Every finding on record at Modoc Medical Center D/P SNF

Based on interview and record review the facility failed to ensure there was a Licensed Nurse (LN) in the facility to provide care for 14 out of 14 residents when LN A left the facility for a lunch break. This had the potential to impact resident health status and could have caused a decline in psychosocial well-being. Findings:A review of the Facility Assessment Tool, dated 11/10/25, indicated the facility would staff two LNs on the night shift.A review of the undated Staffing Ratio for Revamping [changing or redoing] up Staffing, indicated, when the facility census (how many residents were in the facility) was less than 30, there would be one LN working the night shift.During an interview on 1/13/26 at 12:19 pm, Certified Nurse Assistant (CNA) B stated, one night, LN A went outside for a smoke break, and she drove away and was gone for an hour. CNA B confirmed, there was no LN in the facility or on the facility grounds while LN A was gone and stated, it was me and another CNA. CNA B stated a resident that was awake [Resident 1] was upset that the nurse left the facility.During an interview on 1/13/26 at 1:12 pm, Resident 1 confirmed, LN A had left the facility one night and stated, the nurse said she was going on break and didn't come back for a long time, maybe an hour. We waited a long time for her to come back and we notified [the Nurse Manager, NM].During an interview on 1/13/26 at 2:25 pm, NM confirmed, CNA B had called NM in the evening on 12/5/25 due to LN A leaving the facility.During a concurrent interview and record review on 1/13/26 at 2:25 pm, with Director of Nursing (DON), security camera video footage, dated 12/5/25 was reviewed. DON indicated that the review of the security camera footage showed LN A sitting in their car for approximately 15 minutes prior to leaving the facility grounds. DON stated, LN A was out of the building for approximately one hour. DON confirmed that LN A had driven away from the facility approximately 11:10 pm or 11:15 pm and returned approximately 40 to 45 minutes later. DON confirmed, there was no LN in the facility for the time LN A was gone.During an interview on 1/13/26 at 4:33 pm, LN A stated, I left to go get food. LN A confirmed that LN A was the only LN working on the evening of 12/5/25 and stated, a few times [in the past], a nurse just showed up to give me a lunch break, and I'm use to just leaving. I didn't think about being the only nurse. I'm used to having another nurse there. I didn't think, I guess I didn't realize at the time, reporting off [providing resident specific details about their care to another LN] to the CNAs left the facility without a nurse.

Based on interview and record review the facility failed to ensure that medication was stored securely when Licensed Nurse (LN) A left the medication keys at the nurse's station during a lunch break. This failure caused medication to be accessible to facility staff and residents and had the potential to cause a decline in resident health status. A review of the facility's policy and procedure (P&P) titled, Medication Cart, revised 8/1/24, indicated, the Pharmacists and LN would have access to the medication cart. The P&P indicated, If a nurse leaves the floor for any reason, they must turn over the keys to the cart to another nurse. During an interview on 1/14/26 at 11:41 am, Nurse Manager (NM) stated, I heard she [LN A] left one night for her lunch break and threw her medication keys on the counter at the nurse's station. One of the Certified Nurse Assistant's (CNA) called me. During an interview on 1/14/26 at 12:19 pm, CNA B confirmed that LN A had left the facility for a lunch break and left the medication keys unsecured at the nurse's station and Resident 1 had witnessed it. CNA B stated, Resident 1 was awake and knew the nurse left. During an interview on 1/14/26 at 1:12 pm, Resident 1 confirmed being present when LN A placed the medication keys at the nurses' stations and left the facility for a lunch break. Resident 1 stated, She left her med keys, I think, at the nurses station. During an interview on 1/14/26 at 2:24 pm, Director of Nursing (DON) confirmed, when the LN left the facility for a lunch break, they would hand over their medication keys to another LN. DON confirmed, on 12/5/25, LN A left the facility for a lunch break, placed the medication keys at the nurse's station, and the keys were available for anyone to use. During an interview on 1/14/26 at 4:33 pm, LN A confirmed leaving the medication keys in an unlocked area and LN A stated, I left to get food. I told the CNAs I was going to lunch, and put my keys in a drawer at the nurse's station. LN A confirmed that two CNAs and Resident 1 were present at the time LN A placed the medication keys in the unlocked drawer at the nurse's station.

Based on observation, interview, and record review, the facility failed to follow their visitation policy and procedure (P&P) for one out of three sampled residents (Resident 1) when Resident 1 was denied (not allowed) visitors of his choosing, the facility did not notify Resident 1 that his friend (Visitor) had been denied visits, there was no documentation present in the medical record, and rules and regulations regarding visitors were not posted for the public and residents to review. This failure violated Resident 1's right to receive visitors of his choosing and had the potential to cause psychosocial harm. Findings: A review of the facility's P&P titled, Visitation, Acute Hospital/SNF, revised 12/1/19, indicated, residents had the right to visitors of their choosing if they had the ability to make their own decisions. The P&P indicated, A visitor may also be prohibited [not allowed] if in the clinical judgement of the healthcare team, a visitor would negatively impact the health or safety of the patient, facility's staff, or other visitor at the facility. The P&P indicated, In all cases, where visitation is denied, the reasons will be clearly communicated to the patient and also documented in the medical record. The P&P indicated, visiting hours, rules, and regulations would be posted (displayed in a place that could be seen). A review of the Patient Information form, dated 12/14/22, indicated, Resident 1 was admitted to the facility on [DATE]. A review of the History and Physical, dated, 3/18/25, indicated, Resident 1 had diagnoses of history of CVA (stroke, loss of blood flow to part of the brain) and atrial fibrillation with RVR (irregular heart rhythm). A review of the Admissions Minimum Data Set (MDS, a resident assessment tool), dated 3/11/25, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed and Resident 1's BIMS score was 14 out of 15 (indicating good memory). A review of the Quarterly MDS, dated [DATE], indicated Resident 1 had a BIMs score of 15 out of 15. During an interview on 6/10/25 at 9:05 am, Visitor stated, [Risk Management, RM] told me, I was to never set foot on the property again and if I do, they will call the Sheriff. Visitor stated, I visit [Resident 1] every Monday, bring him items that he requests, and now I can't go see him. During a concurrent interview and record review on 6/11/25 at 11:18 am, Resident 1 was observed sitting up in bed and smiling. When Visitor's name was mentioned, Resident 1's facial features softened, and his smile widened. Resident 1 stated, [Visitor] visits me every Monday and hasn't been here this week. Resident 1 confirmed, facility staff had not informed him that Visitor was not allowed to enter the facility or visit with him. Resident 1's smile turned into an angry frown, his face scrunched up, and his face began to turn red. Resident 1's voice became loud and stated, I want [Visitor] to visit and I'm not happy that [Visitor] was told she couldn't visit. During an interview on 6/11/25 at 11:45 am, RM stated, I talked to [Visitor] on 6/4/25, she came in and insisted that staff video tape [Resident 1]. I told her she could not record without express permission. I trespassed her for 30 days (a 30-day trespass was an order issued by the Sheriff's department to a person who has threatened to or has caused physical harm. The trespass makes it illegal for that person to enter the facility for 30 days) due to being aggressive. RM stated, I made the decision based on concerns of resident and staff safety. During a concurrent interview and record review on 6/11/25 at 12:10 pm, an untitled document, written by Licensed Nurse (LN) A, dated 6/4/25 was reviewed with RM. RM confirmed, the document indicated, it was written by LN A due to Visitor requesting LN A being present while Visitor videotaped Resident 1 and LN A felt uncomfortable with the request. RM confirmed, the document did not indicate Resident 1's Visitor had been physically or verbally aggressive to residents or staff. RM confirmed, RM did not speak to Resident 1 regarding the incident or notify Resident 1 that Visitor was not permitted in the building or allowed to visit. RM confirmed, RM had not documented the incident or decision to perform a 30-day trespass on Visitor and confirmed, the facility's P&P regarding visitation had not been followed. RM confirmed, verbally informing Visitor there was a 30-day trespass against Visitor and Visitor was not allowed in the facility. A review of the Patient Information form, dated 5/6/25, indicated, Resident 2 was admitted to the facility on [DATE]. A review of the History and Physical, dated, 5/6/25, indicated, Resident 2 had diagnoses of hypertension (high blood pressure) and depression (a sad mood). A review of the admission MDS, dated [DATE], indicated Resident 2 had a BIMs score of 11 out of 15 (memory was mildly impaired). During an interview on 6/11/25 at 12:20 pm, Resident 2 (Resident 1's roommate) confirmed, Visitor did not make Resident 2 feel unsafe and stated, she doesn't bother me. During an interview on 6/11/25 at 12:25 pm, Certified Nurse Assistant (CNA) B confirmed being familiar with Resident 1 and Visitor. CNA B stated, I've never had any issues with [Visitor] regarding safety for [Resident 1] or staff. During a concurrent observation, interview, and record review on 6/11/25 at 12:27 pm, with Director of Nursing (DON), the entrance of the facility was observed and two information boards (the information boards contained various notices displayed for visitors, staff, and residents to review, such as resident rights and policies and procedures regarding facility rules and regulations) were inspected. DON confirmed, there was no information posted at the entrance of the facility or on the information boards, regarding visitor hours, rules, or regulations. Observed on the information board was an undated document titled, Resident Rights. DON confirmed, the document indicated, residents had the right to visits and reasonable restriction to visit with the resident's permission.

Based on interview and record review the facility failed to ensure bedframes were maintained for resident safety when the Medical Equipment Management Plan and manufacture recommendations were not followed for one of four sampled residents (Resident 1), when the footboard fell off of Resident 1's bed. This had the potential to subject all residents to injury from equipment that the facility had not regularly inspected and maintained for the safe use by residents. Findings: A review of the facility's policies and procedures (P&P) titled, Equipment Management Program, revised 3/1/18, indicated, electronically operated patient beds would be included in the Equipment Management Program. A review of the facility's P&P titled, Preventative Maintenance, revised 3/1/23, indicated, the facility maintained a comprehensive Preventative Maintenance Program for all equipment that included scheduled maintenance and documentation of maintenance. A review of the Medical Equipment Management Plan, dated 1/1/11, indicated, the purpose of the plan was to ensure medical equipment supported safe patient care through maintenance and repair of the equipment. The Medical Equipment Management Plan, indicated, maintenance would be provided based on manufacturer recommendations and work orders would be used for planned maintenance and documentation of maintenance that was performed. A review of the Patient Information form, dated 12/14/22, indicated, Resident 1 was admitted to the facility on [DATE]. A review of the History and Physical, dated, 3/18/25, indicated, Resident 1 had diagnoses of history of CVA (stroke, loss of blood flow to part of the brain) and atrial fibrillation with RVR (irregular heart rhythm). A review of the Quarterly Minimum Data Set (MDS, a resident assessment tool), dated 6/9/25, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed and Resident 1's BIMS score was 15 out of 15 (indicating intact memory). During an interview on 6/11/25 at 11:13 am, Maintenance Lead (ML), stated, Bedframes were inspected on a quarterly basis (every three months). During an interview on 6/11/25, at 11:18 am, Resident 1 stated, the footboard to my bed broke off. Resident 1 was not able to verbalize when it had happened. During a concurrent interview and record review on 6/11/25 at 12:02 PM, with ML, Manufacture Recommendations, dated 1/1/23 was reviewed. ML confirmed, the Manufacturer Recommendations indicated, facility staff should thoroughly and visually inspect the bedframe monthly. ML provided an undated document titled, Headboard/Footboard Safety Weekly Checklist (weekly checklist) ML stated, this [weekly checklist] was created after [Resident 1's] footboard broke. ML confirmed, the weekly checklist was blank and stated, the weekly checklist form has not gone into effect. ML confirmed, there was no documentation present that indicated resident bedframes had been inspected for safety. During a concurrent interview and record review on 6/11/25 at 1:15 pm, ML reviewed work orders from 9/1/24 through 6/11/25 and stated, I don't remember when the footboard broke. ML confirmed, there was no work order that indicated Resident 1's footboard had broken or had been repaired and stated, there should be.

Based on observation, interview and record review, the facility failed to meet this requirement when an expired food product was stored in the refrigerator and available for serving to residents. This had the potential to result in foodborne illness and poor food palatability (flavor, freshness). Findings Review of the facility's policy titled, Food Storage Policy and Procedure dated 2005 indicated, All food should be labeled and dated, and Refrigerated food should be stored upon delivery and careful rotation procedures should be followed. On [DATE] at 12:00 PM, a 15-ounce spray can of Redi Whip whipped topping was observed in the facility's foodservice refrigerator, with a use by date of [DATE] written per the facility's policy. It was observed that the product was nearly two months beyond this use-by date. In a concurrent interview on [DATE] at 12:00 PM, Dietary Manager (DM) confirmed that the whipped topping, Should have been thrown away. DM was observed disposing of the item.

Based on observation, interview, and record review, the facility failed to follow infection control standards for 4 out of 5 residents (Resident 1, Resident 28, Resident 19, and Resident 29) during medication pass when staff did not disinfect medical equipment and when medication containers where brought into residents' rooms and handled by the residents. This had the potential to spread a communicable disease and cause cross-contamination. Findings: The facility's policy titled, Cleaning of Non-Critical Patient Care Equipment, dated 05/2017, indicated the purpose of this policy is to provide guidance on cleaning and disinfection of non-critical, patient care equipment. It is the policy for patient care equipment to be cleaned and disinfected to prevent the potential spread of infection and cross-contamination. The facility's policy titled, Medication Preparation and Administration, revised 2010, indicated this policy is to ensure the most complete and accurate implementation of a physician's medication orders and to optimize drug therapy by administering drugs in an accurate, safe, timely and sanitary manner. A review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include dementia (impairment of memory, thinking and social abilities), hypertension (pressure in your blood vessels is too high), and renal insufficiency (poor function of the kidneys). Review of the most recent Minimum Data Set (MDS, a resident assessment tool), for Resident 1 dated 2/28/25, indicated that Resident 1 had a moderate cognitive deficit, with a brief interview for mental status (BIMS) score of 8 out of 15. During an observation on 4/16/25 at 7:11 am, Licensed Vocational Nurse (LVN) 1 took the blood pressure of Resident 1. Once finished, LVN 1 then placed the blood pressure cuff on the cart without disinfecting the cuff or the cart. A review of Resident 28's record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that include diabetes mellitus (high concentration of sugar in the blood), hyperlipidemia (high concentration of fat in the blood), anxiety, and depression. Review of the most recent MDS, for Resident 28 dated 2/04/25, indicated that Resident 28 had no cognitive deficit, with a BIMS score of 13 out of 15. During an observation on 4/16/25 at 8:03 am, LVN 1 took a medication in the manufacturer's box into the room of Resident 28. The medication box was placed on the bedside table without a barrier. The resident then handled the box. After the medication was administered, LVN 1 put the medication box back into the cart drawer with other boxed medications. During an interview with LVN 1 on 4/16/25 at 11:15 am, LVN 1 confirmed that the blood pressure cuff should have been wiped with a disinfectant wipe, the box for the medication should not have been placed on a bedside table, and the resident should not have touched the medication box. LVN 1 stated, I could have transferred whatever one of the resident may have to another resident. This would be an infection control issue. A review of Resident 19's record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that include mild cognitive disorder (the stage between typical thinking skills and dementia), hypertension (pressure in your blood vessels is too high), seizure disorder (when the flow of electrical signals in the brain are disrupted), and psychotic disorder (mental health illnesses that affect the mind where there has been some loss of contact with reality). Review of the most recent MDS for Resident 19 dated 3/14/25, indicated that Resident 19 had no cognitive deficit, with a BIMS score of 15 out of 15. A review of Resident 29's record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that include hypertension (pressure in your blood vessels is too high), and anemia (blood disorder where the blood has a reduced ability to carry oxygen). Review of the most recent MDS for Resident 29 dated 2/07/25, indicated that Resident 29 had no cognitive deficit, with a BIMS score of 15 out of 15. During an observation on 4/16/25 at 8:23 am, LVN 2 took the blood pressure of Resident 19. At 8:55 am LVN 2 used the blood pressure cuff on Resident 29 without disinfecting the blood pressure cuff in-between the two residents. During an observation on 4/16/25 at 8:23 am, LVN 2 took a medication in the manufacturer's box to Resident 19 who was sitting at a table. The medication box was placed on the table without a barrier. The resident then handled the box. After the medication was administered, LVN 2 put the medication box back into the cart drawer with other boxed medications. During an interview with LVN 2 on 4/16/25 at 11:23 am, LVN 2 confirmed that the blood pressure cuff needed to be wiped down between residents with disinfectant wipes, the box for the medication should not have been placed on a table, and the resident should not have touched the medication box. LVN 2 stated, This is because of infection control. During an interview with the Nurse Manager (NM) and Director of Staff Development (DSD) on 4/16/25 at 10:21 am, both confirmed that the blood pressure cuffs should have been wiped down with disinfectant wipes after each resident. They also confirmed that medical equipment, including carts need to be wiped down. The NM confirmed that the medications boxes should not be placed on tables or allow residents to handle the boxes because of infection control issues. Both confirmed and agreed, Re-education of the nurses is due. During an interview with the Infection Prevention Nurse (IP) on 4/16/25 at 11:27 am, IP confirmed that the blood pressure cuffs should have been wiped with disinfectant wipes because that was an infection control issue. IP also confirmed that residents should not be touching medication boxes, and medication boxes should not touch furniture. IP stated this is another infection control issue. IP stated, It looks like some in-services need to be done.

Based on interview, observation and record review, the facility failed to meet this requirement when a medication cart was observed to be left unlocked on two occasions. This had the potential to result in unauthorized access to medications that had the potential to cause illness and death. Findings: Review of the facility's policy titled Medication Preparation and Administration, last reviewed 2010, indicated, If the nurse leaves the medication cart, it must be locked. On 4/15/25 at 12:32 PM, a medication cart was observed to be unlocked and openable outside room [ROOM NUMBER]. Unsupervised medications were observed to include heart medication, blood pressure medication, antipsychotics (medications for mental health), and diuretics ('blood pressure pills), among many other drugs. No staff was observed nearby to secure the cart while it was open. On 4/15/25 at 12:33 PM, LVN (Licensed Vocational Nurse) was observed coming toward the unlocked cart from a distant hall in the facility. In a concurrent interview, LVN stated she had left it open and forgot to lock it. On 4/16/25 9:50 AM, the med cart was observed second time, unlocked and with no staff present, outside room [ROOM NUMBER]. In a concurrent interview and observation on 4/16/25 at 9:51 AM, LVN came back to the cart from another hall, acknowledged that it was unlocked again, and stated she got sidetracked. In an interview on 4/16/25 at 9:55 AM, DON (Director of Nursing) stated, The med cart should be locked at all times when not attended.

Based on interview and record review, the facility failed to report an injury of unknown origin for one of one residents (Resident 1) sampled for abuse. Resident 1 was found to have significantly large suspicious bruising on both of her breasts from an unknown cause. The facility had not reported this to the California Department of Public Health (CDPH), Ombudsman (Resident advocate agency), or to their local Law Enforcement agency, in accordance with their Abuse Policy. This failure resulted in the inability for CDPH, Ombudsman and Law Enforcement to gather additional information surrounding Resident 1's injuries and conduct their own investigation, which could negatively impact Resident 1's physical, emotional and psychosocial well-being and quality of life. Findings: A review of facility's policy provided by Director of Nursing (DON) titled, Elder Abuse dated January 2012, indicated abuse as the, willful infliction of injury .resulting in physical harm, pain, or mental anguish. Facility policy further indicated it would identify events such as suspicious bruises on patients .that may constitute abuse and determine the direction of the investigation. Facility policy indicated the facility would investigate alleged incidents and complete an SOC 341 form (a form used to report suspected elder abuse to the Ombudsman and CDPH), notify the Ombudsman, local Law Enforcement and call the Department of Health Services Licensing and Certification (CDPH), no later than two hours after the allegation is made. Then complete a written investigation report in writing to the Ombudsman, State Survey Certification Agency, and any other agency according to law. During a record review of Resident 1 ' s admission record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included failure to thrive (decline in overall health, including weight loss, decreased appetite, and reduced physical function stemming from various underlying medical or psychosocial issues), and dementia (loss of memory, language, and other thinking abilities that are severe enough to interfere with daily life). A record review of Resident 1's, Wound, Skin Tear or Bruise Investigation Report dated 8/20/24, completed by Registered Nurse (RN) A indicated, Multiple bruises with different stages found [on Resident 1's breasts] during shower. Possible self-picking? RN A documented that, nursing interventions were to monitor until resolved. A record review of Resident 1's, Nursing Narrative Note Final Report dated 8/20/24 5:03 pm, written by RN A, indicated a Certified Nursing Assistant (CNA), reported that resident has multiple bruises on her breast and her right hand. Assessed resident [Resident 1's] body. Multiple bruises with different stages, yellowish and dark purple color. Physician Assistant assessed the bruises. DON and nurse supervisor notified. Nursing intervention: Monitor until healed .and continue to investigate the incident. A record review of Resident 1's, Long Term Care Progress Note Final Report dated 8/20/24 4:41 pm, Medical Doctor (MD) A documented, Extensive bruising to bilateral breast and right forearm. Noticed today by nursing while the patient received a bath. During a concurrent review of facility's Abuse Policy and interview with the DON on 3/26/25 at 1:48 pm, DON stated, we couldn ' t verify what happened. DON confirmed the facility had not completed an SOC-341 or reported Resident 1's suspicious bruises to CDPH, Ombudsman and local Law Enforcement, in accordance with their Abuse Policy and State and Federal regulations.

Based on observation, interview, and record review, the facility did not protect residents' right to be free from sexual abuse for one of three sampled residents (Resident 1), when Certified Nursing Assistant (CNA) 1, offered to have sexual relations with her to relieve stress. This caused fear and anxiety for Resident 1, and had the potential to negatively impact her emotional and psychosocial well-being. Findings: A review of the facility's policy titled, Elder Abuse dated 6/2023, indicated, Abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse of a patient includes the deprivation of goods or services necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all patients, even those in a coma, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Instances include verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse Includes, but is not limited to: Sexual harassment. Sexual coercion. Sexual assault. Non-consensual sexual contact of any type. Resident 1 was admitted to the facility with diagnoses that included Diabetes and weakness. Resident 1 was alert, oriented and able to make her own health care decisions. Resident 1 was able to engage in daily activities with minimal assistance. On 9/05/23, Resident 1's Minimum Data Set (MDS, an assessment tool), reflected a Brief Interview for Mental Status (BIMS, determines decision making skills and memory), with a score of 15/15 meaning she had no cognitive impairments. During a concurrent interview and record review on 10/24/23 at 2:30 PM, the Director of Nursing (DON) stated, We found out about it [the sexual abuse allegation] October 17, 2023. We took him [CNA 1] off immediately. We offered Resident 1 counseling and support but she didn't want any. The DON provided a copy of the facility's policy titled, Elder Abuse and pointed out the topic of sexual abuse on page two. The DON stated, They know they can't do that with residents. During a concurrent record review and interview on 10/2423 at 4:15 PM, Social Services (SS) stated that on 10/17/23, A CNA came to me with [Resident 1] to report that [CNA1] told [Resident 1], that he could help me with stress relief by getting me off and stated that I had a nice butt and boobs. I immediately called the DON, the Nurse Manager (NM), Human Resources and pulled [CNA 1] in and we talked to him about the allegations. He looked away not saying anything. On 10/24/23 at 5:10 PM, The Licensed Vocational Nurse Manager (NM) was interviewed. The NM stated, I have talked to her [Resident 1] a couple of times about it. She honestly seems fine. Even when we originally talked to him [CNA 1], he didn't deny anything. Even in his written statement he didn't deny he did anything at all and confirmed in writing that he had offered stress relief to [Resident 1]. On 10/25/23 at 7:15 AM, Resident 1 was interviewed in her room. Resident 1 stated that CNA 1, offered to help me with stress relief and said he could get me off. Resident 1 stated, I was really anxious and afraid he was going to continue and force himself on me. Resident 1 added that CNA 1, came back in my room and stood there for five minutes just staring at me and on another occasion he stood there for fifteen minutes watching me. He also said he liked parts of my body, my breasts and butt. Resident 1 indicated that she was afraid of CNA 1, and approached staff for help.

Based on observation, interview and record review the facility failed to ensure one of seven sampled residents (Resident 1), received care according to Resident 1's comprehensive person-centered care plan. This happened when Certified Nursing Assistant (CNA) 2 and CNA 3 had a verbal disagreement in front of Resident 1; CNAs did not exit the room when Resident 1 became agitated; CNA 3 provided care quickly with no breaks between tasks; three CNAs were in the room at the same time and CNAs did not provide a sheet to cover Resident 1 during care. This failure resulted in Resident 1 becoming increasingly agitated and had the potential to cause Resident 1 physical and psychosocial harm. Findings: During a review of facility policy and procedure titled, Resident Right-Resident Behavior and Facility Practice, dated 10/2020, indicated the resident has the right to be free from verbal abuse and the facility must care for residents in a manner and in an environment that promotes maintenance or enhancement fo each resident's quality of life and enhances dignity and respect in full recognition of his/her individuality which includes treating residents with respect. During a review of facility record, Job Description-Certified Nursing Assistant, dated 1/2019, indicated under the heading of General Competencies, the CNA always demonstrates a professional behavior when on duty and demonstrates a positve working relationship with patients visitors and facility staff. During a review of Resident 1's History and Physical, dated 10/26/2021 at 5:04 pm, indicated Resident 1 was admitted to the facility 10/25/2021. Resident 1 had a history of advanced dementia with minimal communicative skills, alcoholism, delusions, hallucinations, agitation and chronic back pain with arthritis and spinal compression fracture. Resident 1 had an increase in agitation, delusions and aggressive behaviors in March of 2021 and was brought to a hospital. Resident 1 stayed in the hospital for six months until a bed was available in the skilled nursing facility. During a review of Resident 1's Minimum Data Set (assessment of resident and care screening) dated 9/8/2023, indicated Resident 1 had unclear speech, severely impaired decision-making skills, disorganized thinking, inattention, short tempered and easily annoyed, delusions, physical behaviors (hitting kicking, pushing, grabbing) toward others and refused care. Resident 1 required at least 2-person physical assist for bed mobility, transfers, toilet use, personal hygiene and was dependent on staff for bathing. During a review of Resident 1's Progress Notes, dated 10/19/2023 at 11:54 am, indicated Resident 1's behaviors had improved with medication change but some staff noted behaviors of striking out. Staff believe it was related to how the staff approached Resident 1. Staff discussed with the physician and spouse regarding what interventions (action taken to meet a goal) needed to be adjusted when approaching Resident 1 to further improve care related behaviors. During a review of Resident 1's active Care Plans indicated: On 2/01/2022, Resident 1's goal under the category of Behaviors, indicated staff should have no more than 2 people in the room (more people tend to stress the resident out). On 4/26/2022, Resident 1's goal under the category of Activities of Daily Living, indicated staff should allow rest breaks between tasks when Resident 1 seems agitated. On 4/28/2022, Resident 1's goal under the category of Communication, indicated staff should watch for signs of agitation from Resident 1 and exit the room and re-approach later. On 1/11/2023, Resident 1's goal under the category of Activities of daily Living, indicated staff should provide a sheet for Resident 1 during incontinent care. Per Resident 1's wife this would help with agitation. On 3/8/2023, Resident 1's goal under the heading of Pain, indicated staff should assist Resident 1 with slow position changes. During an observation on 10/31/2023 at 12:50 pm, in Resident 1's room, Resident 1 had a sign on the door with red capitalized letters underlined indicated, ATTENTION (NAME OF FACILITY) STAFF. Under the red capitalized heading the sign indicated: Please keep yourself and our residents safe by reading and following the resident's care plan. If you run into any problems during care, if the resident appears to be agitated, please step away immediately and call his wife. The bottom of the sign indicated Resident 1's wife's name, availability was 24 hours a day, 7 days a week and her phone number. Resident 1's bed was in the corner on the right side of the room with the head of bed and one side of the bed touching the walls. Resident 1 was using the wall on the side of the bed to lean against and had his legs hanging over the side of the bed. Resident one looked at me briefly when I introduced myself but had no verbal response that was understandable. Resident 1 sat up and drank out of his coffee cup and leaned back against the wall. During an interview on 10/31/2023 at 12:55 pm, CNA 1 stated when Resident 1 was agitated or aggressive the only thing you can do was stand back and let him have his space. CNA 1 stated Resident 1 can become very defensive and combative during care. CNA 1 stated Resident 1 was incontinent of bowel and bladder and providing care could set him off and become agitated. CNA 1 stated when Resident 1 becomes agitated, the staff needs to back off and let him calm down. CNA 1 stated Resident 1's wife was available at any time and should be called when the staff are unable to calm Resident 1. During an interview on 10/31/2023 at 1:20 pm, with Licensed Vocational Nurse (LVN), stated the sign on Resident 1's door indicating to immediately step away when Resident 1 was agitated had been there since Resident 1 was admitted about 2 years ago. LVN stated all staff have been trained to back away from Resident 1 when he was agitated, let him calm down before continuing with care. LVN stated if Resident 1 does not calm down the staff were trained to call Resident 1's wife. LVN stated the staff are expected to follow the training and Resident 1's care plans when providing care. During an interview on 10/31/2023 at 1:30 pm, the Nurse Manager (NM), stated Resident 1 was confused and had agitation and aggressive behaviors since he was admitted . NM stated the facility had numerous trainings for staff on how to care for Resident 1 when he was agitated. NM stated she expected staff to step away from Resident 1 when he was agitated and not to approach Resident 1 until he calmed down. NM stated the staff are expected to follow the training and Resident 1's care plans when providing care. During an interview on 10/31/2023 at 2:10 pm, with Director of Staff Development (DSD), stated the instruction sign on Resident 1's door has been there for years. DSD stated when Resident 1 gets agitated staff have been educated to back off and call Resident 1's wife. During an interview on 10/31/2023 at 2:37 pm, with Chief Nursing Officer (CNO), stated the staff were trained to give Resident 1 space and stop care when he becomes agitated. CNO stated the staff were trained to call Resident 1's wife when Resident 1 could not be calmed down by staff. CNO agreed the CNAs should have allowed Resident 1 a few more minutes to calm down before continuing with his care. During an interview on 11/1/2023 at 10:25 am, CNA 2 stated on 10/24/2023, CNA 3 and CNA 4 entered the room with her to provide care for Resident 1. CNA 2 stated Resident 1's floor, clothing and bed linens were soiled with urine. CNA 2 stated Resident 1 was lying on his bed when CNA 3 quickly started providing care and rolled Resident 1 onto his side causing Resident 1 to become agitated. CNA 2 stated Resident 1 tried to punch CNA 3 after she rolled him onto his side and CNA 3 did not back away from Resident 1 when he became agitated. CNA 2 stated Resident 1 became agitated when CNA 3 provided care to quickly and Resident 1's agitation increased when CNA 3 did not back away from Resident 1. During an interview on 11/1/2023 at 3:30 pm, CNA 3 stated on 10/24/2023, CNA 2 and CNA 4 entered the room with her to provide care for Resident 1 because Resident 1's floor, clothing and linen were soiled with urine. CNA 3 stated Resident 1 rarely answered questions, had serious aggressions, and would get easily agitated with care. CNA 3 stated Resident 1 was sitting on his bed when they entered the room and removed Resident 1's shoes, laid him down on his bed and tried to get his pants off, but Resident 1 became agitated. CNA 3 stated they stepped back and let him calm down then continued with care, but he continued to be aggressive and agitated. CNA 3 stated her, and CNA 2 had a verbal disagreement in front of Resident 1 regarding getting Resident 1's wife to help calm Resident 1. CNA 3 stated CNA 2 left the room to get Resident 1's wife. CNA 3 stated she and CNA 4 continued providing care and removed Resident 1's pants, shirt, and glasses. CNA 3 stated Resident 1 was not provided a sheet or blanket to cover himself while care was provided and Resident 1 was agitated the entire time they provided care. CNA 3 stated Resident 1's increased agitation could have been caused by too many staff in the room, not allowing enough time for Resident 1 to calm down before restarting care and Resident 1 could have heard and felt the tension in the room due to the verbal disagreement between the CNAs while providing care. CNA 3 stated she was aware of the sign on the door that indicated staff were to step away immediately if Resident 1 becomes agitated. CNA 3 agreed she should have given Resident 1 more time to calm down before restarting care and it was inappropriate to discuss disagreements in front of Resident 1 during care.

Based on interview and record review, the facility failed to report a COVID-19 (a contagious virus that caused respiratory illness) outbreak which affected four residents (Residents 5, 19, 43, and 45) and four staff members to the California Department of Public Health (CDPH). This failure had the potential to expose further residents to illness, which could have threatened their health and well-being. Findings: A facility policy, titled, Outbreak Investigation, revised 1/1/12, was reviewed. An outbreak was defined as an excess level of endemic (constantly present in a specific location) disease or statistically (by the numbers) significant increase in endemic level. The time period would have varied according to the infection. The facility's threshold (required number of cases for an outbreak) was defined as greater than five percent of the resident population. If an outbreak was confirmed, it should have been reported to the local county Public Health Department and also to CDPH within 24 hours of the initial identification. A review of Resident 5's record indicated they were admitted to the facility on [DATE]. Resident 5's diagnoses included chronic obstructive pulmonary disease (COPD--a lung disorder) and pneumonia (a lung infection). Resident 5 tested positive for the COVID-19 virus on 9/23/23. A review of Resident 19's record indicated they were admitted to the facility on [DATE]. Resident 19's diagnoses included COPD and heart failure (inability of the heart to pump adequately). Resident 19 tested positive for the COVID-19 virus on 9/21/23. A review of Resident 43's record indicated they were admitted to the facility on [DATE]. Resident 43's diagnoses included COPD and heart failure. Resident 43 tested positive for the COVID-19 virus on 9/23/23. A review of Resident 45's record indicated they were admitted to the facility on [DATE]. Resident 45's diagnoses included dementia (a mental disorder that caused confusion and memory loss) and high blood pressure. Resident 45 tested positive for the COVID-19 virus on 9/28/23. Record review of the facility's census (number of residents) showed that from 9/21/23 to 9/28/23, there were 48 to 49 residents. The number of positive COVID-19 cases (four), would have been approximately eight percent of the facility's resident population at that time. During an interview, on 10/3/23, at 1:42 pm, the Infection Preventionist (IP) stated the facility had four residents who had tested positive for COVID-19 in September of 2023, and IP reported it to their county's Public Health Department. Their county's Health Officer was also the facility's Medical Director. IP stated they did not report it to CDPH. IP had been reporting outbreaks to CDPH and also via another network reporting system, until recent changes in the reporting procedure were implemented. IP stated, We absolutely did have an outbreak in September [2023].

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) who was on duty, eight hours out of every day, seven days a week. This failure had the potential for RN assessment skills and supervision to not be available every day for residents and staff. Findings: Record review of the staffing schedules for the months of August and September 2023 showed there was no RN working on the following dates: 8/5, 8/6, 8/19, and 8/20; 9/2, 9/3, 9/9, 9/10, 9/16, 9/17, 9/23, 9/24, and 9/30. During an interview, on 10/3/23, at 9:18 am, the Administrative Assistant stated they did not have a full-time RN on the weekends during the months of August and September 2023. During an interview, on 10/4/23, at 10:23 am, the Director of Nursing stated they didn't have any policy about nurse staffing or RN staffing. During an interview, on 10/4/23, at 10:42 am, Licensed Nurse (LN) A stated RNs on the floor were sporadic, they came and went. During an interview, on 10/4/23, at 11:41 am, the Nurse Manager stated that for the last month they didn't have an RN working on the weekends.

Based on interview and record review, the facility failed to follow their abuse policy and procedure when a Certified Nursing Assistant (CNA) A, who allegedly abused a resident (Resident 1), was not immediately removed from direct patient care during an abuse investigation. This failure had the potential to place Resident 1 and other residents at risk for harm. Findings: A review of the facility's Elder Abuse policy indicated, Employees who are being investigated for alleged abuse will be either placed in a non-patient work setting or on administrative leave. The California Department of Public Health received a report from the facility on 3/15/23, which indicated CNA A was brushing Resident 1's hair when the brush hit a tangle and pulled her hair and Resident 1 slapped CNA A. Resident 1 alleged CNA A pulled her hair on purpose. This report did not indicate if CNA A had been suspended during the investigation. A review of Resident 1's record indicated she was admitted with diagnoses that included high blood pressure, diabetes, and heart disease. A review of her Minimum Data Set (MDS, a standardized resident assessment tool) dated 2/21/23, included a BIMS (brief interview for mental status) of 12 which indicated mild cognitive impairment. Resident 1 was able to understand and able to convey her needs. During an interview on 5/4/23 at 7:50 am, CNA A said she was getting Resident 1 up around 5 am on 3/15/23, and the resident was grumpy. She was brushing Resident 1's hair and pulled a large knot and Resident 1 started crying so she bent down and the resident slapped her and said, you did that on purpose. CNA A said she put the brush down and finished the rest of Resident 1's care, put away the hoyer lift and reported the incident to the charge nurse. She said she finished the rest of her shift which was about one hour then gave report and did rounds with the oncoming shift from 6:30 am to 7 am. CNA A said she was not put on Administrative (admin) leave. She said she asked about that and was told by the charge nurse that it was too late. CNA A said she did not come in contact with Resident A the rest of the shift. During an interview on 5/4/23 at 8:50 am, the charge nurse said Human Resources (HR) places staff on admin leave and the Chief Nursing Officer (CNO) or Director of Nurses (DON) was the one responsible for notifying HR about allegations of staff to resident abuse. She said CNA A was not placed on Admin leave. During an interview on 5/3/23 at 1:15 pm, the Human Resources Director (HRD) said an email was sent to the Risk Manager on 3/15/23 at 5:25 am, from their internal safety system, that included the details of the incident and indicated that CNA A was instructed to not come in contact with the resident or enter her room until after an investigation was conducted. An email on 3/16/23 at 8:59 am, from the CNO indicated it was he said/she said incident. HRD said she did not find out about this incident until 3/22/23. At that time she sent an email to the CNO on 3/22/23 at 10:57 am, and a follow up email at 11:10 am, wherein she advised the CNO that they put the employee on leave, even it was for just one day, until it could be determined that the incident was unfounded. HRD said CNA A should have been put on Administrative (admin) leave as is their usual protocol. She said even if the staff was off the schedule they should be placed on admin leave. The CNO sent an email to the Risk Manager on 3/22/23 at 11:06 am, in which he said there was no way to corroborate the incident so they were not going to put CNA A on admin leave. The email further stated that the abuse allegation was the resident against an employee and was more about Resident 1 slapping CNA A in the face while she was brushing her hair. During an interview on 5/8/23 9:45 am, the CNO said the night shift charge nurse called him the morning of 3/15/23. He said he waited until he got the social service's notes on 3/20/23 before he completed his five day report to the state but had already determined by 3/17/23 that he could not corroborate abuse. CNO said he did not notify HR because there was no reason to suspend CNA A because she was not on the schedule on 3/15 and 3/16 and by 3/17/23 (her next working day), he already concluded there was no abuse. He was asked if he thought there was any issue with the treatment Resident 1 received, assuming what CNA A said was true and that she had pulled Resident 1's hair when she was brushing it, and he said no. He said the incident was really more about Resident 1 slapping CNA A instead of the opposite.

Based on observation, interview and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect, when Certified Nursing Assistant (CNA) A pulled Resident 1's hair while brushing it. This failure resulted in Resident 1 experiencing pain and had the potential to result in fear and a decline in psychosocial well being. Findings: The California Department of Public Health received a report from the facility on 3/15/23, which indicated CNA A was brushing Resident 1's hair when the brush hit a tangle and pulled her hair and Resident 1 slapped CNA A. Resident 1 alleged CNA A pulled her hair on purpose. A review of Resident 1's record indicated she was admitted with diagnoses that included high blood pressure, diabetes, and heart disease. A review of her Minimum Data Set (MDS, a standardized resident assessment tool) dated 2/21/23, included a BIMS (brief interview for mental status) of 12 which indicated mild cognitive impairment. During a concurrent record review and interview on 5/3/23 at 2 pm, Licensed Nurse (LN) 2 who was the MDS nurse, said Resident 1's last BIMS score on 2/21/23 was 12. She said Resident 1 has some confusion at times but had been stable for the last two prior quarterly MDS assessments. She said Resident 1 was able understand and able to convey her needs. LN 2 confirmed there have been no prior care plans regarding allegations of abuse from or towards staff. During an interview on 5/2/23 at 8:55 am, Licensed Nurse (LN) 1 said this Resident 1's hair was short and thin and although Resident 1 was confused at times she was usually alert, and thought her hair was pulled on purpose. LN 1 said some of the staff have said CNA A finishes in a room as quickly as possible so she can get back on her cell phone. During a concurrent observation and interview on 5/3/23 at 11:45 am, Resident 1 said she doesn't recall a whole lot and said it's been a couple months ago now. She recalled CNA A pulled her hair but said CNA A had not been brushing her hair. Resident 1 put her hands up to her head to demonstrate how her hair had been pulled. She said she had worked with this CNA before and she had never done anything like this. She has had no problems with other staff. She pulled off her crochet hat and her hair was observed to be short to the nape of her neck and thin. During an interview on 5/4/23 at 7:50 am, CNA A said she was getting Resident 1 up around 5 am and Resident 1 was grumpy. She was brushing Resident 1's hair and pulled a large knot and Resident 1 started crying so she bent down and Resident 1 slapped her and said, you did that on purpose. CNA A's human resources file was reviewed on 5/3/23 at 1:15 pm with the Human Resources Director. CNA A had been disciplined on 10/29/22 for being aggressive and disrespectful towards staff members. The facility's policy titled, Resident Rights - Resident Behavior and Facility Practice dated 10/2020, was reviewed and indicated, the facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life and enhances dignity and respect in full recognition of his/her individuality.

Based on interview, and record review, the facility failed to ensure 4 of 8 sampled residents (Residents 3, 8, 25, and 37) who received [CONDITION(S)] drugs (any drug that affects brain activities associated with mental processes and behavior), or antipsychotic drugs (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking) had adequate diagnoses and clinical indications for use including monitoring of target behaviors to assess effectiveness, monitoring of adverse side effects, and documentation by the physician that included the rationale, and duration for as needed (PRN) [CONDITION(S)] drugs that exceeded 14-days. This resulted in or had the potential to result in residents receiving unnecessary medication with adverse side effects, some of which could include permanent neurological side effects, and a deterioration in the clinical condition of these residents. Findings: 1. A review of Resident 3's medical record indicated she was admitted with diagnoses that included lung disease, anxiety disorder, [CONDITION(S)] (form of dementia caused by an impaired supply of blood to the brain) with behavioral disturbances, and major depressive disorder. A review of Resident 3's Physician Orders included an order, dated 11/29/21, for [MEDICATION(S)] (antipsychotic medication) 7.5 milligrams (mg) daily at bedtime. There was no diagnosis or indication for use including specific target behavioral symptoms included in the order. No monitoring of adverse side effects could be located in the medical record. During a concurrent interview, and record review, on 6/14/22 at 4:44 pm, the MDS (Minimum Data Set, resident assessment tool) Nurse, Licensed Nurse (LN) 3 confirmed the above Physician's Order for [MEDICATION(S)] did not include a diagnosis, or indication for use or specific behaviors to monitor. During a concurrent record review, and interview, on 6/15/22 at 10:02 am, the Pharmacy Consultant (Pharm) was asked about Resident 3's Physician's Order for [MEDICATION(S)], dated 11/29/21. The Pharm confirmed there was no diagnoses for the use of this drug, and said he had not identified any irregularity regarding this order during his medication regimen reviews. During a concurrent interview, and record review, on 6/16/22 at 7:59 am, the Charge Nurse (CN) confirmed the diagnosis should be included in Resident 3's Physician Order, as well as the target behaviors. She confirmed the adverse side effects were not being monitored as they should for this resident, and other residents who received [CONDITION(S)] medications. They noted this to be an issue, and new monitoring forms have been ordered that have this capability. 2. A review of Resident 8's medical record indicated, that she was admitted with diagnoses that included dementia with behavioral disturbance, [CONDITION(S)] disorder depressive type (combination of symptoms of [CONDITION(S)], and mood disorder such as depression), and anxiety disorder. Resident 8 received [MEDICATION(S)] (antipsychotic drug) for [CONDITION(S)] disorder. The consent for this drug included the following target behaviors: verbal outbursts, sadness, aggressive behavior during care, and accusatory statements. During a concurrent interview, and record review, on 6/15/22 at 7:33 am, LN 3 confirmed the above behaviors were monitored for use of the drug [MEDICATION(S)]. The behavior monitoring forms for [MEDICATION(S)] indicated a 1 meant verbal outbursts. From 6/1/22 - 6/9/22 a 1 appeared on the day shift. LN 3 was asked how many verbal outbursts did Resident 8 have per day for those days. LN 3 reported that there should be a note with details about the behavior, and how many. From 6/1/22 - 6/9/22, there were no notes regarding behaviors, with the exception of 6/4/22, when there was a specific note about one behavior that shift. LN 3 agreed she was unable to tell if Resident 8 had just one behavior, of verbal outbursts, or more on the other days where there was no note. LN 3 said they have ordered different forms that have capability to enter the number of specific behaviors. LN 3 was asked about monitoring of adverse side effects of the [CONDITION(S)], and antipsychotic drugs this resident took, but she did not know if it was being done, or where it was documented, if done. During a concurrent interview, and record review, on 6/16/22 at 7:43 am, CN confirmed the above. CN said the behavior monitoring was not accurate, and it was hard to tell exactly how many behaviors the Resident 8 had. CN also confirmed adverse side effects were not being monitored, as they should be. CN said they noted this to be an issue, and new monitoring forms have been ordered that have the capability to accurately monitor behaviors as well as side effects. 3. A review of Resident 25's medical record indicated, that he was admitted with diagnoses that included unspecified dementia with behavioral disturbances, delusional disorder (characterized by the presence of one or more nonbizarre delusions that persist for at least one month), and chronic pain. A review of the Resident 25's Physician's Orders included an order, dated 4/4/22, for [MEDICATION(S)] (anti-anxiety medication) 0.25 mg twice per day for anxiety, and a [MEDICATION(S)] 0.5 mg PRN (as needed) order before changing, dated 11/1/21. During a concurrent interview, and record review, on 6/14/22 at 4:57 pm, LN 3 confirmed that Resident 25's orders indicated [MEDICATION(S)] was to be given for anxiety, although no anxiety disorder, was included in the list of diagnoses for this residents. The PRN order for [MEDICATION(S)] was ordered on 11/1/21, and started on 11/2/21. During a concurrent interview, and record review, on 6/15/22 at 8:52 am, the CN confirmed that Resident 25's physician had not documented a reason why the PRN [MEDICATION(S)] needed to be extended past 14-days, and the duration. During a concurrent interview, and record review, on 6/15/22 at 10:02 am, Pharm confirmed that he had not advised the physician of the need to re-evaluate the PRN [MEDICATION(S)] after 14- days, and document the rationale as to why it should continue with the duration, in his medication regimen reviews for this Resident 25. 4. A review of Resident 37's medical record indicated, that he was admitted with diagnoses that included unspecified dementia with behavioral disturbance, [CONDITION(S)], and lung disease. A review of the Resident 37's Physician's Orders included an order dated 5/17/22, for [MEDICATION(S)] (anti-depressant) 30 mg at bedtime for dementia ([MEDICATION(S)] is not approved to treat dementia). There was no specific behavioral symptoms included in this order. There was also an order dated 6/1/22, for [MEDICATION(S)] 125 mg three times per day for behavior disturbance. There was no diagnosis or indication for use, or specific behavioral symptoms included in this order. During a concurrent interview, and record review, on 6/14/22 at 5:06 pm, LN 3 confirmed the above order for [MEDICATION(S)] indicated its use was for dementia, and did not include specific behavior monitors. LN 3 confirmed there was no diagnosis included in the order for [MEDICATION(S)], and no specific behaviors. During a subsequent interview, on 6/15/22 at 8:03 am, LN 3 said the consent for [MEDICATION(S)] listed behaviors as delusions and agitation. For Behavior monitoring a 1 was noted to be for delusions. A 1 was noted on 6/9/22, even though Resident 37 was noted to be combative and not having delusions on that day. CN who was also present, said the notes should include what happened for any behavior documented on the behavior monitoring sheet. During a later interview, on 6/15/22 at 8:55 am, CN confirmed the diagnosis and behaviors should be included in the Physician's Order, and the behaviors on the physician's order and the consent should be the same. CN again confirmed the behavior monitoring was not accurate, and it was hard to tell exactly how many behaviors the resident had. CN also confirmed adverse side effects were not being monitored as they should be. CN said they noted this to be an issue, and new monitoring forms have been ordered that have the capability to accurately monitor behaviors as well as side effects.

Based on interview, and record review, the facility's pharmacy consultant failed to identify drug irregularities which included the diagnoses and necessary indications, including target behaviors, for each [CONDITION(S)] drug (any drug that affects brain activities associated with mental processes and behavior), or antipsychotic drug (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking), and the Centers for Medicare and Medicaid Services (CMS) requirement to limit as needed (PRN) [CONDITION(S)] medications to 14-days, unless there was a documented rationale which included why the medication needed to be extended past 14-days, and the duration, for three of eight sampled resident records reviewed for unnecessary medications (Residents 3, 37, and 25). This failure resulted in, or had the potential to result in residents receiving unnecessary medication with adverse side effects, some of which could be permanent. The facility failed to ensure their pharmacy consultant provided documentation for each resident when the medication regimen review was done on a monthly basis. There was nothing in each resident's medical record to indicate that a medication regimen review was done, if there were no drug irregularities found. This resulted in the inability to ensure that each resident had a monthly medication regimen review. The facility's medication regimen review (MRR) policy did not include timeframe's for the different steps in the process, including the time the pharmacist took to prepare his reports following his review, or steps the pharmacist must take if an irregularity was identified that required urgent action. This resulted in a delay in the pharmacist preparing his reports, and had the potential to result in a delay in physician response to irregularities identified during the medication regimen review. Findings: 1a. Resident 3's medical record was reviewed. Resident 3's was admitted to this facility with the following diagnoses; lung disease, anxiety disorder, [CONDITION(S)] (form of dementia caused by an impaired supply of blood to the brain) with behavioral disturbances, and major depressive disorder. A review of Resident 3's Physician Orders, included an order, dated 11/29/21, for [MEDICATION(S)] (antipsychotic medication) 7.5 milligrams (mg) daily at bedtime. There was no diagnosis, or indication for use including specific target behavioral symptoms included in the order. During a concurrent interview, and record review, on 6/14/22 at 4:44 pm, the MDS (Minimum Data Set, resident assessment) Nurse, Licensed Nurse (LN) 3 confirmed that the above Physician's Order for [MEDICATION(S)] did not include a diagnosis, or indication for use or specific behaviors to monitor. During a concurrent record review, and interview, on 6/15/22 at 10:02 am, the Pharmacy Consultant (Pharm) was asked about the Resident 3's Physician's Order for [MEDICATION(S)], dated 11/29/21. Pharm confirmed there was no diagnoses for the use of this drug, and said he had not identified any irregularity regarding this order during his medication regimen reviews. b. A review of Resident 37's medical record indicated that he was admitted with diagnoses that included unspecified dementia with behavioral disturbance, [CONDITION(S)], and lung disease. A review of the Physician's Orders included an order dated 5/17/22, for [MEDICATION(S)] (anti-depressant) 30 mg at bedtime for dementia. [MEDICATION(S)] is not approved to treat dementia. There was no specific behavioral symptoms included in this order. There was also an order dated 6/1/22, for [MEDICATION(S)] 125 mg three times per day for behavior disturbance. There was no diagnosis or indication for use, or specific behavioral symptoms included in this order. During a concurrent interview, and record review, on 6/14/22 at 5:06 pm, LN 3 confirmed the above order for Resident 37's [MEDICATION(S)] indicated its use was for dementia, and did not include specific behavior monitors. She confirmed there was no diagnosis included in the order for [MEDICATION(S)], and no specific behaviors. During a concurrent interview, and record review, on 6/15/22 at 10:02 am, Pharm said he had completed the medication regimen review for all the residents the last week in May, although he wasn't sure of the specific date. He agreed dementia was not an appropriate clinical indication or diagnosis for the use of [MEDICATION(S)]. Pharm said he had not reviewed the [MEDICATION(S)] order yet, as he had not completed the medication regimen reviews for the month of 6/22. c. A review of Resident 25's record indicated, that he was admitted with diagnoses that included unspecified dementia with behavioral disturbances, delusional disorder (characterized by the presence of one or more nonbizarre delusions that persist for at least one month), and chronic pain. A review of Resident 25's Physician's Orders included an order, dated 4/4/22, for [MEDICATION(S)] (anti-anxiety medication) 0.25 mg twice per day for anxiety, and a [MEDICATION(S)] 0.5 mg PRN order before changing, dated 11/1/21. During a concurrent interview, and record review, on 6/14/22 at 4:57 pm, LN 3 confirmed the orders for Resident 25 indicated [MEDICATION(S)] was to be given for anxiety, although no anxiety disorder, was included in the list of diagnoses for this resident. The PRN order for [MEDICATION(S)] was ordered on 11/1/21, and started on 11/2/21. During a concurrent interview, and record review, on 6/15/22 at 8:52 am, the Charge Nurse (CN) confirmed the physician had not documented a reason why Resident 25's PRN [MEDICATION(S)] needed to be extended past 14-days and the duration. During a concurrent interview, and record review, on 6/15/22 at 10:02 am, Pharm confirmed that he had not advised the physician of the need to re-evaluate Resident 25's PRN [MEDICATION(S)] after 14-days, and document the rationale as to why it should continue with the duration, in his medication regimen reviews for this resident. 2. Monthly medication regimen reviews could not be located in the medical records for Residents 3, 37, and 25. A binder with medication reviews for all residents in the facility was reviewed. This included irregularities, and gradual dose reduction recommendations but did not include medication regimen review (MRR) for residents in which no irregularity had been found. During an interview, on 6/15/22 at 10:02 am, Pharm said there was only a summary report each month. There was not a separate MRR report for each resident. He said there was nothing to indicate he had completed a medication regimen review if there no irregularity had been found. 3. The facility's policy titled, Medication Regimen Review, revised 7/12, was reviewed, and indicated the Director of Nurses would follow up with the physician within the following week after any irregularity was identified by the pharmacist. The policy did not include how long the pharmacist should take to prepare his report following his review, or steps the pharmacist should take if an irregularity required urgent action. During an interview, on 6/15/22 at 10:02 am, Pharm confirmed the most current MRR policy was dated 7/12. Pharm said the most recent residents' MRR's he had completed was during the last week in May. The Pharm said he was still preparing, and and typing those notes and had not finished them yet. The last MRR reports that have been completed were done in 4/22. The Pharm said he usually tries to get the reports done in two weeks, unless it is urgent. During an interview, on 6/15/22 at 11:31 am, the Chief Nursing Officer (CNO) agreed, that the MRR policy needed to be updated. The CNO reported that had previously been identified, and a pharmacy meeting set for today, was postponed due to the survey.

Based on observation, interview, and record review, the facility failed to make sure that the ice machine dispenser area was free of mineral deposits and debris. This failure had the potential to promote the growth of mold which could have cross contaminated the ice and led to foodborne illness among those residents, staff, and visitors who consumed it, which could lead to negative outcomes. Findings: The facility's policy titled, Food Safety: Ice, revised 11/1/21, was reviewed, and indicated that the facility's ice supply would remain free of all possible contaminants. The Food Code of the United States Public Health Service, and Food and Drug Administration, dated 2017, was reviewed, and indicated in Section 4-602.11 the cleaning of equipment such as ice machines: 4-602.11 Equipment Food-Contact Surfaces and Utensils. (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred; (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude (prevent) accumulation of soil or mold. A review of the Scotsman Ice Machine User Manual, dated 4/1/14, indicated directions for scale removal and sanitizing. Scale removal was to have been done at least twice a year, or as often as every three months (quarterly) depending on water conditions. Sanitizing was done every time the scale was removed, or as often as needed to maintain a sanitary unit. A review of the Scotsman Clear One Scale Remover for Ice Machines, label indicated directions for its use. The user was to follow the directions on the ice machine cleaning label or in its manual. If mineral scale remained, the user was to have repeated the removal process. During a concurrent observation, and interview, on 6/14/22 at 9:17 am, with the Certified Dietary Manager (CDM), there was a small amount of rust and some whitish buildup on the top front of the metal interior of the ice bin. The bin was full of crushed ice. When the metal dispenser area was wiped with a clean, dry paper towel, the paper towel had a scant amount of orangish-beige residue with some scant fine gritty material present on it. This finding was confirmed with the CDM. During a concurrent observation, and interview, on 6/14/22 at 3:15 pm, the Director of Maintenance (DM) described the cleaning process he followed for the ice machine as this surveyor, and CDM observed the ice bin. There was some rusty discoloration on the metal and some whitish material that appeared similar to calcium, or lime buildup. The DM stated he did monthly cleaning to maintain the machine, then quarterly sanitation. To sanitize, after cleaning he wiped down the whole interior with a sanitizing cloth. Another clean paper towel test done by this surveyor indicated a scant amount of particulate matter that was beige in color. This finding was confirmed by the DM and CDM. During a concurrent observation, and interview, on 6/15/22 at 2:55 pm, the DM stated, when asked, that he referred to the metal piece of the machine as the metal dispenser. DM stated that no descaler solution was used during the monthly cleaning, and the descaler never reached the bin or the metal dispenser area when used. Those areas were cleaned and sanitized quarterly. This surveyor did another paper towel wipe test which yielded a scant amount of orangish residue on the paper towel. The DM confirmed this observation and finding.

Based on interview, and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to develop and implement a plan of action to correct deficiencies related to unnecessary [CONDITION(S)] medications (any drug that affects brain activities associated with mental processes and behavior). As a result of this failure, a pattern of deficiencies was present regarding unnecessary [CONDITION(S)] medications control that had the potential to harm all residents who received these drugs. (Refer to F 756, and F 758). Findings: During an interview, on 6/16/22 at 9:45 am, the Chief Nursing Officer (CNO) reported that the QAA Committee was working on falls, skin, pain, and [CONDITION(S)] medication issues. Specifically, he said there was a high percentage of [CONDITION(S)] use for the residents in the skilled nursing facility. The CNO said they discuss gradual dose reductions (GDR) during their GDR meetings. He was asked if the QAA committee identified any issues with [CONDITION(S)] drugs being given without diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNO said no, they had not identified these specific issues, but had focused on GDRs only. On 6/16/22 at 9:56 am, the Director of Nurses (DON), who was also present during this interview, said they did discuss monitoring of behaviors, and adverse side effect monitoring in the QAA meeting on 5/22. The DON said they have ordered new forms, that should make it easier for staff to capture this kind of data. The DON said that staff would begin to use this form for better behavior, and adverse side effect monitoring.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and implement all interventions in the care plan including having a sitter, to prevent one of 16 sampled residents (Resident 3), who was a high risk for elopement (leaving the building without permission), from leaving the building. This had the potential to result in a serious injury to Resident 3, which could lead to negative clinical outcomes. Findings: The facility's policy titled, Resident Elopement, revised 3/18, was reviewed, and indicated that facility will have a system in place for the early identification of residents at risk for elopement and will have the implementation of interventions to prevent elopement, and harm as evidenced by the assessment and care planning procedures. The facility reported to the California Department of Public Health on 6/1/22, that Resident 3 had left the faciity on [DATE], and was found about 150-feet away by a staff member who lived in the area. The staff member brought her back to the facility, and there were no injuries. The facility video had been viewed and showed that Resident 3 left the building at 7:31 pm, through the service hallway. The video showed the barricade/stop sign, that was used to deter residents from going down that hallway, was not engaged. The video had no audio so they were unable to tell if the wanderguard alarmed, but staff did not respond as though it was sounding. A review of Resident 3's medical record indicated, that she was admitted with the following diagnoses lung disease, anxiety disorder, [CONDITION(S)] (form of dementia caused by an impaired supply of blood to the brain) with behavioral disturbances, and major depressive disorder. An elopement risk tool completed on 3/15/22, indicated that Resident 3 was at risk for elopement with a history or wandering outdoors. Resident 3 wore a wanderguard (a device attached to a resident's extremity that alarms if they attempt to leave the facility). Resident 3's care plan for elopement included interventions, dated 7/23/19, to redirect from exit seeking, and if resident desires to go outside, take for a walk. A wanderguard was added to the care plan on 8/27/19, and a sitter as needed for escalating behaviors was added to the care plan on 5/21/21. Resident 3's Nursing Notes on 5/26/22 at 2:51 pm, indicated that the resident was having some behaviors including wandering, pacing, and was anxious. The resident was easy to direct. Staff will continue to monitor. Resident 3's Nursing Notes on 5/27/22 at 12:16 am, indicated that resident had been up wandering into other resident's rooms. Resident 3's Nursing Notes on 5/27/22 at 1:52 pm, indicated that it has been observed, and noted by staff that this resident's behaviors, especially those of continued wandering/pacing through the facility were escalating. Staff will have the nurse call her physician to report this change, and request some possible recommendations to her medication regime. Resident 3's Nursing Notes on 5/27/22 at 2:57 pm, indicated that resident was pacing and agitated during this shift. Sitter is currently with her. During an interview, on 6/15/22 at 11:32 am, the Director of Nurses (DON), reported that they do not know definitively how Resident 3 was able to leave the building. She said they checked Resident 3's wander guard, and it worked and staff reported they did not hear the alarm when the resident left the building. The DON said the system was tested , and the alarms worked. The barricade was down in the hallway going toward the kitchen. She said they have done reeducation with staff regarding disarming a door, and doing a head count if an alarm is heard, and staff need an awareness of where this resident is. The DON confirmed the alarms on residents are tested daily, and door alarms are tested daily. Resident 3 has never attempted to go through the barricade, but dietary probably left it down and did not put it back up. In the past when the barricade was up, this resident had not tried to remove it to go past. The DON said it seemed like for some reason the alarm did not go off. The elopement occurred during shift change around 7 pm, and dietary staff were cleaning dishes. On 6/13/22 at 12:12 pm, a wanderguard was observed on Resident 3's right ankle. During an interview, on 6/15/22 at 4:30 pm, Certified Nursing Assistant (CNA) 1 said, if a wanderguard is on the resident's right ankle it sometimes does not seem to work, as well because of the placement of the alarm device on the door.

Based on interview, and record review, the facility did not have the required membership at its Quality Assessment and Assurance (QAA) meetings, when the Medical Director missed the meetings for one quarter. This failure had the potential for unidentified resident care issues to occur, as well as a lack of medical oversight, which could lead to negative clinical outcomes. Findings: On 6/16/22 at 9:23 am, the attendance sheets for QAA meetings from 6/10/21 through 6/9/22, were provided by Administrative Assistant (AA). A review of these documents indicated there had been a total of nine meetings during that period. The Medical Director was present during a meeting on 12/9/21, and 5/12/22, but did not attend meetings held on 1/13/22, and 4/14/22, so he missed one quarterly QAA meeting. During a concurrent interview, and document review, on 6/16/22 at 9:34 am, the Director of Nurses (DON) confirmed that the Medical Director had missed one of the quarterly QAA meetings.

Based on interview and record review, the facility failed to provide adequate supervision and implement the plan of care for one of three residents (Resident 1), to prevent him from falling. The Sitter (an employee, under the supervision of a nurse, that provides close observation of a resident by being in the resident room, at bedside, to maintain constant visualization of the resident) assigned to supervise and prevent Resident 1 from falling did not have a clear view of the resident, was not in a position to quickly reach and assist Resident 1, and the bed alarm (device that sounds when a resident gets out of bed) was turned off. As a result, Resident 1 was able to get himself out of bed unnoticed and subsequently fell , suffered a broken hip, and was transferred for admission to an acute care hospital. Findings: A review of Resident 1's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities that helps nursing staff identify health problems), dated 4/5/18, indicated Resident 1 had cognitive (the mental process of thinking, understanding, reasoning, and decision making) decline with a BIMS (brief interview for mental status) score of 4 (out of a possible 15), indicating cognitive impairment. The MDS also indicated that Resident 1 required extensive assistance with one-person help for dressing, personal hygiene, toilet use, and transfer (moving from one place to another, such as from a bed to a wheelchair). It also indicated that Resident 1 was continent (able to control) his bowel and bladder and was on a toileting program. A further review of Resident 1's clinical record indicated that Resident 1 was assessed as having a fall risk and a At Risk for Falls care plan dated 12/31/17, was initiated upon his admission to the facility. Resident 1's fall history was reviewed and showed; On 1/4/18, Resident 1 suffered a fall and the care plan was updated to include the intervention of having a sitter for 24 hours until further notice. On 3/5/18, Resident 1 was found on the floor. The care plan was updated to include a new intervention for a bed pressure alarm and tabs alarm in the wheelchair (devices to help prevent falls by alarming when a resident attempts to get out of bed or chair ). On 4/13/18, Resident 1 fell and the care plan was updated to include the intervention, Sitter not to leave resident's side until properly communicated to staff and somebody is with resident prior to sitter leaving resident. On 6/6/18 at 3:30 am, Resident 1 was found with his left leg out of bed on the floor mat, with a small abrasion to the back of head. An X-ray indicated a left [MEDICAL CONDITION] and Resident 1 was transferred to an acute care hospital, out of the area, and did not return to the facility. A review of the facility's, Fall Prevention Guidelines, dated 11/2017, indicated, All falls that occur will be investigated by the fall prevention committee to conclude on interventions to prevent future incidents. Each resident at risk for falls will have an individualized care plan with clear fall prevention interventions. A review of the Fall Investigation Follow Up, dated 6/6/18, indicated that a sitter was in the room at the time of the fall, but the pressure alarm was not in place. During an interview on 6/28/18 at 12:55 pm, Sitter A confirmed that he was the sitter assigned to Resident 1 at the time Resident 1 fell . Sitter A said he himself had fallen asleep around 1:30 am on 6/6/18, and was awakened by Certified Nursing Assistant (CNA) D. He said CNA B also walked into the room later, but he heard her and was not asleep at that time. Sitter A said Resident 1 got out of bed all of a sudden and his left leg went down on the ground and he hit the back of his head on the handrail on the side of the bed. Sitter A said he put his hand on Resident 1's arm and partially assisted him back to bed. Sitter A then turned on the call light and CNA D responded. At the time Resident 1 got out of his bed, which was closest to the door, Sitter A said he was lying down in the other bed in the room, the one closest to the window, with the head of the bed slightly elevated. He said the bed alarm did not sound and was turned off. He thought that CNA D forgot to turn it back on after he had assisted Resident 1 to the bathroom earlier in the shift. Sitter A said he was awake at the time Resident 1 got out of bed, but could not get to the resident in time because he had to get up off the bed he was lying on, then move the bedside table and by that time, Resident 1 was already down on the floor. He said if he had been sitting on the other side of the resident's bed he could have gotten to the resident in time to keep him from falling. Sitter A said his main job duty was to keep an eye on Resident 1 and make sure he was safe at all times. He said he was terminated due to unauthorized sleeping on the job. The job description for Patient Sitter, revised 12/2015, was reviewed. The Position Summary, read, Under the supervision of a licensed nurse and/or physician, the Sitter provided direct patient care to high risk patients, remaining in constant attendance with the patient. A termination notice for Sitter A, dated 6/11/18,was reviewed and read : On 6/6/18 you were observed by two employees sleeping during your shift, at two different times during the shift Unacceptable forms of conduct that may result in immediate termination include, but are not limited to, unauthorized sleeping on the job. During an interview on 6/28/18 at 1:45 pm, the Administrative Assistant confirmed there had been Sitter Observation Notes from the prior shift, which ended at 6:30 pm on 6/5/18, but none after Sitter A started his shift. She said she confirmed with Sitter A that he had not made any notes during his shift. During an interview on 7/23/18 at 1:35 pm, CNA B said she went into Resident 1's room around 2:30 am on 6/6/18, and Sitter A was asleep in the other bed and she told him to get up. CNA B said the curtain was pulled partway around the bed the sitter was lying in and she had to walk around the curtain to see the sitter's face. She said with the sitter lying down on the other bed and the curtain pulled part way his view of Resident 1 would have been partially obstructed. CNA B said she did not tell the nurse on duty about Sitter A sleeping, until after the resident fell which was about an hour later. She said Resident 1 told her he got up to go to the bathroom, fell and hit his head on the dresser and Sitter A picked him up and put him back in bed. CNA B confirmed the bed alarm did not go off. During an interview on 7/25/18 at 7:05 am, Licensed Nurse (LN) C said she was the nurse on duty at the time Resident 1 fell on [DATE]. She said she was told by Sitter A that Resident 1 had fallen around 3:30 am. At that time, she said she was at the nurses station and did not hear an alarm going off. When she arrived at the room, Resident 1's left leg was off the bed and lying on the floor mat. LN C said Resident 1 told her he fell while going to the bathroom then later told her he fell while going to the closet. She confirmed she had not been told by CNA B or CNA D that Sitter A had been sleeping, prior to Resident 1's fall. During an interview on 7/26/18 at 9 am, the Director of Nurses (DON) confirmed Sitter A had been sleeping, was not in a position to have a clear view of Resident 1, and get to Resident 1 in time to prevent the resident from falling, and the bed alarm was not turned on. DON said although Sitter A told her he did not assist Resident 1 back to bed after he fell , she agreed that it was not likely Resident 1 could have gotten back to bed without assistance from staff and Sitter A should have waited for the nurse to assess the resident before getting him back to bed.

Based on observation, interview, and record review the facility failed to ensure adequate pain control, assessment and/or treatment for [REDACTED]. 1. Resident 4 had ongoing, uncontrolled pain in his back, the back of his head, neck, and both arms which he described as constant and severe, and rated his pain 8/10 (0=no pain, 10=worst pain imaginable on a pain scale of 1 to 10) without adequate assessments and interventions. The resident had a resultant functional decline in his ability to perform Activities of Daily Living (ADL's) due to ongoing pain. Refer to F 314. 2. Resident 9 had frequent, daily uncontrolled back and leg pain, rated 8.5-9/10 (severe) by the resident, without adequate assessments and interventions. This contributed to significant, ongoing weight loss due to poor intake related to pain. Refer to F 325. 3. Resident 6 did not have pain medication ordered to treat her moderate pain and her pain was not assessed or documented consistently. This had the potential for Resident 6's pain to go unrecognized, posing a risk for complications and an overall decline in health status. These failures resulted in ongoing, uncontrolled severe pain for Resident 4 with resultant functional decline, ongoing, uncontrolled severe pain for Resident 9, and had the potential for Resident 6 and other residents who have pain to be adversely affected in their ability to maintain their highest practicable well being. Findings: 1. The Record for Resident 4 was reviewed on 7/20/15. Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS, a standardized assessment), dated 5/18/15, indicated Resident 4 complained of frequent pain that made it difficult for him to sleep at night. Resident 4 was able to walk in the hallways, perform personal hygiene, and bath himself with the minimal assistance of one staff member. He was able to independently feed himself and move in bed. A review of the most current physician's orders [REDACTED]. The ADL Tracking Form (document used to identify the level of staff assistance a resident requires), dated 5/2015, indicated between the dates of 5/11/15 and 5/31/15 the resident was able to walk in his room and required only supervision or limited staff assistance. He was able to move in bed independently. Between the dates of 5/5/15 and 5/31/15, he required limited assistance of one staff member to assist him in his personal hygiene. Between the dates of 5/6/15 and 5/31/15, he was able to toilet with limited assistance of one staff member 16 of 25 reviewed days. The ADL Tracking form, dated 7/2015, indicated between the dates of 7/9/15 and 7/22/15, indicated Resident 4's condition had declined. Resident 4 required extensive assistance of two staff members to assist him to walk in his room and he had not walked in his room for six days. He previously moved in bed requiring limited assistance of one staff until but now required extensive assistance of one staff member. Resident 4 required extensive or total assistance of two staff members to perform his personal hygiene. Starting on 7/12/15 he began to require the extensive assistance of one staff member for his toileting assistance and, beginning 7/16/15, was totally dependent on two staff to provide him toileting assistance. On 7/17/15, Resident 4 displayed another decline in function, documented to be totally dependent upon two staff members for his bed mobility. During an interview with Resident 4 on 7/21/15 at 3:18 pm, Resident 4 stated he had ongoing pain in his back, the back of his head, neck, and both arms which he described as constant, severe, and rated his pain 8/10 on a 0-10 pain scale. Resident 4 stated complained to nursing staff as well as the physician repeatedly, but, they haven't done anything just give me excuses. Resident 4 stated when he was admitted he was more independent, was able to walk in the halls, and mostly did for myself. Resident 4 stated, now all I can do is lay here (in bed) and wait until someone has time for me. I can't do for myself anymore. Resident 4 attributed his decline in function to ongoing uncontrolled pain. Resident 4 stated that physician had ordered physical therapy for his arms, but he refused because his pain was too severe to participate. Resident 4 stated he had requested to see a pain specialist, both to nursing staff and the physician, but stated he did not know if an appointment had been made. During an interview and record review with Licensed Vocational Nurse (LVN) A, on 7/21/15 at 3:55 pm, she reviewed the Medication Administration Record [REDACTED]. LVN A stated, he gets [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME], a medication for anxiety), [MEDICATION NAME], and staff started to provide him heating packs to his arms this week. LVN A stated she was unaware of the resident's request to see a pain specialist and confirmed no consultation with a pain specialist had been ordered. LVN A acknowledged she was aware of Resident 4's ongoing complaints of pain and stated the physician had been notified but declined to prescribe any medication. LVN A reviewed the MAR for Resident 4 and confirmed, despite the resident's ongoing complaints of pain, staff were documenting that his pain medication was effective by placing a Y (indicating yes) in the available area for documentation. When asked to describe how she assessed the resident's pain after medication, LVN A stated she does not reevaluate residents after providing them pain medication. LVN A stated if the medication was not effective the resident must initiate a complaint of uncontrolled pain to the staff. LVN A stated this is standard facility practice. During a concurrent interview and record review with LVN C, on 7/21/15 at 4:05 pm, she stated she follows the facility practice of documenting pain medication was effective without any reassessment unless the resident complained directly to her. LVN C confirmed the physician ordered physical therapy, but the resident refused to participate, stating he was in too much pain. LVN C stated the physician indicated the pain Resident 4 was experiencing was from Carpal Tunnel Syndrome (pressure placed on nerves that causes pain and numbness in the hands and fingers, however, Resident 4's record did not include this diagnosis. LVN C was unable to clarify how the pain in Resident 4's neck, back of head, and back could be attributed to Carpal Tunnel Syndrome. LVN C confirmed staff were documenting Y to indicate Resident 4's pain was relieved after medication, without post pain medication re-assessment. During an interview with Resident 4's physician (MD G), on 7/21/15 at 4:50 pm, he was asked about Resident 4's pain control and prescribed treatments. MD G stated he did not believe the resident was having pain and stated, he complains about pain but he looks just fine and stated Resident 4's hands function normally. When asked how he assesses the resident's pain, MD G stated he speaks with the nurses and the resident. When asked to describe how he would review the effectiveness of pain medications without documented reassessments, he was unable to clarify. During a concurrent interview and record review with Certified Nurse Assistant (CNA) F, on 7/23/15 at 8:45 am, she reviewed the ADL Tracking forms for Resident 4. CNA F acknowledged staff documented a decline in the residents abilities and the resident stated this was due to his unrelieved pain. CNA F stated, He just really declined a week or two ago, described the resident as very weak, and stated the resident was no longer able to walk. 2. The record was reviewed for Resident 9 on 7/22/15. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's most recent MDS, dated [DATE], indicated Resident 9 complained of frequent, moderate pain and was experiencing weight loss. A review of the physician's orders [REDACTED]. [MEDICATION NAME] 300 mg PO BID (Restless leg syndrome (RLS) pain (unpleasant tickling or twitching sensation in leg muscles when sitting or lying down); [MEDICATION NAME] 50 mg PO QID (four times daily) for moderate pain; Tylenol 650 mg PO Q6 PRN mild pain (every six hours as needed); [MEDICATION NAME] (a narcotic pain medication) 2 mg, PO Q8 PRN (every 8 hours as needed) for severe pain; and Sombra Cream (an over the counter topical treatment) to back ache Q4 PRN (every 4 hours as needed) for pain/back aches. Her Monthly Weights Record indicated the following weights and ongoing weight loss: 1/3/15, 130.1 pounds (lb) 2/2/15, 114.2 lb (15.9 lb 12.22% of total body weight lost in one month) 3/1/15, 113.7 lb (loss of 0.5 lb) 4/2/15, 111.5 lb (loss of 2.2 lb) 5/2/15, 107.4 lb ( loss of 4.1 lb) 5/31/15, 110 lb 6/29/15, 107.4 (loss of 2.6 lb, 17.45% of body weight lost in six months) 7/2/15, 106.8 (loss of 0.6 lb). During a concurrent interview and record review with the Registered Dietician (RD) on 7/22/15 at 11:20 am, she reviewed the record for Resident 9's weight loss. When asked to describe what interventions had been put in place to address Resident 9's ongoing weight loss, RD stated staff monitor the resident's intake and provide her catered meals (staff ask the resident her preferred food at meals). RD stated she interviewed Resident 9 in January and the resident told her she didn't feel well enough to eat and wasn't hungry. RD stated she did not ask the resident if she was having pain or what her decreased appetite might be related to. RD acknowledged she reviewed Resident 9 again in February, at which time Resident 9 was only eating between 10 to 45% of her meals, and again, the resident complained she did not feel well enough to eat. The RD stated did not ask the resident if she was having pain. The RD interviewed the resident in March, after continued weight loss, and Resident 9 again told the RD she didn't want to eat or get out of bed. The RD did not inquire if this was related to pain. The RD stated she ordered snacks for the resident. When asked about what interventions beyond meal intake monitoring, catering, and snacks had been initiated when the resident had continued weight loss, the RD stated she could not address Resident 9's weight loss because she is in complete control of her menu and intake. When asked to describe any further interventions considered, the RD stated, I don't know any more. I don't know what to do. When asked to describe how she was collaborating with the physician to address ongoing weight loss, the RD was unable to clarify and acknowledged she had not met or talked to the physician to discuss Resident 9's poor appetite. The RD acknowledged she had not considered the resident's poor intake might be related to pain. During a concurrent interview and record review with LVN A, on 7/22/15 at 12 pm, she was asked to review the physician's orders [REDACTED]. LVN A stated she provides medications as ordered which is [MEDICATION NAME] twice daily and [MEDICATION NAME] four times daily for moderate pain. LVN A acknowledged she does not reassess the resident after pain medication and documents the medication was effective, unless the resident directly complains. When asked how she would know Resident 9 required additional medication to control her pain, LVN A stated the resident would have to complain directly to the staff. After reviewing the MARs, LVN A acknowledged Resident 9 was infrequently provided additional pain medications and was unable to clarify why Resident 9 continued to complain of pain when staff documentation indicated the resident's pain was effectively relieved. During an interview with Resident 9, on 7/22/15 at 5:05 pm, she complained of ongoing, unrelieved pain in her back and right leg. She described the pain as frequent, everyday, and rated it 8.5-9 (severe) out of ten (0-10 scale.) Resident 9 stated she told the physician and nursing staff of her ongoing uncontrolled pain, but they do nothing and the doctor is worthless. Resident 9 stated she used to attend activities but no longer can, due to the severity of her pain, which leaves her unable to get out of bed. Resident 9 stated she stopped reporting her pain, despite it remaining unrelieved because, They never do anything anyway. Why would I bother? They don't care. Resident 9 stated she was unaware she had lost weight, but acknowledged she had a poor appetite and described her refusal to eat as related to her ongoing pain. Resident 9 stated, When you're hurting this bad for this long it's all you can think about. I don't want to eat. I don't want to move. I can't do anything. During an interview with the physician (MD G), on 7/23/15 at 8:53 am, he stated he was aware of Resident 9's weight loss. He stated he had initiated no interventions because he, wanted to wait and see. He acknowledged the RD did not consult with him regarding interventions to address Resident 9's ongoing weight loss and refusal to eat. 3. Resident 6's clinical record was reviewed. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's quarterly MDS, dated [DATE], indicated Resident 6 had severe cognitive impairment, rarely/never understood. On 7/21/15 at 11:15 am, during an interview and a review of Patient 6's record, LVN C confirmed Resident 6's Weekly Nurses Assessments identified she had moderate pain. LVN C confirmed Resident 6 had one physician order [REDACTED]. LVN C stated they do not have a consistent routine manner for assessing and documenting pain in the medical record. On 7/21/15 at 10:30 am, during an interview with the Director of Nurses (DON) and the Chief Nursing Officer (CNO), they confirmed licensed nurses document the effectiveness of routine and PRN pain medications right after the medications is given, rather than waiting until the medication has had time to take effect. The CNO and the DON confirmed they could not locate/provide a policy for doing consistent routine pain assessments.

Based on observation, interview, and record review, the facility failed to ensure its Fall Policy was implemented to prevent falls for three of ten sampled residents (Residents 1, 4, and 7) when: 1. The facility failed to prevent Resident 1 from falls and resultant injuries, failed to provide a sitter (designated staff assigned to directly supervise the resident at all times), conduct post fall Interdisciplinary Team (IDT) evaluations, and investigate the falls to prevent future falls with injury. Resident 1 suffered 10 falls in a seven month period. Resident 1 sustained a broken arm, bilateral shoulder pain, head laceration (cut), head contusions (bruise) and head/neck pain, and disfigured fingers to her left hand requiring casting in the hospital emergency room (ER) and stitches to her left forehead/eyebrow area. 2. Resident 4 suffered two falls within one week resulting in four skin tears. The post fall investigation did not identify a contributing factor for falls. The Fall Huddle (Fall Committee member discussion about a resident fall) was not reviewed/evaluated by the Director of Nursing (DON) or Minimum Data Set Coordinator (MDS C). A Fall Committee review was not completed for the falls. 3. Resident 7 suffered three falls in a seven month period. The facility's Fall care plan did not accurately reflect Resident 7's falls and post fall investigations were not completed. The facility's nursing staff made a decision to physically restrain Resident 7 inappropriately, as a fall prevention intervention, and did not involve the other appropriate departments to make decisions about post-fall care. These failures resulted in avoidable falls with significant injuries to Resident 1, two falls with injury to Resident 4, three falls for Resident 7 and incomplete fall assessments, nursing/fall committee review, and unnecessary restraints, placing residents at risk for future falls with the potential for serious injuries. Findings: On 7/22/15 at 10 am, the Charge Nurse stated, a fall packet that contained instructions and forms to be utilized by the nurse when a resident had fallen was kept at the nurses station for nurses to complete. A concurrent review of the fall packet indicated the packet included the following: Standards to Follow When a Fall Occurs, undated, instructed the charge nurse or the nurse caring for the resident will initiate the Fall Investigation Follow-up Form. The original will go to the Director of Nursing (DON), and Minimum Data Set (MDS) Coordinator will receive a copy. MDS Coordinator will then be responsible in communication with the rest of the fall committee. Residents will be reviewed and evaluated based on current condition . concerns related to the fall including underlying medical and environmental issues. These items are to be documented on the Fall Investigation Follow-up Form. Fall Risk Assessments are to done at admission, upon every fall, and quarterly by the MDS Coordinator. This is kept is the resident's chart. Care Plans are reviewed and revised based on individual needs. At least one new approach in fall prevention needs to be implemented after a fall occurs. The date of the fall does not need to go on the care plan . there needs to be a new intervention immediately after the fall. Make sure the intervention had a date. A post fall huddle is to be done as soon as possible, this will include the Fall Committee team members. During night shifts and weekends the post fall huddle will be coordinated with fall committee members present, though they will do a review on the next business day. Fall Committee members: DON, Administrative Assistant, MDS Coordinator, Director of Staff (DSD) Development/Charge Nurse, Social Services, and Physical Therapy/Rehab Nurses Aide. A Fall Investigation Follow-up indicated the following information or questions were to be addressed: Summary of the fall, type of injury, restraint(s) in use, medication changes, resident changes in function, call light in reach, alarms in use, gait belt used if fall occurred during a transfer, non-skid foot ware, environmental factors, vital signs, therapy notification. The form included a place for signatures of the nurses, date signed, who completed the form, date turned into the MDS Coordinator and copy made for the DON, date Physical Therapy/Rehab Nurses Aide were notified of the fall. A document, The Fall Investigation Committee, Post Fall Huddle Conclusion (Required immediately after any Fall) reflected the following: date reviewed by DON, MDS Coordinator, date of Post Fall Huddle, list of staff present, if the fall occurred during normal office hours or after office hours, factors believed to have contributed to the fall, care plan updated to include .by whom, additional comments/concerns, Reviewed by Fall Committee: Date and Sign (one space). A Neurological Check Flow Sheet, which included space for vital signs (temperature, blood pressure, heart rate, respiration rate) and assessments. A policy titled, Fall Prevention Guidelines, effective 4/2014, indicated, Procedure, all residents will be assessed on admission and continuing throughout the stay using the fall assessment guidelines. All falls that occur will be investigated by a fall prevention committee to conclude on interventions to prevent future incidents. Each resident at risk for falls will have an individualized care plan with clear fall prevention interventions. Ensure optimal communication regarding the resident's condition and potential for fall with other care providers during shift changes. Include all disciplines when transferring information about the resident with the resident with his/her family about the fall prevention issues . Post fall huddles are to take place immediately after a fall occurs. This will be carried out by an established Fall Prevention committee. If established committee is not present, this will be carried out by the Charge Nurse on duty who will organize the post fall huddle and chart review. When neither establish fall committee, nor Charge Nurse are present, such as night shift, the Nurse assigned to the resident will complete the huddle, fill out the Fall Investigation Follow UP form along with the Post Fall Huddle form and turn original in to DON and copy to the MDS Coordinator. Documentation with fall details is to be completed in the Nurses Notes. The Care Plan is to be updated with new intervention when a fall occurs. These interventions are to be carried out immediately and documented in the Nurses Notes. An SOC-341 (form used to report potential abuse to state agencies) is required if a fall results in significant injury. 1. Resident 1's record was reviewed. Resident 1 was admitted [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. A physician acute care History and Physical (H&P) note, dated 6/23/14, documented Resident 1 was admitted to the acute care facility due to a fall and fracture to her sternum (chest bone) and inability to care for self, due to dementia and she had lived alone. She was transferred and admitted to the long term facility on 6/24/14. Resident 1 was able to freely walk about the facility on admission per nurse's notes on 6/24/14. The record indicated Resident 1 had ten falls between 8/27/14 and 3/22/15, documented in the nurse's notes, on 8/27/14, 9/2/14, 9/9/14, 9/24/14, 10/12/14, 10/20/14, 12/13/14, 12/18/14, 1/23/15, and 3/22/15. No Interdisciplinary Team (IDT) process or fall team investigation was found in Resident 1's record for these 10 falls. a. On 8/27/14 at 5:30 am, Resident 1 was found on bedroom floor lying on her right side, she complained of shoulder pain on both right and left sides and stated she hit everything. She sustained a long scratch to her left forehead. On 8/27/14 at 7:50 am, the nurse's notes read Resident 1 was transferred to the ER for x-rays of her left shoulder that revealed a humerus head fracture (top of upper arm bone was broken). On 7/22/15 at 4 pm, the Minimum Data Set Coordinator (MDS C) provided fall investigation reports that were not kept in the medical records. The 8/27/14 post fall investigation identified cause was not wearing non-slip socks (an intervention that was on her care plan since 6/27/14). New interventions suggested were to assist with transfers and to place a pressure alarm at night (a pad that goes under the resident and alarms as resident gets up). However, the pressure alarm was not added to the care plan until 9/24/14. b. On 9/2/14 at 11:15 pm, a nurse's note read, Resident 1 was in a recliner with the foot raised, scooted forward falling out of the chair, hitting the left side of her forehead, sustaining a one and a half inch laceration above her left eyebrow. Her left arm was in a sling due to the previous fracture. There was no post fall investigation for this fall and no new intervention(s) care planned. A physician's orders [REDACTED]. c. On 9/9/14 at 12:15 am, a nurse's note read, Resident 1 was found on the floor in her room, stating she fell and landed on her buttocks while trying to change her shirt. No injury was noted by the nurse. The 9/9/14 post fall investigation identified cause was that Resident 1 took off her non-slip socks, turned off the pressure alarm, with a sling on left arm, and did not use the call light. New interventions suggested were a full time sitter, frequent room checks at night, and observe throughout the day. These suggested interventions were not added to Resident 1's care plans until 10/12/14. On 9/9/14 at 2:45 pm, a nurse's note read, Resident 1 had a sitter for the day. At 3:02 pm, a nurse's note read, new bed alarm and pad in place on bed and was not added to the care plans at this time. On 9/10/14 at 12:45 am, a nurse's note read, Resident 1 continued to have a sitter. At 3:56 pm an X-ray of residents left arm and wrist was ordered. On 9/11/14 at 1:30 pm, a nurse's note read, a sitter was with Resident 1 at all times. No further nurses notes of a sitter or 1:1 staff were found until 9/21/14 at 12:40 pm, when Resident 1 was walking with a shuffle and nearly fell twice. d. On 9/24/14 at 3 am, a nurse's note read, Resident 1's condition had changed; she had increased restlessness, wandering in the hallways with very unsteady gait, stumbling many times, and staff has had to walk beside her for safety. On 9/24/14 at 2:20 pm, a nurse's note read, at 1:45 pm, Resident 1 was found on the bedroom floor laying on her right side with a laceration and contusion above left eye. She complained of left shoulder and arm pain and head pain. She was transferred to the ER. She developed a bump on the back of her head from this fall. An investigation report was not completed for this fall. A care plan intervention to use a Lap buddy (a soft pillow restraint that tucks into a wheel chair over the resident's lap keeping her restrained in the wheelchair) was added to her fall care plan on 9/24/14. On 9/26/14 at 5:15 pm, the physician ordered morphine (a powerful pain relief medication) and a Lap buddy for postural support when up in the wheel chair. The nurse's notes indicated Resident 1 was not sleeping for several days, unstable walking, more confused, and was refusing fall interventions, prior to this order. On 9/29/14 at 6 am, a nurse's note read, Resident 1 had a severe lack of safety awareness. She had 1:1 staff all night shift because she was refusing to stay in bed. Nurse's notes from 9/26/14 to 10/9/14 read, Resident 1 continued to use a lap buddy and a 1:1 sitter when at risk. She was able to remove the lap buddy and would strike out at staff when staff would put the restraint back in place. e. A fall investigation record provided by the MDS C identified on 10/12/14 at 8:30 am, Resident 1 was found in her bathroom on the floor, no injury was identified. No new care plan interventions were suggested on this form. The fall care plan read, Sitter to provide 1:1 supervision, added 10/12/14. f. On 10/20/14 at 2:30 pm, a nurse's note read, Resident 1 was found on the floor, next to her bed on a floor mat, laying on her left side, complaining of right shoulder and neck pain. X-rays were ordered. The post fall investigation identified the causes of the fall were Resident 1's restlessness in her bed. New interventions suggested were a curved mattress to help keep her from falling from her low bed and a 24 hour sitter. There was no evidence that a curved mattress was used. Nurse's notes from 10/21/14 to 11/6/14 read, Resident 1 had a sitter with her. On 11/1/14, a physician's progress note documented, She (Resident 1) is suffering with some pain related to repetitive falls. When she has a sitter, she is doing much better and not falling. On 11/3/14 at 4:45 pm, the physician ordered the use of a merry walker (a four wheel walker that has a seat and encloses/restrains the resident in a plastic tube frame, that she could not get out of without staff assist), as needed for weak truncal muscles. This restraint intervention was not added to the fall risk care plan until 11/7/14. The facility's Fall Risk and Self-Care Deficit care plans, last reviewed 6/29/15, both read, the sitter was discontinued on 12/1/14. g. On 12/13/14 at 10:40 pm, a nurse's note read, Resident 1's bed alarm had sounded and she was found to have fallen, laying on the floor on her left side. She sustained a laceration to her left forehead above her eyebrow and disfigurement of her fingers of her left hand. Resident 1 was sent to the ER. The post fall investigation again identified restlessness and possibly the bedside mat contributed to the fall. A new intervention suggestion read, May need sitter reinstated, every 15 minute room checks while in bed to observe for restlessness, if restless, place in merry walker. The former DON's written response to the above suggestions was There has never been an order for [REDACTED]. On 12/14/14 at 1:30 am, a nurse's note read, Resident 1 returned from the hospital with her left forearm in a cast and seven to ten stitches to her left eyebrow/forehead area. h. On 12/15/14 at 12:20 am, a nurse's note read, though Resident 1 stated understanding of using her call light when getting up from bed, her bed alarm had gone off as she got up unassisted, as she forgets to use the call light. On 12/18/14 at 7:40 pm, a nurse's note read, at 5:45 pm, Resident 1 had a fall with no injury. No details were given in the nurse's note as to where the fall occurred or how she was found. The post fall investigation did not identify where she was located at the time of her fall, but indicated Resident 1 climbed out of her merry walker, and stated, I did it on purpose. A new intervention to keep resident in eye sight when up in the merry walker was added to her care plan. The nurse added a on this form, I am at my wits end. What has changed to make a sitter un-needed. On 12/28/14 at 12:45 pm, a nurse's note read, Resident 1 was up in her merry walker. On 1/7/15 at 10 pm, a nurse's note read, Resident 1 continues to call out for help in order to have someone stay with her. i. On 1/23/15 at 2:30 pm, a nurse's note read, when Resident 1 was found on the floor, she stated, I removed myself from my walker and sat down on the floor. No details of where Resident 1 was at the time of her statement were documented. No injuries were noted. No post fall investigation or care plan intervention changes were documented. On 1/24/15 at 7 am, a nurses note read, Resident 1 removed her left arm/hand cast (that had previously been split due to swelling). A metal backed splint was then applied, as ordered by the physician. On 2/5/15, a physician's progress note documented, Previously a sitter had been ordered, but the sitter came, she did well, but then the sitter did not come back for reasons unknown to me. On 2/9/15, a late entry nurse's note read, a new cast was applied to Resident 1's left hand on 2/3/15. On 3/2/15 at 7 pm, a nurse's note read, Resident 1's cast (due to a fall on 12/13/14) was removed. A splint was continued. j. On 3/22/15 at 2:15 am, a nurse's note read, Resident 1's pressure alarm was heard and staff found resident on floor in a sitting position with her back up against her roommates bed. Resident 1 was noted to have redness to her middle back, no other injury, able to move all extremities, and no complaints of pain, except the left hand. Resident 1 stated she wanted to use the bathroom and not bother anyone. The post fall investigation was incomplete and was not signed by the MDS C or new DON. On 4/21/15 at 6:08 pm, a nurse's note read, Resident 1 was medicated for increased complaints of pain as physical therapy was working with her bad hand, (the left hand injured in a fall on 12/13/14). On 7/22/15 at 4 pm, during an interview and review of the above documentation, the MDS C stated not all of Resident 1's falls had appropriate follow up. On 7/28/15 at 8:20 am, the new DON stated the facility had not been following the fall policy. On 7/28/15 at 10 am, MDS C nurse stated she coordinates the fall prevention program and had not involved other disciplines (Activities, Social Service, Dietary, Physical Therapy) since IDT's for falls were stopped over a year ago, and that she should have ensured and documented communication when considering the fall prevention plans and interventions. MDS C stated the fall investigations are investigated and reviewed by her and the DON, but these reviews were not kept in the active record. MDS C stated none of the falls included documented an IDT process of evaluation and decision making in the record. 2. The record for Resident 4 was reviewed on 7/23/15. Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He had two falls since admission to the facility; one on 7/12/15, and a second on 7/17/15. a. The facility's Fall Investigation Follow-Up for 7/12/15 was reviewed. The fall was described as, Res (resident) fell from bed, reaching for water on bed side table, which resulted in four skin tears (tThe form failed to identify that the resident had a decline in his ability to perform his activities of daily living (ADLs), according to the ADL Tracking form, dated 7/2015). A Post Fall Huddle was performed on 7/12/15 and identified it was held by one Licensed Vocational Nurse and four Certified Nursing Assistants. No registered nurse, physical therapists, physicians, pharmacists, or social service personnel were identified as being in attendance. The document identified the fall was reviewed with the DON and MDS C on 7/13/15, but were not signed by the DON or MDS C. There was documentation that this incident had been reviewed by the Fall Committee on 7/13/15. However, the staff members of the Fall Committee were not identified. b. The Fall Investigation Follow Up for 7/17/15 was reviewed. The fall was described as, found res (resident) on floor. There was no documentation to indicate this form was shared with the MDS nurse or physical therapy staff. The Post Fall Huddle was performed on 7/17/15 and identified it was held by one Licensed Vocational Nurse and four CNAs. There was no documentation that the Fall Committee had reviewed this incident. During an interview with the Director of Staff Development (DSD) on 7/28/15 at 8:40 am, she stated the Post Fall Huddle included one nurse and the CNA's working in the area. She confirmed she had not attended a Fall Committee meeting for over one year and was not involved in the Post Fall Huddles. The DSD confirmed the Fall Committee does not include herself, the DON, MDS C, the physician, or a physical therapist. 3. Resident 7's record was reviewed and indicated Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A concurrent review of Resident 7's record was conducted on 7/27/15 at 5 pm with the MDS Coordinator (MDS C) and indicated the following: A physician's orders [REDACTED]. The Nurses Notes indicated on 7/14/15 at 5:20 pm, Resident in dining room stood up, knees buckled, and rolled to floor. Skin tear to left elbow. At 5:30 pm, MD and responsible party aware. Nurses Notes, dated 7/15/15 indicated, 12 pm, MD at this time is not ready to apply restraint, will think about it. At 1 pm, new orders received. A document titled, Fall Risk Assessment indicated, assessments for fall risk were done on 11/15/14, 1/(illegible, unable to read day)/15, 1/7/15, 3/30/15, 6/24/15, and 7/14/15. The document did not indicate if the assessments were completed after a fall or part of a quarterly review. A Fall Risk Care Plan, indicated the following approaches: low bed with bedside mat and pressure alarm while in bed and in wheelchair (5/21/14), non-skid foot wear, put resident in bed after meals to prevent attempt to self transfer, frequent room checks (3/20/15), observe resident while up in chair to ensure that she in not attempting to transfer self (3/31/15), Fall (7/14/15), ask MD for a self release seatbelt trial, Self releasing seat belt in wheelchair (7/15/15). The care plan did not indicate a plan for instruction in the use of a self release seat belt, who was responsible to instruct Resident 7 in the use of the belt, or monitor her response. The care plan did not indicate if and when Resident 7 had previously fallen, except the fall on 7/14/15. The clinical record did not contain evidence of specific dates when Resident 7 had fallen, and did not include completed post fall investigations or documented factors about previous falls. On 7/28/15 at 5:30 pm, after the concurrent record review, during an interview, the MDS C confirmed Resident 7 had three falls in the last seven months, one recent fall on 7/14/15, and two previous falls on 1/7 and 3/30/15. The MDS C provided additional documents which were not contained in Resident 7's record which were concurrently reviewed and included three two sided reports titled, Fall Investigation Follow-up which indicated, Resident 7 had fallen on the following dates and times; 7/14/15 at 5:20 pm in the dining room, 3/30/15 at 5:30 pm in the dining room, and 1/17/15 in her room. The MDS C stated the Fall Investigation Follow-up reports were completed by the nurse, MDS C, and the DON, and after the form was completed, was sent to the Risk Department and not filed in the resident's record. The Fall Investigation Follow-up, dated 7/14/15, indicated Resident 7 stood up from her wheelchair and her knees buckled and she rolled to the floor. The MDS C stated the Post Fall Huddle Conclusion, dated 7/15/15, was signed by four nursing staff, under Section, Present for Post Fall Huddle Print/Sign and indicated, LVN C, LVN A, CNA N, and another staff (illegible, unable to read), documented Care plan updated to include . ask MD for self release seat belt trial. At the bottom of the form, Additional Comments/Concerns, indicated, Patient has had multiple falls within the last three months, attempts to stand and fall-needs intervention, family wants next step to prevent fracture. The MDS C stated she discussed Resident 7's fall with the other nurses and she made the recommendation to use a self release seat belt. She confirmed other facility departments were not involved with the recommendation. On 7/28/15 at 10:38 am, during a observation and interview with Physical Therapy Assistant (PTA), Resident 7 was seated in her wheelchair and a self release seatbelt (SRSB) was across her lap and in use. Resident 7 was questioned by PTA about the SRSB. He asked her to demonstrate how it worked. Resident 7 looked at the seat belt, touched the belt and looked at PTA. PTA then demonstrated how the SRSB was released and close. Resident 7 then attempted to release the belt and was unable to reach the opener or manipulate her hands around the belt. PTA then stated the SRSB was a restraint and should not be used. PTA stated there were other supports or systems to consider first, which were less restrictive to help remind Resident 7 not to get up from her wheel chair unassisted. PTA stated he was previously more involved post-falls, but things had changed. PTA stated he was informed of resident falls informally and did not attend post-fall reviews. On 7/28/15 at 12:02 pm, the Chief Executive Officer stated the nursing department made decisions about residents care after they had fallen. The nurses did not involve other appropriate departments to make decisions about post-fall care.

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when nutritional interventions and assessments were not adequate or consistent for five of ten sampled residents (Residents 1, 2, 5, 9, and 10) and one resident outside the sample (Resident 13) when: 1. Resident 9 had an avoidable 23.3 pound (lb) weight loss over a six month period. The facility failed to ensure an Interdisciplinary Team (IDT) process to evaluate Resident 9's poor intake to determine the underlying cause of her lack of appetite and weight (wt.) loss and Activities of Daily Living (ADL) documentation was incomplete, missing documentation of meal consumption percentages and snacks consumed/provided. 2. Resident 1 had 20.8 lbs weight loss by 2/2015, since admission in 6/2014. The facility failed to provide a House Product nutritional supplement (fortified shake, ensure or pudding) three times a day, as recommended by the facility's Registered Dietitian (RD) on 12/3/14 (when Resident 1 had lost 9.2 lbs in a month), and again on 2/18/15, (after Resident 1 lost 13.6 lbs in a month). 3. Resident 2 had a 9 % body weight loss in three months, was not positioned properly during feeding by Certified Nursing Assistant (CNA) R, and weekly weights were not done. Refer to F 327. 4. Resident 13 had a change in weight, which could not be re-assessed by the RD on 7/5, 7/12, and 7/19/15, due to a broken scale. 6. The facility's Hoyer lift scale (a sling type lift used for non-ambulatory residents) did not work properly for over two weeks resulting in five resident's (Residents 2, 5, 10, 12, and 13) having significant weight changes that did not appear to be accurate and these residents could not be re-weighed until the Hoyer scale was repaired. Without the weights the RD could not establish goals and dietary recommendations or review if the previous interventions had been effective. These failures resulted in unplanned weight losses for Residents 1 and 9, and the potential for further weight loss, malnutrition, and inaccurate weight assessments and nutritional evaluations for residents who are at risk for nutritional compromise or weight loss. Findings: The Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM) for Long Term Care, parameters for evaluating significance of unplanned and undesired weight loss, include: Significant Weight Loss (5% in one month / 7.5% in 3 months / 10% in 6 months). Severe Weight Loss (Greater than 5% in one month / greater than 7.5% in 3 months / greater than 10% in 6 months). The facility policy and procedure titled, Monitoring Resident's Weight dated 2006, indicated, Any significant and unplanned weight gain or loss of over five pounds in 30 days or ten pounds in 90 days shall be reported to the attending physician . the consulting dietician will review the weights of all newly admitted residents and at least quarterly thereafter and will make recommendations as to dietary changes if problems are identified. 1. The record was reviewed for Resident 9 on 7/22/15. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's most recent Minimum Data Set (MDS, a resident assessment), dated 5/11/15, indicated she complained of frequent moderate pain and was experiencing weight loss. A review of the Alteration in Nutrition care plan, last reviewed 7/1/15, indicated Resident 9 had a poor appetite and decreased oral intake. The care plan goal was for Resident 9 to eat more than 70% of meals. On 2/2/15, the care plan was revised to include a diet change from regular to pureed foods and Certified Nursing Assistants (CNAs) were to feed the resident for all meals. On 5/21/15, the care plan was revised to include selecting foods that the resident enjoys eating, and on 5/22/15, to encourage the resident to eat most of her meal and snacks. There were no revisions to this care plan after 5/22/15. A review of the facility's Physician's Progress Notes, Monthly Weight Records, Activities of Daily Living (ADL) charting, and Nurses Notes for Resident 9 from 1/2015 through 7/2015, indicated the following: On 1/3/15, Resident 9 weighed 130.1 pounds (lb). The January 2015 nurses notes, dated 1/4 to 1/5/15, indicated Resident 9 had a respiratory illness with related fever and lethargy. On 1/14/15, in a late entry, the physician's progress noted indicated the facility had numerous patients who were sick with respiratory illness. The January 2015 ADLs charting indicated Resident 9 expressed not feeling well, not wanting to eat or drink, and was incontinent (involuntary loss of control) of loose stool, and weak. Resident 9 consumed 75% for only one meal in 31 days; Staff documented Resident 9 refused 39 meals and some snacks, and the remaining documented meal intake percentages were 50% and below. The ADLs records were incomplete; missing documentation of meal consumption % for 14 meals and 21 snacks consumed/provided. On 2/2/15, Resident 9 weighed 114.2 lb (a 15.9 lb, 12.22% total body weight loss in one month. A severe weight loss is a loss of above 5% in a single month). In February 2015, the ADLS charting indicated Resident 9 continued to have poor oral intake. Resident 9 consumed 70% or more for only 11 meals in 28 days. Resident 9 continued to consume less than her 70% goal for the remaining meals and/or refused meals and some snacks. The ADLs records were incomplete; missing documentation of meal consumption % for 19 meals and 19 snacks consumed/provided. On 3/1/15, Resident 9 weighed 113.7 lb (a loss of 0.5 lb). In March 2015, the ADL charting indicated Resident 9 vomited on 3/10/15, continued to have poor intake, and consumed 70% or greater for only six meals in 31 days. Resident 9 continued to consume less than her 70% goal for the remaining meals and/or refused meals and some snacks. The ADLs records were incomplete; missing documentation of meal consumption % for 3 meals and 13 snacks consumed/provided. On 4/2/15, Resident 9 weighed 111.5 lb (a loss of 2.2 lb). On 4/3/15, a physician's progress notes indicated Resident 9 had decreased cognition and slept quite a bit. The April 2015 ADL charting indicated Resident 9 seemed more sleepy, had loose stool, and continued poor intake. Resident 9 consumed 70% or greater for only 13 meals in 30 days. Resident 9 continued to consume less than her 70% goal for the remaining meals and/or refused meals and some snacks. The ADLs records were incomplete; missing documentation of 18 snacks consumed/provided. On 5/2/15, Resident 9 weighed 107.4 lb (a loss of 4.1 lb). On 5/5/15, a physician's progress noted indicated Resident 9 was losing weight, not interested in food and seems more sleepy than usual. The May 2015 ADL charting indicated Resident 9 was not interested in food and was sleepy. Resident 9 consumed 70% or greater for only 23 meals in 31 days. Resident 9 continued to consume less than her 70% goal for the remaining meals and/or refused meals and some snacks. The ADLs records were incomplete; missing documentation of meal consumption % for 1 meal and 11 snacks consumed/provided. On 5/31/15, Resident 9 weighed 110 lb. In June 2015, ADL charting indicated Resident 9 was having liquid, runny stools and consumed 70% or greater for only 22 meals in 30 days. Resident 9 continued to consume less than her 70% goal for the remaining meals and/or refused meals and some snacks. The ADLs records were incomplete; missing documentation of meal consumption % for 4 meals and 15 snacks consumed/provided. On 6/29/15, Resident 9 weighed 107.4 (a loss of 2.6 lb, 17.45% of body weight lost in six months. A severe weight loss is anything over 10% in 6 months), and on 7/2/15, Resident 9 weighed 106.8 lb (a 0.6 lb loss). In July 2015, ADL charting indicated Resident 9 was feeling ill, had a low-grade fever, and continued to have loose, watery stools. Resident 9 consumed 70% or greater for only 13 meals in 22 days. Resident 9 continued to consume less than her 70% goal for the remaining meals and/or refused meals and some snacks. The ADLs records were incomplete; missing documentation of meal consumption % for 2 meals and 5 snacks consumed/provided. A review of the facility's registered dietitian (RD) progress notes, dated from 1/5/15 through 7/8/15, indicated: In January: Resident 9's wt. was 130.1 lb (down 5.7 lb in the quarter), she had low nutritional intake, and was receiving a 2 gram (gm) sodium fortified mechanical soft (chopped foods) diet with small portions. On 1/14/15, estimated nutritional needs were revised, Resident 9 expressed not feeling well and did not complain about the foods served. On 1/23/15, Resident 9 was noted to have a decline and was not hungry. The RD's plan included monitoring, offering a catered diet, encouragement. In February, Resident 9 was noted to have a significant wt. loss on 2/18/15, weighing 114.2 lb (down 14% in 6 months). Her diet included mechanical soft 2 gm sodium and she was to receive snacks three times daily. The RD documented Resident 9's recommended daily allowances were not met. The RD's plan was to monitor progress. In March, on 3/4/15, Resident 9's wt. was 113.7 lb (a 15% loss in 6 months). Resident 9 expressed not feeling good enough to eat or get up, but had no food complaints. The RD documented the physician was aware of Resident 9's decline. There were no new recommendations. In April, on 4/8/15, Resident 9's wt. was 111 lb (a 2.7 lb loss). The RD documented, Resident 9's gradual wt. loss was due to the resident having control of her choices, eating in her room, and refusing to eat more. The RD documented, catered diet offered. MD aware of wt. loss. RDA's not met. Plan to encourage increased intakes and cater. On 4/11/15, a special catered menu was developed. Resident 9's wt. was 108 lb (down 3 lb). In May, on 5/6/15, Resident 9 weighed 107.4 lb (an additional 3.6 lb loss). The RD documented, no appetite for food, refusing catered diet. Pureed fortified snacks three times daily. No labs. RDA's not met. The RD recommended discontinuing Resident 9's therapeutic diet and planned to continue to monitor. On 5/21/15, the RD documented the diet was changed to regular pureed and Resident 9 expressed taking in more nutrition recently. On 5/29/15, Resident 9's intake was a little better. The RD's plan was to monitor. In June, on 6/2/15, the RD recommended selected menu choices. On 6/3/15, Resident 9 weighed 110 lb (up 2.5 lb in one month). The RD documented the catered diet may be helping. In July, on 7/8/15, the RD documented Resident 9 responds well to male assistants, had low intake, and Resident 9's wt. was 107 lb (down 3 lb). During a concurrent interview and record review with the Registered Dietician (RD) on 7/22/15 at 11:20 am, she reviewed the record for Resident 9's weight losses. When asked to describe what interventions had been put in place to address Resident 9's ongoing weight loss, she stated, staff monitor the resident's intake and provide her catered meals (staff ask the resident her preferred food at meals). The RD stated she interviewed Resident 9 in January 2015 and the resident told her she didn't feel well enough to eat and wasn't hungry. RD stated she did not ask the resident if she was having pain or what her decreased appetite might be related to. The RD stated she reviewed Resident 9 again in February 2015, the resident was only eating between 10 to 45% of her meals and Resident 9 again complained she did not feel well enough to eat. The RD did not ask the resident if she was having pain. The RD interviewed the resident in March 2015, after continued weight loss, and Resident 9 again told the RD she didn't want to eat or get out of bed. The RD did not inquire if this was related to pain. The RD stated she recommended snacks for the resident. When asked what interventions beyond meal intake monitoring, catering, and snacks, had been considered when the resident had continued insidious (proceeding in a gradual, subtle way, but with harmful effects) and significant weight loss despite these interventions, the RD stated she could not address Resident 9's weight loss because she is in complete control of her menu and intake. When asked to describe any further interventions considered, the RD stated, I don't know any more. I don't know what to do. When asked to describe how she was collaborating with the physician to address ongoing weight loss, the RD stated she had not met with/talked to the physician to discuss Resident 9's continued poor appetite and low intake. The RD stated she had not considered that Resident 9's poor intake might be related to pain and did not evaluate further to determine the underlying cause of her refusal to eat. During an interview with Resident 9, on 7/22/15 at 5:05 pm, she complained of ongoing unrelieved pain in her back and right leg. She described the pain as frequent, everyday, and rated it 8.5-9 (severe) out of ten (0=no pain, 10=worst pain imaginable on a pain scale of 1 to 10). Resident 9 stated she told the physician and nursing staff about her ongoing uncontrolled pain, but they do nothing. Resident 9 stated she had stopped reporting her pain, despite it remaining unrelieved because, they never do anything anyway. Why would I bother, they don't care? Resident 9 stated she was unaware she had lost weight and stated she had a poor appetite and described her refusal to eat as related to her ongoing pain. Resident 9 stated, When you're hurting this bad for this long it's all you can think about. I don't want to eat. I don't want to move. I can't do anything. During an interview with the physician (MD G), on 7/23/15 at 8:53 am, he stated he was aware of Resident 9's weight loss. He stated he had initiated no interventions because he, wanted to wait and see. He stated Resident 9 had not recently complained of pain and he had discontinued one of her pain medications ([MEDICATION NAME] - a long acting medication to treat chronic moderate and severe pain) the previous month (6/26/15). He confirmed the RD did not consult him regarding interventions to address Resident 9's ongoing weight loss and refusal to eat. 2. Resident 1's record was reviewed. Resident 1 was admitted [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Review of the facility's Self-Care Deficit care plan, last revised 6/29/15, indicated Resident 1 required staff assistance with setting up her meals and encouragement to eat. A review of the facility's Vital Signs and Weight Record for Resident 1 indicated: Resident 1's weight on admit (6/2014) was 113.2 pounds (lbs); In 10/2014, she weighed 117.0 lbs; In 11/2014, she weighed 111.2 lbs (a 5.8 lb loss in a month or 5 percent (%) of her body weight); In 12/2014, she weighed 102.0 lbs (a 9.2 lb loss in a month or 8.3 percent (% ) of her body weight); In 1/2015, she weighed 106.0 lbs; and On 2/2015 she weighed 92.4 lbs (a 13.6 lb loss in a month or 12.8 % of her body weight). Resident 1 lost a total of 20.8 lbs or 18.4 % of her body weight by 2/2015, since admission in 6/2014. On 7/22/15 at 10:30 am, during an interview and record review, the facility's Registered Dietician (RD) stated the facility did not have an IDT meeting approach for weight loss concerns. She stated she made a recommendation for Resident 1, on 12/3/14 (when she had lost 9.2 lbs in a month), for a House Product supplement (fortified shake, ensure or pudding) three times a day, but this was not followed up by the nursing staff and ordered by the physician. That Resident 1 continued to lose significant weight and she requested the House Product supplement a second time on 2/18/15 (after Resident 1 lost 13.6 lbs in a month). A concurrent review of RD Nutritional Assessment Records, indicated on 12/3/15, the RD recommended a House Product three times daily as a nutritional supplement. On 2/18/15, the RD documented, Fortified Product offered three times a day was not in the orders. The nutritional supplement three times a day was not ordered until 2/23/15 at 2:56 pm. 3. Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was totally dependent for all aspects of her care. The Physician Orders, dated 7/2015, indicated a dietary order for regular fortified food pureed (ground food to a smooth, think consistency), dysphagia, at risk for aspiration (food or liquid into the lung(s), liquids honey thick consistency. A Care Plan, dated 6/17/15, titled, At Risk for Aspiration (food/liquid going into the windpipe/lungs) with Fear of Choking, instructed, Approaches, notify physician of any changes as needed. Observe for signs and symptoms (s/s) of dehydration (occurs when water/fluid intake is insufficient to replace fluid loss of bodily functions; such as urine, sweat and breathing). A progress note by the RD, dated 7/8/15, indicated, Resident 2 had a significant weight loss: Weight 94.4 pounds, decrease 9 percent in three months. Intakes 54 percent. Assessment: declining intakes. Plan: Take more time with meal assistance. Ideal body weight 121 to 149 pounds. On 7/21/15 at 7 am, Certified Nursing Assistant (CNA) R was observed attempting to feed Resident 2. Resident 2 was positioned on her right side with the head of the bed barely elevated (the head of bed should be elevated for residents who are at risk of choking or aspirating). CNA R offered Resident 2 her pureed food, but Resident 2 refused and pulled her head away from the spoon and verbalized sounds as CNA R attempted to feed her. CNA R stated she was new and she was not given instructions about how to position or feed Resident 2. On 7/21/15 at 7:20 am, a different CNA, CNA Q, was observed feeding Resident 2. Resident 2 was positioned on her left side with the head of the bed elevated several inches. Resident 2 was accepting the food presented to her on her spoon. CNA Q stated the other CNA did not know that Resident 2 is fed when on her left side with the head of the bed elevated. CNA Q stated Resident 2 will eat most of her meal when fed slowly and on her left side. A Care Plan, dated 6/17/15, titled, Impaired Nutritional Status - Less than Body Requirement; 7/8/15 Significant weight loss in three months, indicated, Goals, resident dietary needs will be met within her abilities and wishes. Approaches: encourage resident to eat more than 75 % (percent) of meals, and good fluid intake. Monitor weight, observe for s/s dehydration secondary to the need for thickened fluids. The care plan did not include instructions about positioning Resident 2 at meal time. On 7/22/15 at 3 pm, the RD stated Resident 2's positioning and staff who fed Resident 2 was important and seemed to make a difference in her intake. She stated, in order for Resident 2 to make gains with her wound healing and maintain her weight, she needed to have accurate weights to make appropriate recommendations, and without weekly weights she could not do her job. The RD stated she did not write the resident's care plans and confirmed the care plan did not include information about specific positioning. 5. Resident 13 record was reviewed and indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A review of the Monthly Record indicated Resident 13's weights were, in 1/2015, 162.7 lbs, and on 5/1/15, 151 lbs. Her weight was monitored weekly thereafter. On 7/1/15, her weight was documented on the 1st Month Weight, July 2015, as 146.7 lbs. On 7/22/15 at 3 pm, the RD stated slow weight loss was planned for Resident 13. The RD stated the 7/1/15 weight of 146.7 pounds was a concern because of the amount of weight Resident 13 had lost, over 15 pounds since 1/15, a significant weight loss. RD stated she wanted to evaluate the next weight. RD stated without her current weight, she could not evaluate if Resident 13's weight loss had stabilized or if she had continued loss and required intervention. 6. On 7/22/15 at 2:15 pm, during an interview and concurrent record review, the Charge Nurse (CN) stated all residents were weighed monthly at the beginning of the month, and residents who had weight loss were weighed weekly. She stated the facility used a regular walk-on scale for ambulatory and wheelchair residents, and for non-ambulatory residents used a Hoyer lift scale. The facility's documents titled, 1st Month Weight, July 2015, July Re-weights, Sunday Weekly Weights Sheet for 7/15 (two different forms with the same title) were reviewed. The following residents who were weighed by using a Hoyer lift scale had the following documented weights: a. For Resident 2, 1st Month Weight, July 2015, 94.4 pounds (a weight loss of over three pounds, compared to 5/31/15, documented as 98.1 pounds on the Monthly Weights); Entries on the Sunday Weekly Weights Sheet on 7/5, 7/12, and 7/19/15 indicated, Hoyer broken, and did not include a weight. b. For Resident 5, 1st Month Weight, July 2015, 149.9 pounds, on the July Re-weights was 148.3 pounds, and on the Sunday Weekly Weight Sheet, dated 7/5/15, was 159.8 pounds. No further weights were recorded. c. For Resident 10, 1st Month Weight, July 2015, 114 pounds and a second weight on the form was 111.2 pounds. The Sunday Weekly Weight Sheet, dated 7/12/15, indicated, Hoyer scale broken. d. For Resident 12, a resident fed with a feeding tube (a tube inserted into the stomach for the purpose of administering liquid nutrition), on 7/1/15 was 155.4 (a 11% drop from the previous month indicating severe weight loss). Another weight recorded on an undated document titled, July Re-weights indicated, 155-Hoyer. There were no other weights or comments on the 7/2015 weight documents. e. For Resident 13, 1st Month Weight, July 2015 was 146.7 pounds Hoyer, and entries on the Sunday Weekly Weights Sheet indicated, on 7/5, 7/12, and 7/19/15, Hoyer broken, and did not include a weight. The CN stated the Hoyer lift scale had not worked for over two weeks. She stated, on 7/1/15, five resident's (Residents 2, 5, 10, 12, and 13) weights did not appear to be accurate when the Hoyer lift scale was used. CN stated the Hoyer lift scale did not work and was pending repair. On 7/22/15 at 2:30 pm, the Director of Nurses (DON) stated she questioned the accuracy of the Hoyer lift scale after she reviewed the 7/1/15 weights, and stated some of the resident's weight losses were too extreme and the percentage of loss did not match their intake or condition. She asked for some of the residents to be reweighed and the staff informed her the Hoyer lift scale was broken and needed repair. The DON stated Resident 10 had a large weight loss, and there were four residents currently affected by the broken scale that cannot be weighed until the Hoyer lift scale is repaired. She stated she was concerned about two of the four residents, Residents 2 and 12, because of their fragile status. On 7/22/15 at 2:45 pm, the Registered Dietitian (RD) was interviewed. The RD stated she followed all the residents weights on a monthly basis, and if a resident had weight loss, she would follow their weight weekly. The RD stated she had been informed the Hoyer lift scale was broken and several residents could not be weighed. She stated there were five residents, Residents 2, 5, 10, 12, and 13, that she needed to know their current and accurate weights, and on 7/8/15, she wrote a note instructing staff to contact her when the residents were weighed. The RD stated without the weights she could not establish goals and dietary recommendations or review if the previous interventions had been effective. A review of a repair requisition, dated 7/5/15, indicated, weight Hoyer will not go up and down, in . for repair. On 7/22/15 at 5 pm, the facility's documents titled, 1st Month Weight, July 2015, July Re-weights, and Sunday Weekly Weights Sheet were reviewed concurrently with the Chief Nursing Officer (CNO). After the review, the CNO stated the forms used on two different months were different. The facility's current method to obtain and record resident's weight was not consistent, and the documentation was not clear. The CNO stated it was unacceptable that residents had not been weighed as planned, and the resident's who needed to be reweighed or weighed weekly, needed to be weighed immediately. She stated the facility had other methods to weigh residents, such as a wheelchair scale.

Based on interview and record review, the facility failed to promptly notify the attending physician when Resident 1 developed complications while receiving [MEDICATION NAME] (a blood-thinning medication, used for preventing blood clots). Excessive thinning of the blood can lead to major bleeding. Nursing service did not inform the physician when Resident 1 first vomited bloody fluid (a potential indication that there was too much thinning of the Resident's blood), or when Resident 1's blood pressure dramatically dropped, she was less responsive and eventually became unconscious. These failures resulted in a delay of care and treatment for [REDACTED]. Findings: Resident 1, a [AGE] year old female, was admitted to the facility on [DATE] for physical therapy following a knee injury. Her [DIAGNOSES REDACTED]. She chose to have all life sustaining treatments, except for CPR (cardiopulmonary resuscitation, a method to restore breathing and/or heartbeat), if needed. Her Minimum Data Set (MDS - a standardized assessment tool), dated [DATE], indicated that Resident 1 was alert and oriented and capable of making her own decisions. On [DATE], Resident 1's physician did a history and physical examination [REDACTED]. The test results showed that Resident 1's hemoglobin (HGB - a protein in red blood cells that carries oxygen) was 11.9 (normal range 12 - 16) and hematocrit (HCT - a test to measure red blood cell concentration) was 36.1 (normal range 35 - 55). Red blood cells and the hemoglobin contained within them are necessary for the transport and delivery of oxygen from the lungs to the rest of the body. Without a sufficient supply of oxygen, organs throughout the body (brain, heart, lungs) can be adversely affected. On that same day, the physician wrote orders for [MEDICATION NAME] 7.5 milligram (mg) on day one, then 5 mg daily, to be started in order to prevent Resident 1 from getting another blood clot in her leg. And, to recheck Resident 1's [MEDICATION NAME] Time (PT) on Friday ([DATE]). [MEDICATION NAME] Time is a blood test for anticoagulation monitoring essential in ensuring the dose of [MEDICATION NAME] is high enough to prevent the development of blood clots, and low enough so that the resident is not at risk for serious bleeding. On [DATE], Resident 1's PT/INR ([MEDICATION NAME] time/international normalized ratio, a blood test used to help determine the level of blood thinning from [MEDICATION NAME]) was 15.6 (Normal ,[DATE]) and flagged as "high." The INR was 1.72 (normal ,[DATE]). There was no documentation, in the record, that the physician was notified of the of the high PT result. Resident 1 continued to receive 5 mg of [MEDICATION NAME] daily. When Resident 1's PT/INR was checked again, on [DATE], the PT was flagged as "high" at 22.3, and the INR was 3.22. That same day, Resident 1's HGB/HCT were within normal range at 13.2 and 39.3 respectively. The physician's progress note, dated [DATE], acknowledged the INR test result of 3.2, however, the physician did not order any further PT/INR tests. Resident 1's [MEDICATION NAME] dosage was not changed; it remained at 5 mg daily until her decline on [DATE]. On [DATE] at 2:40 pm, during an interview, Certified Nurse Assistant (CNA) A stated that on [DATE] between 12 am and 6:30 am, Resident 1 became lethargic and unresponsive at times. She further stated that at about 2 or 3 am, Resident 1 complained of stomach pain and vomited liquid which tested positive for the presence of blood. According to CNA A, she reported the positive test immediately to Licensed Nurse (LN) B and kept LN B informed of the Resident 1's status during the night. In an interview on [DATE] at 3:05 pm, LN B recalled that on [DATE] at 3 am, she notified Physician D that Resident 1 vomited, but did not remember if she told the physician that it tested positive for blood. She stated that Physician D ordered Resident 1 to be given [MEDICATION NAME] (a medication to suppress nausea), which she gave at 3:15 am. LN B stated that Resident 1 had no further vomiting, and was "doing well" when she left work at 6:30 am. In an interview, on [DATE] at 8:30 am, Physician D stated that the facility had called him on [DATE] at 3 am to report that Resident 1 had vomited, but that the caller had not mentioned that it tested positive for blood. He further stated that he was not notified that the resident had any change in her level of consciousness. During an interview on [DATE] at 5:15 pm, CNA E stated that on [DATE] at about 7:30 am, Resident 1 vomited red liquid, which tested positive for blood. She notified LN C, who said to let her know if it happened again. CNA E stated that Resident 1 had a red-colored bowel movement later that morning, which also tested positive for blood. She again notified LN C. CNA E recalled that Resident 1 was acting "sluggish," and by 1 pm, Resident 1 was becoming "unresponsive." She notified LN C, who told her to encourage Resident 1 to drink fluids. In an interview on [DATE] at 11:15 am, LN C stated that on [DATE] at about 11 am, Resident 1 had a large, "bloody" bowel movement and that the resident's blood pressure was "lower than normal." She called Physician D at 11:45 am, who ordered a PT/INR, a complete blood count and basal metabolic panel (tests that count the number of blood cells, and measure the blood chemistry), and to give 4 milligrams of [MEDICATION NAME] (a medication for nausea) sublingual (under the tongue). On [DATE] at 11:55 am, Physician D arrived at the facility. During an interview on [DATE] at 8:30 am, Physician D stated that he visited Resident 1 in the late morning, around noon, on [DATE]. And, at that time Resident 1 was alert and oriented, though she didn't feel very good. During an interview on [DATE] at 9:40 am, LN C recalled that Resident 1 was alert when Physician D visited at 12 pm, but was otherwise quite lethargic throughout the day, only opening her eyes briefly in response to voice or touch. The laboratory tests were run on [DATE] at 1:08 pm, and revealed a PT of 55.7 and an INR of 16.03. The laboratory report flagged both results as "critical high," indicating too much thinning of the blood. Resident 1's HGB and HCT dropped to 9.6 and 29.3 and were flagged as "Low." LN C notified Physician D of the results at 1:20 pm; he ordered Vitamin K (a medication used to counteract the effects of [MEDICATION NAME]) to be given to Resident 1. LN C stated that at about 4 pm, Resident 1's blood pressure was ,[DATE]; she called Physician D, who ordered a 500 ml (milliliters) [MEDICATION NAME] of intravenous (IV) fluid (rapidly giving fluid directly into the blood stream), then decrease the IV rate to 150 cc per hour. According to LN C, Resident 1's blood pressure went up to ,[DATE] after 500 ml of intravenous fluid was administered. This information was also documented in the nurses note dated [DATE] at 4 pm. LN C stated that by 6:30 pm, Resident 1 was moaning and "moving a bit" when spoken to or touched. Physician D stated that on [DATE] at 4 pm, when Resident 1's blood pressure dropped, he had the nurses give her intravenous fluids, which raised her blood pressure back to normal. He recalled that at that point he felt that Resident 1 was stable. LN B stated that when she arrived at work on [DATE] at 6:30 pm, Resident 1 was receiving intravenous fluids and was unresponsive, with a blood pressure of ,[DATE]. She recalled that according to the report she received from LN C, the day shift nurse, Resident 1 was stable, and there were orders to call the physician if there were any further changes in Resident 1's condition. LN B stated that she called Physician D at 9:30 pm (three hours later) when Resident 1's blood pressure dropped to ,[DATE]. The nurses note dated [DATE] at 6 pm read, "No vomiting or diarrhea." There was no documentation that Resident 1's blood pressure was rechecked during the two hour period after the IV rate was decreased to 150 cc per hour. The next nurses note, made at 7 pm read, "Remains unresponsive, B/P (blood pressure) ,[DATE]..." There was no documentation that the physician was notified that Resident 1's blood pressure had decreased from ,[DATE] to ,[DATE] or that she was unresponsive. Resident 1's vital sign record contained an entry dated [DATE] "Sunday PMs" (untimed) noting that Resident 1's blood pressure was ,[DATE]. There was no documentation that the nurse or the physician was notified of this blood pressure reading. Physician D stated that he was unaware of any changes in Resident 1's level of consciousness until 9:30 pm that night, when a nurse called to tell him that Resident 1's blood pressure dropped again, and that she was unresponsive. He ordered that she be transferred to the hospital emergency department immediately. The emergency department nursing record, dated [DATE] at 10:15 pm, indicated that upon arrival, Resident 1 was unresponsive, and her pupils were dilated and did not react to light (a possible indication of brain damage). Resident 1 received one unit (200 milliliters) of O negative blood before being transferred to a larger acute care hospital by medical air ambulance at 11:40 pm. Resident 1's history and physical, dated [DATE], done by Physician F, a consulting doctor at the acute care hospital where she was transferred, noted that Resident 1 had "Acute [MEDICAL CONDITION]" due to "Marked coagulopathy" (too much blood thinning), "She has suffered substantial end-organ damage (irreversible), and "The Resident's overall prognosis is quite grim." Resident 1's death summary, dated [DATE], by Physician G, a consulting doctor at the acute care hospital, indicated that after aggressive treatment in the intensive care unit with intravenous fluids, maximum doses of medications to support blood pressure ([MEDICATION NAME], and [MEDICATION NAME]), and CPR, she was pronounced dead on [DATE] at 9:17 am. Resident 1's death certificate indicated that the cause of death was gastrointestinal hemorrhage (bleeding) due to, or as a consequence of [MEDICATION NAME] ([MEDICATION NAME]) use. The facility failed to promptly notify the attending physician when Resident 1 developed complications after receiving [MEDICATION NAME] (a blood-thinning medication, used for preventing blood clots). Excessive thinning of the blood can lead to major bleeding. Nursing service did not inform the physician when Resident 1 first vomited bloody fluid (a potential indication that there was too much thinning of the Resident's blood), or when Resident 1's blood pressure declined and she was experiencing a decreased level of consciousness on [DATE] after 4 pm until 9:30 pm. These failures resulted in a delay of care and treatment for [REDACTED].