, a standardized resident assessment), dated 12/26/17, indicated Resident 51's influenza vaccine was not offered. A review of Resident 51's Immunization Consent dated 12/29/17, indicated that Resident 51 gave consent on 12/19/17 to be administered an influenza vaccination. During an interview on 2/1/18 at 11 am, LN A stated that the vaccine would be given on 2/2/18. During an interview on 2/1/18 at 11:15 am, LN C stated that Resident 51 had no contraindications to receive the flu vaccine since 12/29/17. LN C stated that the facility was waiting for the outpatient clinic to do it for billing purposes. The facility's policy and procedure titled, Influenza in California LTC (long term care) Facilities, Recommendations for the Prevention, Detection and Control Of, undated, was reviewed and indicated, Vaccination of persons at high risk . of influenza is currently the most effective measure for reducing . influenza and should be done each year before the influenza season, beginning in October.

Based on interview and record review, the facility failed to notify and request an examination by Resident 1's physician when Resident 1's condition continued to decline and he continued to refuse all fluids and food. Resident 1 was hospitalized with admitting [DIAGNOSES REDACTED]. Electrolytes control the fluid balance of the body and are important in muscle contraction, energy generation, and almost every major biochemical reaction in the body) imbalance, which he did not survive. Dehydration (happens when your body doesn't have as much water as it needs. Without enough, your body can't function properly) was a contributing factor in his death. The failure to notify the physician delayed further evaluation and treatment that could have changed Resident 1's outcome. Refer to F 327, F 329, and F 333. Findings: A review of Resident 1's record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's wife was his designated responsible party (RP) to make healthcare decisions for him. According to facility's nursing notes for Resident 1, by [DATE], it was noted Resident 1 had escalating behaviors where he was striking out at staff. He was given [MEDICATION NAME] (an antipsychotic medication used for the treatment of [REDACTED]. He was noted to be confused, lethargic, and refusing oral intake on [DATE], at which time the physician was notified and labs were ordered. A review of labs done on [DATE] included a Blood Urea Nitrogen (BUN, a test to see how well the kidneys were working. Dehydration can make the BUN high). The result was 35 (normal range is ,[DATE]). The labs also included a Creatinine level (test to check kidney function). The result was 1.24 (normal range is 0.55 - 1.3). The sodium (Na) level was 153 (normal range is ,[DATE]). The White Blood Cell (WBC, test for infection) count was 13.7 (normal was 4.5 - 11). The Hematocrit (HCT, ratio of the volume of red blood cells to the total volume of blood) was 47.8 (normal is 42 - 52). According to the facility's nursing notes for Resident 1, the physician was notified of the labs on [DATE] and ordered a urinalysis (urine test) with culture (to test for specific bacteria) if indicated. On [DATE] at 8:15 pm, Resident 1 was noted to be lethargic (decreased level of consciousness), sleepy, refused medications, and refused to open his mouth. The nurse noted, on [DATE], Resident 1 refused to eat. Resident 1 had been incontinent of urine so the nurse catheterized him (inserted tube into the bladder) to get a urine sample for the urinalysis which had been ordered, but was not able to get any urine. On [DATE] at 10:10 am, it was noted Resident 1 continued to refuse anything by mouth. On [DATE] at 12:45 pm, it was noted Resident 1's physician was present in the facility to examine Resident 1 and called his RP. According to the physician's note from the hospital record, Resident 1's RP wanted Resident 1 treated for [REDACTED]. Resident 1 was transferred to an acute care hospital at 3:40 pm. The hospital records indicated he was admitted for severe dehydration with electrolyte abnormalities. Resident 1 expired on [DATE] at 9 am. A review of the unit diet sheets included the amounts of meals, snacks, and fluids consumed by Resident 1 as noted by the Certified Nursing Assistants. On ,[DATE] and [DATE], Resident 1 ate less than one third of his meals and drank less than 900 milliliters (ml) fluids. On [DATE], Resident 1 drank 240 ml, and refused all food and fluids on ,[DATE], ,[DATE], and [DATE]. The nurses also noted no oral intake from ,[DATE]-[DATE] except for sips of water taken on [DATE]. The initial assessment by the facility's dietitian, dated [DATE], estimated Resident 1's fluid needs at ,[DATE] ml per day. There was nothing in the notes to indicate the physician had been notified about Resident 1's continued refusal to take food and fluids on ,[DATE] and [DATE], until [DATE]. Labs were repeated upon admission to the hospital on [DATE] at 4:35 pm. The BUN had increased to 102 and the Creatinine had also increased to 4.63 (indicating severe dehydration and impaired kidney function). The Na had increased to 164 (causes of increased sodium include dehydration). The Hct (Per LabTests Online by American Association for Clinical Chemistry, the most common cause of an elevated Hct is dehydration) had increased to 57. The WBC count had increased to 28.1. During an interview on [DATE] at 2 pm, the Chief Nursing Officer (CNO) confirmed they had no hydration policy and procedure and confirmed no calls to the physician regarding Resident 1's condition were documented on ,[DATE] and [DATE]. During an interview on [DATE] at 12:20 pm, Charge Nurse (CN) 1 also confirmed it was not documented that the physician was called regarding Resident 1's condition on ,[DATE] and [DATE] (Saturday and Sunday). CN 1 stated from Monday through Friday, either she or CN 2 were working and were available for staff, at Facility B, where Resident 1 resided. CN 1 stated that on the weekends both she and CN 2 were off, so there was no charge nurse present at Facility B. CN 1 said there was a supervisor available at Facility A, on the weekends, should staff need to call her. During an interview on [DATE] at 8:15 am, RP said she was in to visit Resident 1 on [DATE] and he was sedated and not very responsive. She was there again on [DATE] with another family member and he was still sedated and didn't know they were there. RP stated she called over the weekend of ,[DATE] and [DATE], but was not given any specific information about Resident 1's condition. On [DATE], she received a call from Resident 1's physician and he was then transferred to the hospital. During an interview on [DATE] at 11 am, MD (Resident 1's physician) stated he had been told Resident 1 was refusing to eat and drink. At that time, he asked the nurse if he needed to come see Resident 1 or if it could wait until he returned, after the weekend of ,[DATE] and [DATE], and was told it could wait until he returned. MD stated he has to rely on the nurses to tell him how a resident looks. MD said when he arrived on [DATE], he could tell Resident 1 looked pretty sick and called Resident 1's RP to see how she wanted to treat him. Resident 1 was admitted to the hospital with [REDACTED]. MD said he indicated Resident 1's cause of death to be sudden cardiac death with dehydration as a contributing factor. A review of the death certificate listed other significant conditions contributing to death but not resulting in the underlying cause as severe dehydration.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with sufficient fluid intake to maintain adequate hydration when: The facility was unable to demonstrate it comprehensively assessed Resident 1's fluid status when his fluid intake decreased and he did not drink adequate fluids (Resident 1's estimated fluid needs were ,[DATE] milliliters (ml) per day. The facility failed to recognize symptoms of dehydration (when a person uses or loses more fluids than taken in so the body does not have enough water and other fluids to carry out its normal functions) including lethargy (sleepiness, unresponsiveness, and inactivity), confusion, and eventual refusal of all fluids. The facility failed to notify and request an examination by Resident 1's physician when Resident 1 continued to refuse all fluids and food. These failures resulted in Resident 5's hospitalization with admitting [DIAGNOSES REDACTED]. Dehydration was a contributing factor in his death. Refer to F 329. Findings: A review of the Mayo Clinic diseases and conditions definition of Dehydration, dated [DATE], included that older adults and people with chronic illnesses are most at risk. The signs and symptoms of mild to moderate dehydration include sleepiness and tiredness, dizziness or lightheadedness, and symptoms of severe dehydration include confusion in adults. This can result in kidney failure, a potentially life-threatening problem which occurs when your kidneys are no longer able to remove excess fluids and wastes from your blood. A review of Resident 1's record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's wife was his designated responsible party (RP) to make healthcare decisions for him. According to the [DATE] nursing notes, by [DATE], it was noted Resident 1 had escalating behaviors where he was striking out at staff. He was given [MEDICATION NAME] (an antipsychotic medication used for the treatment of [REDACTED]. He was noted to be confused, lethargic, and refusing oral intake on [DATE], at which time the physician was notified and labs were ordered. A review of labs done on [DATE] included a Blood Urea Nitrogen (BUN, a test to see how well the kidneys were working. Dehydration can make the BUN high). The result was 35 milligrams per deciliter (mg/dl, normal range is ,[DATE] mg/dl). The labs also included a Creatinine level (test to check kidney function). The result was 1.24 mg/dl (normal range is 0.55 - 1.3 mg/dl). The sodium (Na) level was 153 milliequivalents per liter (mEq/L, normal range is ,[DATE] mEq/L). The White Blood Cell (WBC, test for infection) count was 13.7 (normal was 4.5 - 11). The Hematocrit (HCT, percent ratio of the volume of red blood cells to the total volume of blood) was 47.8 (normal is 42 - 52). According to the [DATE] nursing notes, the physician was notified of the labs on [DATE] and ordered a urinalysis (urine test) with culture (to test for specific bacteria) if indicated. At 8:15 pm, Resident 1 was noted to be lethargic, sleepy, refused medications, and refused to open his mouth. The nurse noted, on [DATE], Resident 1 refused to eat. Resident 1 had been incontinent of urine so the nurse catheterized him (inserted tube into the bladder) to get a urine sample for the urinalysis which had been ordered, but was not able to get any urine. On [DATE] at 10:10 am, it was noted Resident 1 continued to refuse anything by mouth. On [DATE] at 12:45 pm, it was noted in the nursing notes, Resident 1's physician was present in the facility to examine Resident 1 and called his RP. According to the physician's note from the hospital record, Resident 1's RP wanted Resident 1 treated for [REDACTED]. Resident 1 was transferred to an acute care hospital at 3:40 pm. A review of the prehospital care sheet from the ambulance indicated IV (intravenous) fluids were started 1000 milliliters wide open (rapid infusion). The hospital records indicated he was admitted for severe dehydration with electrolyte abnormalities. Resident 1 expired on [DATE] at 9 am. A review of the unit diet sheets included the amounts of meals, snacks, and fluids consumed by Resident 1, as noted by the Certified Nursing Assistants. On ,[DATE] and [DATE], Resident 1 ate less than one third of his meals and drank less than 900 milliliters (ml) fluids. On [DATE], Resident 1 drank 240 ml, and refused all food and fluids on ,[DATE], ,[DATE], and [DATE]. The nurses also noted no oral intake from ,[DATE]-[DATE] except for sips of water taken on [DATE]. The initial assessment by the facility's dietitian, dated [DATE], estimated Resident 1's fluid needs at ,[DATE] ml per day. There was nothing in the notes to indicate the physician had been notified about Resident 1's continued refusal to take food and fluids on ,[DATE] and [DATE], until [DATE]. The labs were repeated upon admission to the hospital on [DATE] at 4:35 pm. The BUN had increased to 102 mg/dl and the Creatinine had also increased to 4.63 mg/dl (indicating severe dehydration and impaired kidney function). The Na had increased to 164 mEq/L (causes of increased sodium include dehydration). The HCT (Per LabTests Online by American Association for Clinical Chemistry, the most common cause of an elevated HCT is dehydration) had increased to 57. The WBC count had increased to 28.1. During an interview on [DATE] at 2 pm, the Chief Nursing Officer (CNO) confirmed they had no hydration policy and procedure. The CNO also confirmed no calls to the physician regarding Resident 1's condition were documented on ,[DATE] and [DATE]. During an interview on [DATE] at 12:20 pm, Charge Nurse (CN) 1 also confirmed it was not documented that the physician was called regarding Resident 1's condition on ,[DATE] and [DATE] (Saturday and Sunday). CN 1 stated from Monday through Friday either she or CN 2 were working and were available for staff, at Facility B, where Resident 1 resided. CN 1 stated that on the weekends both she and CN 2 were off, so there was no charge nurse present at Facility B. CN 1 said there was a supervisor available at Facility A, on the weekends, should staff need to call her. During an interview on [DATE] at 8:15 am, RP said she was in to visit Resident 1 on [DATE] and he was sedated and not very responsive. She was there again on [DATE] with another family member and he was still sedated and didn't know they were there. RP stated she called over the weekend of ,[DATE] and [DATE], but was not given any specific information about Resident 1's condition. On [DATE], she received a call from Resident 1's physician and he was then transferred to the hospital. During an interview on [DATE] at 11 am, MD (Resident 1's physician) stated he had been told Resident 1 was refusing to eat and drink. At that time, he asked the nurse if he needed to come see Resident 1 or if it could wait until he returned, after the weekend of ,[DATE] and [DATE], and was told it could wait until he returned. MD stated he has to rely on the nurses to tell him how a resident looks. MD said when he arrived on [DATE], he could tell Resident 1 looked pretty sick and called Resident 1's RP to see how she wanted to treat him. Resident 1 was admitted to the hospital with [REDACTED]. MD said he indicated Resident 1's cause of death to be sudden cardiac death with dehydration as a contributing factor. A review of the death certificate listed the cause of death as cardiopulmonary arrest, sudden cardiac event, [MEDICAL CONDITION] cardiovascular disease. Under significant conditions contributing to death, but not resulting in the underlying cause, the death certificate included severe dehydration.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) did not receive unnecessary drugs when Resident 1 received six excessive doses of [MEDICATION NAME] (antipsychotic medication used to control behavior), and failed to adequately monitor common side effects for [MEDICATION NAME] (anti-anxiety medication), and [MEDICATION NAME] (an anticonvulsant medication used to control [MEDICAL CONDITION] or as a mood stabilizer). These failures resulted in oversedation of Resident 1, which in turn led to refusals of food and fluids and abrupt clinical decline, along with other adverse side effects that led to a hospitalization from which he did not survive. Refer to F 333. Findings: A review of Resident 1's record indicated he was an [AGE] year old admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1's wife was his designated responsible party (RP) to make healthcare decisions for him. According to nursing notes by [DATE], it was noted he had escalating behaviors where he was striking out at staff. He was given [MEDICATION NAME] (an antipsychotic medication) for aggressive behaviors 4 milligrams (mg) six times from [DATE] through [DATE]. A review of the Minimum Data Set (MDS, a resident assessment), dated [DATE], indicated Resident 1 was severely cognitively impaired. He was noted to have had physical behavioral symptoms directed towards other which occurred four to six days, but less than daily. It was noted that the behaviors put others at significant risk for physical injury. A review of the physician's orders [REDACTED]. There was an order dated [DATE] for [MEDICATION NAME] 250 mg twice per day, increased to 500 mg twice per day on [DATE]. There was also an order [REDACTED]. A review of a physician's telephone order (nurse called the physician to get the order), dated [DATE], for [MEDICATION NAME] 4 mg intramuscularly (IM, injection in the muscle) one time for a psychotic episode (an incident in which reality judgment is severely affected). The nursing notes indicated Resident 1 was hitting, kicking, biting, and unable to be re-directed. After multiple attempts at re-direction including one on one care, he continued to be extremely violent and hitting and abusing staff with any interaction. According to the Medication Administration Record [REDACTED]. There was another physician's orders [REDACTED]. There was a physician's telephone order on [DATE] at 6 pm, to repeat [MEDICATION NAME] 4 mg IM now for aggressive behavior not responsive to re-direction or other prn medications. According to the nurses notes, [MEDICATION NAME] was given at 12:30 pm and again at 8 pm on [DATE]. There was only one dose signed as given, without the time, on the front page of the MAR. During a concurrent interview and record review on [DATE] at 2 pm, the Chief Nursing Officer (CNO) confirmed only one dose was signed on the front page of the MAR for [DATE] although two doses had been given. During a subsequent interview on [DATE] at 1:30 pm, CNO confirmed the first three doses of [MEDICATION NAME] came from the facility's E-kit (emergency supply of medications). According to the MAR, [MEDICATION NAME] was given again on [DATE] at 12 pm, [DATE] at 9 pm, and [DATE] at 3 am. The nursing notes indicated Resident 1 was physically combative and unable to be redirected when the above [MEDICATION NAME] doses was given. The notes also indicated Resident 1 had eaten or drank very little. According to the nursing notes on [DATE], Resident 1 was noted to be lethargic and refusing oral intake and had experienced a six and a half pound weight loss in the prior week. A review of the unit diet sheets included the amounts of meals, snacks, and fluids consumed by Resident 1 as noted by the Certified Nursing Assistants. On [DATE], Resident 1 drank 240 milliliters (ml), and refused all food and fluids on ,[DATE], ,[DATE], and [DATE]. The nurses also noted no oral intake from ,[DATE] - [DATE] except for sips of water taken on [DATE]. On [DATE] at 12:45 pm, it was noted Resident 1's physician was present in the facility to examine Resident 1 and called his RP. According to the physician's note from the hospital record, Resident 1's RP wanted him treated for [REDACTED]. Resident 1 was transferred to an acute care hospital at 3:40 pm. The hospital records indicated he was admitted for severe dehydration with electrolyte abnormalities. Resident 1 expired on [DATE] at 9 am. A review of Resident 1's care plans for alterations in behaviors and thought process included information relating to antipsychotic, antidepressant, anticonvulsant, and anti-anxiety medications. This information indicated common central nervous system side effects of the above medications which included sedation, drowsiness, and confusion; and common gastrointestinal side effects for antidepressant medications which included nausea and anorexia (loss of appetite). A review of the [MEDICAL CONDITION] drug evaluation (form the facility uses which included the numbers of times the drug was given, number of behaviors, and number of side effects) for [MEDICATION NAME] and [MEDICATION NAME] for ,[DATE] - ,[DATE], for [MEDICATION NAME] for ,[DATE] - ,[DATE], and for [MEDICATION NAME] for ,[DATE] - [DATE], and the Medication Administration Record [REDACTED]. A review of the Unnecessary Drugs policy, dated [DATE], listed the maximum daily dosage of [MEDICATION NAME] as 4 mg. A form supplied by the facility labeled, Revised Standards Implemented [DATE] - Unnecessary Drugs listed the daily dose threshold for [MEDICATION NAME] as 2 mg. During an interview on [DATE] at 12:30 pm, the Director of Pharmacy (DOP) confirmed according to Centers for Medicare and Medicaid Services (CMS), the maximum daily dosage for [MEDICATION NAME] was 2 mg. He said 4 mg was a high dose to start with and the dosage usually goes from the lowest to the highest dose. He said 4 mg would be used for an acute psychotic break but an acute psychotic break needs to be treated like one and the resident needs to be evaluated for a possible higher level of care. He stated he would not be surprised to see side effects from the 8 mg dose Resident 1 received on [DATE]. He said [MEDICATION NAME] was kept in the emergency medication kit (E-kit) so the nurses would have taken it out of the E-kit. DOP confirmed he was not working on [DATE] and [DATE], at the time the physician orders [REDACTED]. During a later interview on [DATE] at 2 pm, DOP stated he had been told of the doses given to Resident 1, on ,[DATE] (Friday evening) and [DATE] (Sunday), when he returned to work on [DATE], and was told Resident 1 had extreme combative behavior over the weekend and [MEDICATION NAME] was helping. DOP refilled the E-kit with three vials of [MEDICATION NAME] and provided one dose of [MEDICATION NAME] for Resident 1's pharmacy drawer. DOP said he relies on current standards of practice from the CMS regulations, FDA (Food and Drug Administration), package inserts from the manufacturer, Lexicomp, and BEERS lists (inappropriate medication use in older adults). According to Lexi-Comp online (a drug reference company for professionals): adverse effects include drowsiness and anorexia: Elderly patient have an increased risk to antipsychotics. In light of this risk and relative to their small beneficial effect in the treatment of [REDACTED]. Also according to Lexi-comp Online, [MEDICATION NAME] carries a Boxed Warning which is the sternest warning by the U.S. Food and Drug Administration (FDA) that a medication can carry and still remain on the market in the United States. The boxed warning states that [MEDICATION NAME] is not approved to treat dementia-related [MEDICAL CONDITION] in the elderly and increases their risk for sudden death by heart failure and pneumonia. A review of an article from the FDA included the following information: [MEDICATION NAME] comes with a black box warning (the most serious warning from the FDA) that atypical antipsychotics (includes [MEDICATION NAME]) were associated with an increased risk of death and [MEDICATION NAME] injection had not been approved for the treatment of [REDACTED]. Cases of sudden and unexpected death, Q-T prolongation, and Torsades de Pointes (heart irregularities) have been reported in patients receiving [MEDICATION NAME]. (accessdata.fda.gov/drugsatfda_docslable/,[DATE]s079lbl.pdf) Also according to Lexi-Comp Online, Geriatric Considerations - Although there is little data in elderly for the use of valproate ([MEDICATION NAME]) in the treatment of [REDACTED]. It is important that the clinician understand that serum concentrations do not correlate with behavior response; likewise, it is imperative to monitor LFTs (liver function tests)and CBC (complete blood cell count) during the first 6 months of therapy. See Warnings/Precautions, Monitoring Parameters, and Additional Information. Elimination is decreased in elderly. Studies of older adults with dementia show a high incidence of somnolence (which is usually transient); cognitive side effects generally minimal. In some patients, this was associated with weight loss. Starting doses should be lower and increased slowly, with careful monitoring of nutritional intake and dehydration. During an interview on [DATE] at 11 am, Resident 1's Medical Doctor (MD) said he was unable to explain why he started with a 4 mg dosage of [MEDICATION NAME] and said he didn't intentionally go over the 2 mg maximum dosage. MD said he thought it was an emergency situation because Resident 1 was trying to harm others and typically a nurse or pharmacist would catch the excessive dose, and he thought the order would go through the after hours pharmacy. MD said, on [DATE], he was asked for an additional order after the second dose of [MEDICATION NAME] had already been given. He questioned the nurse who was asking for the order for the second dose of [MEDICATION NAME] and she said she didn't know that the first dose had already been given. MD stated it would have been a good idea to send the resident to the emergency room for an evaluation of ongoing [MEDICAL CONDITION]. MD said some loss of appetite and refusals to eat may have come from the use of the [MEDICATION NAME]. During a concurrent record review and interview on [DATE] at 12:20 pm, Charge Nurse (CN) 1 confirmed she gave a dose of [MEDICATION NAME] on [DATE] at 4 pm. CN 1 stated she was unaware 4 mg of [MEDICATION NAME] was double the daily threshold dose, at the time it was given. CN 1 confirmed the facility form, Revised Standards Implemented [DATE] - Unnecessary Drugs which listed the daily dose threshold for [MEDICATION NAME] as 2 mg, was automatically placed in all charts so it was already in place in Resident 1's chart when he was admitted .

Based on observation, interview, and record review, the facility failed to protect Resident 1 from verbal and physical abuse by Resident 2 when: On 2/16/15, Resident 2 grabbed Resident 1's wheel chair, shaking Resident 1 back and forth, hitting Resident 1 in the head. On 3/18/15, Resident 2 had grabbed Resident 1's wheel chair (while he was in the wheel chair) and pushed it against a wall. On 3/25/15, Resident 2 yelled at and hit Resident 1 resulting in a large goose egg (protruding soft tissue impact injury) to Resident 1's left eye with bruising. These failures resulted in Resident 1 being abused by Resident 2 on three occasions leaving Resident 1 feeling anxious and fearful about Resident 2 assaulting him and causing a large goose egg with bruising on his left eye, and has the potential for Resident 1 to continue to abused by Resident 2 and places other residents at risk for mistreatment, neglect and/or abuse. Findings: The facilities policy titled, Abuse, Resident, dated 10/19/11, indicated the resident has the right to be free from abuse including abuse from other residents. The staff will assess, care plan and monitor residents with needs and behaviors which might lead to conflict or neglect. The facility will protect resident and will take steps to prevent other opportunities of abuse from occurring which includes resident to resident altercations. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, a resident assessment), dated 1/31/15, indicated that Resident 1 was moderately cognitively impaired, had difficulty with communication, and used a wheel chair for mobility. Resident 1 was Spanish speaking only. A Nursing Care Plan (CP), dated 1/27/15, titled, Alteration in Behavior indicated Resident 1 was restless and had anxiety, agitation, and depression. The CP approach included to give medications, smile and use a calm approach, monitor triggers and provide intervention, allow verbalizations and listen, and communicate using short sentences. A facility document titled, Investigation Tool Form (ITF), dated 2/16/15, indicated, it was witnessed by a the Activity Staff (AS) that Resident 2 had shook and hit Resident 1 from behind while he was seated in his wheelchair. There were no injuries. Resident 1's Nurse's Progress Note (NPN), dated 2/16/15, indicated, that Resident 2 had followed Resident 1, and it was witnessed that Resident 2 grabbed Resident 1's wheel chair, shaking Resident 1 back and forth, hitting Resident 1 in the head. Resident 1 took his hat off and attempted to hit Resident 2 with his hat who was behind him. Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 2's CP titled, Alteration in Mood and Behavior, dated 2/16/15, indicated, agitation with Resident 1. An update to the CP on 3/18/15 indicated, Abusing other resident, keep these residents apart as much as possible. Resident 1's NPN and an ITF, both dated 3/18/15, indicated in an unwitnessed event, Resident 2 had grabbed Resident 1's wheel chair (while he was in the wheel chair) and pushed it against a wall. The event was reported to Certified Nurses Aide (CNA) C by Resident 1. Resident 2 (who was alert and oriented) confirmed the above and stated, that he had made me mad, then I reached and lifted him up, and said the next time I will rip your head out. So he knows not to come around. The ITF indicated the CP was revised, and included to protect the resident and indicated, .do not leave these residents alone together. Resident 1's Physician's Progress Note, dated 3/19/15, indicated Resident 1 has been anxious about another resident who had been physically assaulting him. The plan indicated, Victim of abuse by another nursing home resident. The other nursing home resident's (Resident 2) medications have been adjusted. He (Resident 2) has had multiple discussions with nursing staff as well as his physician and if he continues with this behavior, he will be leaving the facility. A form titled, SOC 341 (report of suspected abuse), dated 3/25/15, was completed by the facility and indicated, Alarm sounding, CNA responded, heard yelling, Resident 2 was saying, I'm going to kill you mother f---er. CNA asked Resident 2 if he hit Resident 1 and he stated yes. Large goose egg to Resident 1's left eye with bruising. The IFT, dated 3/25/15, indicated the facility had determined resident to resident abuse occurred because Resident 2 does not like Resident 1 and confirmed Resident 1 had a left eye bruise with a big goose egg bump on his head. Number nine on the form indicated, Was Care Plan followed? and the answer was marked Yes. Number 11 on the form indicated Resident 1 was afraid of Resident 2, Resident 2 is always looking for Resident 1. Interview of Resident 2, admits hitting Resident 1. Number 24 on the form indicated, Continue to keep these residents separated. Resident 1's NPN, dated 3/26/15, indicated that Resident 1 has a large goose egg on the right side of his head and has black eyes. Resident will no longer will have altercation with Resident 2. Resident 1 will be safe from this resident abuse. On 4/8/15 at 3:15 pm, during an observation and interview, Resident 2 stated that he had hit Resident 1 and if he had the chance, he would beat his head in. On 4/29/15 at 2:50 pm, an interview with Charge Nurse (CN) A and CN B, and a concurrent record review of the three resident to resident altercations that involved both Residents 1 and 2 on 2/16, 3/18, and 3/25/15 was conducted. Both CN A and B stated that Resident 2 was out to get Resident 1 and confirmed that Resident 1 had not been kept safe from Resident 2. CN A acknowledged and stated the care plan for Resident 1 had not been followed to keep the residents separated from each other, in accordance with the facility's Abuse, Resident policy which indicates the resident has the right to be free from abuse including abuse from other residents, the staff will assess, care plan and monitor residents with needs and behaviors which might lead to conflict or neglect, and protect the resident, taking steps to prevent other opportunities of abuse from occurring which includes resident to resident altercations.

Based on observation, interview and record review, the facility failed to properly assess, provide treatment and services to promote healing per their policy, protocol, and nursing care plan for one of fifteen sampled residents Resident 10). The facility failed to prevent new pressure ulcers (skin breakdown due to prolonged pressure, inadequate circulation, and lack of repositioning) from developing. Pressure ulcer care plans were not followed or developed to include individualized care interventions. Resident 10 developed a Stage III pressure ulcer (full thickness tissue loss, Site 1), and a new Stage II (partial thickness loss, Site 2) below Site 1 that were not present on his admission. These failures contributed to incomplete assessments, delayed services, and the development of pressure ulcers that required long term treatment and surgical debridement (cleaning out the wound bed with a sharp instrument). Findings: Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Sets (MDS, an assessment) dated 12/20/14, and 3/22/15, indicated that Resident 10 was at risk for developing pressure ulcers and that he did not have any pressure ulcers during these time periods. Resident 1's MDS, dated [DATE], was reviewed. The section titled, Brief Interview for Mental Status (BIMS), indicated Resident 10 was mentally intact with a score of 15. The MDS further indicated Resident 10 required extensive assistance from staff with transfers, bed mobility (turning from side to side), bathing, and personal hygiene. Under pressure ulcers, the MDS identified Resident 10 had acquired a Stage III pressure ulcer and was not present on admission. The measurements of the Stage III pressure ulcer were documented to be 5.5 centimeters (cm) length (L) x 2.0 width (W) cm x 1.2 cm depth (D). The ulcer was described to have yellow or white slough (the accumulation of dead tissue) adhered to the wound bed in strings or thick mucus clumps. A review of' Resident 10's clinical record on 8/25/15 at 9:40 am, with Licensed Nurse (LN) E, the Charge Nurse, stated Resident 10 was not admitted to the facility with a pressure ulcer, and the Stage III was acquired at the facility. On 8/26/15 at 7:10 am Resident 10 was observed sitting in his wheelchair in the Dining Room waiting for breakfast. On 8/26/15 at 9:30 am, Certified Nurse Assistant (CNA) R and CNA S stated Resident 10 tried to help them turn him, and he had never refused to be turned. On 8/26/15 at 10:30 am, Resident 10 was interviewed. He was alert and oriented to person, place, date, and the President of the United States. He stated that after breakfast, he had gone to an exercise activity and then to church service. Resident 10 also stated he had, been dealing with the sore on his bottom for four months now. Resident 10 stated he cannot turn himself in bed and, staff were not turning him and that is why he developed a sore on his bottom. During interview and concurrent observation, on 8/26/15, at 10:40 am, of a dressing change while Resident 10 was in bed after he was observed in his wheelchair for three consecutive hours, LN G stated that he identified that Resident 10 had developed new skin breakdown below his Stage III pressure ulcer. During a review of Resident 10's record, a document titled, Nurse's Pertinent Observation - Progress Notes dated 4/7/15 at 11:10 am, indicated, glut (gluteal area on the buttocks) is very red /purple in color and that [MEDICATION NAME] (prescribed for yeast infection) powder was applied to his scrotum. A review of a Nurse's Pertinent Observation - Progress Notes, dated 4/15/15 at 10:30 am, seven days later, indicated that Resident 10 had a pressure ulcer to his right coccyx (tailbone area) measuring 8 cm length (L) x 3 cm width (W) with no documented depth or stage. The National Pressure Ulcer Advisory Panel (NPUAP) instructs that staging is a standardized assessment. In 2007 NPUAP, along with the original Stage I through IV added two additional stages to include deep tissue injury and unstageable pressure ulcers. NPUAP directs that bruising indicates deep tissue injury. The staging standards include: Stage I- intact skin with non-blanchable redness (skin loses redness) of a localized area over a bony prominence. Stage II- partial thickness loss of dermis presenting as a shallow open ulcer with a red wound bed without slough. Stage III- full thickness tissue loss. Subcutaneous fat may be visible. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunneling. Stage IV- full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (a dry, dark scab or falling away of dead skin) may be present on some parts. Often includes undermining and tunneling. Unstageable/ Unclassified - full thickness skin or tissue loss, depth unknown when actual depth is completely obscured by slough (yellow, tan, gray, green or brown) and or eschar (tan, brown or black, dead tissue) in the wound bed. Until enough slough and or eschar tissue can be removed to expose the base of the wound, the depth can not be determined but it will either be a Stage III or IV. Suspected Deep Tissue Injury -depth unknown- Purple or maroon localized area or discolored intact skin or blood filled blister due to damage of the underlying soft tissue from pressure and shearing (when two surfaces have opposing forces, for example: When a person slides over a surface, like a bed or chair). On 8/26/15 at 3 pm, during an interview and review of Resident 10's record, Licensed Nurse (LN) F presented an admission nursing assessment, dated 12/17/13, indicating that Resident 10 was admitted to the facility with no pressure ulcer. She stated, while looking at the assessment, that Resident 10 scored a 16 (high risk) on his Braden Scale (a standardized skin assessment for predicting pressure ulcer risk). She stated that she documented the pressure ulcer on 4/15/15, at 10:30 am, in the Nurse's Pertinent Observation- Progress Notes and that it was large and dark purple with an undetermined depth and staged it as a Stage II. LN F confirmed that the ulcer should have been staged as a Stage III, per current pressure ulcer staging standards, due to the documented undetermined depth. LN F stated that for a Stage III to suddenly develop, indicated that Resident 10 had not been repositioned and turned every two hours. LN F confirmed there was no documentation by Resident 10's physician that the pressure ulcer was unavoidable. A facility Pressure Ulcer policy and procedure, revised 6/21/05, was reviewed. It instructed that the LN discovering the pressure ulcer would thoroughly assess the area, noting the type of wound, stage, location, color, measurements, depth, and amount of drainage. A Pressure Ulcer Progress Report would be created and include weekly measurements. Intake and Output (I&O - monitoring of fluid intake and output) would be measured and recorded to ensure the resident received adequate nutrition and hydration to promote healing. A Nurse's Pertinent Observation - Progress Notes, dated 4/15/15 at 10:30 am, assessed Resident 10 as having a Stage III pressure ulcer. The document indicated that the LN received a physician's orders [REDACTED]. A review of a Pressure Ulcer Progress Note, dated 4/21/15, ten days after the right coccyx area measuring 8 cm L x 3 cm was found, indicated the size had not changed and the depth was unstageable with a black eschar (dead tissue) in the center. The wound bed was described to be 100 percent covered with yellow slough, still referring to it as a Stage II, although it was a Stage III, according to NPUAP staging standards. The next entry from 4/21/15, on the Pressure Ulcer Progress Note was dated 6/16/15, (documented out of order), greater than a month later, which indicated LNs were not documenting weekly measurements per the facility pressure ulcer protocol. Resident 10's pressure ulcer was now documented as a Stage III measuring 5.5 cm L x 2.0 W x 1.0. The pressure ulcer was assessed on the following dates as: 6/2/15 Stage III - 5.5 cm L x 2.0 cm W x 1.2 cm D 5/19/15 Stage III - 6.5 cm L x 2.5 cm W x 0.5 cm D 5/28/15- with no documented staging or measurements 5/12/15 -with no documented measurements, and 5/5/15 Stage III - 6.5 cm L x 2.5 cm W x 0.5 cm D with debridement at the wound clinic. A Registered Dietician's note dated 5/5/15 was reviewed. It recommended Resident 10's estimated fluid needs for wound healing was 2200 milliliters (ml) per day. A review of the I&O documentation from 5/5/15 to 8/26/15, for Resident 10, indicated the following: From 5/5/15 to 5/31/15, Resident 10 received less than 2200 ml intake per day for 12 days and the remaining 15 days had incomplete documentation. In 6/2015, Resident 10 received less than 2200 ml intake per day for seven days with the remaining 23 days of incomplete documentation. In 7/2015, - Resident 10 received less than 2200 ml intake per day for eight days with 22 days of incomplete documentation. From 8/1/ to 8/26/15, Resident 10 received less than 2200 ml intake for one day with 25 days of incomplete documentation. During an interview on 7/27/15 at 7:40 am, LN E confirmed the missing documented I&Os and totals for Resident 10. She stated it was the Certified Nursing Assistants' responsibility to record Resident 10's I&Os, and the night shift LNs were to review and total them every night shift. On 8/26/15 at at 3:40 pm, during an interview with LN E, the Charge Nurse, she confirmed that Resident 10 does stay up from breakfast, 7 am to 10:30 am, once a week for exercises and then church. During an interview with LN E, the Charge Nurse, and concurrent observation made in Resident 10's room on 8/26/15 at at 3:40 pm, Resident 10 had a Hill-Rom bed (brand of hospital bed) with a blue air mattress, P500, set on a soft setting and a wheel chair cushion that was a piece of foam folded in half and duct taped. LN E stated the facility received the alternating air mattress around 7/2015, three months later because it was never recommended earlier. LN E confirmed that Resident 10's wheelchair cushion was not a specialized pressure relief cushion but only foam folded in half with duct tape. She confirmed that Resident 10 does stay up till 10:30 am from breakfast time once a week for exercises and then church. During an interview on 8/26/15 at 4 pm, CNA R confirmed that Resident 10 had been up in his wheelchair for three hours and had not been repositioned every two hours per protocol. On 8/26/15 at 4:10 pm, both LN E and LN F stated Resident 10 did not refuse to turn, but liked to wiggle on to his right side while in bed. A review of Resident 10's turn sheets (documents for recording when a resident was repositioned) indicated that prior to his Stage III pressure ulcer identified on 4/15/15, there was no documentation by the CNAs that he had been repositioned from 4 am to 10 pm on 4/11/15, from 12 am to 4 pm on 4/12/15, and from 6 pm to 10 pm on 4/13/15. On 8/27/15 at 8 am, LN E confirmed the blank entries in Resident 10's turn schedule, prior to the development of his Stage III pressure ulcer. A review of a Nutritional Screening and Assessment, initiated by the Dietary Manager on 12/8/13, for Resident 10 noted there was no indication of skin breakdown. A review of a monthly note by the RD, dated 4/9/15, had no documentation of a pressure ulcer or skin breakdown. The documentation indicated that Resident 10 was ill with an upper respiratory infection and had gained five pounds. The next monthly note, dated 5/5/15 indicated Resident 10 had an open area, staged with the letter L circled incorrectly indicating that the open area was on his left side instead of the right. RD documented that Resident 10 had lost ten pounds, significant . (5% loss of body weight in one month) and when staging was done he had a Stage III pressure ulcer and that the protocol would be followed. The RD was documented as being notified on 4/15/15. The assessment was conducted on 5/5/15, twenty days later. A physician's orders [REDACTED]. The order included a specialized air bed that repositioned every two hours along with Registered Nurse weekly visits at the wound clinic until healed. A facility pressure ulcer policy and procedure, revised 6/21/05, instructed that a separate care plan is required for each pressure ulcer and contributing factors must be considered and addressed with interventions that will enhance healing such as pressure relieving devices and turning. On 8/27/15 at 11 am Resident 10's physician (Medical Director, MD) was interviewed. He stated that he considered Resident 10 alert and oriented. MD stated that during that time Resident 10 developed the Stage III pressure ulcer (Site 1) he had developed pneumonia and was not expected to survive. Resident 10 care plans were reviewed. A pressure ulcer care plan, dated 4/21/15 for the right gluteal pressure ulcer related to decreased mobility had a goal that the ulcer would resolve with no complications by 9/16/15. The goals included to chart healing every week on the Pressure Ulcer Progress Sheet, turn every two hours, and keep off the right gluteal. On 4/22/15, the care plan was revised to include a wound consult. On 5/1/15, the care plan was updated to include to off load (remove pressure) as much as possible, with the use of an egg crate or wedge. On 8/27/15 at 11:50 am, LN F confirmed the care plan was not followed, Resident 10 was not repositioned every two hours, and the pressure ulcer protocol was not followed. She confirmed the care plans were not with new interventions for relieving and minimizing pressure to Resident 10's pressure ulcer while he was in bed or up in his wheelchair for activities.

Based on interview and record review the facility failed to ensure that one of 19 sampled residents (Resident 3) had her plan of care reviewed and revised and updated with new interventions to protect her from falls and injuries per the facility's Post Fall Packet policy. This resulted in Resident 3 having multiple falls that resulted in pain, bruises, skin tears and a fractured pelvis. Findings: 1. The clinical record for Resident 3 was reviewed on 8/25/15. Resident 3 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS - a resident assessment), dated 6/8/15, indicated she had no symptoms of psychosis (severe mental disorder in which thoughts and emotions are so impaired that contact with reality is lost,) was able to walk independently, transferred independently, and had fallen prior to her admission to the facility. She was placed in the dementia unit for safety and supervision. A review of Resident 3's care plan number 14 titled, Potential for Injuries/Falls, dated 5/26/15, identified her as being a fall risk as a result of her fall risk score, poor safety awareness, and vision impairment. Interventions included: to monitor the resident for fatigue or dizziness, maintain a well lit, clutter free environment, and to notify the physician and physical therapy for any significant changes in gait or balance. A review of Resident 3's clinical record indicated Resident 3 had six falls after she was admitted to the facility. Post fall assessment documentation indicated, on 6/6/15, Resident 3 had a witnessed fall (staff saw the incident) while she was walking and tripped over a bench in the hallway. Resident 3 sustained an abrasion to the bridge of her nose. Post fall assessment documentation indicated, on 6/15/15, Resident 3 was found on the floor in her room (fall was unwitnessed.) After the fall Resident 3 complained of pain. The post fall assessment documentation indicated, on 7/27/15, Resident 3 was ambulating on the patio and fell . She struck the back of her head and sustained a skin tear to her left elbow. Post fall assessment documentation indicated, on 8/8/15, Resident 3 fell in the Activities Room. This was unwitnessed by staff. After this fall the resident complained of pain. Post fall assessment documentation indicated, on 8/11/15, Resident 3 had a witnessed fall in her room while ambulating. Post fall assessment documentation indicated, on 8/12/15, Resident 3 was found on the floor in her room (unwitnessed fall) . Resident 3 sustained a bruise to her left eyebrow and a skin tear on her left knee. The investigative tool form, dated 8/20/15, indicated that on 8/15/15, Resident 3 was transferred to the acute care hospital for evaluation due to pain and an inability to bear weight. She was diagnosed with [REDACTED]. Resident 3's physician's orders [REDACTED]. A physician's orders [REDACTED]. (Resident 3 had four falls after this increase). A physician's orders [REDACTED]. During interview and concurrent record review on 8/26/15, at 10:15 am, Licensed Nurse (LN) E stated the following: No new interventions had been documented after Resident 3 fell on [DATE] and that physical therapy was not notified per care plan. After Resident 3 fell on [DATE], an alarm was added to her bed and the door to her room was to be kept open. No interventions had been added to Care Plan 14 Potential for Injuries/Falls, dated 5/26/15, after Resident 3 fell on [DATE] and LN E presented a second care plan for concurrent review titled Fall with Injury Care Plan 20, dated 7/27/15. The only intervention related to her fall risk, was to have a staff member assist her when she was on the patio. The intervention to supervise the resident while on the patio was added to Care Plan 14 on 8/7/15 (11 days later). No new interventions had been documented on any Care Plan after Resident 3 fell on [DATE]. LN E confirmed a physician's orders [REDACTED]. walk her and she didn't use it at all, and confirmed this intervention was not documented. LN E confirmed that a 72 hour trial for a Merry Walker (a seated walker that encloses a resident - more restrictive than a front wheeled walker) was then initiated and documented on Care Plan 14. LN E confirmed that physical therapy had not been notified of the resident's multiple falls and had not assessed Resident 3 for the use of a front wheeled walker or the Merry Walker. LN E confirmed that the IDT (IDT - related disciplines such as nursing, physical therapy, and activities meet together to discuss care)had not reviewed placing Resident 3 in a Merry Walker and consent had not been obtained from the Responsible Party for the use of the Merry Walker. After Resident 3 fell on [DATE], the trial of the Merry Walker was concluded and a physician's orders [REDACTED]. Merry Walker for unsteady gait, PRN. After Resident 3 was found on the floor (unwitnessed fall,) on 8/12/15, Care Plan 14 was updated on 8/13/15 with a request to reduce to the dose of Resident 3's Risperdal and a urinalysis test had been sent to rule out an urinary tract infection. The result came back negative. LN E confirmed that a prior intervention had identified that Resident 3 would have an alarm while in bed. LN E clarified that the initial intervention was to only use the bed alarm when Resident 3 was sleeping at night, and not any time she was in bed. Resident 3 was transferred to the acute care hospital on [DATE] with a complaint of pain and inability to bear weight on one leg. LN E reviewed documentation, dated 8/15/15, and confirmed Resident 3 had been diagnosed by the acute care hospital with a fractured pelvis. LN E stated that Resident 3 was placed on bedrest. She confirmed that the care plans for Resident 3 had not been consistently updated and interventions had not been consistently followed. LN E confirmed that Resident 3 was last assessed by physical therapy on 5/27/15, upon admission. LN E confirmed that the most recent IDT meeting for Resident 3 occurred on 6/9/15. LN E stated that IDT only meets quarterly and Resident 3 was not due for review. During an interview with the Responsible Party (RP - person designated to make decisions for an impaired resident) on 8/26/15 at 9:15 am, she stated she was aware Resident 3 had multiple falls and was now on bed rest. RP stated she was unaware that Resident 3's Risperdal dose had been increased on 7/23/15 and had spoken to the physician to request the dose be reduced, due to her concerns about Resident 3's falls. RP was unaware of what a Merry Walker was, and confirmed the physician had not spoken to her about this device or obtained her consent for it's use. RP stated that the physician did not discuss any alternatives or differing interventions related to the use of Risperdal or bed rest and expressed her concerns that Resident 3 would be weaker and more prone to falls after two weeks of immobility. During an interview with the Physician (MD C), on 8/27/15 at 7:12 am, she reviewed the record for Resident 3. MD C stated she was aware of Resident 3's multiple falls. When asked about the relationship of Risperdal to the residents fall risk and the increased dose, MD C stated, It's not like we increased the dose and she immediately fell , and, We looked at all potential causes before reducing the dose. MD C confirmed she had not obtained consent for the dose increase and had not reviewed the medication for continued use after admission, stating Resident 3 had been admitted on the medication. MD confirmed she had not ordered physical therapy to evaluate Resident 3 stating, As far as physical therapy, that's just a band-aid. You have to treat the cause, which is what we were doing. MD confirmed she had not obtained informed consent from the RP for the use of a Merry Walker. The facility's policy and procedure titled, Post Fall Packet, dated 10/21/05, directed To ensure accurate tracking of falls and to provide information necessary in the assessment of residents after a fall episode and to facilitate fall prevention . Under Procedure, Complete the post fall assessment . if an injury occurs initiate care plan: Fall With Injury . Update Fall Risk Assessment and make new interventions on Risk for Falls Care Plan. Document assessment date on the form and care plan . Tracking, trending and fall risks will occur quarterly with IDT.

Based on observation, interview and record review, the facility failed to protect one resident from abuse when Certified Nursing Assistant (CNA) A forcefully pushed a resident down onto his bed (Resident 1). This resulted in anxiety and agitation as evidenced by the resident becoming more agitated, requiring additional reassurance from the staff following the incident. Findings: On 11/13/13 at 7:47 am, the Department of Public Health received a fax notification from the facility reporting a witnessed inappropriate staff to resident interaction. The report indicated that on 11/12/13, CNA A was witnessed by CNA B to physically push Resident 1 down onto his bed. The facility's records indicated that on 11/12/13, the local law enforcement agency was also notified regarding this incident. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS, an assessment tool) for Resident 1 dated, 10/1/13, indicated that Resident 1 had both short and long term memory deficits and severe impairments in regards to his daily decision making abilities. Resident 1's care plan titled, "Impaired Cognition/Communication," dated 10/1/13 indicated that due to his condition, he experienced intermittent difficulty verbalizing needs, had impairments with processing information and had frustration with articulating needs. Staff interventions to assist Resident 1 in coping were to allow him adequate time to communicate his needs, and if he becomes frustrated take a break and re-approach at a later time. During an interview and observation, on 11/26/13 at 10:15 am, with Resident 1 in his room it was noted that he was extremely hard of hearing, partially blind and had obvious cognitive deficits making communication extremely difficult. During a telephone interview, with CNA B on 11/26/13 at 3:15 pm, she reported that on the night of 11/12/13 at about 11 pm, she responded to Resident 1's bed alarm. CNA A was already present in the room and she could hear CNA A repeatedly telling Resident 1 to "sit down." CNA B reported that Resident 1 had difficulty processing information and could become frustrated easily. CNA B stated that upon entering the room she observed CNA A place his hands on Resident 1's chest and forcefully push him down onto his bed "very hard". CNA A then left the room with no explanation provided as to his actions. CNA B stated that she had to reassure Resident 1 because he became extremely agitated following this interaction and being shoved onto his bed. CNA B stated that she felt that CNA A's actions were abusive and represented inappropriate patient care. The facility's abuse policy dated, 12/2011, read, "It is this facility's intent to ensure that each patient has the right to be free from abuse (verbal, physical and mental) including corporal punishment and involuntary seclusion. Patients must not be subjected to any of the above by anyone, including, but not limited to, facility staff, other patients, consultants, volunteers and other agencies that service the patient, family members, legal guardians, friends or other individuals... Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish..." CNA A's employee file was reviewed on 11/26/13. CNA A had received the following training on 12/25/12; Communication with Cognitively Impaired Clients, Elder Abuse and Resident Rights. According to CNA A's 2012 Employee Evaluation; CNA A was written up on 2/18/12 for having a bad attitude with a co-worker. CNA A was written up on 5/10/12 after a verbal confrontation with co-workers at the nurse's station. CNA A was written up on 10/1/12 for patient care issues which resulted in a three day suspension. CNA A's 2013 Employee Evaluation dated, 11/18/13, read, "CNA A has to be told what to do daily. fell ow co-workers would prefer not to be assigned with him due to his work performance." During an interview and record review, with Charge Nurse (CN) C on 11/26/13 at 9:10 am, she confirmed CNA A had been immediately sent home after she was made aware of the incident on 11/12/13. CN C reported that her investigation had substantiated the allegation of abuse and that combined with a history of "unflattering" job performances, resulted in CNA A's termination from the facility.

Based on observation, interview, and record review, the facility failed to ensure supervision was provided for four residents while they ate their morning meal. (2 of 17 sampled residents (Residents 5 and 9), and 2 unsampled residents (Residents 21 and 22)). Residents 5, 9, 21, and 22 were not supervised as required by their care plan. Resident 5 was observed chewing and trying to swallow the clip from her personal tab alarm (an alarm that attaches to her clothing with a metal clip). This failure had the potential of a choking hazard and/or injury caused by physical abuse behaviors An Immediate Jeopardy (IJ) was declared on 6/11/13 at 5:30 pm, for failure to supervise the residents during meals with the Director of Nursing, Administrative Assistant, and Licensed Nurse D. An immediate plan of corrective action provided by the facility was accepted on 6/11/13 at 6:08 pm. On 6/12/13 at 1 pm, the Immediate Jeopardy was abated when the facility Director of Nursing provided and implemented an acceptable plan of action for staff to be assigned to specific areas of the locked back unit and for Resident 5 to be monitored closely during meal times and snack times. Findings: On 6/11/13, Resident 5's record was reviewed. Resident 5 was [AGE] years old, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's Minimum Data Set (an assessment tool), dated 6/3/13, described her as requiring one person extensive assistance with her daily care, (dressing, toilet use, bathing). She was to ambulate with assistance and used a merry walker (a device made of plastic piping that enclosed the residents but allowed them to ambulate and sit down without assistance). Resident 5 required supervision with meals, was unable to make safe everyday decisions, and had both short and long term memory loss. She was alert to her name only, she could sometimes understand others, and was rarely understood. According to Resident 5's care plans (goals, plans, and interventions by staff for her care and safety) since her admission, she had displayed numerus behaviors that were a potential for harm to other residents and to herself. Those behaviors were that she would eat non-food items; napkins, paper towels, placemats, artificial flowers, plants, cotton balls, and glue. She was at risk for aspiration (sucking into the airways food or fluids as the resident breathes inward) from eating to fast and pocketing food in her mouth. Resident 5 would take other residents food from their meal trays and try to feed other residents. She would wander into other residents rooms wake them up and it was difficult to redirect her movements and behaviors. Resident 5 would also remove her personal tab alarm that would sound an audible alarm to alert staff when Resident 5 would try to stand up or lean too forward. Interventions were for staff to monitor and care for Resident 5 with medications (Haldol - used as needed for behaviors, Seroquel - routine use for behaviors, Ativan- as needed for anxiety, and Depakote - used as a mood stabilizer), use of a bed and personal tab alarm, keep trash bags tied, keep close watch on her whereabouts, monitor her and other residents food and trays, and to keep non-food items in locked cabinets. Behaviors not addressed on Resident 5's care plans that were obtained by interview, on 6/12/13 at 12 pm, with licensed nurse (LN) H were insomnia and sundowners (where the resident has their days and nights switched in their mind). This would cause Resident 5 to wander throughout the unit during the night and sleep throughout the day. LN H explained that Resident 5 required supervision during her meals for trying to eat non-food items, napkins, placemats, salt, pepper, and sugar packets that came with the meals. LN H stated Resident 5 had been placed in the activity room because there was not sufficient room in the main dining room to keep her away from other residents food and the paper products on their trays. On 6/11/13 at 8:35 am, Resident 5 and three other residents were sitting in the activity room eating their morning meal unsupervised. LN H was observed outside the activity room pouring medications and was unable to see the residents in the room. Two certified nursing assistants (CNAs) were in the main dining room, across and down the hall from the activity room, assisting the other 12 residents with their meals. Resident 5 was observed placing a one inch long, metal clip (at the end of her personal tab alarm) attached to a string into her mouth. She also used the clip as a spoon to scoop up her hot cereal than proceeded to place it into her mouth with the string hanging out while she tried to chew and swallow the clip. She tried to chew and swallow the clip four more times. At 8:40 am, this surveyor brought Resident 5's behavior to the attention of LN H who removed the clip from Resident 5's mouth and attached the clip to the back of her blouse. LN H remained with Resident 5 until CNA O returned to the activity room at 9 am, 20 minutes after finding the residents unsupervised in the activity room. In a concurrent interview with LN H she stated she was not aware that the residents had been left alone in the dining room and she was not informed by CNA O of her departure to assist another resident at the other end of the hall. LN H stated that the four residents that took their meals in the activity room required supervision at all times during meals. Residents 21 and 22 had behaviors of physical and verbal abuse towards others. Resident 9 took other residents food to eat, and Resident 5's behavior of eating non-food items, made supervision necessary to protect themselves and others. During an interview on 6/11/13 at 9:05 am, CNA O stated she heard a call light down the hall and looked out and did not see anyone answering the call light. She went down and required another CNA to assist her to reposition the resident back up in bed. This resident was on contact isolation (isolation of a resident related to a known bacteria or other contaminant where anyone coming in direct contact with the resident's skin, clothes, or body fluids would spread the infection) and the staff had to place isolation gowns, and gloves on prior to assisting with her care. CNA O stated that was why she was gone so long from her post of supervising the residents. CNA O also stated she forgot to notify LN H of her whereabouts and confirmed she had left the four residents unsupervised.