Every finding on record at Meadows Ridge Care Center

Based on interview and record review, the facility failed to ensure prescribed medication was administered in accordance with the physician's orders for one of four sampled residents (Resident 1) when Resident 1 had an order to received Phenytoin (medication for seizures - a sudden movement of electrical activity in the brain causing shaking of the limbs and stiffening of the body) and was not administered from June 7, 2026, to June 17, 2026 (a total of 19 doses). This failure resulted in Resident 1 being transferred to an acute care hospital after experiencing seizure activity. During a review of Resident 1's Face Sheet (contains medical and demographic information), the Face Sheet, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included epilepsy (a brain disorder that causes repeated seizures), hemiplegia (complete loss of movement on one side of the body), hemiparesis ( muscle weakness on entire side of the body) and hypertension (elevated blood pressure).During a review of Resident 1's Order Summary Report, dated June 2, 2026, the Order Summary Report indicated Resident 1 had an order for, Phenytoin capsule 100 MG (milligram - unit of measurement) Give 1 capsule by mouth to be given at 9:00 AM, 1:00 PM and 5:00 PM, for seizures.During an interview on July 1, 2026, at 2:05 PM, with Licensed Vocational Nurse 1 (LVN 1), when asked if LVN 1 administered Phenytoin Sodium Extended Oral Capsule 100 MG to Resident 1 on June 17, 2026, LVN 1 stated, That is the only medication I did not give her because the bubble pack (a prepared sheet with seal bubbles containing individual doses of medications, organized by days) was empty.During an interview on July 1, 2026, at 2:15 PM, with LVN 2, LVN 2 stated there were no Phenytoin capsules in Resident 1's bubble pack for a couple of days and she faxed the order to the pharmacy for refill more than once because the medication was not available in the medication cart. LVN 2 further stated, I did not call the pharmacy to follow up about the medication because I always thought the pharmacy would deliver the medication. LVN 2 could not provide a specific date when the order for Phenytoin was faxed to the pharmacy and stated she (LVN 2) did not remember if she told any staff to follow up.A review of Resident 1's Medication Administration Record (MAR [a legal document used by healthcare professionals to track exactly what medication a patient receives, when it was given, and who administered it]), for June 2026, indicated Phenytoin Sodium Extended Oral Capsule 100 MG capsule was not administered for the following times:1) June 7, 2026, at 9:00 AM, 1:00 PM and 5:00 PM2) June 8, 2026, at 9:00 AM and 5:00 PM3) June 9, 2026, at 9:00 AM and 1:00 PM4) June 11, 2026, at 5:00 PM5) June 12, 2026, at 9:00 AM and 5:00 PM6) June 15, 2026, at 9:00 AM, 1:00 PM and 5:00 PM7) June 16, 2026, at 9:00 AM, 1:00 PM and 5:00 PM8) June 17, 2026, at 9:00 AM, 1:00 PM and 5:00 PMDuring a concurrent interview and record review on July 1, 2026, at 2:30 PM, with the Director of Nursing (DON), Resident 1's MAR for the month of June 2026, was reviewed. The DON stated, on June 17, 2026, LVN 2 reported that Phenytoin Sodium Extended Oral Capsule 100 MG for Resident 1 was not available on June 17, 2026. The DON acknowledged medication administration for Resident 1 was not administered for eight days (19 doses). The DON further stated medications must be available for residents, and if they are not, the pharmacy is contacted immediately for delivery with the physician's orders.During an interview on July 1, 2026, at 3:02 PM, with the Pharmacist (Pharm) from [Name of Pharmacy], the Pharm stated that nine capsules of Phenytoin 100 mg-a three day supply-were delivered to the facility on June 2, 2026, for Resident 1. The Pharm stated that on the same day, she contacted LVN 2 and requested that the facility obtain clarification from Resident 1's physician, as Resident 1 was also receiving an anticoagulant that could reduce the effectiveness of Phenytoin. The Pharm further explained that because the facility did not provide the required clarification before June 18, 2026, the pharmacy did not issue a refill until that date, when the facility contacted the pharmacy with Resident 1's physician's clarification.A review of Resident 1's clinical record, COC (Change in Condition) /INTERACT ASSESSMENT FORM (SBAR - Situation Background Assessment Recommendation, a communication tool used by nurses to share vital information during a patient's change of condition or a sudden decline)], dated June 17, 2026, indicated, . NURSING NOTES 1. Licensed Nurse Note. 1550 (3:50 PM) Resident noted with petite mal (brief, sudden lapses of consciousness) seizure. Resident noted with second petite mal seizure at 1940 (7:40 PM) .BP (Blood Pressure) 162/111 (normal range 120/80) MD (Medical Doctor) made aware with new order to DC (discharge) resident to [Name of hospital] for further eval (evaluation).During a record review of the facility's policy and procedure (P&P) titled, Administering Medications indicated, Policy Statement Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns .

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food safety practices to prevent foodborne illness when:1a. There were three clean dishes found to have green and brown food debris, brown grease buildup, remnants of lettuce leaf, and crumbs inside it, when stored under a food prep table in the kitchen.1b. A storage shelf under a food prep table had a white dried substance and greasy black substance with food crumbs on it where clean dishware was kept.2. Eight (8) plastic cups containing a white colored liquid which resembled milk were found in the refrigerator with no date label. These failures had the potential to result in food contamination and foodborne illness to a population of 84 medically compromised residents who reside in the facility.Findings: 1a. During a concurrent observation and interview on January 26, 2026, at 8:30 AM, inside the facility's kitchen, with Consultant Registered Dietician 1 (CRD 1), there were three aluminum dishes found on a shelf under a food prep table which had green and brown food debris, brown grease buildup, remnants of lettuce leaf, and crumbs inside it. The CRD 1 stated the dishes under the food prep table were all clean and were used for cooking. CRD 1 observed dishes with the food debris, crumbs, and grease buildup and stated it was not acceptable for clean dishes to be dirty and that staff was expected to ensure clean dishes were kept clean.1b. During ongoing observation and interview on January 26, 2026, at 8:34 AM, inside the facility's kitchen, with the CRD 1, a food prep table was observed to have a shelf which had a white dried substance and greasy black substance with food crumbs on it. Multiple clean dishes were stored on this shelf. The CRD 1 stated staff were supposed to keep the shelves clean where dishware was kept.During a concurrent interview and record review on January 29, 2026, at 11:25 AM, with the facility's CRD 1, CRD 1 and Dietary Service Supervisor (DSS), the RD stated kitchen staff were supposed to clean the kitchen daily and document the cleaning on a form titled, Dietary Cleaning Schedule. CRD 1 provided the Dietary Cleaning Schedule, for January 1, 2026, through January 29, 2026 (date of interview). The DSS stated staff were supposed to sign for each cleaning task on the cleaning schedule once the cleaning was completed.During a concurrent interview and record review on January 29, 2026, at 11:26 AM, with CRD 1 and the DSS, the facility documents titled, Dietary Cleaning Schedule, dated January 1, 2026, through January 29, 2026, were reviewed. It indicated the following, -Area must be clean by the end of the shift. -Please keep ALL areas clean daily, and plan to deep clean on the days assigned to the dietary personnel above. The document had tasks for cleaning which included but were not limited to, .prep area, spice/condiment shelves; vents/hood; oven/toaster; .Stove; can opener/slicer; microwave, blender; area around the steam table including shelves; stove, around the stove, top shelves; mixer, food processor; utensil drawers, bottom shelves, knife holder; refrigerator/dispose of leftovers; dishwashing racks, chemical area; food prep area, including bottom shelves, floor, and floor corners. Upon further review, the document was completely blank and did not include any documentation to indicate cleaning was conducted on 12 out of 28 days in January 2026. Furthermore, an additional four (4) days had only partial documentation regarding completion of the assigned daily completion tasks. In total 16 out of 28 days in January 2026, had either no documented cleaning or only partial completion of daily cleaning tasks. Both CRD 1 and the DSS acknowledged the Dietary Cleaning Schedule, dated January 1, 2026, through January 29, 2026, had 12 days with no documentation that kitchen cleaning was completed and four (4) days with only partial cleaning documented. The CRD 1 and DSS stated they did not know why the cleaning log was not completed. The facility was unable to provide any other evidence that the kitchen was cleaned in the frequency and manner as indicated in their policy and procedure.During a review of the facility's policy and procedure (P&P) titled, Cleaning Schedule, undated, the P&P indicated, All areas and equipment in the kitchen should be cleaned daily. The assigned dietary personnel will deep clean the area equipment assigned for them that day using the dietary cleaning schedule.Dietary cleaning schedule has daily tasks for dietary personnel based on shift and position. The assigned dietary personnel will complete the task assigned by the end of the shift and initial on the dietary cleaning schedule. Dietary service supervisor will initial after each shift to make sure the assigned area and equipment has been cleaned.During a review of the facility's P&P titled, Sanitizing Equipment and Surfaces, undated, the P&P indicated, .6. Dietary staff should ensure that all equipment, shelves, serving utensils, and surface areas are clean and in good condition.2. During a concurrent observation and interview on January 26, 2026, at 8:40 AM, in the facility's kitchen, with CRD 1, eight (8) plastic cups full of white liquid which resembled milk was stored in a refrigerator with no date or label. CRD 1 stated the cups were full of milk products and were supposed to be dated when placed in the fridge. CRD 1 further stated she was not sure of why there were cups of milk in the fridge which were undated and she was unsure when they were placed in the fridge or when they were prepared.During a review of the facility's P&P titled, Dating and Labeling, undated, the P&P indicated, To ensure food safety and prevent contamination within the facility, all food items should be properly covered, dated, and labeled in dry storage and refrigerator/freezer areas.7. Staff should be trained on the importance of food labeling and proper storage procedures to maintain food safety.

Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when:1. Resident 7's oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) was found unlabeled and undated per facility's policy and procedure (P&P). 2. One laptop mounted to an Intravenous (IV) cart (a mobile cart used by licensed nurses to store and transport medication and supplies) was found visibly soiled, with dried white substance on it, on unit one outside nursing station.3.Resident 11's Enhanced Barrier Precautions (EBP-an infection control guideline that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading infectious diseases) protocol were not followed in accordance with facility's P&P.4. On January 28, 2026, Licensed Vocational Nurse 3 (LVN3) was observed entering the room of Resident 32, who was on EBP precautions, without wearing wearing the required personal protective equipment (PPE) and performing a blood glucose check. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 83 medically compromised residents and staff in the facility.Findings: 1. During a review of Resident 7's admission Record (contains medical and demographic information), the admission Record indicated Resident 7 was admitted to the facility on [DATE] with the diagnoses which included heart failure (the heart doesn't pump enough blood to meet the body's needs), shortness of breath (sensation of being unable to breathe normally), Diabetes Mellitus (difficulty in blood sugar control). During a review of Resident 7's Physician Order dated October 05, 2025, the Physician Order indicated, Change oxygen tubing q [every] night shift, on Sunday and PRN [as needed]. During an observation on January 26, 2026, at 11:08 AM, in hallway of unit 3, Resident 7 was observed independently propelling himself down unit three hallway in his wheelchair. There was an oxygen nasal cannula tubing not in use by Resident 7, attached to an oxygen concentrator (device that provides supplemental oxygen). The oxygen nasal cannula tubing was unlabeled and undated. During a concurrent observation and interview on January 26, 2026, at 11:08 AM, with a Licensed Vocational Nurse 1 (LVN 1), in the hallway of unit three, LVN 1 inspected Resident 7's oxygen nasal cannula tubing. LVN 1 stated the oxygen nasal cannula tubing was not labeled and should have been labeled and dated. During a concurrent interview and record review on January 28, 2026, at 10:58 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration, dated January 2026 was reviewed. The P&P indicated, . 10. The date, time and initials should be noted on oxygen equipment when it is initially used and then when changed. The DON stated the P&P was not followed and should have been for infection control prevention. 2. During a current observation and interview on January 28, 2026, at 9:28 AM, with Registered Nurse (RN) Supervisor 1, on unit one outside nursing station, a laptop mounted to an IV cart was found visibly soiled, with dried white substance. RN Supervisor 1 acknowledged the laptop was dirty with white substances, RN Supervisor 1 stated the facility's expectation is for resident care equipment to be cleaned to prevent potential cross contamination. During a concurrent interview and record review on January 28, 2026, at 11:05 AM, with the DON, the facility's Policy and procedure (P&P) titled, Cleaning and Disinfecting of Resident Care Items and Equipment, dated September 2022, was reviewed. The P&P indicated, . Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected.c. Non-critical resident care items include bedpans, blood pressure cuffs, crutches and computers. The DON confirmed that the P&P was not followed and stated that adherence is critical due to the increased risk for infection within the resident population. 3. During a review of Resident 11 's admission Record the admission Record indicated Resident 11 was admitted to the facility on [DATE] with the diagnoses which included, Chronic Obstructive Pulmonary Disease (COPD- a progressive lung disease that blocks airflow, making it hard to breathe), Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Epilepsy (a brain condition that causes recurring seizures). During a review of Resident 11's Physician Order dated January 27, 2026, the Physician Order indicated, EBP-Enchased Barrier Precautions R/T [related to] G TUBE (gastrostomy- a tube placed through the stomach to receive nutrients and medications). During an observation on January 28, at 5:22 AM, inside Resident 11's room, observed LVN 2 administering the following medications via Gastrostomy tube; Hydrocodone 10 milligrams (MG—a unit of measurement) /Acetaminophen 325 MG (used to manage moderate to severe pain) to Resident 11 on EBP without wearing the required protective gown. During an interview on January 28, 2026, at 5:35 AM, with LVN 2 outside Resident 11's room LVN 2 confirmed and verified, Resident 11 is on EBP related to resident's g tube. LVN 2 confirmed that she did not wear required protective gown during her medication administration. LVN 2 acknowledged that she did not follow the facility's P&P for EBP. During a concurrent interview and record review on January 28, 2026, at 10:16 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated June 2025, was reviewed. The P&P indicated, .2 . EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.a.Gloves and gowns are applied prior to performing high contact resident care activities.3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include.g. device care or use( central line, urinary catheter, feeding tube, tracheostomy/ ventilator, etc).5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. The DON stated the policy was not followed and further state it is important for the P&P to be followed to prevention the spread of infectious diseases. 4. On January 28, 2026, at 5:19 AM, Licensed Vocational Nurse 3 (LVN3) donned gloves and mask, entered Resident 32's room and performed a blood glucose check to Resident 32 at bedside. Resident 32 was on Enhanced Barrier Precautions - Gown and Gloves Required for Room Entry as indicated by the signage posted above the resident's bed. LVN 3 did not wear a gown prior to entering the room as required and proceeded to provide care without wearing the gown. During an interview on January 28, 2026, at 5:30 AM, LVN 3 stated, I forgot to put on the gown before going in. I always wear a gown for EPB patients, I just forgot this time. A review of Resident 32's Face Sheet (lists resident demographic information) indicated Resident 32 was admitted at the facility on April 19, 2023, with diagnoses which include paraplegia (paralysis, or significant impairment, of the lower half of the body, affecting the legs and sometimes the trunk), neuromuscular dysfunction of bladder ( lack of bladder control due to brain, spinal cord or nerve problems), retention of urine (inability to fully empty the bladder, resulting in urine building up inside). A review of Resident 32's Physician's Order dated October 2, 2025, indicated, ENHANCED BARRIER PRECAUTIONS related to Foley Catheter. During an interview with facility's Infection Preventionist (IP) on January 28, 2026, at 10:26 AM, the IP stated her expectations are that staff follow facility's Infection Prevention Policies and Procedures at all times. The IP stated LVN 3 should have used the available PPE, including the gown, before performing blood glucose check for Resident 32 to decrease the risk of transmission of multidrug-resistant organisms (MDROs) to other residents and staff. During a concurrent interview on January 28, 2026, at 11:22 AM with the Director of Nursing (DON), and record review of the facility's Infection Control Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated June 5, 2024, the P&P was reviewed. The P&P stated, 1. Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-dmg resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 2.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk . 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted outside of resident's room or head of the bed indicating the type of precautions and PPE required. 11. PPE is available outside/inside of the resident rooms. 13. Colonized residents are at risk of developing invasive infections and clinical diseases and can transmit to other residents depending on the situation and recommendation from your local Public Health, based on these guidelines and facility discretion the implementation of EBPs or CPs (Contact Precautions) will apply. The DON acknowledged the facility's EBP P&P was not followed and stated his expectations are that staff must adhere to all facility's Infection Prevention and Control Policies and Procedures, including the Enhanced Barrier Precaution P&P, to decrease the risk of transmission of multidrug-resistant organisms (MDROs) to other residents, staff and visitors. The DON further stated that this failure to follow PPE requirements is not in accordance with facility's policy and federal regulations for infection prevention and control.

Based on observation, interview, and record review, the facility failed to maintain accurate records of destroyed medications when nine (9) medications that were disposed were found with missing witness signature from the second licensed nurse for one of one sampled Medication Disposition Record/Pass Log (document used to record the destruction of a medication for tracking purposes). This failure had the potential to have prescription medication available for staff use.Findings: During a concurrent interview and record review on January 28, at 12:09 PM, with the DON and Registered Nurse (RN) Supervisor the Medication Disposition Record/Pass Log for month of January was reviewed. The Medication Disposition Record/Pass Log indicated the following:1.nine (9) missing witness signatures of a second licensed nurse.The DON and RN Supervisor acknowledged the medication disposition record/pass log was not complete due to the missing witness signatures of a second license nurse.During a concurrent interview and record review on January 28, 2025, at 12:49 PM, with the DON facility's Policy and Procedure (P&P) titled, Disposal of Medication and Medication-Related Supplies, dated January 2025 was reviewed. The P&P indicated, .C. Non-controlled medication destruction occurs in the presence of two licensed nurses.D. The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form.6. signatures of witnesses. The DON stated the P&P was not followed because it was missing the second signature of a licensed nurse.

Based on observation, interview, and record review, the facility failed to ensure staff provided assessment and monitoring for one of one resident (Resident 88) investigated for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) when:a. There was no documented evidence staff performed assessment of Resident 88's dialysis access site every nursing shift (day, evening, and night shift) as ordered by the physician.b. There was no documented evidence to indicate staff performed a pre (before) and post (after) assessment of Resident 88's dialysis access site (the location where a dialysis machine is connected to a patient) for bruit (a low-pitched, rushing, or whooshing sound heard with a stethoscope over the site of a fistula) and thrill (a distinct, rhythmic buzzing or humming vibration felt upon palpation [touching] of a patient's vascular access) and bleeding. These failures had the potential for a delay in the staff identification and subsequent treatment of possible dialysis associated complications such as symptoms of infection, or severe bleeding for Resident 88Findings: During a review of Resident 88's Face Sheet (contains medical and demographic information), the Face Sheet indicated Resident 88 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidney failure), dependence on renal dialysis (the state where an individual's kidneys have permanently failed and they require regular dialysis treatments to sustain life), anemia in chronic kidney disease (is a condition where damaged kidneys produce insufficient erythropoietin (EPO), a hormone necessary for producing red blood cells), and arteriovenous fistula (AV fistula - a dialysis access site formed by joining a vein and an artery in the arm).During a review of Resident 88's Minimum Data Set Assessment (MDS assessment - a comprehensive clinical assessment tool used in nursing homes to evaluate the physical, psychological, and psychosocial functioning of residents), dated January 27, 2026, the MDS assessment indicated in Section C (section for cognitive functioning), Resident 88 had a BIMS (Brief Interview for Mental Status - a 0-15 point assessment to screen for cognitive impairment) score of 14 (score of 13-15 means the resident is cognitively intact with normal thinking and memory).During a concurrent observation and interview on January 26, 2026, at 4:04 PM, in Resident 88's room. Resident 88 was lying in bed with his eyes closed. Resident 88 stated he had dialysis three times a week and his dialysis access site was on his right arm. Resident 88 stated the nurses from the facility did not always check his dialysis access site (AV fistula) when he returned from dialysis.a. During a review of Resident 88's care plan (an individualized plan for the medical care of a resident) titled, Potential for unavoidable bleeding on the AV shunt site and/or central line related to ESRD w/hemodialysis [with hemodialysis], dated January 23, 2026, the care plan indicated the following goal, Will reduce risk of occurrence of emergency bleeding through intervention daily until the next assessment. Interventions for the care plan included, document monitoring of dialysis site every shift and as needed for any evidence of changes in condition to include (but not limited to): bleeding, vital signs, access site patency (bruit/thrill), breathing pattern/breath sounds, level of consciousness, low b/p [blood pressure], diaphoresis [sweating], paleness. Notify physician of any changes.During a review of Resident 88's physician's orders, an order dated January 21, 2026, indicated, resident may have dialysis with [name of dialysis clinic] Monday, Wednesday, Friday.During a review of Resident 88's physician's orders, an order dated January 21, 2026, indicated, [DIALYSIS] Monitor.for bleeding (document the following); 0 = absence 1= presence, every shiftDuring a review of Resident 88's Medication Administration Record (MAR - a document used to record medications and treatments administered to the resident), dated January 2026, the MAR was blank for two of three shifts on January 24, 2026 (day shift and evening shift) for the task of monitor.for bleeding.During a review of Resident 88's physician's orders, an order dated January 21, 2026, indicated, [DIALYSIS] Monitor.for swelling (document the following); 0 = absence 1 = presence, every shiftDuring a review of Resident 88's MAR, dated January 2026, the MAR was blank for two of three shifts on January 24, 2026 (day shift and evening shift) for the task of monitor.for swelling.During a review of Resident 88's physician's orders, an order dated January 21, 2026, indicated, [DIALYSIS] Monitor.for pain (document the following); 0 = absence 1 = presence, every shiftDuring a review of Resident 88's MAR, dated January 2026, the MAR was blank for two of three shifts on January 24, 2026 (day shift and evening shift) for the task of monitor.for pain.During a review of Resident 88's physician's orders, an order dated January 21, 2026, indicated, [DIALYSIS] Monitor shunt/graft site (document the following) BRUIT; (auscultate) [to listen with a stethoscope] 0 = absence of sound 1 = presence of sound, every shiftDuring a review of Resident 88's MAR, dated January 2026, the MAR was blank for two of three shifts on January 24, 2026 (day shift and evening shift) for the task of monitor shunt/graft site.Bruit.During a review of Resident 88's physician's orders, an order dated January 21, 2026, indicated, [DIALYSIS] Monitor shunt/graft site (document the following) THRILL; palpate [examine by touch] 0 = absence of vibration 1 = presence of vibration, every shiftDuring a review of Resident 88's MAR, dated January 2026, the MAR was blank for two of three shifts on January 24, 2026 (day shift and evening shift) for the task of monitor shunt/graft site.thrill.During a concurrent interview and record review on January 28, 2026, at 12:55 PM, with the Assistant Director of Nursing (ADON), the ADON stated staff were supposed to follow physician's orders and perform assessments of Resident 88's dialysis site every shift as ordered by the physician to ensure there were no complications like bleeding or a change in vital signs. Resident 88's MAR dated January 2026, was reviewed. The ADON acknowledged the five dialysis tasks for monitoring of bleeding, swelling, pain, bruit, and thrill were all blank for the day and evening shifts on January 24, 2026. The DON stated staff should be performing and documenting the assessments as ordered by the physician, but they did not.b. During a review of Resident 88's care plan titled, Potential for unavoidable bleeding on the A.V. shunt site and/or central line related to ESRD w/ hemodialysis. Dated January 20, 2026, the care plan indicated Resident 88 had an AV shunt site (for dialysis) on his right forearm. The care plan also indicated, Risks: 1. Adverse effect of dialysis 2. Compromise of dialysis access port.During a review of Resident 88's Dialysis Communication Record (document sent with resident to and from dialysis center for documentation of resident assessment prior to, during, and after dialysis treatments), dated January 23, 2026, the pre and post dialysis assessment conducted by the facility incorrectly indicated Resident 88 had a left upper arm shunt/graft (the resident had a right forearm shunt). Additionally, the Dialysis Communication Record, was also blank on the pre and post section of the form where it indicated whether bruit and thrill were present or absent. Furthermore, the question Bleeding at site: yes or no was left blank.During a concurrent interview and record review on January 28, 2026, at 12:49 PM, with the Assistant Director of Nursing (ADON), The ADON stated staff were supposed to document the assessment of the dialysis site and complete the pre and post dialysis assessment on the Dialysis Communication Record, on the days Resident 88 had dialysis. The ADON stated the importance of performing the pre and post dialysis assessment was to ensure there were no complications of the dialysis access site. Resident 88's Dialysis Communication Record, Dated January 23, 2026, was reviewed. The ADON acknowledged there was no documentation to indicate staff assessed bruit or thrill and bleeding at the dialysis site prior to or after the resident returned from dialysis.During a concurrent interview and record review on January 28, 2026, at 1:16 PM, with the Director of Nursing (DON), Resident 88's Dialysis Communication Record, dated January 23, 2026 was reviewed. The DON stated staff should be completing the form for the assessment thoroughly and stated there were blanks for the bruit, thrill, and bleeding at the site. The DON also stated staff documented that Resident 88 had his dialysis access site on his left upper arm but his active dialysis access site was on his right forearm.During a review of the facility's policy and procedure (P&P) titled, Care of Resident Receiving renal Dialysis, undated, the P&P indicated, Objective: To ensure that nursing staff are aware of special needs of residents receiving renal dialysis, and provide care accordingly.4. Nursing assessment identifies shunt area: a. check shunt area for bruit and thrill b. Obtain MD order for monitoring shunt area for presence of bruit and thrill Q shift.9. Complete Dialysis Communication Record during dialysis days and send the form with the resident to be completed by the dialysis nurse. Completed Dialysis Communication Record will be sent back with resident and facility nurse will complete post dialysis. A. Complete pre-dialysis assessment: .iii. Access site (central line, shunt, graft site), iv. Document presence or absence of bruit and/or thrill, v. bleeding at site.B. Complete post-dialysis assessment on return from treatment.

Based on observation, interview, and record review, the facility failed to provide supervision to one of one resident (Resident 56) when on January 25, 2026, Resident 56 left the facility without staff being aware. Resident 56 was found down the street from the facility in a parking lot near a gas station. This failure had the potential to result in harm to Resident 56 who was at risk for injuries.Findings: During a review of Resident 56's Face Sheet (contains medical and demographic information), the Face Sheet indicated Resident 56 was initially admitted to the facility on [DATE], with diagnoses which included aphasia (a language disorder that affects the ability to speak, understand, read and/or write), epilepsy (seizure disorder), anxiety disorder (a condition characterized by excessive fear of or apprehension about real or perceived threats), schizoaffective disorder (a mental health condition characterized by the combination of schizophrenia symptoms [e.g., hallucinations, delusions, disorganized speech] and mood disorder symptoms), and leukemia (cancer of the blood).During a review of Resident 56's care plan (an individualized plan for the medical care of a resident), titled, Risk for wandering/elopement dx [diagnosis] of anxiety, schizoaffective disorder.episodes of elopement, poor safety awareness, impaired cognition, dated May 16, 2025, the goal of the care plan indicated, The resident will not leave facility unattended and.the Resident's safety will be maintained.During an observation on January 26, 2026, at 10:31 AM, Resident 56 was observed to be inside his room with a 1:1 (one on one) staff member (a safety intervention where a dedicated staff member remains within arm's reach or in constant line-of-sight of a single patient) at his bedside. During an interview on January 28, 2026, at 1:29 PM, with the Director of Nursing (DON), the DON stated Resident 56 was last seen by staff at 4:25 PM on January 25, 2026. The DON further stated Resident 56's sister came into the facility on January 25, 2026, to visit Resident 56 and when Resident 56's sister could not find the resident in his room, Resident 56's sister went to talk to Licensed Vocational Nurse 1 (LVN 1) at 5:15 PM to inquire about Resident 56's whereabouts. The DON stated a search for Resident 56 began and the resident could not be found anywhere in the facility. The DON stated Resident 56 was eventually found down the street in a parking lot next to a gas station at 6:03 PM. The DON stated cameras inside the facility were viewed by facility staff and it was identified that Resident 56 walked out the front door of the facility at 4:39 PM. The DON stated a staff member is usually assigned to be at the front desk (near the front door of the facility) until 8:00 PM, but at the time Resident 56 left unsupervised, there was nobody at the front desk because the individual who was scheduled to be at the front desk called off.During a review of Resident 56's Interdisciplinary Team (IDT) note dated January 26, 2026, the IDT note indicated, IDT met to discuss an event that occurred on 1/25/26 when resident was noted absent from facility. Upon the start of pm shift at 3 PM, charge nurse did usual rounds of the facility and noted resident in his room sleeping. By 4:25 PM last saw resident walking in the hallway. By 5:15 PM resident's sister was letting LVN know that he might be in the dining room because he was not in his room. Code for elopement announced. Search immediately conducted inside building (bedroom, bathrooms, closets, common areas) outside building. Staff drove around the vicinity. Police department notified at 5:48 PM.found resident off neighboring parking lot at 6:03 PM. Resident was brought back to facility grounds immediately. DON, administrator, and MD were notified.During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Systems Approach to Safety.2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.During a review of the facility's P&P titled, Wandering and Elopements, revised July 2025, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interview, and record review, the facility failed to ensure resident's right were followed for one of three sample residents (Resident 7) when Resident 7 was administered lorazepam ( medication used to treat short-term anxiety, panic attacks, and sleep problems) without being informed in advance of the risks and benefits of the medication, the treatment alternatives or other options. This failure resulted in Resident 7 not being fully informed about the care and treatment provided.Findings:During a review of Resident 7's admission Record (contains medical and demographic information), the admission Record indicated Resident 7 was admitted to the facility on [DATE] with the diagnoses which included Anxiety (a feeling of fear, dread, or uneasiness, ), heart failure (the heart doesn't pump enough blood to meet the body's needs), shortness of breath (sensation of being unable to breathe normally), and diabetes (difficulty in blood sugar control).During a review of Resident 7's Physician Order dated November 18, 2025, the Physician Order indicated, Lorazepam 0.5 milligrams (MG-a unit of measurement) give one tab by mouth every four hours as needed for anxiety.During a concurrent interview and record review on January 29, 2026, at 11:42 AM, with the Case Manager, Resident 7's informed consent form for psychotherapeutic drugs was not signed by Resident 7 or Resident 7's Physician. The Case Manager stated, It does not appear he received informed consent prior to the start of lorazepam; I am unable to find a signed informed consent in Resident 7's chart.During a concurrent interview and record review on January 29, 2026, at 1:12 PM, with Resident 7, in Resident's 7 room. Resident 7 stated his provider did not discuss the side effects, risk and benefits of his anti-anxiety medications with him. Resident 7 stated he's been on the medication for a while.During a concurrent interview and record review on January 29, 2026, at 1:33 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Psychotherapeutic Drugs Informed Consent, dated January 2020 was reviewed. The P&P indicated, .Purpose: To ensure that residents and /or their representatives are fully informed of the benefits, risk, frequency/duration, possible side effects and alternative approaches before initiating the administration of psychotherapeutic drugs.4.The prescriber must sign an informed consent form after explaining all necessary information to the resident or their representative.6.The resident and /or their representative have the right to: accept, decline, or revoke consent at any time.10. The informed consent form shall be maintained in the resident's clinical record. The DON stated the P&P was not followed and Resident 7 should have received informed consent prior to medication administration and documentation should be in the resident's chart.

Based on interview and record review, the facility failed to ensure a resident was able to exercise the right to access personal and medical records for one of two residents (Resident 1), when Resident 1 requested her medical records but were not provided within 48 hours of the request as per the facility's policy. This failure resulted in a violation of Resident 1's right to have access to medical records as requested by Resident 1. Findings: During a review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with diagnosis that included polyneuropathy (a condition where multiple peripheral nerves throughout the body are damaged). During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated April 5, 2025, under Section C, it indicated her Brief Interview for Mental Status (BIMS) score was 14. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During an interview on June 23, 2025, at 9:55 AM with Resident 1, Resident 1 presented emails that she had sent to the Medical Record (MR 1) and the Director of Nursing (DON 1). She indicated that she has not yet received her medical record and has not received any communication from them. She expressed her desire to arrange a meeting with them to discuss this matter. During a concurrent Record Review and Interview on June 23, 2025, at 10:15 AM, in the Medical Record office with Assistant Medical Record (AMR 1). Both incoming and outgoing emails were examined. The incoming emails revealed that on May 13, 2025, the Medical Record Department had received a request for psychiatric records from resident 1. On May 20, 2025, the Medical Record Department had received a request for a complete copy of medical records from resident 1. On May 29, 2025, the Medical Record Department had received a request for a medical release form from Resident 1. On May 30, 2025, the Medical Record Department had received an urgent follow-up email regarding the failure to provide medical records from Resident 1. On June 5, 2025, the Medical Record Department had received a request for a medical record release form from Resident 1. The outgoing emails indicated that an email was sent to Resident 1 on May 23, 2025. AMR 1 confirmed that only one response email was sent to Resident 1. During a concurrent interview on June 23, 2025, at 10:59 AM with Resident 1, the Assistant Medical Record (AMR 1), and the Administrator (Admin 1). Resident 1 indicated that the records department only supplied her with the psychiatric notes she had requested through email on May 13, 2025, but did not respond to her emails concerning her medical record requests. The resident mentioned that she had requested her complete medical record via email on May 20, 2025, and followed up on her request through email on May 29, 2025, again on May 30, 2025, and once more on June 5, 2025. However, she has yet to receive her medical record or any replies to her emails regarding her medical record requests. During a concurrent Record Review and Interview on June 23, 2025, at 11:59 AM, in the Medical Record Office with the Medical Record (MR 1). MR 1 acknowledged that she had received Medical Record request via email from Resident 1 on May 20, 2025, May 29, 2025, May 30, 2025, and June 5, 2025. The MR 1 indicated that, according to her understanding of the policy, she is required to provide Resident 1 with the requested documents within 48 hours. She stated that when a resident requests medical records, it implies a request for the complete record. She acknowledged that Resident 1 has not yet received the complete medical record that was requested and admitted that she did not respond to Resident 1's emails. Furthermore, she could not provide a reason for her lack of response to the emails, nor could she explain why the records have not been released, suggesting that she is simply busy. She noted that, according to policy, in this situation, she is not meeting the expected standards. During an interview on June 23, 2025, at 12:30 PM, in the Medical Record Office with the Admin 1. The Admin 1 expressed his agreement that MR 1 is failing to meet the expectations outlined in the policy regarding the provision of requested documents to residents. A review of the facility Policy and Procedure (P&P) titled, Release of information , dated November 2009, indicate .10. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services .

Based on interview and record review the facility failed to ensure that appropriate procedures were followed after an unwitnessed fall of one of four sampled resident (Resident 1). There was no documentation of the fall, physician notification, and no indication that Resident 1 was monitored following the incident. This failure had the potential for Resident 1's overall medical condition to decline and go undetected by the facility. Findings: During a review of Residents 1's (R1) admission Record (general demographics), the document indicated R1 was admitted to the facility on [DATE], with diagnoses that included orthopedic after care, (period following surgery or treatment where patient receives ongoing care to receive to support recovery and healing), fracture tibia and fibula ( lower leg fracture), abnormality of gait and mobility (deviation from a normal walking pattern), type 2 diabetes mellitus (body has trouble controlling blood sugar), hyperlipidemia (high levels of fat in the blood ), kidney disease ( damage to the kidneys), hypertension ( high blood pressure), syncope (fainting spell). During an interview with R1 on May 28, 2025, at 1:15 PM, R1 stated call lights were not being answered; he needed to wait for one hour or even longer at times. R1 stated , he called during the night and waited for hours for someone to empty his urinal. He got up, slipped, and fell in the process. Shortly after he fell, a Licensed Vocational Nurse 1 (LVN1) came to his room to answer the light and saw his wheelchair had fallen off the floor. R1 told LVN 1 that he has been calling for assistance and nobody came. R1 told LVN 1 that he slipped and fell on the floor. R1 further stated, I'm not sure if the nurse documented that I fell that night. I don't think she called my doctor to let him know that I fell. During an interview with LVN 2 on May 28, 2025, at 2:10 pm, LVN 2 stated LVN 1 mentioned to him that R1 fell during her shift and did not sustain any injury. R1 also made LVN 2 aware that he had a fall incident during the night. When HFEN asked LVN 2 if there was a change of condition notification (COC), vital signs, neuro checks done by LVN 1, LVN 2 stated that he was not sure since it did not happen on his shift. LVN 2 stated there should have been a COC notification to primary physician, monitoring of R1 post fall, and the incident should have been documented. During a concurrent record review and interview with the Registered Nurse (RN 1) on May 28, 2025, at 2:25 pm, RN1 stated there was no COC notification and no documentation of the fall incident on the progress notes for R1. When RN1 was asked if there should have been a COC notification and monitoring done after the fall incident, RN1 stated documentation should have been done according to the facility's policy. The facility could not provide documentation that a COC was completed which includes situation (change in condition, symptoms, or signs observed), background (diagnosis, medication alerts, vital signs, mental status), appearance, review, and notification information or that the facility was monitoring for medical changes after this fall. During a continued interview with LVN 2, in the presence of RN 1 and the Director of Nursing (DON), on May 28, 2025, at 3:15 PM, DON stated she was not aware about R1's fall incident. LVN 2 stated LVN 1 reported to him R1 had an unwitnessed fall when he came to work that morning. RN 1 also stated there was no documentation of the fall incident and COC notification was not completed. The DON stated LVN 1 should have documented the incident, completed the COC, notified the physician, and monitored R1 after the fall incident. DON stated that she will follow up on it. The facility policy and procedure titled Changes in Residents Condition or Status revised March 2023, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident right, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather pertinent information for the provider, including (for example) information prompted by the interact SBAR Communication Form. RN1 and DON stated there should have been a COC notification and documentation of the fall incident.

Based on observation, interview, and record review the facility failed to follow its policy and procedure for Administering Medications for one of four sampled residents (Resident 4) when licensed staff did not monitor Resident 4's blood pressure and heart rate every six hours as ordered by resident 4's physician and give Hydralazine (medication to treat high blood pressure) as needed. This failure resulted in Resident 4 a clinically compromised resident being sent to the hospital for evaluation and treatment. Findings: During a review of Resident 4's Admission Record (general demographics), the document indicated Resident 4 was last admitted to the facility on [DATE], with diagnoses that included, hypertension (a condition when the blood pressure is high), hemiplegia (weakness that affect one side of the body), type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), end stage renal disease (a disease when the kidneys are no longer working). During a review of Care Plan Report, indicated, Focus: Resident is at risk for cardiac distress At risk for shortness of breath, chest pain irregular pulse, dizziness, edema, elevated BP (blood pressure), hypotension, altered mental status, headache . Goal: Will have no unrecognized s/s (signs and symptoms) of cardiac distress daily . Interventions: Observe for headache, chest pain, irregular pulse, edema, shortness of breath, elevated BP, dizziness . Monitor pulse rate and BP as ordered . During a review of Weights and Vitals Summary the last seven days prior to Resident 4 being sent to the hospital (February 18, 2025) indicated, were taken on February 17, 2025: 119/76 and February 10, 2025: 121/77. During review of Licensed Nurses Note dated, February 18, 2025, it indicated, Resident was sent to [Name of hospital], at 2340 via gurney accompanied by two from [Name of ambulance company] due to hypertension . During a concurrent interview and review on February 27, 2025, at 11:05 AM, with Licensed Vocational Nurse (LVN 1), the Medication Administration Record (MAR) was reviewed. Medications to be given included hydralazine HCI oral tablet 25 MG (Hydralazine HCI) Give 1 tablet by mouth every six hours as needed for HTN (hypertension) Hold if SBP (systolic blood pressure) < (less than) 110 or HR (heart rate) < 60. There was no blood pressure and heart rate recordings on the MAR from February 1, 2025, to February 17, 2025, except February 18, 2025. LVN 1 stated, I did not check his blood pressure every six hours. During a concurrent interview and review on February 27, 2025, at 11:10 AM, with the Director of Nursing (DON), the physician's orders (Order Summary Report) was reviewed. Orders included hydralazine HCI oral tablet 25 MG (Hydralazine HCI) Give 1 tablet by mouth every 6 hours as needed for HTN (hypertension) Hold if SBP (systolic blood pressure) < (less than) 110 or HR (heart rate) < 60. DON stated, Nurses were doing weekly blood pressure check. During a concurrent interview and record review on February 27, 2025, at 11:30 AM, with the DON, the facility's policy and procedure P&P titled, Administering Medications dated April 2019, was reviewed. The P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed. DON stated, Staff did not follow physician's orders by checking the resident (Resident 4)'s blood pressure and heart rate as stated in the physician's order. I expected staff to have followed the physician's order.

Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from financial exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion) by a staff member. This failure had the potential to cause significant emotional and financial harm to Resident 1 and had the potential to place other residents at risk of abuse, neglect and exploitation. Findings: During a review of Resident 1 ' s Face Sheet (a document containing clinical and demographic information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included depression (feeling sad and low motivation), anxiety (feeling restless), and colonostomy status (an opening in the abdominal wall to allow waste to exit the body through the colon). During a review of the State of California Form 341 REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE, dated December 5, 2024, it indicated Resident 1 came into activities dining room [ROOM NUMBER]/4 (December 4, 2024) to paint her nails well we were seating down she asked me how my thanksgiving was I told her that it was nice but quiet, she then stating saying if I ever need anything to let her know, that she had 2,300 ($ 2,300) on her card and was able to help Employee 1 because she was able to make Thanksgiving happen to year . During an interview with Resident 1, on December 6, 2024, at 9:35 AM, Resident 1 stated that three days before Thanksgiving, Employee 1 told her she needed items for her family's Thanksgiving dinner. Resident 1 stated she voluntarily gave Employee 1 her EBT (Electronic Benefits Transfer- used in California for the delivery, redemption, and reconciliation of issued public assistance benefits) card and PIN with the condition that the total purchase does not exceed $600.00. Resident 1 further stated Employee 1 copied her EBT card number and PIN onto her phone and used it to make purchases through an online grocery delivery application. Resident 1 further stated that most items purchased were kept by Employee 1. During a concurrent phone interview and record review with the Administrator (Admin), on December 6, 2024, at 10:40 AM, the Receipts print out [name of supermarket] dated December 4, 2024, at 8:21 PM was reviewed. The receipts indicated two transactions as follows: a. November 17, 2024, a total purchase of $436.51. b. November 21, 2024, a total purchase of $225.70. The Admin acknowledged that Employee 1 used Resident 1 ' s EBT card to make the purchases, with a total purchase of $662.21 for both transactions. The Admin further stated this action violated the facility ' s policy, which explicitly prohibits employees from accepting money, gifts from the residents. During a review of Resident 1 ' s Change of Condition dated December 6, 2024, at 11:52 AM, it indicated, Resident 1 is experiencing emotional distress due to alleged financial abuse with staff member [Employee 1] . Resident was assisted to the room to lay down to relax due to emotional distress . During an interview with the Social Worker (SW 1), on December 6, 2024, at 12:14 PM, the SW 1 stated that she was not aware that Resident 1 had an EBT card in her possession, as the facility provided for all residents with their needs. The SW 1 further stated that the facility financial abuse prevention policy was not followed this case. The SW 1 emphasized that employees should not be handling or using resident financial resources. During a concurrent interview and record review with the Social Worker 1 (SW 1), on December 6, 2024, at 12:19 PM, the II. Rules of Conduct dated June 2023 was reviewed. It indicated, The following conduct is prohibited and will not be tolerated by the Company .A. Resident / Patient Care .5. Borrowing any money or accepting a gift of any type, monetary or otherwise, from a resident . The SW 1 stated Employee 1 violated the facility ' s Rule of Conduct by accepting and using Resident 1 ' s EBT card, which should not have occurred. During a concurrent phone interview and record review on January 3, 2025, at 10:38 AM, with the Admin and the Director of Nursing (DON), the facility ' s undated policy and procedure (P&P) titled Abuse & Mistreatment of Residents was reviewed. It indicated, 8. Misappropriation of Resent property means the deliberate misplacement, exploitation, or wrongful use, temporary or permanent, of a resident ' s belongings of money without the resident ' s consent. The Administrator and DON agreed that the incident was a clear case of financial abuse and confirmed that the facility ' s policies were not followed by the Employee 1. During a concurrent phone interview and record review on January 3, 2025, at 10:39 AM, with the Admin, the facility ' s policy and procedure (P&P) titled Resident Rights dated February 2021 was reviewed. It indicated C. be free from abuse, neglect, misappropriation of property, and exploitation; The Admin stated the policy was not followed by the Employee 1.

Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to follow their policy in providing Activities of Daily Living (ADLS) when personal hygiene was not provide as needed and failing to notify responsible party (RP) of Resident 1 ' s shower refusals. This failure has potential in putting Resident 1 ' s health and safety at risk when hygiene needs were not met. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: cerebral infarction (blood blocked to brain, causing tissue death), Benign Prostatic Hyperplasia (enlarged prostate) Neurogenic Bladder (bladder retention), Urinary tract infection, schizoaffective disorder (hallucination s, delusions), hypertension (high blood pressure). During a concurrent interview and record review of Resident 1 ' s Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Task ALDs Shower /Bath self from September 11, 2024- October 09, 2024, 22 bed baths recorded, only 2 showers: September 01, 2024, Hair washed, skin moisturized marked Yes (Nails trimmed and shaved marked No) September 05, 2024, hair washed, skin moisturized shaved marked, shower and skin check marked Yes, nails trimmed marked No. 2. Careplan (No documentation of shower refusals). 3. No Progress Notes of documentation of shower refusals. 4. No Change in Condition for shower refusals, No responsible party notification. During an interview on October 10, 2024, with the Director of Staff Development (DSD), the (DSD) stated, For showers, we were told to chart it down, we go back 3 times after they refuse to see if the resident changes their mind in taking a shower. The charge nurse and the Certified Nursing Assistant (CNA) documents shower refusals. I printed out the bed baths provided, but I only have 2 shower sheets since September 1, 2024, until now. I don ' t know what happened. I ' m not sure for this resident what happened, there is no documentation. During an interview on October 10, 2024, with the Director of Nurses (DON), the (DON) stated, If Resident 1 is not showering, he needs a bed bath. Showers should be as schedule if he doesn ' t refuse. The charge nurses will be the one to notify me of his refusals. For Refusals we do a Change of Condition of behaviors refusal of Care. Responsible Party and doctor will be notified. I can agree, no records on careplan, there are no refusals for showers. I did not know about the refusals of showers, I never knew of his refusals, it would have been part of his behaviors. During a review of the facility ' s policy and procedure titled, Activities of Daily Living ADL, supporting revised March 2018, the policy and procedure indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .(3) refuses care and treatment to restore or maintain functional abilities and (a) the resident and or representative has been informed of the risk and benefits of the proposed care or treatment .(c) the refusal and information are documented in the residents clinical record.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety, when: 1. On [DATE], two unopened one-pound bags of mini marshmallows, with an expiration date of [DATE], were found stored on top of a shelf in the dry storage room and was available for use. 2. On [DATE], one 4 oz (ounce- a unit for measuring liquid) cup of apple juice and one 4 oz cup of cranberry juice, with the date [DATE], were found on Resident 51's bedside table and were available for consumption. These failures have the potential to compromise food safety and increase the risk of foodborne illness (caused by the ingestion of contaminated food or beverages) for 84 vulnerable residents receiving food from the facility's kitchen. Findings: 1. During a concurrent observation and interview on [DATE], at 8:19 AM, with the Dietary Supervisor (DSS), in the kitchen, the dry storage room was inspected. Two unopened one-pound bags of mini marshmallows, with an expiration date of [DATE], were found stored on top of a shelf. (54 days expired.) The DSS acknowledged that two bags of mini marshmallows were outdated and stated those bags should be removed. During a concurrent interview and record review on [DATE], at 3:38 PM, the DSS reviewed the facility's undated Policy and Procedure (P&P) titled Storage of Canned and Dry Goods which indicated, .No food item that is expired or beyond the best buy date are in stock. The DSS acknowledged that the policy was not followed. 44841 2. During a concurrent observation and interview on [DATE], at 10:26 AM, with License Vocational Nurse (LVN 1), in Resident 51's room, there were two cups of fruit juices (one apple and one cranberry) on top of Resident 51's bedside table. Both cups were labeled with the date [DATE] [[DATE]]. LVN 1 acknowledged that the juices were two days old. LVN 1 further stated that the cups were from the meal tray and should not have been left overnight. During an interview, on [DATE], at 10:50 AM, with the Administrator (Admin), the Admin stated the practice for passing the tray was to come back to check if the resident consumed the food and pick up after each meal. The Admin further stated the two fruit juices found on Resident 51's room should have not been left at the bed side overnight. During a concurrent interview and record review, on [DATE], at 11:00 AM, with the Admin, the facility's P&P titled Assistance with Meals revised [DATE], was reviewed. The P&P indicated, .Resident confined to bed: . 4. Nursing services . will pick up resident's food trays after each meal .All residents: . 2. To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 F to 135 F) will be kept to a minimum. Foods that are left on trays without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded . The Admin stated the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to ensure infection control prevention were implemented among a highly vulnerable population of 86 residents, when an oxygen tubing (thin plastic tube that connects a machine, which makes extra oxygen to a person's nose) and related oxygen supplies were not replaced in accordance with the facility's policy and procedure for one of five residents reviewed for oxygen (Resident 34). This failure has the potential to cause and increased risk of infection to Resident 34 due to prolonged use of respiratory equipment without proper replacement. Findings: During a record review of Resident 34's Admission Record (contains demographic and medical information), it indicated Resident 34 was admitted to the facility on [DATE], with diagnoses of cerebrovascular disease (like a stroke, where the blood flow to part of the brain is block), dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function,), and dysphagia (difficulty of swallowing). During a review of Resident 34's Physician Orders, dated October 4, 2024, it indicated Oxygen related supplies, including the humidifier (a small device that adds moisture to the oxygen coming from a machine that helps people breath) were to be changed every night shift every Sun [Sunday.] During an observation on October 1, 2024, at 3:48 PM, in Resident 34's room, Resident 34 was lying in the bed, resting. On the right side of Resident 34's bed, there was an oxygen concentrator (machine that helps people who have trouble breathing), which had a set up bag attached to it. The set-up bag, which contained oxygen tubing and other respiratory supplies, was inspected. The oxygen tubing and setup bag were marked with a date of January 1, 2024 (Nine months ago.) During a concurrent observation and interview on October 1, 2024, at 3:53 PM, with Registered Nurse (RN 1), in Resident 34's room, RN 1 acknowledged the findings and stated it should have been replaced weekly. RN 1 stated the night shift staff was responsible for changing and supplies every Sunday, but this was not done. During a concurrent interview and record review on October 3, 2024, at 4:44 PM, with the Administrator (Admin), the Admin reviewed the facility's undated policy and procedure (P&P) titled, Oxygen Administration, which indicted The oxygen tubing should be changed weekly and as needed, including changing the mask, cannula, nebulizer equipment, etc. When not in use, the oxygen tubing should be stored in a clean bag. The [NAME] acknowledged the policy and stated the staff failed to follow the oxygen administration policy, which mandated the weekly replacement of oxygen tubing and related supplies.

Based on observation, interview, and record review, the facility failed to ensure one of six residents reviewed for nutrition (Resident 39) received a diet prescribed by their physician in a timely manner. This failure had the potential to place Resident 39 at risk for further nutrition and medical decline. Findings: During a review of Resident 39's Admission Record (contains demographic and clinical data), it indicated Resident 39 was admitted to the facility on [DATE], with diagnoses of protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dystonia (movement disorder), and epilepsy (brain disorder that causes recurring, unprovoked seizures). During a review of Resident 39's Outpatient Clinic Prescription from her Primary Care Physician, dated August 8, 2024, it indicated Please d/c [discontinue] current diet and follow recommendations per Barium test result. Small quarter size chopped soft diet w/ [with] thin liquids by teaspoon or small open cup sips . A review of Resident 39's physician orders were reviewed from August 8, 2024 through August 25, 2024, there was no documented evidence to indicate the diet order from Resident 39' s PCP was written and carried out by the facility. During a review of Resident 39's physician order, dated August 26, 2024, it indicated Resident 39 had an order to have a regular diet, mechanical soft texture, thin consistency, small bites and sips, 1:1 supervision, sips need to be slow. This order was carried out 18 days after original diet order was received. During a concurrent interview and record review, on October 4, 2024, at 2:00 PM, with the Director of Nursing (DON), the DON reviewed Resident 39's Outpatient Clinic Prescription, dated August 8, 2024, and Resident 39's current diet order, dated August 26, 2024 and stated the diet order was not carried out timely. During a review of the facility's policy and procedure titled Physician Orders and Telephone Orders, dated January 2004, it indicated . 3. All orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. Each order shall include the diagnosis/condition to support the order. During a review of a facility document titled Job Description - Registered Nurse (RN), dated January 27, 2022, it indicated, The Registered Nurse is responsible for assuring physician's orders are followed and quality care is provided on each shift in a skilled care facility . Makes actual patient rounds, assessing and observing the following at least three times per day .Hydration/nutritional status/feeding program.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with prescriber's orders and facility policy for one resident reviewed for use of antibiotic (medication used to treat bacterial infections) (Resident 39). This failure had the potential to make the antibiotic less effective and prolong the course of treatment, placing Resident 39's health at risk. Findings: During a review of Resident 39's Admission Record (a document that contains demographic and clinical data), the Admission Record indicated, Resident 39 was admitted to the facility on [DATE], with the diagnoses of protein-calorie malnutrition, (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dystonia (movement disorder), and epilepsy (brain disorder that causes recurring, unprovoked seizures). During a review of Resident 39's physician order, dated August 21, 2024, it indicated, Ertapenem Sodium (Ertapenem Sodium-antibiotic used to treat bacterial infections) Injection Solution Reconstituted 1 GM (gram- unit of measurement) Inject 1 gram intramuscularly (IM- a method of delivering medication directly into a muscle) in the evening for infection/UTI (urinary tract infection- infection that can occur in any part of the urinary system) for 10 days. During a review of Resident 39's Medication Administration Record (MAR) for the month of August 2024, it indicated Resident 39 received the first dose of Ertapenem Sodium on August 21, 2024. Further review indicated on August 22, 2024, Resident 39 was not administered the prescribed antibiotic. During a review of Resident 39's nursing progress notes, dated August 22, 2024, for 17:00 PM dose, documented by LVN 2, it indicated, Ertapenem Sodium Injection Solution Reconstituted 1 Waiting delivery from pharmacy. During a concurrent interview and review of Resident 39's clinical records, with a Registered Nurse (RN 1), on October 4, 2024, at 4:48 PM, RN 1 acknowledged that Resident 39 was not administered Ertapenem Sodium on August 22, 2024. RN 1 stated the medication was available in the Emergency Kit (Ekit- designed to support both staff and residents, ensuring continuity of care and safety during emergencies.) and LVN 2 should called the pharmacy to inform them that she was getting another dose in the Ekit because the antibiotic still has not arrived. During a concurrent interview and record review with RN 1, on October 4, 2024, at 5:06 PM, RN 1 reviewed the facility's policy and procedure (P&P), titled, Administering Medications, revised April 2019, which indicated Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation - .4. Medications are administered in accordance with prescriber orders, including any required time frame. RN 1 stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure one of eight residents reviewed for Range of Motion (ROM- full movement potential of a joint) (Resident 39) receives appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM when Resident 39's Restorative Nursing Assistant (RNA- help residents improve and maintain their physical abilities and ADLs, and prevent further decline) orders were not carried out in a timely manner. This failure could have potentially caused a delay of preventing severe contractures (a medical condition characterized by the shortening and hardening of muscles, tendons, or connective tissues, which can lead to stiffness and restricted movement in joints) of all extremities. Findings: During a review of Resident 39's Admission Record (a document that contains demographic and clinical data), it indicated Resident 39 was admitted to the facility on [DATE], with diagnoses of protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dystonia (movement disorder), and epilepsy (brain disorder that causes recurring, unprovoked seizures). A review of Resident 39's physician's orders, dated August 7, 2024, indicated, RNA (Restorative Nursing Assistant) for AAROM (Active Assistive Range of Motion) exercise, left (L) LE (lower extremity), 3x/week as tolerated. RNA for exercise, Right LE 3x/week as tolerated. Physician's orders, dated September 19, 2024, indicated, RNA to perform L UE (upper extremity) AAROM exercise 5x/week or as tolerated. RNA to perform R UE AAROM exercises 5x/week or as tolerated. RNA to apply rolled hand towel to R hand 5x/week or as tolerated, RNA to apply rolled hand towel to L hand 5x/week or as tolerated. (This RNA order was rewritten on September 30, 2024.) During a review of Resident 39's RNA progress notes for the months of August 2024, it indicated Resident 39 started receiving her AAROM exercises on August 14, 2024. (One week after the order was written.) During a concurrent interview and record review with RNA Supervisor and the Director of Nursing (DON), on October 4, 2024, at 3:30 PM, Resident 39's RNA orders and RNA weekly progress notes for the month of August 2024 were reviewed. RNA Supervisor and DON acknowledged that the RNA orders were not carried out timely. During a concurrent interview and record review with RNA Supervisor and the DON, on October 4, 2024, at 3:45 PM, RNA Supervisor and the DON reviewed the facility's policy and procedure, (P&P), titled, Physician Orders and Telephone Orders, dated, January 2004, indicated: .GUIDELINES: 1. A resident shall be admitted or accepted for care on the order of a physician. The admission order is to begin with Admit to and include, but not limited to, the following orders: a. Diet, . c. Treatment (specific treatment, frequency, site), d. Activity limitation. 7. Computer generated physician's order shall be reviewed by a qualified person, preferable by a licensed Nurse, prior to placement of these orders into the resident's health record. RNA Supervisor and the DON acknowledged the policy and stated Resident 39's RNA orders were not carried out timely and was started in a delay.

Based on the interview and record review, the facility failed to ensure that Significant Change of Status Assessments (SCSA- required when a resident's condition has significantly changed, either improving or declining, and the change is expected to last longer than two weeks) of the Minimum Data Set (MDS- federally mandated assessment tool) were completed within 14 days for one of three residents reviewed for pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device)(Resident 39) when Resident 39 had a significant decline in her condition due to severe weight loss and changes in the stage (a system used to classify severity) of her pressure ulcers. This failure resulted in Resident 39's care plan not being updated and revised to reflect her current status, which had the potential to delay the implementation of her care and support needs. Findings: During a review of Resident 39's Admission Record (a document that contains demographic and clinical data), it indicated Resident 39 was admitted to the facility on [DATE], with diagnoses which included protein calorie malnutrition (condition caused by not getting enough protein and calories in the diet, which can lead to weight loss, muscle wasting, and a weakened immune system) and unstageable (wound that we can't see how deep the sore is because it is covered with dead skin or other material) pressure ulcer of sacral (tailbone) region. During a concurrent interview and record review with the Director of Nursing (DON) and Administrator (Admin), on October 4, 2024, at 3:21 PM, the DON and the Admin reviewed Resident 39's clinical record which indicated Resident 39's weight were as follows: July 2, 2024, weight : 133 pounds; August 2, 2024, weight : 125 pounds; September 4, 2024, weight : 116 pounds. The DON and the Admin acknowledged that Resident 39 had a severe weight loss from July 2024 to September 2024 with a total of 17 pounds weight loss which was 12.8% in 3 months period. (7.5 % in three months is the suggested parameter for evaluating significance of unplanned and undesired weight loss.) During further interview and record review with the DON and the Admin, on October 4, 2024, at 3:30 PM, the DON and the Admin reviewed Resident 39's Skin Progress Report, dated July 2, 2024, which indicated . Date first observed 07/02/2024 [July 2, 2024] . site coccyx [tailbone] . length. 2.1. Width 1.2. Stage. Suspected deep tissue injury [is a type of wound happen from pressure on the skin usually looks like a purple or dark red spot, skin not open/break] . weekly progress report date 08/13/2024 [August 13, 2024]. Current stage. UTD [Unstageable] . Wound measurement (cm [unit in measurement centimeter]) 5.4 [length] x 8.5 [width] . The DON and the Admin acknowledged Resident 39's pressure ulcer was bigger in size and worsening in stage. During a follow up interview with the DON and the Admin, on October 4, 2024, at 3:40 PM, Resident 39's Admission MDS assessment dated [DATE], and Quarterly MDS assessment dated [DATE], were reviewed. The DON stated that instead of Resident 39's Quarterly Assessment, the assessment completed should be SCSA MDS. The DOn further stated We missed it. (After a significant decline in Resident 39's status, of significant weight loss and pressure ulcers, a SCSA was not completed after 14 days) During a concurrent interview and record review with the DON and the Admin, on October 4, 2024, at 3:50 PM, the DON and the Admin reviewed the facility's policy and procedure (P&P) titled Weight Assessment and Intervention, revised March 2022, which indicated .the threshold for significant unplanned and undesirable weight loss will be based on following criteria [where percentage of body weight loss =(usual weight-actual weight)/(usual weight) x 100]: a. 1-month 5% weight loss is significant; greater than 5% is severe. b. 3-month 7.5% weight loss is significant; greater than 7.5% is severe. c. 6-month 10% weight loss is significant; greater than 10% is severe . A review of the facility policy and procedure titled Change in Resident's Condition or Status, revised March 2023, indicated .2. A significant assessment is major decline or improvement in resident status that will: a. Will not normally resolve itself without intervention . b. impact more than one area . c. requires interdisciplinary review and/or revision of the care plan .9. If a significant change in resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA [is a federal law that establishes regulations for nursing facilities] regulation governing resident assessment and as MDS RAI [Resident Assessment Instrument. It's a tool used in nursing homes to assess residents' health and needs] instruction manual . A review of the RAI manual, revised October 2023, indicated . The SCSA is a comprehensive assessment for a resident . It can be performed at any time after the completion of an Admission assessment .The MDS completion date (item Z0500B) must be no later than 14 days from the ARD [(Assessment Reference Date) is the last day of this observation period] (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met

Based on observation, interview, and record review, the facility failed to ensure a certified nursing assistant was able to demonstrate competency in skills and techniques for one of three sampled residents (Resident 1) when a Certified Nursing Assistant (CNA 1) did not report Resident 1's redness on the nose to a licensed nurse. This failure had the potential to result in delayed treatment and care for Resident 1, placing Resident 1 ' s health at risk. Findings: During a review of Resident 1 ' s Admission Record (contains demographic and medical information), the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of malignant neoplasm of the stomach (stomach tumor), malignant neoplasm of unspecified kidney (kidney tumor) and repeated falls. During a concurrent observation and interview on September 5, 2024, at 9:58 AM, with Resident 1, in Resident 1 ' s room, Resident 1 was lying in bed. Resident 1 ' s bed was in the lowest position. Resident 1 had redness on her nose, appearing like flushing on her nose. Resident 1 stated she did not know how she got it. During an interview on September 11, 2024, at 1:47 PM, with CNA 1, CNA 1 stated she noticed the redness but did not report it to the licensed vocational nurse (LVN 1) or the registered nurse (RN). CNA 1 further stated she was busy and forgot to tell the licensed staff. During an interview on September 11, 2024, at 2:08 PM, with LVN 1, LVN 1 stated he saw the redness on Resident 1 ' s nose but stated he believed it had already been identified due to Resident 1 ' s behavior of hitting her face. LVN 1 further stated it was his expectation for the CNA ' s to report any skin changes. During an interview on September 11, 2024, at 2:16 PM, with RN, the RN stated he was not informed until later that Resident 1 had redness to her nose. The RN further stated Resident 1 when asked about her nose, Resident 1 could not state what happened to her nose. The RN stated it is his expectation for the staff to report any changes with the residents. During a concurrent interview and record review on September 26, 2024, at 12:01 PM with the Administrator (Admin) and Director of Nursing (DON), the facility ' s document titled Certified Nursing Assistant (CNA) Job Description dated August 23, 2011, was reviewed. The Certified Nursing Assistant (CNA) Job Description indicated .Essential Duties and Responsibilities . observes resident ' s skin and documentations and reports skin conditions .Other Duties . Recognize and reports resident pain. Abnormal skin condition, incident, etc., to the charge nurse. The Admin stated the job description was not followed by CNA 1. During a concurrent interview and record review on September 26, 2024, at 12:02 PM, with the Admin and DON, the facility ' s policy and procedure (P&P) titled, Change In A Resident ' s Condition or Status dated revised February 2021 was reviewed. The P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition .1. The nurse will notify the resident ' s attending physician . when there has been a(an ) a. accident or incident involving the resident; b. discovery of injuries of unknown source . The Admin stated CNA 1 did not follow the policy when CNA 1 did not report to the charge nurse the redness on Resident 1 ' s nose. The Admin further stated CNA 1 was terminated.

Based on observation, interview and record review, the facility failed to ensure services were provided in accordance with resident needs and safely for one of 3 Residents (Resident 1) when: 1.Resident 1 acquired an open wound to right hand pinkie finger. 2.No wound dressing as ordered noted on pinkie finger open wound. 3.No wound care treatment as per Treatment Record for September 23, 2024. This failure resulted in a clinically compromised resident, (Resident 1) health and safety at risk, when the developed in facility and wound was exposed with possibility for infection. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included: enterocolitis due to clostridium difficile (disruption of normal bacteria in colon from antibiotics causing diarrhea), mononeuropathy (compression of nerve, cause loss of movement/sensation), muscle weakness, abnormal posture, dysphagia (difficulty swallowing), protein calorie malnutrition, dystonia (involuntary muscle contractions). During an observation on September 24, 2024, of Resident 1, Resident 1 right hand pinkie finger open wound with blood smearing noted in between pinkie and ring fingers and no wound dressing as ordered. During a record review of Resident 1 ' s medical records, reviewed and verified the following: 1. Wound Risk Assessment: dated July 03, 2024=Score 21 and July 10, 2024= Score 20 .High Risk skin breakdown. 2. Wound Management September 18, 2024, pinkie right finger open wound . 3. Order: September 18, 2024, at 12:33 Moisture Associated Skin Damage (MASD) right Pinkie everyday shift for skin management, cleanse with NS, pat dry apply Xeroform (yellow petroleum gauze to cover and protect wounds), cover with foam dressing. Reassess in 30 days. 4. Treatment Administration Record (TAR) for September 2024: (MASD) Right Pinkie everyday shift for skin management. Cleanse with Normal Saline, pat dry, apply Xeroform, cover with foam dressing. Reassess in 30 days. (Missing wound treatment on September 23, 2024. 5. Careplan: Altered skin integrity with open wound .5th finger pinkie right hand, interventions: administer treatments as ordered .may have hand roll on right hand with therapy, every shift assessment to determine skin status report. Date initiated September 19, 2024. (Careplan has no resident refusals of hand rolls, as per interviews with staff). During an observation and interview in resident 1 ' s room at bedside on September 24, 2024, with the Certified Nursing Assistant (CNA 1), CNA1 states, Resident 1 has the rolls in the hand, we tell her at least for one hour but she cries to take them off. When asked, did she have a wound dressing on pinkie finger? CNA states, no, but they did the dressing yesterday, no she didn ' t have the dressing on her pinkie today, I didn ' t tell the nurse because they do the treatments daily. During an observation and interview in resident 1 ' s room at bedside on September 24, 2024, with the License Vocational Nurse (LVN 1), states, I ' m doing wound treatments today, the treatment nurses are not in today. Resident 1 is supposed to have Xeroform on the wound with a dressing. I can see the right pinkie finger is supposed to have a dressing on it and does not, I ' m not sure why she doesn ' t. She did have treatment yesterday. Her wounds are right pinkie and an unstable to coccyx. During an interview on September 24, 2024, with the Director of Nursing (DON), DON states, The open wound to pinkie finger started this month, just a few days ago. Based on her comorbidities she is a high risk for skin breakdown, she has an open coccyx wound. (Acknowledgement of the pinkie finger open wound should have a dressing and was not aware of the blood in between fingers). States will have to educate staff on this. During an interview on September 24, 2024, with the Administrator (Admin), states, The open pinkie finger wound, it should have had a dressing as per the order. The nurse should have been notified by CNA staff of open wound with no dressing on. During a review of the facility ' s policy and procedure titled, Wound Care revised March 2023, the policy and procedure indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Reporting; report other information in accordance with the facility policy and professional standards of practice. During a review of the facility ' s policy and procedure titled, Prevention of Pressure Injuries revised March 2023, the policy and procedure indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific factors .1. Keep skin clean and hydrated.

Based on interview, and record review, the facility failed to provide safeguards for one of six sampled Residents (Resident A) who was under conservatorship due to being gravely disabled as a result of a mental disorder when he was allowed to leave the facility unaccompanied on pass and when he did not return, the facility failed to notify the police or conservator. This had the potential for Resident A to be placed in an unsafe circumstance due to his mental disorder as well as, physical danger related to having bilateral nephrostomy tubes (a tube inserted through the skin and into the kidneys to drain urine) he was unable to care for himself. Findings: An abbreviated survey was conducted on (MONTH) 30, (YEAR) at 4:38 PM to investigate a complaint related to resident rights. During an interview with the Social Services Designee (SS1) on (MONTH) 30, (YEAR), at 5:00 PM, she stated Resident A had a conservator. Resident A signed himself out on pass on (MONTH) 29, (YEAR), and had not returned back to the facility. The SS1 further stated, the staff did not search for Resident A or call the police. SS1 stated, Our policy states that after 72 hours, he is considered to be on pass against medical advice. During a concurrent record review with SS1, she stated the court orders for conservatorship of Resident A were not in his chart. They (court orders) should be in his chart. A review of the clinical record for Resident A was conducted. The face sheet (contains demographic information) indicated, Resident A was readmitted to the facility on (MONTH) 10, (YEAR) with an initial admitted (MONTH) 15, (YEAR). Resident A had [DIAGNOSES REDACTED].) He had bilateral nephrostomy tubes (a tube inserted through the skin and into the kidneys to drain urine) which required frequent emptying. A review of a document titled, Multidisciplinary Progress Record indicated the nurse documented on (MONTH) 29, (YEAR) at 5:00 PM, Resident A had not been seen in the facility since 4 PM. A resident stated he said goodbye and was catching the bus to head home to Riverside. No family listed in his chart. Left a message for guarantor's office. Dr. made aware. Resident is self aware and has 72 hours to return back to facility. There was no documented evidence that a search for Resident A was done at the time he was noted to be missing. The next entry by any staff was dated on (MONTH) 30, (YEAR) at 4:00 PM, (24 hours after the resident was last seen) written by the Social Service Director (SSD) and indicated, SSD was made aware resident went out on pass on 5-29-18 (May 29, (YEAR)) around 4 PM but resident has not returned back to facility. Nursing staff notified (name of conservator) of resident continuing to be out on pass. Staff called all hospitals near facility. During an interview with the Director of Nursing (DON), on (MONTH) 30, (YEAR), at 5:53 PM, he stated The doctor said (name of Resident A) could go out on pass. (Used name of Resident A) has the mental capacity to sign out. The DON further stated the facility did not call the police after Resident A did not return back to the facility, or start looking for the resident until prompted by the conservator's call on (MONTH) 30, (YEAR). The DON confirmed the resident did not leave with his medication and that he had nephrostomy tubes which nursing staff was monitoring and emptying. The facility did not consider it as a problem until the conservator called in regards to Resident A's failure to return from pass. During an interview with the Social Services Director (SSD) on (MONTH) 31, (YEAR) at 9:55 AM, she stated, Admissions or Nursing informs the doctor when a conserved resident is admitted . The SSD stated she does not inform the physician when a conserved resident is admitted under a conservatorship. The SSD further stated she did not call the police the morning of (MONTH) 30, (YEAR). During an interview with the Medical Director on (MONTH) 31, (YEAR) at 11:08 AM, she stated, It's the responsibility of the facility to inform the physician of conservatorship. He (resident A) should have not been on pass. During an interview with the Assistant Director of Staff Development (ADSD) on (MONTH) 31, (YEAR) at 12:30 PM, he stated, The doctor wrote an order for [REDACTED]. A concurrent record review for Resident A was done with the ADSD, he stated an elopement assessment was not done. He further stated, Resident A should not have been allowed to go out on pass. During an interview with the Admissions Coordinator (AC) on (MONTH) 31, (YEAR) at 2:06 PM, he stated. We didn't put it in writing (information to the physician regarding Resident A's conservatorship). During an interview with a Licensed Vocational Nurse (LVN 1) on (MONTH) 31, (YEAR) at 4:25 PM, she stated, (Used name of Resident A) talks to himself once in a while. LVN 1 further stated that Resident A had nephrostomy tubes, He has pulled them out three times. We empty it for him and sometimes he does it (empties his urine) himself and dislodges the tubes. We were monitoring his input and output to make sure everything (urine) was flowing properly. A physician's orders [REDACTED].May go out and is self-responsible. If out on pass exceeds 72 hours, unless the physician's orders [REDACTED]. During an interview with the Primary Physician (PMD) for Resident A an on (MONTH) 31, (YEAR) at 6:10 PM, he stated, the facility did not inform him that Resident A had a conservator due to a mental disorder. The PMD stated, They did not tell me. If I would have known I would not have let him go (on pass). During a review of the clinical record for Resident A, the Petition for reappointment of Conservator of the person and estate dated (MONTH) 15, (YEAR), indicated Petitioner .1. On (MONTH) 16, (YEAR), the above Conservatee was initially adjucated to be a gravely disabled person and Petitioner was appointed Conservator .Under the section titled Verification .I am the conservator of the person and the estate of the above-named Conservatee. The facility policy and procedure titled Out on Pass undated, indicated Procedure::.4. Residents/responsible party will be asked to sign out-on-pass book at nurses' station to indicate date, time and destination of out-on-pass. The facility policy and procedure titled Missing Resident undated listed the Objective: To reduce possible injury or death of a resident; to provide an organized method for locating a resident. Steps: 1. Verify that resident is missing. Question roommates, other residents, visitors and staff as necessary. 2. Notify Charge Nurse, Nursing Supervisor, Director of Nursing and Administrator. 3. Search entire building .7. If resident still hasn't been located within an hour of starting search, notify the police, responsible party/residents family, and attending physician. 8. If resident still hasn't been located within two hours of starting search, check hospitals .11. Chart all events and notifications . Substandard quality of care and an Immediate Jeopardy (IJ - a crisis situation which has threatened or is likely to threaten the health and safety of a resident) were called for the following: An IJ was called under 483.25, Quality of Life (refer to F 689 - Free of Accident Hazards/Supervision) on (MONTH) 31, (YEAR) at 10:27 AM, and verbally notified in the presence of the Administrator and the Director of Nursing. An corrective action plan was received and accepted on (MONTH) 1, (YEAR) at 12:42 PM, with the following information: a. Medical records completed an audit for all residents on conservatorship and Public guardian. Inservices started for residents out on pass and elopement. b. All residents with conservatorship and public guardian were identified. All physicians were contacted to review and revise History and Physicals to reflect current status. c. Medical records will provide a list of residents to Director of Nursing or Designee with conservatorship and public guardian who should not have an out on pass order. d. The Interdisciplinary Team will review upon admission, quarterly and as needed any residents with conservatorship and their status. The ID Team will schedule a care conference with resident and conservator on a quarterly basis and as needed. e. Ensure all conservatorship documentation is available in medical records chart for residents. f. Prior to admission all prospective residents will prescreen all residents for history of elopement or wandering risks and behaviors. g. Any residents exhibiting behaviors or signs of elopement will be assessed immediately for appropriate interventions and or placement. h. The results will be reported to the QAPI (Quality Assurance Performance Iimprovement) Committee Quarterly for review, monitoring and recommendations as needed. After interviews and document reviews confirmed that the corrective action plan had been implemented, the IJ was removed on (MONTH) 1, (YEAR) at 12:51 PM, in the presence of the Administrator and the Social Services Director.

Based on observation, interview, and record review, the facility failed to ensure facility's policy and procedure related to abuse prevention were implemented by staff, for three of 29 sampled residents (Resident 59, Resident 203, Resident 55) when: 1. Resident 59 and Resident 203 were told If you don't shut your mouth, I will not give your pain medication! and Shut your mouth, you are not the only resident here! from facility Licensed Vocational Nurse 7 (LVN 7). 2. Resident 55 was told You should read the bible and practice what you read from the facility Administrator (ADM). These failures affected the mental and psychosocial well beings of the residents causing each of them to be anxious, scared, with feelings of degradation and humiliation. Findings: 1. During an observation on (MONTH) 4, (YEAR) at 8:30 AM, Resident 59 and Resident 203 were in their beds, awake, alert and able to talk coherently. Concurrent interviews with Resident 59 and Resident 203 were conducted. Resident 59 stated, she was upset with Licensed Vocational Nurse 7 (LVN 7) because LVN 7 yelled and was rude at her. She said LVN 7 refused to give Resident 59's pain medication. Resident 59 stated that on (MONTH) 24, (YEAR) at 11 PM to 7 AM shift (night shift), both she and Resident 203 were both in need of pain medications. Resident 59 pushed on her call button to call LVN 7. LVN 7 came to their room and turned off Resident 59's call button and spoke only to Resident 203. LVN 7 ignored Resident 59. Resident 59 stated when LVN 7 was about to leave the room, Resident 203 asked her, Wait, what about her pain medication? (referring to Resident 59). LVN 7 ignored Resident 203, and left the room. Resident 59 used her call button again to ask for her pain medication from LVN 7, but LVN 7 did not return to their room. During a concurrent interview with Resident 203, she stated LVN 7 did not return to give her pain medication for an unknown amount of time. Resident 203 yelled for LVN 7 to come to their room. LVN 7 returned to their room and yelled at Resident 59, and stated, If you don't shut your mouth up, I will not give your pain medication! Resident 59 got upset with LVN 7 and told her she was not the one who yelled for her but Resident 203 did. Resident 203 stated, She (LVN 7) then yelled and was nasty at me, and said Shut your mouth! You are not the only resident here! Resident 203 further stated that LVN 7 gave the medication to her but not to Resident 59. Resident 59 added, that LVN 7 never returned to their room. Resident 59 used her cell phone to call the nursing station to ask help from another charge nurse to give her pain medication. Resident 59 stated that she asked for her routine pain medication from LVN 7. Resident 59 stated LVN 7 knew she had a scheduled pain medication at 4:00 AM. Resident 59 was already in pain so she asked for it earlier at 3:00 AM. Resident 59 got her pain medication 5:30 AM from a different Licensed Vocational Nurse 5 (LVN 5). Resident 59 and Resident 203 stated they reported the incident to the Licensed Vocational Nurse 6 (LVN 6) in the morning of (MONTH) 25, (YEAR). Resident 59 and Resident 203 stated they were both worried LVN 7 will still yell at them since LVN 7 was still on schedule at work and assigned to them. During an interview with LVN 6 on (MONTH) 4, (YEAR) at 2:30 PM, she stated that she was working on (MONTH) 25, (YEAR) and the two residents (Resident 59 and Resident 203) reported about their incident with LVN 7. LVN 6 stated she reported the incident to the Director of Nursing (DON) on (MONTH) 25, (YEAR). During an interview with the DON on (MONTH) 5, (YEAR) at 7:00 AM, he stated, he interviewed both Resident 59 and Resident 203. He stated, he did not follow the facility abuse policy and procedure of reporting to California Department of Public Health (CDPH) the alleged abuse, and not suspending the alleged abuser while his investigation was still going on, but instead he just reassigned LVN 7 to different patients and allowed her to work in the facility. The DON stated that he has not completed his investigation of the alleged abuse. During an interview of LVN 7 on (MONTH) 5, (YEAR) at 11:00 AM, LVN 7 stated she worked on (MONTH) 24, (YEAR) at the 11- 7 shift. LVN 7 stated she was just explaining to Resident 59 and Resident 203 why she was late giving them their medications and it was Resident 59 and Resident 203 who were mad at her. LVN 7 stated that she had plenty of residents who needed her help that was why she was late attending to Resident 59 and Resident 203. Review of the clinical record of Resident 59 indicated, she was admitted to the facility on (MONTH) 24, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 59's Minimum Data Set (MDS, a comprehensive resident clinical assessment) under section C0500 Brief interview for mental status (BIMS), indicated she had 14 out of 15 total score, which was considered oriented and coherent. A review of Resident 59's Physician Order, dated (MONTH) 1, (YEAR), indicated an order of [MEDICATION NAME] (pain medication) four (4) milligrams (unit dose) by mouth every four hours. A review of Resident 59's care plan, dated February, (YEAR) indicated, she has pain and discomfort because of chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] and that she needed her ordered pain medications to be given as ordered. A review of Resident 203's clinical record indicated she was admitted to the facility on (MONTH) 4, (YEAR) with diagnoses, which included chronic pai[DIAGNOSES REDACTED] and [MEDICAL CONDITION] arthritis (joint pains). A review of Resident 203's MDS, under section C0500, BIMS, indicated she had 13 out of a total score 15, which was considered oriented and coherent. A review of Resident 203's Physician order, dated (MONTH) 21, (YEAR), indicated an order of [MEDICATION NAME] (pain medication)10 325 milligrams (unit dose) one tablet by mouth every six hours as needed for pain. A review of Resident 203's care plan dated (MONTH) 23, (YEAR), indicated, she has pain and discomfort because of arthritis and one intervention is to give the pain medication as ordered. A review of the work schedule of LVN 7, entitled, Punch Detail, time period from (MONTH) 1, (YEAR) thru (MONTH) 31, (YEAR), indicated, LVN 7 worked (MONTH) 24, (YEAR), (MONTH) 30, (YEAR), and (MONTH) 31, (YEAR). The facility and procedure titled, Abuse Allegation Investigation, undated, indicated under content, .3. Interview staff members accused of alleged abuse, document findings, suspend staff members pending outcome of investigation . 2. During an observation of Resident 55, on (MONTH) 04, (YEAR), at 9:15 AM, Resident 55 was alert and oriented. Resident 55 was in bed, with a bible and magnifying glass on top of his over bed table. Resident 55 had above the left knee amputation, and a wheelchair on the side of the bed. Resident 55 was able to answer questions. He was alert, and oriented. A record review of Resident 55's medical records, on (MONTH) 04, (YEAR), at 10:00 AM, the facesheet (demographic medical information) indicated that Resident 55 was admitted on (MONTH) 24, 2012, with [DIAGNOSES REDACTED]. A review of Resident 55's medical records titled, History and Physical, dated (MONTH) 31, (YEAR), indicated This resident: 1. Has the capacity to understand and make decisions. A review of Resident 55's document titled, Quarterly Minimum Data Set, dated dated (MONTH) 4, (YEAR), indicated Section C Cognitive Patterns: BIMS (Brief Interview for Mental Status) Summary Score 14. During an interview with Resident 55, on (MONTH) 04, (YEAR), at 9:15 AM, Resident 55 stated he had a recent incident that bothered him, and kept thinking about the incidents. The Administrator (ADM), Social Services Designee 2 (SSD 2), and the CNA 1 visited Resident 55 spoke to him in his room. The Resident 55 further stated the ADM stated, You are the problem here, not my staff. You should not do that to my staff. You read the bible and practice what you are reading. The Resident 55 stated: I felt so little. I felt that I am nothing in this world. I felt humiliated, I want to cry, but I just kept it in my chest. Resident 55 further stated the ADM spoke to him because of the incident two weeks ago and the most recent one with Certified Nursing Assistant (CNA 1). Resident 55 stated the first incident was two weeks ago during bathing, Resident 55 held CNA 1 wrists and yelled at her (CNA 1) that he still wanted more time for shower. Resident 55 said the second incident happened few days ago when Resident 55 called the CNA 1 snake like my sister. During an interview with the Licensed Vocational Nurse (LVN 1), on (MONTH) 4, (YEAR) at 3:55 PM, the LVN 1 was asked about Resident 55's behavior and he (LVN 1) stated, The resident is very particular with his ADLs (Activities of Daily Living), but a very nice guy and very religious. During a follow up interview with Resident 55, on (MONTH) 4, (YEAR), at 4:02 PM, he stated, I feel humiliated and I feel offended. The words that she (Administrator) said keeps running to my head. She (Administrator) said 'You should read the bible and practice what you read.' I felt that she tried to humiliate me in front of (name of the SSD 2) and (name of the CNA 1). Resident 55 further stated, I am not comfortable talking to her (Administrator) anymore. I am thinking of what she (Administrator) told me to read the bible and practice what I am reading. She (Administrator) was very tough in saying that. That is why if I feel that if she (Administrator) was walking in the hallway and I am in my wheelchair I would just turn my back and pretend to watch television and wishing that she will not come to my room. She (Administrator) is very firm and told me, If I would have been here years ago, I will kick you out. During an interview with the ADM, on (MONTH) 4, (YEAR) at 4:23 PM, the ADM was asked about the allegations of Resident 55, and she (ADM) did not confirmed the allegations. The ADM stated The CNA came to us (the ADM and the SSD 2) and then we went to his room to talk to him. And I cannot say those words to him. During an interview with the SSD 2, on (MONTH) 5, (YEAR), at 7:55 AM, the SSD 2 stated As what I remember, (name of the Administrator) said to him (Resident 55) 'this is not an acceptable behavior and that is not the way you talk to the staff that is providing care for you. The SSD 2 further stated the ADM is always firm in talking to people. During an interview with the CNA 1, on (MONTH) 5, (YEAR), at 8:30 AM, CNA 1 was asked if she (CNA 1) heard what the ADM told Resident 55, and she stated Yes. But I cannot remember it all, she said 'don't do that to my staff' and I cannot remember the rest. The CNA 1 further stated the ADM pointed out that Resident 55 should not do that again. During a concurrent interview with the SSD 1 and record review of Resident 55's medical records, on (MONTH) 5, (YEAR), at 9:30 AM, the SSD 1 stated the CNA 1 spoke to her (SSD 1) and was aware of the incident. The SSD 1 also stated I did not document it. I know that I must document it and must follow up. But I was not able to document it. There was no documented evidence that the incident in the shower room was documented in the SSD notes nor the nurses' notes, and it was not care planned. A review of facility's policy and procedures titled Policy: Abuse Allegation Investigation, indicated Purpose: To ensure that a complete and thorough investigation is conducted for all allegation of abuse . 2. Interview resident and document allegations. 3. Interview staff member (s) accused of alleged abuse; document findings, suspend staff member (s) pending outcome of investigation A review of facility policy and procedures titled Policy: Abuse & Mistreatment of [REDACTED]. Definitions: 2. Verbal Abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. A review of facility document titled Job Description: Administrator, dated (MONTH) 12, 2011, indicated Essential Duties and Responsibilities include the following: Assist residents and families with programs and document problem as needed following the Company's Concern Reporting Policy and Procedure; review and document appropriate investigation and follow up as needed .Communicates the facilities policies and procedures to employees, residents, family members, visitors, government agencies, etc. as necessary and ensure established policies and procedures are followed .Reviews resident complaints and grievances and make written reports of action taken in coordination with the Centers policies and procedures. An Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment or death to a resident) was called related to verbal abuse, on (MONTH) 5, (YEAR) at 8:05 AM, in the presence of the Administrator and the Director of Nursing. A corrective action plan was requested from the facility to lift the immediacy of the situation. The facility provided an acceptable corrective action plan. The Immediate Jeopardy (IJ) was abated on (MONTH) 7, (YEAR) at 12:42 PM, in the presence of the Regional Director of Operations and the Director of Nursing (DON) after review and verification of the elements submitted in the corrective action plan. The facility's corrective action plan stated as follows: - The involved residents were assessed and interviewed to ensure their safety and the involved staff were immediately refrained from interacting with residents. The Social Service Designee (SSD1) interviewed the three residents involved to provide emotional support. - Statement of Correction (S[NAME] 341) was completed and sent to California Department of Public Health (CDPH) and Ombudsman on (MONTH) 5, (YEAR). - SSD1, Admissions, and Marketing Director conducted resident interviews on (MONTH) 5, (YEAR) to check if any other residents had concerns regarding staff's behaviors towards them. No other residents were found affected by the action. - A one on one in-service was provided to the involved staff members regarding facility policy and Abuse Prevention and Abuse Allegation Reporting. The Administrator was counseled on abuse reporting and investigation time frames. - Effective immediately, the Director of Nursing will assume the position as Abuse Coordinator. -An in-service was initiated on (MONTH) 5, (YEAR) and concluded on (MONTH) 6, (YEAR) to all staff by Director of Nursing and designee regarding facility policy on Abuse Prevention and Abuse Allegation reporting. - The Director of Nursing and Interdisciplinary Team (IDT) reviewed the Concern Record regarding alleged incidents and appropriate resolutions were indicated. - The Regional Director of Operations evaluated the incident involving the Administrator for failure to follow facility policy in reporting allegations of abuse. The employee's infraction of facility policy led to discharge and was discussed (MONTH) 6, (YEAR). A notice to employee as a Change in Relationship was signed by both Regional Director of Operations and the employee. The final check was provided at the time of termination. EED pamphlets were provided and COBRA was discussed. - Any other employees who were not able to attend in-service on (MONTH) 5, (YEAR) and (MONTH) 6, (YEAR) will not be able to return to work until they have received an in-service by the Director of Staff Development (DSD) regarding facility policy on Abuse Prevention and Abuse Allegation.

Based on observation, interview and record review the facility failed to identify weight loss trends and implement interventions in a timely manner after the resident ' s weight loss became significant (a weight loss of more than 5 % in 1 month, 7.5 % in 3 months or 10 % in 6 months) for 1 of 18 sampled residents (Resident 1) in a universe of 88 residents. This deficient practice resulted in harm as evidenced by severe weight loss (36 lbs. (pounds) in 6 months from December 6, 2013 to July 2, 2014, 10 lbs. in 1 month from March 17, 2014 to April 9, 2014 and 21 lbs. in 3 months from April 9, 2014 to July 2, 2014) and a decline in activities of daily living (ADL) for Resident 1. Findings: On September 15, 2014, at 11:15 AM, Resident 1 was observed lying in bed. Resident 1 ' s [DEVICE] feeding (Gastrostomy tube, a tube inserted through a small incision in the abdomen into the stomach and is used for long-term nutrition) was turned off and resident did not verbally respond when greeted. During a concurrent interview with Licensed Vocation Nurse (LVN 1), she stated that Resident 1 was confused, incontinent of bowel/bladder, got up in the wheelchair as tolerated, and had a pressure ulcer to left heel. LVN 1 further stated that Resident 1 had no weight loss. On September 16, 2014 a review of Resident 1's Electronic Medical Record (EMR) indicated that Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On September 16, 2014 at 10:50 AM, during an observation of Resident 1 ' s wound care treatment by the wound care nurse, a maroon colored localized area with a blister was noted to Resident 1 ' s left heel. On September 16, 2014 a review of Resident 1's Minimum Data Set (MDS-resident assessment) was conducted and noted to be coded as follows: Annual MDS assessment dated [DATE] indicated: a) Eating-Independent eater, setup help only-Weight 149 lbs. b) Dressing-Extensive assistance, one person physical assist c) Functional limitation in Range of Motion (ROM)-Upper extremities with no impairment, lower extremities with impairment on both sides Quarterly MDS assessment dated [DATE] indicated: a) Eating-Limited assistance with one person physical assist-Weight 137 lbs. Significant Change in Condition assessment dated [DATE] indicated: a) Eating-Total Dependence, one person physical assist-Weight 116 lbs. On September 15, 2014, a concurrent review of physician's history and physical, dated August 27, 2014, indicated that Resident 1 could make needs known, but not make decisions. On September 16, 2014 at 1:30 PM, during a meal observation, Resident 1 was observed in bed and had consumed 0% of the lunch meal and approximately 8 ozs water. On September 16, 2014 at 3:25 PM, a review of Resident 1's weights from January 7, 2014 through July 16, 2014 in the (EMR) was conducted, and indicated that Resident 1 had a Severe unplanned weight loss greater than 5% within 1 month (May 7, 2014 to June 9, 2014-9 lbs.), greater than 7.5 % in 3 months (March 10, 2014 to June 10, 2014 -22 lbs.) and greater than 10 % in 6 months (January 7, 2014 to July 2, 2014-32 lbs.) as follows: a) December 6, 2013-150 lbs. b) January 7, 2014 -148 lbs. - Down 2 lbs. c) February 7, 2014-146 lbs. - Down 2 lbs. d) March 10, 2014-147 lbs. - Down 1 lb. e) March 17, 2014-144 lbs. - Down 3 lbs. f) March 26, 2014-141 lbs. - Down 3 lbs. g) April 2, 2014-138 lbs. - Down 3 lbs. h) April 9, 2014-137 lbs. - Down 1 lb. i) April 16, 2014-134 lbs. - Down 3 lbs. j) May 7, 2014-134 lbs. - 0 Change k) June 9, 2014-125 lbs. - Down 9 lbs. l) June 24, 2014-123 lbs. - Down 2 lbs. m) June 25, 2014-122 lbs. - Down 1 lb. n) July 2, 2014-116 lbs. - Down 6 lbs. On September 17, 2014 a review of the EMR and the clinical record for Resident 1 was conducted with the Licensed Vocational Nurse/Minimum Data Set Nurse (LVN/MDS) and findings were as follows: A review of the Nutrition Care Plan, dated October 14, 2013 indicated Nutritional Risks related to DM, Hypertension, Dementia, Depression, history of weight loss and declining to wear dentures. Resident 1 ' s goals included " will show no sign or evidence of weight loss of more than 10% in the next 90 days " . Interventions/Approach Plans included diet as ordered, monitor and record weights, report weight changes as: 5 lbs. +/- every week, 5% in 1 month: 7.5 % in 3 months and more than 10% in 6 months, report to Medical Doctor (MD) and Registered Dietician (RD) to re-evaluate. A review of the the Nutrition Care Plan was signed as reviewed quarterly and not updated when weight loss changes occurred for Resident 1 of greater than 5% in 1 month, greater than 7.5 % in 3 months and greater than 10 % in 6 months from January 7, 2014 to July 2, 2014. A review of the Dietary Notes documented by the Dietary Services Supervisor (DSS), dated January 13, 2014, documented that Resident 1 was alert and weighed 148 lbs. Resident had upper and lower dentures and had no chewing or swallowing problems. Diet, mechanical chopped, No Concentrated Sweets (NCS), No Added Salt (NAS), with 4 oz house nourishment with meals and a bedtime snack of a meat sandwich. A review of the Physicians History and Physical, dated March 13, 2014 indicated that Resident 1 was admitted to a General Acute Care Hospital (GACH) on March 13, 2104 for evaluation of worsening [MEDICAL CONDITION] and appearance of gangrene (open sores and wounds with dead tissue) . Resident 1 was readmitted to the facility from GACH on March 15, 2014 with [DIAGNOSES REDACTED]. A review of the General Nurses Notes, dated March 18, 2014, noted that Resident 1 had increased somnolence (drowsy) and poor PO intake and ate 50% of dinner meal and drank only fluids only for that date. A review of the General Nurses Notes, dated March 19, 2014 at 4:35 PM indicated that Resident 1 was observed to have difficulty swallowing. Resident 1 was noted to gag while attempting to swallow and had an episode of emesis (vomiting) during lunch. Snacks between meals with poor intake. MD aware, Speech Therapy (ST) evaluation ordered. A review of the Dietary Notes, documented by the Registered Dietician (RD 1), dated March 19, 2014, noted that Resident 1 weighed 144 lbs., with documented PO intake of 70% of meals for the last week with recommendations implemented that included: a) Consider beginning Pro-Stat 64 (protein drink), 1 oz. (ounce) BID (twice daily) for wound healing b) Consider beginning [MEDICATION NAME] (organisms that provide health benefits) supplement due to antibiotic use c) Consider beginning supplementations of iron d) Will continue to observe weights, labs, changes and follow up as needed. The next RD consultation for Client 1 was on June 10, 2014 A review of the General Nurses Notes, dated March 20, 2014 at 1:59 AM indicated that Resident 1 continued to be monitored related to decrease in PO intake and refused bedtime snack. A review of the Speech Therapy (ST) evaluation, dated March 20, 2014, with recommendations that included, diet change to puree with thin liquids, supervision and assistance with feeding all meals/snacks and strict use of aspiration precautions (prevent breathing in liquid or food). A review of the physician's orders [REDACTED]. Diet changed to puree fortified NCS, NAS diet (smooth soft diet with added nutrients and no added salt and no added sweet. A review of physician's progress Notes dated March 20, 2014, noted, "Per staff not eating well" with recommendations for bilateral (both) toe ulcers - follow up with vascular, continue wound care. A review of the Nutrition Care Plan, noted that there was no update of the recommendations from ST, with interventions and diet change for Resident 1. A review of the General Nurses Notes, dated March 23, 2014, at 4:08 PM noted that resident 1 had lost 3 lbs. within one week from 144 -141 lbs. Resident consumed 30 % of her meals and 360 ml (milliliters) fluid. MD notified, awaiting reply. A review of the General Nurses Notes dated March 28, 2014, at 4:06 PM noted MD 1 aware of discoloration to left 4th toe, no new orders (requests). A review of the General Nurses Notes dated March 31, 2014, at 10:16 AM noted resident 1"s weight 140 lbs. Noted 1 lb. weight loss in 7 days. Diet recently changed to fortified puree diet, now on dependent feeding program (rely on others for feeding). MD aware, no new orders. A review of the General Nurses Notes dated March 31, 2014 at 7:47 PM noted Resident 1 had emesis X 1, ate 40% dinner, 50% of water. A review of the General Nurses notes dated April 2, 2014, noted that resident 1 lost 7 lbs. since readmission on March 15, 2014 (18 days). Resident consumed 40 % meals, 35 % fluid, nourishment offered but refused. No changes to nutrition plan noted. There was no documentation in the clinical record or EMR that the Nutrition Care Plan was updated with a weight change or that the Registered Dietician or Physician was notified of Resident 1's 7 lb. weight loss in 18 days. A review of a Radiology Report, dated April 3, 2014 indicated "Potential osteo[DIAGNOSES REDACTED] (infection in the bone) of big toes bilaterally" . A progression of the infection of Resident 1's diabetic ulcers to the toes from March 13, 2014. Orders from MD 1 for [MEDICATION NAME] (antibiotic) 300 mg po q 12 hours x 14 days. A review of the Dietary Notes, dated April 14, 2014, documented by the Dietary Services Supervisor (DSS), noted that Resident 1 had an 11 lb. weight loss from January 2014 to April 2014 (3 months). Will continue to monitor weight and PO intake per facility protocol and have RD consulted as warranted. There was no documentation to show that the RD had been notified, that the Nutrition Care Plan had been updated with interventions to address Resident 1's 11 lb. weight loss in 3 months. A review of the physician progress notes [REDACTED]. A review of Dietary Notes documented by the DSS, dated June 2, 2014, noted, weight for May 2014 was 134 lbs., current weight 125 lbs. (9 lb. weight loss in 1 month), with average intake noted to be 40-50 % consumed. Resident tolerating the new diet change, no issues with swallowing at this time. Will continue to monitor weight and PO intake per facility protocol and have RD consult as warranted. No further interventions indicated. There was no documentation that the DSS had notified the RD with the severe weight loss. The Nutrition Care Plan was not updated or that an Inter Disciplinary Team (IDT-a group of healthcare professionals who meet to discuss ongoing resident healthcare issues and concerns) meeting had occurred to address Resident 1's 9 lb. weight loss in one month. A review of the General Nurses Notes, dated June 4, 2014 at 3:53 PM, noted that Resident 1 was not verbally responsive and continued to be resistive to eating and drinking. Resident 1 had no urinary output since night shift. MD 1 notified, orders received for intravenous fluids (fluids through the vein) at a rate or 50 cc/hour x 2 days, labs, Foley catheter (tube in the bladder to drain urine) and needs Percutaneous Endoscopic Gastrostomy (PEG-Feeding tube). A review of the physician progress notes [REDACTED]. Action Plan-1. Poor PO intake, needs PEG, 2. Poor hydration (poor intake of fluids), check BMP (basic metabolic panel-lab test to assess level of hydration), 3-ALOC-secondary to dementia and [MEDICAL CONDITION], responds well to daughter " . Consultation for PEG did not take place until July 2, 2014. A review of the General Nurses Notes, dated June 5, 2014 at 10:54 PM, noted that the intravenous access was dislodged and Resident 1 refused another. MD 1 was notified, with no new orders. Resident 1 had received less than the 2 days of intravenous fluids ordered by the physician to treat Resident 1 ' s dehydration (loss of more fluid than is taken in). A review of the General Nurses Notes, dated June 7, 2014, noted a 9 lb. weight loss in 1 month, ate 0% of dinner and nourishment. A review of the General Nurses Notes, dated June 10, 2014 at 4:32 PM at 1:04 AM, noted that Resident 1 reportedly consumed 0% of breakfast, 240 cc fluids and 10 % of lunch. 250 cc yellow urinary output via Foley catheter. MD 1 made aware of residents intake and output x 24 hours, decreased urinary outpu and decreased oral intake of fluids, no new orders. A review of the first Weight Variance Committee meeting notes that was dated June 10, 2014 at 2:52 PM was reviewed for Resident 1. The average meal intake for breakfast, lunch, dinner and dietary nourishments was between 50-75%, 9 lb. weight loss X 30 days with known or suspected cause of the current trend listing, skin ulcer to left 1st toe, current UTI, decreased PO intake and dementia. Recommendations included continuing all interventions in place. MD notified June 10, 2014. Resident placed on [MEDICATION NAME] TID (an appetite stimulant) on June 11, 2014. A review of the Dietary Notes documented by the RD, dated June 10, 2014 at 6:08 PM noted progressive and severe unplanned 1, 3 and 6 month weight losses with 6.7%/month loss, 15%/3 month loss and 16.7 %/ 6 month loss. Abnormal nutritional labs potentially related to wound. Poor nutritional quality of life related to therapeutic diet restrictions and advanced age as evidenced by salt and sugar restrictions and [AGE] year old liberalize to offer increased calories and food variety and taste. R great toe wound progressing. RD recommendations and implemented as follows: a) Weekly weights X 4 b) Check Serum iron [MEDICAL CONDITION] marker (not ordered by physician) c) Discontinue previous diet order, change to Liquefied Puree texture, fortified diet d) Ice cream TID with meals e) Discontinue sandwich between meal, resident preference and not of tolerated texture f) 8 oz juice TID (3 times daily) with and between meals A review of Physician's Progress Notes dated June 11, 2014 noted a GI (gastrointestinal consult) for PEG placement due to decreased PO intake/weight loss. A review of the General Nurses Notes, dated June 12, 2014 at 1:48 PM, noted, physician notified of Resident 1's poor intake and received orders for 6 X/day small meals. A review of the General Nurses Notes, dated June 13, 2013 at 10:44 AM, noted that Resident 1 refused breakfast and refused medications for the morning. MD aware, no new orders. A review of the Weight Variance Committee, dated July 2, 2014 at 4:06 PM noted 50-75% average meal intake, 7 lb. weight loss X 1 week with current interventions listed as Fortified diet, Multivitamins, Vitamin C, Iron and [MEDICATION NAME]. On June 19, 2014 ice cream to meals TID added, 8 oz juice between meals (RD recommendations dated June 10, 2014). [DEVICE] pending date. A review of the General Nurses Notes, dated June 19 2014 at 3:41 PM, noted that dietary recommendations made by the RD were received and reviewed by MD 1,. 9 days after the RD consulted and made recommendations on June 10, 2014. A review of the General Nurses Notes, dated June 20, 2014, noted Resident refused dinner and in between meal stating that she was not hungry, had already eaten. Resident 1 also refused medication for the entire shift. MD notified with no new orders. A review of the Physician's Progress Notes, dated June 30, 2014, noted that Resident 1 was eating and sleeping well. A review of the General Nurses Notes, dated July 1, 2014, noted a 6 lb. weight loss in 1 week from 122 lbs. to 116 lbs. Resident continues to refuse multiple meals as well as medications. MD aware of resident ' s refusal and upcoming appointment for possible Gastrostomy Tube ([DEVICE]) placement. A review of the General Nurses Notes, dated July 2, 2014 noted that Resident 1 on monitoring related to 6 lb. weight loss from 122-116 lbs. resident assisted in eating dinner and consumed 50 % of meal and drank 240 cc liquid. A review of the Physician ' s Progress Notes, dated July 7, 2014 noted dental screening complete for upper and lower dentures (false teeth). A review of the General Nurses Notes, dated July 10, 2014 at 3:05 PM noted [DEVICE] placement, call placed to RD and made aware of recommendations pending. A review of the Dietary Notes by RD, noted to be completed remotely on July 10, 2014 at 5:50 PM with recommendations to initiate [DEVICE] nutrition feeding. On September 17, 2014 at 10:30 AM, an interview was conducted with the LVN/MDS during concurrent record review for Resident 1. When asked how the RD was notified of a significant weight loss, LVN/MDS stated, " If there is a weight loss of 3 lbs. in 1 week or 5 lbs. in 1 month, the RD is notified " . The LVN/MDS during concurrent record review confirmed that the RD was not consulted for Resident 1 when a 7 lb. weight loss was identified on April 2, 2014 (18 days after readmission to the facility), a Nutrition Care Plan was not updated and an IDT meeting did not take place at the time weight loss was noted per facility policy and procedure for Resident 1 ' s significant weight loss of greater than 5% in 1 month, 7.5% in 3 months and greater than 10 % in 6 months. The LVN/MDS further stated that the facility had recognized through the Quality Assurance (QA) process, that there needed to be a plan with the dietician in place to follow up with residents who had been identified as having significant weight loss. On September 17, 2014 an interview was conducted with the Administrator in Training (AIT) and the Director of Nursing (DON). The DON stated that the dietician visited the facility weekly and received a report of monthly weights, residents on [MEDICAL TREATMENT] (a mechanical process to filter waste from the blood due to kidney failure) and residents with wounds. The RD prioritized residents that needed to be seen and before the RD left the facility, recommendations are discussed. Sometimes the RD did rounds late, and then a written report with recommendations would be left for review. RD Recommendations were usually delegated to either the charge nurse, the Registered Nurse Supervisor and on occasion the DON to notify the physician. The DON further stated that an RD consultation per facility Policy and Procedure was warranted for Resident 1, and could offer no explanation as to why the RD was not consulted, other than that the facility had identified a concern related to the importance of the RD involvement in the overall nutritional health of the residents. When asked, the DON stated that the RD did not attend any weight variance committee meetings, weekly or monthly. The DON and the AIT gave no verbal response when asked why RD recommendations dated June 10, 2014 were not addressed by the facility or the physician was not notified until June 19, 2014 (9 days later). On September 17, 2014 at 3:30 PM, during an interview with the DSS, when asked if the RD was consulted after the DSS had noted an 11 lb. weight loss in 3 months on April 14, 2014, and a 9 lb. weight loss in one month on June 2, 2014, the DSS stated, " I think so " , but was unable to show documentation that the RD was notified. On September 17, 2014 at 3:50 PM, during an interview with the RD, the RD stated that she had been trained to vary hours and visited the facility once per week, 30 hours/month and any overtime per approval from the facility administrator. When asked if there was enough time during facility visits to complete all the recommended referrals from the facility, she stated, " With input from facility reports and staff, I prioritize cases and try to address the most pressing ones first. When I exit, I notify the facility of anything that still needs to be addressed " . The RD was asked if she had been notified regarding Resident 1's severe weight loss of 9 lbs. from June 10 2014, through July 2, 2014 or during progressive weight loss from March 19, 2014 through June 10, 2014. The RD was unable to show any documentation that she had been notified or that any recommendations were made by the RD during facility visits regarding Resident 1, other than those documented on March 19, 2014 and June 10, 2014. On September 22, 2014, a review of "Registered Dietician Resident Review Summary" , noted facility visits by the RD in 2014 as follows (the amount of time spent during each visit was not available for review): January-No RD reviews documented February-1 visit by RD March-4 visits by RD - (Recommendations for Resident 1 noted on March 19, 2014) April-3 visits by RD May-4 RD visits June-3 RD visits - (Recommendations for Resident 1, noted on June 10, 2014) July-4 RD visits A review of the RD consultant billing statements was conducted and indicated billing for 32 hours of service for the months of April, May, June 2014 and 27.25 hours for July 2014 which indicated that facility visits by the RD were conducted on an irregular basis, which had the potential to affect the ongoing assessment, treatment and monitoring of residents with nutritional concerns in the facility. On September 22, 2014, a review of Meals and Snack Roster for Resident 1 was conducted. It noted the following: 1. Snacks when offered between meals, were frequently refused by Resident 1 2. March 2014, Resident 1 refused to eat or frequently ate less than 60 percent of meals (27 of 87 meals served). 3. April 2014, Resident 1 refused to eat or ate less than 60 percent of the following meals (26 of 89 meals) 4. May 2014; Resident 1 refused to eat or ate less than 60 percent of the following meals (26 of 89 meals) 5. June 2014, Resident 1 refused to eat or ate less than 60 percent of the following meals (62 of 90). 6. July 2014, Resident 1 refused to eat or ate less than 60 percent of the following meals (20 of 27) A review of the facility's policy and procedure titled " Weight Assessment and Intervention " , dated January 22, 2013, indicated: " 3. Any weight change of 5 % or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the physician and the dietician. Notification must be recorded in the medical record. " " 4. The dietician will respond within 72 hours of receipt of the notification. " 5. The Dietician will review the weight records by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the Inter Disciplinary Team whether or not the criteria for " significant " weight change has been met " . A review of facility Policy and Procedure titled, " Weight Variance Committee / Weight Monitoring " , dated January 21, 2013 indicated: " Procedure: " " 3. When significant weight change is identified, the physician and the resident ' s responsible party will be notified by nursing staff. Referrals will be made to the weight variance committee and the dietitian. Care plans will be developed and implemented to address the weight change. " " 13. The consultant dietician will review progress of residents on the weight variance program and make further recommendations as necessary " . The facility's failure to intervene and maintain acceptable parameters of nutrition for Resident 1 and notify the dietician and the physician per facility policy and procedure of such changes, resulted in: 1. A severe progressive weight loss (Poor oral food and fluid intake, inability to consume meals provided, development and worsening of diabetic skin ulcers and wounds, osteo[DIAGNOSES REDACTED], urinary tract infection [MEDICAL CONDITION] and failure to notify the physician) as evidenced by: 1. No IDT meeting held timely to address progressive weight loss 2. No timely and effective interventions especially from April 2014 with failure to notify MD and implement RD recommendations for 9 days after they were written by the RD on June 10, 2014. 3. Care plan was not updated so that all staff knew the interventions