Every finding on record at Mountain View Care Center

Based on observation, resident interview, record review and staff interview the facility failed to ensure each resident was provided with medically related social services. The facility failed to correctly interpret the results of abuse investigations. They failed to report all allegations of abuse in the required time frames. The facility failed to ensure residents knew how to file grievances and could do so anonymously. In addition they failed to ensure grievances were resolved timely once filed. The facility also failed to complete accurate social service assessments and trauma screens. They failed to provide discharge planning to short term care residents. They also failed to ensure all residents were invited to participate in their care plan meetings. They failed to ensure resident was afforded the right to formulate their own advance directives and to have those directives honored. They failed to ensure each resident was afforded the right to have their medical record remained private and confidential. Finally the facility failed to ensure resident were assisted to get dental and vision services in a timely manner resulting in delays in receiving glasses and needed dental work. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident Identifiers: #21, #8, #49, #70, #74, #128, #55, #38, #129, #130, #63, #33, #77, #94, #76, #98, #7, #6, #11, #124, #4, and #26. Facility Census: 109 a) Privacy of Medical Record1) Resident #63 On [DATE] at 8:28 am an interview with the Medical Power of Attorney for Resident #63 it was discovered the facility sent excerpts of the medical record to another facility without the permission of the MPOA. She stated, things are better now but they did do that last year. A review of Resident #63's medical record found the following Social Service Progress note: Not Dated [DATE] ar 9:23 AM read as follows: (Name of out of state facility) contacted social services with an inquire of additional notes. 7 days of notes sent per request. Awaiting response.Note dated [DATE] at 12:08 pm read as follows: SS (Social Services) submitted 60 days worth of note to (Name of Out of State nursing facility) per their request. Will continue to follow up. Note Dated [DATE] at 2:42 PM read as follows: (First name of Resident #63) daughter declined the transfer to the psychological facility, after SW (social worker) got her a bed. An interview with Nurse Consultant #131 at 1:15 pm on [DATE] confirmed excerpts of Resident #63's medical record was sent to an out of state facility. She further confirmed the medical contained no evidence the MPOA gave permission for the records to be sent. b) Resident Grievances 1) Resident Council MeetingDuring the Resident Council Meeting on [DATE] at 2:10 PM, The Resident Council agreed that they do not know how to file a grievance in writing or anonymously.Resident #88 pointed at the wall and stated, They put that box up over there today and I guess that is what that is for, but there aren't any forms in it.During an interview on [DATE] at 12:55 PM, the Licensed Social Worker (LSW) #100 stated, They keep the forms behind the nurses station. Most of the residents would need help filling them out anyways. During an interview on [DATE] at 12:58 PM, at the A/B nurses station, Licensed Practical Nurse (LPN) #66 stated, I thought Social Services had the forms.LPN #85 stated, I am not sure where they are at. Let me look.The Director of Nursing (DON) came out to the A/B nurses' station to help LPN #85 locate a binder, in a cabinet that was for grievances. This process from the start of the interview until the form was found, took approximately 10 minutes.The DON further confirmed that the grievance forms were not readily available for residents and/or family members to file a grievance.2) Resolution of Missing Item GrievancesDuring an interview with Resident #33 at 3:53 PM on [DATE] she stated, I don't always get my clothes back from laundry. She stated she is still missing several items and stated she does not send her clothes to the laundry no more. She then asked the surveyor if she thought it would be okay for them to take her to the laundry mat so she could wash he own clothes.Review of the grievances found the resident filed a grievance on [DATE] reporting she was missing green, red blue elastic pants black pull on jacket white jacket Brand new underwear blue long sleeve shirt with grandmas love bugs all grandkids names listed.The grievance indicated they located the red elastic pants, new underwear, and her blue love bug shirt and her white jacket. The grievance indicated the other items were replaced by the facility with a resolution date of [DATE]. On the morning of [DATE] the facility was asked to provide evidence the other items were replaced since the resident was still claiming they were still missing. On the morning of [DATE] the facility provided a receipt from a local store which indicated the items had been purchased. The date on the receipt was [DATE] at 4:55 pm which was after the surveyor's request. An interview with Nurse Consultant on [DATE] at 11:00 am confirmed the items were not replaced until after the surveyor asked about them. A review of the grievance log found several other grievances related to missing items. The following grievances were identified as not being resolved by the facility in spite of the fact they claimed the items had all been replaced. There was no evidence to indicate the facility had replaced the items. Resident #128 Grievance filed on [DATE] which listed three (3) Pair of stretchy small sweatpants, one (1) long sleeve shirt (Local college team) small, one (1) Pair of house shoes rubber sole size 10m and missing blue jacket size small. The investigation found the items were not located. Actions taken was listed as Items will be replaced by facility. Resolved date was listed as [DATE]. The facility was unable to provide evidence that the items were replaced.Resident #55 Grievance filed [DATE] which listed blue shorts (Size 16-18), Tan/brown Shorts (size 16-18), grey sweater (size unknown), burgundy sweater (size unknown) all missing. The results of the investigation indicated the items were not found. The resolved date was listed as [DATE] and the summary of actions taken was that the items would be replaced. The facility was unable to provide evidence that the items were replaced.Resident #38 Grievance filed [DATE] which listed missing items as peach/orange nightgown, 4 pairs [NAME] socks and 1 single nonskid sock. The investigation revealed the items were not located. The resolved date was listed as [DATE] and the summary of actions taken was Items will be replaced. The facility was unable to provide evidence that the items were replaced.Resident #129 Grievance filed [DATE] which listed under the grievance details the following: We did an audit and resident stated that she had a robe missing. The investigation indicated the item was not located. The resolved date was listed as [DATE] and the summary of the actions taken was the items will be replaced. The facility was unable to provide evidence that the items were replaced.Resident #130 Grievance filed [DATE] which listed un the grievance details the following: We did an audit and resident stated that had clothes missing. Summary of investigation indicated the items were not located. Summary of actions taken indicated the items would be replaced by the facility. The resolved date was [DATE]. The facility was unable to provide evidence that the items were replaced.Resident #63 Grievance filed [DATE] which listed un the grievance details the following: We did an audit and resident stated that had clothes missing. Summary of investigation indicated the items were not located. Summary of actions taken indicated the items would be replaced by the facility. The resolved date was [DATE]. The facility was unable to provide evidence that the items were replaced.An interview with the Corporate Nursing Home Administrator (CNHA) #140 at 1:09 pm on [DATE] confirmed they were unable to locate any receipts to show that Residents #128, #55, #38, #129, #130 and #63 had their items replaced. He stated, we are going to follow up with them and get the items replaced now. c) Advance Directives 1) Resident #11A review of Resident #11's medical record on the morning of [DATE] found a physician determination of capacity which was completed by Resident #11's attending physician on [DATE]. This form indicated Resident #11 had capacity to make medical decisions. This was the most recent capacity form located in Resident #11's medical record. Further review of the medical record found a Physician Order for Scope of Treatment (POST) form which was dated [DATE]. The medical record revealed Resident #11 was admitted to the facility on 11//22. This post form was the most recent POST form in the resident's medical record and indicated the resident was to be a full code. Further review of the post form found it was signed by someone other than Resident #11. Social Worker #100 at 12:57 pm on [DATE] confirmed during an interview the POST form was not signed by Resident #11. When asked if Resident #11 should have been given the opportunity to complete a new post form when she regained her capacity on [DATE] she stated, Yes she should have. 2) Resident #124 A review of Resident #124's medical record found a POST form signed by Resident #124 on [DATE] which indicated the resident wished to not receive CPR and wanted only comfort focused treatments. A review of the physician's orders entered into Resident #124's medical record found the following order entered on [DATE], ADC: Full Code/ Full treatments/no artificial means of nutrition desired/has capacity. An interview with Nurse Consultant #131 and the Nursing Home Administrator in the afternoon of [DATE] confirmed the order entered into the physician's orders did not match Resident #124's expressed wishes and needed to be corrected. d) Reporting of Abuse Allegations 1) Resident #74A review of a reportable incident dated [DATE] involving alleged victim Resident #74 and alleged perpetrator Resident #97. Under the section what was reported the following was written:(First and Last name of Resident #74) was sitting by nurses station (First name of Resident #97) he rolled by and reached between (First name of Resident #74's) legs and (First name of Resident #74) smacked his hands away CNA redirected the residents.The date and time of the incident was listed as [DATE] at 1:12 PM. Further review of the reportable incident found the report was faxed to the state agency at 5:49 PM on [DATE] which was four (4) hours and 37 minutes after the time of the incident. An interview with Corporate Nurse #131 and the Nursing Home Administrator (NHA) at 1:44 PM on [DATE] confirmed this incident was not reported within the required two (2) hours. e) Interpretation of Abuse Investigation Findings and Protection of Residents during the investigation. 1) Resident #21, #8, #49A policy titled, Abuse reads, in the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident.In a nurse note dated [DATE] at 5:58PM it is documented, It was reported to this nurse that resident 94036643 and resident 94036696 was sitting in the hallway holding hands and resident 94036643 had resident 94036696 hands in between resident 94036643 legs. Resident's were separated and resident 94036643 was put on [one-on-one] 1:1 and [every fifteen] q15 minute checks. PCP [Primary Care Physician] and RP [Responsible party] notified. According to the witness statements, this incident occurred at approximately 2:30PM between Resident #8 and Resident #21. The intervention was to place Resident #8 on one-on-one (1:1) observations immediately pending investigation. Resident #21 is listed as non-verbal with a Brief Interview of Mental Status (BIMS) score on the Minimum Data Set, dated [DATE] of 00 indicating Resident #21 is not capable of making decisions regarding daily living activities and has no recall ability.During an interview with Resident #49 on [DATE] at 3:40PM, she stated she was yelled at and called names over a man and it made me feel degraded. Upon further investigation, a nursing note dated [DATE] at 6:27PM reads, It was reported to this nurse that resident 94036643 verbally threatened to kick resident 94036540's but. Resident 94036540 reported that she didn't want resident 94036643 to kick her but. Resident 94036643 put on 1:1 [one-on-one]. PCP [primary care physician] and RP [responsible party] notified. According to witness statements, this incident occurred at approximately 4:00PM between Resident #49 and Resident #8.Another incident occurred on [DATE] at 4:31PM per documentation involving Resident #8 in which Resident[#8] called this nurse in resident's room demanding to speak to the administrator now. Resident stated that unit manager had hit her. Resident pointed to her wrist and lower arm and stated She hit me right here. This nurse reported incident to risk nurse. This nurse assessed resident's skin and there was no marks or redness on resident's skin. According to witness statements and facility reported incident investigation, this incident occurred due to unit manager attempting to separate Resident #8 and Resident #21.In an interview with Social Services #100 on [DATE] at 3:00PM, she confirmed Resident #8 was not on one-on-one (1:1) at the time of these incidents. During an interview with Corporate Registered Nurse #131 on [DATE] at 3:50PM, she confirmed, per documentation, Resident #8 was supposed to be on one-on-one (1:1) observations from the 2:30PM incident. According to the Medication Administration Record, the one-on-ones did not start until 7:00PM on [DATE].2) Resident #74A review of a reportable incident with an incident date of [DATE] involving Resident #74 as the victim and Resident #90 as the alleged perpetrator found the following description of the incident, (First and Last Name of Resident #74) was sitting by the nurses station, (First name of Resident #90), he rolled by and reached between (First Name of Resident)' s legs. and (First name of Resident #74) smacked his hands away/CNA redirected the residents.A review of the five day follow up found the following listed under conclusion: Due to the incident being witnessed by center staff, the incident has been verified. The investigation confirms that the event did occur due to staff witness account. However, the investigation is inconclusive for abuse due to not indication of physical or psychosocial harm, unknown if intentional due to incapacity of alleged perpetrator and BIMS of 3.0 and no recollection of incident by either resident.During an interview with the Nursing Home Administrator (NHA), Nurse Consultant #131 and Social Worker #100 on [DATE] at 1:44 PM they agreed abuse should have been verified and the investigation was not inconclusive. 3) Resident #70A review of a reportable incident with an incident date of [DATE] found the following description of the incident: Resident made contact with other resident. The alleged victim was identified as Resident #70 and the alleged perpetrator was Resident #63. A review of the investigation found a statement from Nurse Aide #72 who assigned 1:1 aide for Resident #63 at the time of the incident. The statement read as follows, I was following the 1:1 (resident #63's assigned medical record number) when I saw (First Name of Resident #70) coming out of (Resident #63's assigned Medical record number) room. I immediately approached (First Name of Resident #70) to guide him out of the room and back into his room which is next) door. Resident (resident #63's assigned medical record number) became irate as soon as she saw someone in her room, they propelled self suddenly forward in the wheelchair and kicked (first name of Resident #70) in the lower legs. Resident (resident #63's assigned medical record number) attempted to punch (First name of Resident #70) again. I continued to separate and redirect. Other staff came and assisted. (First Name of Resident #70) presented to be unaware of the situation. A review of the Five day follow up related to this incident found the following conclusion, The facility has unsubstantiated abuse due to diagnosis and low BIMS score related to intent. Facility did interview like residents on hall with no variances regarding safety.During an interview with the Nursing Home Administrator (NHA), Nurse Consultant #131 and Social Worker #100 on [DATE] at 1:44 PM they agreed abuse should have been verified. The NHA indicated he thought because Resident #63 had a diagnosis of dementia and a low BIMS he could not find intent. When asked if the resident kicked the other resident voluntarily, he stated, yes. He agreed it was not an accident, she did it on purpose but she did not know what she was doing cognitively. He stated, I understand now what that means. f) Discharge Planning 1) Resident #77An interview with Resident #77 in the afternoon of [DATE] he stated, I want to go home but I lived with my fiance and she don't want me there so I don't know what I will do.Resident #77 was admitted to the facility on [DATE]. A review of Resident #77's record found only one capacity statement which was completed on [DATE] which indicated the resident has capacity to make medical decisions. A review of Resident #77's Minimum Data Set with an Assessment Reference Date (ARD) of [DATE]. Found Section Q. Was completed by interviewing the resident's family and was coded to indicate the resident did not wish to return to the community and that active discharge planning was not underway. A review of Resident #77's care plan found the following care plan related to discharge: Focus Statement: Short tem Discharge plan: (First Name of Resident #77) is expected to be at the facility on a short term basis and return to the community. This focus statement was initiate on [DATE] and has not been revised since. The goal associated with this focus statement reads: Resident will return to the community successfully when ready thru the review period. This was also initiated on [DATE] and has a target date of [DATE]. The interventions include: -- Coordinate with physician regarding discharge plans as indicated--make community DME referrals as indicated--refer for community resources as indicated and per resident/resident representative preference-- refer the resident to the local contact agency if indicated by the resident -- review and update discharge plans with the resident when needed A review of Resident #77's medical record found a Social Service Quarterly Note dated [DATE] completed by Social Worker #100. Under Section N. Quarterly Discharge Plan Review the following was noted: Mr. (Last name of Resident #77) could live alone with some assistance he has voiced he would like to find a place. During an interview with Social Worker #100 on the afternoon of [DATE] she indicated she was aware the resident wanted to go home. She stated, I just found that out and was going to start working on his discharge planning this week but have not had the chance. When asked about the care plan dated [DATE] and the social service note date [DATE] the social worker remained silent. g) Inviting Residents to Care Plan Meeting 1) Resident #11During the initial interview on [DATE] at 11:30 PM, Resident #11 said that she has not been to a care plan meeting and they don't tell her what is going on.A record review on [DATE] at 12:21 PM, revealed that Resident #11 was deemed incapacitated since admission until [DATE] when she regained capacity.Resident's care plan signature page, up until [DATE], was completed with the Medical Power of Attorney (MPOA), via telephone. Resident #11's signature is not present.During an interview on [DATE] at 2:11 PM, The Licensed Social Worker (LSW) #100 stated, That resident would not have got the notice before because she just recently got her capacity back. The State Agency (SA) asked, If the resident does not have capacity do they still invite or involve them in the care plan meeting? LSW #100 replied, If they do not have capacity then we do not involve them in the care plan meeting.2) Policy A review on [DATE] at 2:37 PM, of the policy titled {Care Planning- Interdisciplinary Team} reads under number 3 as follows:The Resident, the resident's family and or the residents legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the residents care plan.Number 4 reads as follows:Every effort will be made to schedule the care plan meeting at the best time of the day for the resident and family.h) Vision 1) Resident #7On initial interview on [DATE] at 1:00PM, Resident #7 states he went to the eye doctor a month or so ago but never got his glasses. In an interview with Social Services #100 at 11:55AM on [DATE], she stated, I don't know anything about it. As far as I know, they [Resident's glasses] could be sitting at that doctor's office. At 12:00PM on [DATE], the Director of Nursing (DON) stated she did not know anything about new glasses, but she would check into everything. The facility was able to produce one page of the visit note from the visit to the eye doctor on [DATE] which did not show any follow-up information. In an interview with [NAME] Virginia Eye Consultants on [DATE] at 1:00PM, the receptionist stated there are two (2) prescriptions for glasses waiting at the office.It was confirmed with the DON at 1:20PM on [DATE] that Resident #7 did not receive his glasses after his eye appointment and no effort was made by the facility to get further notes or glasses.2) Resident #6 During an interview with Resident #6 on [DATE] at 3:15 PM she stated, I saw the eye doctor eight (8) weeks ago and still have not received them. She stated, I asked the social worker about them and found out they had not been paid for but that was a few weeks ago and she still has not heard anything. A review of Resident #6's medical record found she saw the eye doctor in house on [DATE] and the invoice was sent to the facility on [DATE]. Social Worker #100 was asked to provide any information she had concerning Resident #6's glasses on the afternoon of [DATE]. On the afternoon of [DATE] no information had been provided to the surveyor. The surveyor again asked for any information regarding Resident #6's glasses and the Nursing Home Administrator (NHA) stated they paid for them yesterday after the surveyor asked what was going on with them. The social worker then provided the following emails between Social Worker #100 and the in-house eye doctor: Email from Social Worker #100 to the in-house eye doctor sent on [DATE] at 2:41 pm read red as follows, We have Several residents that still haven't received glasses. Do you know when they may be in? Reply received from the in house eye doctor at 3:39 pm on [DATE], read as follows: Can you send me a list of who is still waiting as I will have to look in their charts to get the status. Social Worker #100 replied on 3:51 pm on [DATE]th 2026 which read as follows: (First and Last Name of Resident #6) and (First and Last Name of Resident #6) for sure . They keep asking and they were seen four weeks ago. Another reply from Social Worker #100 at 3:57 pm listed the following residents (First and Last Name of Resident #8), (First name of Resident #10 and a different last name.) (First and Last Name of Resident #15), (First and Last Name of Resident #6). May Be more! Please let me know. Reply from in house eye doctor at 4:26 pm [DATE] read as follows: (First Initial and Last Name of Resident #15) Invoice was sent to the facility on [DATE]. (First Initial and Last name of Resident #6) invoice was sent to the facility on [DATE] (First and Last Name of Resident #8) - Invoice Sent to the facility on d[DATE] (First name of Resident #10 and different last name similar to Resident #10's)- Not in our system. Email from Social Worker #100 to in house eye doctor on [DATE] at 4:42 pm read as follows: We did not receive them, were they signed for, how were they sent? Email from in house eye doctor at 9:56 am on [DATE] read as follows: The invoices will need to be paid in full before the glasses will be ordered. Email from Social Worker 100 to in house eye doctor on [DATE] at 10:02 am read as follows, What the Glasses were not sent because they need payment? Can I have the invoices and we will pay it. Please. Reply from in house eye doctor on [DATE] at 10:12 am read as follows, Attached are all the invoices that will need to be paid before the glasses can be ordered. I did not find a (First name of Resident #10 and a Last Name similar to Resident # 10 ) in our system however there is a (First and Last Name of Resident #10 ) with that same DOB (date of birth ) and I have attached his invoice as well Please let me know if you have any other questions. Social Worker #100 also provided a copy of a check for Resident #6's glasses which was sent to the in house eye doctor on [DATE]. The NHA confirmed the glasses were not paid until after the surveyor asked about them but it was taken care of then. i) Dental Services 1) Resident #26 During an initial interview on [DATE] at 1:13PM, Resident #26 stated she had an appointment for dentures about a year ago. However, she states her wheelchair would not fit through the door and therefore she was not seen. A review of the records showed Resident #26 had a denture evaluation appointment with Dr. (name) on [DATE]. Across the top of the paper in black marker is written: Please use smaller wheelchair! The facility could not produce evidence of having rescheduled this appointment. In an interview with Director of Nursing at 3:25PM on [DATE], she confirmed Resident #26 has not had any dental follow up since appointment on [DATE]. 2) Resident #4 Review of Resident #4's physician's orders showed an order written on [DATE] for Resident needs referral to dental for mouth pain. A change in condition assessment had been completed on [DATE] at 6:55 PM which stated, Resident is having continued complaints of mouth pain in the upper teeth. Tylenol administered as ordered. Documentation showed Tylenol was effective in relieving the resident's pain. Review of Resident #4's electronic health record showed the resident had a dental appointment on [DATE] for a toothache. He was prescribed an antibiotic. No reports for a more recent dental appointment were located in the resident's records. On [DATE] at 4:14 PM, Registered Nurse (RN) #119 stated [DATE] was Resident #4's most recent dental appointment. She stated the resident was on the list for a dental appointment, but an appointment had not yet been made. j) Inaccurate Social Service Assessments and Trauma Screens 1) Resident #76 A review of Resident #76's medical record on the morning of [DATE] found a Social Service Initial Evaluation version two (2) which was completed on [DATE] at 11:29 am. This evaluation indicated Resident #76 was a female. It should be noted Resident #76 is a male. During an interview with Nurse Consultant #134 in the morning of [DATE] she confirmed Resident #76 was a male and the Social Service evaluation incorrectly identified his gender. 2) Resident #98 A review of Resident #98's medical record on the morning of [DATE] found a Trauma Screen Dated [DATE]. This screen indicated Resident #98 was not interviewable. However Resident #98's name was listed under Name of the person interviewed. A review of Resident #98's capacity statement indicated the resident was capacitated to make medical decisions. A review of Resident #98's Brief Interview of Mental Status (BIMS) found he scored a 15 which indicated the resident is cognitively intact. An interview with Corporate Nurse #131 on the morning of [DATE] confirmed the Trauma Screen dated [DATE] was inaccurate because Resident #98 is interviewable. 3) Resident #77 A review of Resident #77's medical record on the morning of [DATE] found a social service assessment dated [DATE] which indicated the resident needed and/or requested an interpreter. An interview with Social Worker #100 at 3:36 pm on [DATE] confirmed the social service assessment was inaccurate and Resident #77 did not need an interpreter.

Based on record review and staff interview, the facility failed to ensure an account of all controlled drugs was maintained and periodically reconciled. The facility failed to ensure the controlled substance count was signed by the on-going and off-going nurses performing the count. The facility also failed to identify and investigate a possible drug diversion for Resident #98. These findings were random opportunities for discovery. Resident Identifier: #98. Facility Census: 109. Findings included: a) Controlled substance counts The facility's policy titled, Controlled Substances, with effective date September 2018 and revision date August 2020, stated that an accurate inventory of all controlled medications would be maintained at all times. However, no specific information regarding counting the medications was given in the policy. On 06/03/2026 at 7:30 AM, the B hallway medication cart was inspected with Licensed Practical Nurse (LPN) #103 in attendance. LPN #103 stated the number of controlled substance cards were counted whenever the medication nurse left and a new medication nurse came. The cards are packs that contain medications for each resident. LPN #103 stated number of medications remaining on each card are also counted at that time. LPN #103 presented forms located in a notebook on the medication cart. The forms were titled, Narcotic count. LPN #103 stated the controlled substance count was recorded on these forms. The forms had areas for the date and times of the controlled substance count to be recorded as well as the signatures of the off-going nurse and on-coming nurse. The amount of cards were also recorded. On 06/03/26 at 7:00 AM, the off-going nurse had not signed the form. On 06/02/26 at 7:00 PM, the on-coming nurse had not signed the form. On 06/01/26 at 7:00 PM, the off-going nurse had not signed the form. On 05/31/26 at 7:00 PM, the off-going nurse had not signed the form. On 05/30/26 at 7:00 PM, the off-going nurse had not signed the form. LPN #103 confirmed the controlled substance counts had not been signed by both the on-coming and off-going nurses. No further information was provided through the completion of the survey process. b) Resident #98 A review of Resident #98's medical record found he was ordered oxycodone Ir 10 mg every 8 hours. A review of the Controlled Substance Log and the Medication Administration Record (MAR) for 05/01/26 through 06/07/26 found on the following four (4) occasion Liscensed Practicalk Nurse #58 signed out Resident #98's Oxycodone on the Controlled Substance Log but failed to document it as administered on the MAR . The dates and times are as follows: -- 05//15/26 at 6:00 am -- 05/28/26 at 6:00 am -- 06/02/26 at 6:00 am and -- 06/07/26 at 6:00 am An interview with Nurse Consultant #131 at 4:00 PM on 06/08/26 confirmed the above findings and agreed it should have been identified as possible drug diversion.

Based on observation, record review and staff interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration each resident's preferences. This deficient practice was found during the dining observation. This deficient practice has the potential to affect more than a limited number of residents. Resident identifier: #13, #23, #68 and #89 . Facility census: 109. Findings included: a) Resident #13 On 06/01/26 at 12:35 PM during the lunch meal service, Resident #13 received her lunch and did not receive a nutritious pudding, as stated on her tray ticket. I asked the Business Office Manager (BOM) if Resident #13 received the nutritious pudding, and she stated she does not have it and I will go get it. Physicians order dated 02/04/26, for Nutritional Supplement in the afternoon, fortified pudding with lunch, 4oz serving. b) Resident #23 On 06/01/26 at 12:40 PM during the lunch meal service, Resident #23 received her lunch and did not receive her mandarin oranges. I asked Certified Nurse Assistant #82 if Resident #23 should have received the mandarin oranges , and she stated yes she should have, I will go ask for them. c) Resident #68 On 06/02/26 at 12:27 PM during the lunch meal service, Resident #68 received her lunch and did not receive her key lime pie. I asked the facility staff in the dining room if they could go get a serving of this for Resident #68, and they did. d) Resident #89 On 06/01/26 at 2:19 PM, Resident #89 stated I have told them I do not like mixed vegetables, and I still receive them. Resident #89 has capacity with a BIMS of 15.

Based on record review, resident interviews and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe food temperatures to prevent foodborne illness and an appetizing temperature of the food. The facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice was true for one (1) of one (1) meal tray tested throughout the survey process. This failed practice had the potential to affect more than a limited number residents. Resident identifier: #49, 12, 89, 44 and 65. Facility census: 109 Findings include: a) Policy #ADM-015-Food Temperature Control states: Policy: All foods shall be cooked, held, and served at safe temperatures to prevent foodborne illness. Purpose: To ensure compliance with FDA Food Code and CMS F812 standards Procedure:Hot foods > 135 degrees F; cold foods < 41 degrees F. Food temperatures will be taken once cooked, before, during and after service. Thermometers shall be calibrated daily and sanitized after use. Corrective action will be taken immediately for any unsafe reading. b) Initial walkthrough of the kitchen on 06/01/26 at 11:00 AM. The Director of Dining Services (DDS) accompanied this surveyor and verified the findings to be true. I asked to see the food temps for the meals for the month of May 2026, and the facility were only taking and recording the temperatures of the food items that were on the main menu. They were not recording any alternate or always available food items before serving them to the residents. The DDS stated We will start recording temps for those items also. The facility is not following state or federal guidelines, or their own policy for taking and recording food temperatures on all food items prepared in the dietary department, before serving the residents these items. They do not know if the temperatures meet the food code standards, because they were not taking all of them per the guidelines. c) Resident Council on 06/02/2026 at 2:00 PMThe residents attending this meeting stated the bread is always hard. d) Resident #89 stated the food is cold sometimes, and the breadsticks are hard as a rock. e) Resident #44 stated the food is not good here. f) Resident #65 stated the hot food is cold at times. g) Resident #49 stated the food is nasty.

Based on observation and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than a limited number of residents. Facility census: 109Findings include: a) Policy #ADM - 077 - Label and Dating Requirements states: Policy: All prepared, opened, or repackaged foods shall be labeled and dated to ensure proper rotation and safety. Purpose: To prevent spoilage and maintain compliance with sanitation standards. Procedure: Each container must be labeled with product name, preparation or open date, and discard date. b) Policy #ADM - 018 - Equipment Cleaning and Maintenance states: Policy: All dietary equipment shall be maintained in good repair and kept in a clean, sanitary condition at all times. Purpose: To ensure food is prepared and served safely and that equipment operates efficiently in accordance with CMS F812. Procedure: Equipment will be cleaned and sanitized after each use following manufacturer guidelines. c) Policy #ADM - 024 - Master Cleaning Schedule (sanitation Program) states: Policy: All dietary areas, equipment, and utensils shall be cleaned and sanitized on a defined schedule to maintain sanitary conditions. Purpose: To prevent food contamination and ensure regulatory compliance. Procedure:A written cleaning matrix (daily / weekly / monthly / PRN) will assign tasks and responsible staff.Food-contact surfaces: wash-rinse-sanitize between tasks and at shift end.Non-food-contact surfaces (walls, floors, hoods, vents) are cleaned per schedule and as needed.Approved detergents / sanitizers are used per label instructions.The Dietary Manager audits completion and corrective actions weekly.d) Policy #ADM-153-Manual Ware Washing Procedures states: Policy: Manual washing of pots, pans, and utensils shall follow the three-compartment-sink method using approved detergents and sanitizers. Purpose: To ensure all food-contact items are properly cleaned and sanitized when dish machines are unavailable or for oversized equipment. Procedure: Set up sink compartments.ScrapWash (110 degrees F minimumRinseSanitizeRecord sanitizer test results before each meal period to ensure proper PPM.e) Policy #ADM-440-Mechanical Dish Machine Standards Policy: All mechanical dish machines shall operate per manufacturer and regulatory standards for time, temperature, and sanitizer concentration. Purpose: To ensure all dishware and utensils are effectively sanitized during mechanical cleaning. Procedure:Verify wash temperature > 150 degrees FFinal rinse temperature > 180 degrees F (high-temp machines)Record results each meal service period f) Initial walkthrough of the kitchen on 06/01/26 at 11:00 AM. The Director of Dining Services (DDS) accompanied this surveyor and verified the findings to be true. -The floor in the walk-in refrigerator was soiled and needed sweeping and mopping.-Multiple juice cups were not dated in the walk-in and the reach-in refrigerators.-The reach-in refrigerator had beverage spilled on the bottom shelf.-Two (2) containers of honey thickened juice were not dated properly in the reach-in refrigerator.-The drip pan located under the stove was soiled with food debris.-The top interior of the microwave was soiled.-The toaster was soiled.-The fronts of both conventional ovens were soiled.-One (1) package of flour was opened, not sealed, and not dated properly.-The dish machine was missing multiple temperatures that were not recorded for the month of May 2026 and for breakfast on June 1 2026.-All three (3) handwashing sinks located in the dietary department were soiled.-One foam cup of sugar was not sealed, labeled or dated properly in the side one (1) pantry.-One container of coffee was not dated properly in the side one (1) pantry.-The microwave in the side one (1) pantry was heavily soiled on the inside.-Two (2) can openers were soiled.-Interview with Director of Dining Services (DDS) at 11:40 AM on 06/01/26 DDS stated, We will get these items cleaned, and I will discard the items not dated properly. Follow up visit to the kitchen on 06/02/26 at 10:15 AM-One (1) can opener was soiled.-The dish machine temperature was not taken and recorded prior to washing breakfast dishes this morning.-The three (3) compartment sink water temperatures are not being recorded. The facility is only recording the sanitizer's parts per million (PPM).One soiled pair of gloves was located on the countertop near the coffee maker.-Interview with Director of Dining Services (DDS) on 06/02/26 at 10:25 AM DDS stated, The can opener will be replaced today. I will update the form and we will start taking the water temperature for the three (3) compartment sink.

Based on observation and staff interview, the facility failed to store and dispose of garbage and refuse properly. The lids for the trash cans located in the kitchen and the dish room were not on during two different observations of the kitchen during the survey process. This failed practice has the potential to affect more than a limited number of residents at the facility. Facility census: 109. Findings include: a) Policy #ADM -300 - Garbage and Waste Disposal states: Policy: All garbage and food waste shall be handled and disposed of safely and frequently to maintain sanitation and odor control. Purpose: To prevent pest attraction, odor buildup, and contamination in food-service areas. Procedure:Keep the lids closed at all times and when not in use.Clean and sanitize garbage cans daily, including exterior surfaces.b) The Initial walkthrough of the kitchen took place on 06/01/26 at 11:00 AM The Director of Dining Services (DDS) accompanied this surveyor and verified the findings to be true. There was no lid on the trash can located beside the handwashing sink. I asked The DDS if there was a lid available for this trash can and she stated, Yeah somewhere, but I cannot find it. I will remove it from the kitchen. At 11:20 AM on 06/01/26, the trash can located in the dish room did not have a lid on it. The DDS did put the lid on after the surveyor brought it to her attention. At 11:46 AM on 06/01/26 the trash can located in the dish room did not have the lid on it again. The DDS stated, I will speak to my staff about leaving the lids on the trash cans when not in use.

Based on record review and staff interview, the facility failed to ensure medical records were complete and accurate. This deficient practice had the potential to affect nine (9) of 35 residents reviewed in the long-term care survey sample. Resident Identifiers: #11, #12, #98, #94, #77, #76, #20 and #6. Facility census: 109. Findings included: a) Resident #11 Review of Resident #11's physician's orders showed an order written on 04/07/26 for gabapentin oral capsule, 100 milligrams (mg), give one (1) capsule by mouth every eight (8) hours related to neurocognitive disorder with Lewy bodies. Gabapentin (Neurontin) is a medication typically used to prevent seizures or to treat nerve pain. A physician's progress note written on 04/07/26 stated, Seen today at the request of the resident to discuss escalating pain control with gabapentin. On 06/08/2026 at 1:07 PM, Corporate Nurse #131 confirmed the indication given for the gabapentin order for Resident #11 was incorrect. Corporate Nurse #11 stated gabapentin was prescribed for the resident for pain and not for neurocognitive disorder with Lewy bodies. No further information was provided through the completion of the survey process. b) Resident #12 Resident #12 had the capacity to make his own medical decisions. On 09/04/25, Resident #12 completed and signed a tuberculosis questionnaire and consent. The questionnaire stated: To your knowledge in recent years, has the resident ever had: A TB (tuberculosis) skin test? (The resident answered yes and also wrote in a question mark.) An allergic reaction to a TB skin test? (The resident answered no.) A positive reading from a skin test? (The resident answered no.) A chest x-ray to detect TB? (The resident answered yes.) I do authorize a TB skin test to be performed to determine if I have active TB or have been exposed to TB in the past. (The resident answered no.) Review of Resident #12's medication administration record (MAR) for September 2025 showed the resident received TB skin tests on 09/05/25 and 09/15/25. On 06/09/26 at 1:52 PM, Registered Nurse (RN) #97 stated she was the Infection Preventionist in September 2025 and had completed the TB test consent form with Resident #12. She stated the resident verbally consented to TB testing but had misunderstood the consent form. He thought the last item on the form had been asking if he had ever received a TB skin test. RN #97 confirmed Resident #12's TB test form had been incorrectly completed. No further information was provided through the completion of the survey process. c) Resident #98 The facility's policy titled, Administration Procedures for All Medications, with effective date September 2018 and revision date August 2020, stated that after a medication is administered, the administration should be documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Review of Resident #98's physician's orders showed an order written on 01/12/26 for tuberculin purified protein derivative (PPD) intradermal injection to screen for tuberculosis (TB) infection. The injection had not been signed as given on the resident's MAR for January 2026. On 06/09/26 at 2:19 PM, Registered Nurse (RN) #97 stated she was the Infection Preventionist in January 2026. She presented a notebook in which she made hand-written notes to track vaccinations given to residents. In the notebook was a page for Resident #98 labeled Vaccination Consents/TB information. The document indicated that the resident had received a tuberculin PPD test on 01/12/26. RN #97 verified the tuberculin PPD test had not been signed out on the MAR to indicate the test had been given. No further information was provided through the completion of the survey process. e) Resident #94 A review of Resident #94's medical record on the afternoon of 06/02/26 found a Physician Determination of Capacity statement dated 12/10/25. The form indicates Resident #94 does not have capacity to make medical decisions. Further review of the record found it was void of any paperwork identifying who would be making the medical decisions for Resident #94. Nurse Consultant #131 was asked to provide paperwork identifying who was making medical decisions for Resident #94 in the late morning of 06/02/26. The facility provided a Surrogate Appointment form dated 11/26/25 which appointed the residents son as his Health Care Surrogate. This form was completed at a local hospital. Further review of the form found the form was not printed from the hospitals system until 06/02/26 at 12:27 PM which was after the surveyor had requested the facility provide the paperwork. An interview with Social Worker #124 at 1:00 PM on 06/02/26 confirmed the facility did not have a copy of the Health Care Surrogate Form in Resident #94's medical record. She stated, I called the hospital after you asked for it and they sent it to us. f) Resident #76 A review of Resident #76's medical record on the morning of 06/10/26 found a Social Service Initial Evaluation version two (2) which was completed on 08/05/25 at 11:29 am. This evaluation indicated Resident #76 was a female. It should be noted Resident #76 is a male. During an interview with Nurse Consultant #134 in the morning of 06/10/26 she confirmed Resident #76 was a male and the Social Service evaluation incorrectly identified his gender. g) Resident #6 A review of Resident #6's medical record on the morning of 06/09/26 found under the task documentation for Walking 10 foot and 50 foot the resident was coded as dependent on staff for walking 10 foot and/or 50 foot once standing on the following days: 10 Foot: 05/04/26 05/05/26 05/07/26 05/10/26 05/13/26 05/14/26 05/18/26 05/19/26 05/22/26 05/23/26 05/24/26 05/26/26 05/27/26 05/28/26 and 06/01/26 50 Foot 05/02/26 05/04/26 05/05/26 05/07/26 05/10/26 05/13/26 05/14/26 05/15/26 05/18/26 05/19/26 05/22/26 05/23/26 05/24/26 05/26/26 05/27/26 05/28/26 and 06/01/26. During an interview with consultant nurse #131 in the afternoon of 06/09/26 it was confirmed Resident #6 is not able to stand and walk at all. She stated, They said she has not walked since coming back from the hospital. Further review of the medical record found Resident #6 was readmitted to the facility from the hospital on [DATE] and has had no discharges since. h) Resident #20 A review of Resident #20's medical record on the morning of 06/08/26 found two (2) dental/oral assessments dated 01/17/25 and 05/22/26 under number 7. Number of teeth no answer was recorded on either assessment. Corporate Nurse #131 completed an oral assessment on Resident #20 at 2:00 pm on 06/08/26 and confirmed Resident #20 has six (6) natural teeth. She reviewed the assessments and confirmed they were inaccurate. i) Resident #98 A review of Resident #98's medical record on the morning of 06/10/26 found a Trauma Screen Dated 02/01/26. This screen indicated Resident #98 was not interviewable. However Resident #98's name was listed under name of the person interviewed. A review of Resident #98's capacity statement indicated the resident was capacitated to make medical decisions. A review of Resident #98's Brief Interview of Mental Status (BIMS) found he scored a 15 which indicated the resident was cognitively intact. An interview with Corporate Nurse #131 on the morning of 06/10/26 confirmed the Trauma Screen dated 02/01/26 was inaccurate because Resident #98 is interviewable. j) Resident #77 A review of Resident #77's medical record on the morning of 06/09/26 found a social service assessment dated [DATE] which indicated the resident needed and/or requested an interpreter. An interview with Social Worker #100 at 3:36 pm on 06/09/26 confirmed the social service assessment was inaccurate and Resident #77 did not need an interpreter.

Based on record review, resident interviews, and staff interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. This deficient practice affected four (4) residents reviewed in the long-term care survey sample. Resident Identifiers: #1, #76, #6, and #116. Facility census: 109. Findings included: a) Resident #116A policy titled, Social Services-Transportation, read as follows: our facility shall help arrange transportation for residents as needed.According to the hospital discharge orders for Resident #116 from 07/04/26, a follow up was scheduled with the Congestive Heart Failure (CHF) Clinic on 07/14/26 at 1:40 PM and a follow up was recommended with Nephrology, (name of physician) in one to two (1-2) weeks from hospital discharge.A review of the transportation schedule for July 2025 does not show either appointment. The facility was unable to produce evidence that they had provided transportation to scheduled appointments or that the resident attended those appointments.In an interview with Corporate Registered Nurse (CRN) #131 on 06/04/26 at approximately 1:00 PM, CRN #131 confirmed according to documentation Resident #116 was not provided transportation and did not attend follow up appointments.b) Resident #6A review of Resident #6's medical record on the morning of 06/02/26 found a physician order which read, : Post - Dialysis: obtain a full set of vital signs and weight after dialysis treatment on Monday, Wednesday and Friday. No BP (blood pressure) in left arm. This order was entered into the residents medical record on 01/09/26 and was the active order at the time of this review.A review of Resident #6's electronic medical record on the morning of 06/02/26 found under the vital signs tab under blood pressure the residents blood pressure had been obtained in her left arm on the following dates and times: 05/02/26 at 8:02 am 05/02/26 at 10:44 pm 05/03/26 at 8:32 am 05/04/26 at 12:03 pm 05/05/26 at 12:32 am 05/06/26 at 11:00 am 05/007/26 at 8:03 am05/08/26 at 12:22 pm05/09/26 at 9:55 pm05/10/26 at 7:38 am05/11/26 at 11:43 am 05/12/26 at 7:57 am05/12/26 at 7:52 am05/13/26 at 6:00 am05/13/26 at 1:28 pm05/14/26 at 1:13 am 05/14/26 at 9:45 am 05/15/26 at 11:00 am 05/16/26 at 7:59 am 05/16/26 at 8:33 pm 05/17/26 at 7:42 am 05/18/26 at 10:08 am 05/19/26 at 10:37 am 05/20/26 at 11:00 am 05/20/26 at 11:50 am 05/21/26 at 7:41 am 05/23/26 at 7:21 am 05/24/26 at 7:49 am 05/25/26 at 11:00 am 05/25/26 at 11:21 am 05/25/26 at 9:41 pm 05/26/26 at 7:44 am 05/27/26 at 6:00 am 05/27/26 at 6:11 am 05/27/26 at 1:27 pm 05/28/26 10:02 am 05/28/26 at 4:59 pm 05/29/26 at 11:00 am 05/31/26 at 8:05 am 06/01/26 at 5:46 am 06/01/26 at 12:30 pm and 06/02/26 at 10:10 am. An interview with the DIrector of Nursing (DON) at 2:17 pm on 06/02/26 confirmed there was an order for the blood pressure not to be taken in the left arm. She reviewed the blood pressure vital signs tab and agreed the staff had documented taking the blood pressure in Resident #6's left arm on multiple occasions. Hill Valley Healthcare policy titled Change In a Resident's Condition states:c) Resident #76 Policy: The facility will promptly notify the resident, his or her physician / practitioner, and representative of changes in the resident's medical / mental condition and / or status.Specific Procedures:The nurse will notify the resident's Attending Physician / practitioner or physician on call when there has been a (an):a. accident or incident involving the resident;b. discovery of injuries of an unknown source;c. adverse reaction to medication;d. significant change in the residents physical, mental, or psychological status (that is a deterioration in health, mental, or psychological status in either life-threatening conditions or clinical complications)e. need to alter the resident's medical treatment significantly;f. refusal of treatment or medications two (2) or more consecutive times;g. need to transfer the resident to a hospital / treatment center;h. discharge without proper medical authority;i. specific instruction to notify the physician / practitioner of changes in the resident's condition.Resident #76 had a fall with a major injury on 09/10/25 at 6:15 PM. He received a physicians order for an x-ray on 09/12/25. The X-ray findings were Cortical irregularity at the coronoid. The X-ray conclusion was question coronoid fracture, consider CT. The Physician ordered a CT scan on 09/12/25. The CT scan was not scheduled until 09/24/26. The CT scan findings were Moderate body wall edema. Marked edema within the dorsal soft tissues of the imaged upper extremity. Lucency can be seen within the radial head worrisome for traumatic fracture best appreciated within coronal and sagittal reformats. No dislocation. The CT scan conclusion was Traumatic radial head fracture with dorsal soft tissue edema.The Physician was not notified of the CT scan findings until 10/06/26. On 10/06/26 the Physician ordered an Orthopedic referral. Resident #76 went to the Orthopedic Specialist appointment on 10/17/25 at 8:00 AM. The Orthopedic Specialist ordered non weight bearing to the right upper extremity (RUE) and a follow up appointment in six (6) weeks. The appointment was scheduled for 12/05/25 at 8:00 AM. Resident #76 never made it to that appointment.On 10/08/25 at 1:05 PM the facility Physician wrote a progress note stating, The patient (Resident #76) is seen for a follow-up visit at Mountainview. Resident #76 received the CT past ordered.Interview with Director of Nursing (DON) on 06/04/26 at 1:42 PM. This surveyor asked the DON why the facility Physician was not notified of the CT scan results from 09/24/25 until 10/06/25, and why Resident #76 missed the follow-up appointment with the Orthopedic Specialist on 12/05/25. She stated, It was just missed.d) Resident #1A record review on 06/09/26 at 9:27 AM, revealed that from 10/20/25 to 12/09/25 Resident #1 had an order for dialysis Monday, Wednesday, and Friday, with chair time at 6:00 AM.A review of the Medication Administration Record (MAR) from 10/20/25 to 10/31/25 revealed that on 10/20/25, 10/22/25, 10/27/25, and 10/31/25 Resident #1 did not get the following morning medications as ordered: Docusate sodium Capsule 100 Milligrams (MG) for constipation, Eliquis Oral Tablet 2.5 MG for Atrial Fibrillation, and Nateglinide Oral Tablet 120 MG for Diabetes Mellitus.Additionally, Resident #11 did not receive a prescribed antibiotic (Cephalaxin) on the mornings of 10/22/26 and 10/27/26.A review of the MAR from 11/01/26 to 11/30/26 revealed that on 11/05/26, 11/10/26, 11/14/26, 11/19/26, 11/25/26 and 11/28/26 Resident #1 did not receive the following morning medications as ordered: Docusate sodium Capsule 100 Milligrams (MG) for constipation, Eliquis Oral Tablet 2.5 MG for Atrial Fibrillation, Nateglinide Oral Tablet 120 MG for Diabetes Mellitus, and Multivitamin oral tablet as a supplement.Additionally, Resident #11 did not receive a prescribed antibiotic (Cephalaxin) on the morning of 11/10/25.The above dates correlate with Resident #11's dialysis schedule.During an interview on 06/09/26 at 9:35 AM, Corporate Consultant Nurse (CCN) #131 confirmed that for the months of 10/2025 and 11/2025 Resident #1 did not receive all of her morning medications on dialysis days as prescribed by the physician.

Based on record review, staff interviews, and resident interviews, the facility failed to include incapacitated residents in care plan meetings, and failed to revise care plans regarding tube feeding and transfer status. This deficient practice was found true for (3) three of 35 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers: #11, #4, and #6. Facility Census: 109. a) Resident #6 A review of Resident #6's care plan found the following: Focus Statement: MAINTENANCE: (First and Last Name of Resident #6) is a long-term care resident and requires assistance with their ADL's related to chronic health conditions, muscle weakness, COPD, difficulty in walking, lack of coordination. Date Initiated: 12/14/2024 Goal: (First Name of Resident #6) will maintain her current level of function as able through review period Date Initiated: 12/14/24 Revision on: 05/28/26 Target Date: 09/02/26. Interventions Included: TRANSFERS: Hoyer lift for all transfers x 2 staff Date Initiated: 12/14/2024. -- Wheeled [NAME] for ambulation and transfers date initiated 12/14/24. Both interventions were current at the time of this review on the morning of 06/08/26. An interview with Nurse Consultant #131 at 12:34 PM on 06/08/26 confirmed both could not be correct. She later stated, (Resident #6) needs a hoyer lift the other intervention should have been removed from the care plan. b) Resident #4 Review of Resident #4's current physician's orders showed an order written on 10/27/25 that stated, Enteral Feed: five times a day check G-tube [gastrostomy tube] placement by confirming the pH of aspirate; Notify PCP [primary care physician] if pH is greater than 5. Review of Resident #4's comprehensive care plan showed the following focus initiated on 11/06/24 and revised on 04/12/25: [Resident] is at risk for complications related to G-Tube. The following intervention was initiated on 11/06/24 and revised on 04/12/25: Two times a day check G-tube placement by confirming the pH of aspirate; Notify PCP [primary care physician] if pH is greater than 5. On 06/03/26 at 10:57 AM, the Director of Nursing [DON] confirmed Resident #4's comprehensive care plan was incorrect regarding the number of times per day pH testing should be performed to confirm the gastrostomy tube was in correct placement. No further information was provided through the completion of the survey process. c) Resident #11 During the initial interview on 06/01/26 at 11:30 PM, Resident #11 said she had not been to a care plan meeting and that staff had not told her what was going on. A record review on 06/09/26 at 12:21 PM, revealed that Resident #11 was deemed incapacitated since admission until 03/24/26 when she regained capacity. Resident's care plan signature page, up until 03/24/26 was completed with the Medical Power of Attorney (MPOA), via telephone. Resident #11's signature was not present. During an interview on 06/09/26 at 2:11 PM, the Licensed Social Worker (LSW) #100 stated, That resident would not have got the notice before because she just recently got her capacity back. The State Agency (SA) asked, If the resident does not have capacity do they still invite or involve them in the care plan meeting? LSW #100 replied, If they do not have capacity then we do not involve them in the care plan meeting. A review on 06/09/26 at 2:37 PM, of the policy titled {Care Planning- Interdisciplinary Team} reads under number 3 as follows: The Resident, the resident's family and or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Number 4 reads as follows: Every effort will be made to schedule the care plan meeting at the best time of the day for the resident and family.

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for two (2) of 58 resident rooms, and the main dining room, observed during the long-term care survey process. Dining room doors in disrepair. Rooms #209 and #210 were in disrepair. Resident Identifiers: #52, 65, 48 and 28. Facility Census: 109. Findings include: a) Hill Valley Healthcare policy titled Homelike Environment states: Residents will be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Environment: refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. Homelike Environment: is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the residents to use those personal belongings that support a homelike environment. A determination of homelike should include the residents opinion of the living environment. The facility team will provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. b) 06/01/26 at 3:50 PM room [ROOM NUMBER] - (Resident #52 and #65) has a blank electrical outlet cover that needs to be moved over to cover the hole in the wall. The television (TV) cable going to Resident #52's TV is lying on the floor away from the wall. Resident #52 stated that Resident #65's wheelchair had gotten tangled up with this cable before, and I had to help her get unstuck. There is ceiling damage in the room near a fire sprinkler that measures approximately a 12 inch by 12 inch square. On 06/01/26 at 4:05 PM, I showed the administrator these areas of concern and he stated I will put a work order in for my maintenance department to fix these, we have a lot of things that I want to get fixed, and we will continue to work on this. c) 06/02/26 at 8:30 AM room [ROOM NUMBER] - (Resident #28 and #48) I asked Resident #48 if she had any concerns, and she stated I would like my bathroom to be fixed. The vanity has a laminate strip missing, which prevents it from being easily cleanable. The strip is approximately 24 inches long and two (2) inches wide. There is a crack in the paint above the toilet measuring approximately 30 inches long. There are three small holes located above the glove holder on the wall near the bathroom door. There are two (2) areas beside the bathroom mirror that need drywall and paint repair. They both measure approximately 12 - 14 inches long. On 06/02/26 at 11:20 AM, I showed the Administrator Resident #48's concerns with her bathroom and he stated this is unacceptable and will be fixed. I will put a work order in now. d) On 06/02/26 at 11:00 PM this surveyor noticed that the paint is chipping and falling off both doors leading into the main dining room. The Corporate Registered Nurse (RN) #131 agreed that both doors need to be sanded and painted.

Based on record review, staff interviews, and resident interviews, the facility failed to ensure residents knew how to file a grievance, including anonymously if desired, and failed to adequately resolve resident grievances. This deficient practice was confirmed during the Resident Council Meeting and was a random opportunity for discovery. This had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifiers: #128, #55, #38, #129, #130, #63, #33. Facility census:109. Findings Include: a) Resident Council Meeting During the Resident Council Meeting on 06/02/26 at 2:10 PM, the Resident Council agreed that they did not know how to file a grievance in writing or anonymously. Resident #88 pointed at the wall and stated, They put that box up over there today and I guess that is what that is for, but there aren't any forms in it. During an interview on 06/02/26 at 12:55 PM, the Licensed Social Worker (LSW) #100 stated, They keep the forms behind the nurses station. Most of the residents would need help filling them out anyways. During an interview on 06/02/26 at 12:58 PM, at the A/B nurses' station, Licensed Practical Nurse (LPN) #66 stated, I thought Social Services had the forms. LPN #85 stated, I am not sure where they are at. Let me look. The Director of Nursing (DON) came out to the A/B nurses' station to help LPN #85 locate a binder in a cabinet for grievances. This process from the start of the interview until the form was found, took approximately 10 minutes. The DON further confirmed that the grievance forms were not readily available for residents and/or family members to file a grievance. b) Resolution of Missing Item Grievances During and interview with Resident #33 at 3:53 PM on 06/01/26 she stated, I don't always get my clothes back from laundry. She stated she is still missing several items and stated she does not send her clothes to the laundry no more. She then asked the surveyor if she thought it would be okay for them to take her to the laundry mat so she could wash he own clothes. Review of the grievances found the resident filed a grievance on 05/21/26 reporting she was missing green and red elastic pants, a blue elastic pant, a black pull-on jacket, a white jacket, brand-new underwear, and a blue long-sleeve shirt with all grandkids' names listed as 'grandma's love bugs'. The grievance indicated they located the red elastic pants, new underwear, and her blue love bug shirt and her white jacket. The grievance indicated the other items were replaced by the facility with a resolution date of 05/29/26. On the morning of 06/02/26 the facility was asked to provide evidence that the other items were replaced since the resident was still claiming they were missing. On the morning of 06/03/26 the facility provided a receipt from a local store which indicated the items had been purchased. The date on the receipt was 06/02/26 at 4:55 pm which was after the surveyor's request. An interview with the Nurse Consultant on 06/04/26 at 11:00 am confirmed the items were not replaced until after the surveyor asked about them. A review of the grievance log found several other grievances related to missing items. The following grievances were identified as not being resolved by the facility, despite the fact they claimed the items had all been replaced. There was no evidence to indicate the facility had replaced the items. Resident #128 Grievance filed on 10/24/25 which listed three (3) pairs of stretchy small sweatpants, one (1) long-sleeve shirt (Local college team) small, one (1) pair of house shoes rubber sole size 10m, and a missing blue jacket size small. The investigation found the items were not located. Actions taken was listed as: Items will be replaced by facility. Resolved date was listed as 11/07/25. The facility was unable to provide evidence that the items were replaced. Resident #55 Grievance filed 09/15/25 which listed blue shorts (Size 16-18), tan/brown shorts (size 16-18), grey sweater (size unknown), burgundy sweater (size unknown) all missing. The results of the investigation indicated the items were not found. The resolved date was listed as 09/25/25 and the summary of actions taken was that the items would be replaced. The facility was unable to provide evidence that the items were replaced. Resident #38 Grievance filed 09/10/25 which listed missing items as a peach/orange nightgown, 4 pairs [NAME] socks and 1 single nonskid sock. The investigation revealed the items were not located. The resolved date was listed as 09/17/25 and the summary of actions taken was: Items will be replaced. The facility was unable to provide evidence that the items were replaced. Resident #129 Grievance filed 10/17/25 which listed under the grievance details the following: We did an audit and resident stated that she had a robe missing. The investigation indicated the item was not located. The resolved date was listed as 10/24/25 and the summary of the actions taken was: the items will be replaced. The facility was unable to provide evidence that the items were replaced. Resident #130 Grievance filed 10/17/25 which listed under the grievance details the following: We did an audit and resident stated that had clothes missing. Summary of investigation indicated the items were not located. Summary of actions taken indicated the items would be replaced by the facility. The resolved date was 10/24/26. The facility was unable to provide evidence that the items were replaced. Resident #63 Grievance filed 10/17/25 which listed under the grievance details the following: We did an audit and resident stated that had clothes missing. Summary of investigation indicated the items were not located. Summary of actions taken indicated the items would be replaced by the facility. The resolved date was 10/24/26. The facility was unable to provide evidence that the items were replaced. During an interview at 1:09 PM on 06/04/26, the Corporate Nursing Home Administrator (CNHA) #140 confirmed they could not locate any receipts showing that Residents #128, #55, #38, #129, #130, and #63 had their items replaced. He stated, we are going to follow up with them and get the items replaced now.

Based on record review and resident and staff interviews, the facility failed to correctly interpret the results of abuse allegation investigations and prevent further potential abuse while an investigation was in progress. This was true for five (5) of six (6) residents sampled for abuse during the Long-Term Care survey process. Facility census: 109. Resident identifiers: #21, #8, #49, #74, and #70. a) Resident #21, #8, #49 A policy titled, Abuse reads, in the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. In a nurse note dated 02/17/26 at 5:58 PM it is documented, It was reported to this nurse that resident 94036643 and resident 94036696 was sitting in the hallway holding hands and resident 94036643 had resident 94036696 hands in between resident 94036643 legs. Resident's were separated and resident 94036643 was put on [one-on-one] 1:1 and [every fifteen] q15 minute checks. PCP [Primary Care Physician] and RP [Responsible party] notified. According to the witness statements, this incident occurred at approximately 2:30 PM between Resident #8 and Resident #21. The intervention was to place Resident #8 on one-on-one (1:1) observations immediately pending investigation. Resident #21 was listed as non-verbal with a Brief Interview of Mental Status (BIMS) score on the Minimum Data Set, dated [DATE] of 00 indicating Resident #21 was not capable of making decisions regarding daily living activities and has no recall ability. During an interview with Resident #49 on 06/03/26 at 3:40 PM, she stated she was Yelled at and called names over a man and it made me feel degraded. Upon further investigation, a nursing note dated 02/17/26 at 6:27 PM reads, It was reported to this nurse that resident 94036643 verbally threatened to kick resident 94036540's but. Resident 94036540 reported that she didn't want resident 94036643 to kick her but. Resident 94036643 put on 1:1 [one-on-one]. PCP [primary care physician] and RP [responsible party] notified. According to witness statements, this incident occurred at approximately 4:00 PM between Resident #49 and Resident #8. Another incident occurred on 02/17/26 at 4:31 PM per documentation involving Resident #8 in which Resident[#8] called this nurse in resident's room demanding to speak to the administrator now. Resident stated that unit manager had hit her. Resident pointed to her wrist and lower arm and stated She hit me right here. This nurse reported incident to risk nurse. This nurse assessed resident's skin and there was no marks or redness on resident's skin. According to witness statements and facility reported incident investigation, this incident occurred due to unit manager attempting to separate Resident #8 and Resident #21. In an interview with Social Services #100 on 06/03/26 at 3:00 PM, she confirmed Resident #8 was not on one-on-one (1:1) at the time of these incidents. During an interview with Corporate Registered Nurse #131 on 06/03/26 at 3:50 PM, she confirmed, per documentation, Resident #8 was supposed to be on one-on-one (1:1) observations from the 2:30 PM incident. According to the Medication Administration Record, the one-on-ones did not start until 7:00 PM on 02/17/26. b) Resident #74 A review of a reportable incident with an incident date of 01/19/26 involving Resident #74 as the victim and Resident #90 as the alleged perpetrator found the following description of the incident, (First and Last Name of Resident #74) was sitting by the nurses station, (First name of Resident #90), he rolled by and reached between (First Name of Resident)' s legs. and (First name of Resident #74) smacked his hands away/CNA redirected the residents. A review of the five day follow up found the following listed under conclusion: Due to the incident being witnessed by center staff, the incident has been verified. The investigation confirms that the event did occur due to staff witness account. However the investigation is inconclusive for abuse due to not indication of physical or psychosocial harm, unknown if intentional due to incapacity of alleged perpetrator and BIMS of 3.0 and no recollection of incident by either resident. During an interview with the Nursing Home Administrator (NHA), Nurse Consultant #131 and Social Worker #100 on 06/04/26 at 1:44 PM they agreed abuse should have been verified and the investigation was not inconclusive. c) Resident #70 A review of a reportable incident with an incident date of 03/19/26 found the following description of the incident: Resident made contact with other resident. The alleged victim was identified as Resident #70 and the alleged perpetrator was Resident #63. A review of the investigation found a statement from Nurse Aide #72 who the assigned 1:1 aide for Resident #63 at the time of the incident. The statement read as follows, I was following the 1:1 (resident #63's assigned Medical record number) when I saw (First Name of Resident #70) coming out of (Resident #63's assigned Medical record number) room. I immediately approached (First Name of Resident #70) to guide him out of the room and back into his room which is next) door. Resident (resident #63's assigned Medical record number) became irate as soon as she saw someone in her room, they propelled self suddenly forward in the wheelchair and kicked (first name of Resident #70) in the lower legs. Resident (resident #63's assigned Medical record number) attempted to punch (First name of Resident #70) again. I continued to separate and redirect. Other staff came and assisted. (First Name of Resident #70) presented to be unaware of the situation. A review of the Five day follow up related to this incident found the following conclusion, The facility has unsubstantiated abuse due to diagnosis and low BIMS score related to intent. Facility did interview like residents on hall with no variances regarding safety. During an interview with the Nursing Home Administrator (NHA), Nurse Consultant #131 and Social Worker #100 on 06/04/26 at 1:44 PM they agreed abuse should have been verified. The NHA indicated he thought becuase Resident #63 had a diagnosis of dementia and a low BIMS he could not find intent. When asked if the resident kicked the other resident voluntarily he stated, yes. He agreed it was not an accident she did it on purpose but she did not know what she was doing cognitively. He stated, I understand now what that means.

Based on record review and staff interview, the facility failed to notify the resident in writing of the reason for the transfer to the hospital and send a copy of the notice to the ombudsman. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for the care area of hospitalization. Resident Identifiers: #2, #11, and #9. Facility Census: 109. Findings included: a) Policy Review The facility's policy titled, Transfer or Discharge, Preparing a Resident for, with original date 10/01/21, gave no guidance regarding a discharge or transfer form. However, the policy stated the business office or social services were responsible for informing the resident or the resident representative of readmission appeal rights. b) Resident #2 Review of Resident #2's electronic health record showed the resident was transferred to the hospital on [DATE] due to abnormal vital signs. The resident's electronic health record showed no documentation of a transfer notice giving information regarding appeal rights and the contact information for the long-term care Ombudsman. On 06/03/2026 at 10:02 AM, the Director of Nursing (DON) stated the facility did not provide a notice of transfer to the resident or resident representative giving information regarding appeal rights and the contact information for the long-term care Ombudsman. The DON also stated there was no documentation that the Ombudsman had been notified of Resident #2's transfer to the hospital on [DATE]. c) Resident #11 Review of Resident #11's electronic health record showed the resident was transferred to the hospital on [DATE] due to abnormal vital signs. The resident's electronic health record showed no documentation of a transfer notice giving information regarding appeal rights and the contact information for the long-term care Ombudsman. On 06/10/2026 at 09:05 AM, the Director of Nursing (DON) stated the facility did not provide a notice of transfer to the resident or resident representative giving information regarding appeal rights and the contact information for the long-term care Ombudsman. The DON also stated there was no documentation that the Ombudsman had been notified of Resident #11's transfer to the hospital on [DATE]. d) Resident #9 Facility was unable to produce ombudsman notification for April transfers to the hospital for Resident #9. It was confirmed by Administrator at 12:15PM on 06/03/26 that there is no proof of ombudsman notification for transfers to the hospital for Resident #9 for 04/02/26 or 04/08/26.

Based on resident interview, record review, observation and staff interview the facility failed to develop and or implement the care plan for three (3) of sampled residents reviewed during the long term care survey process. For Resident #77 they failed to develop a care related to his feelings of being abandoned by his girlfriend. For Resident #6 they failed to implement her care plan related to her wheelchair cushion. Finally for Resident #98 they did not develop his care plan related to his discharge goals and preferences. Resident Identifiers: #77, #6, and #98. Facility Census: 109. a) Resident #77 During an interview with Resident #77 on 06/01/26 at 12:42 pm he stated his family abandoned him. Mostly his fiancee, with whom he lived. He stated, I have anxiety and depression and this is part of the reason I feel like that. A review of the resident's care plan showed no mention of the resident's feelings of being abandoned by his fiancee. During an interview with Social Worker #100 on the afternoon of 06/09/26 she confirmed she was aware the resident's relationship ended with his girlfriend and stated she was aware of his feelings of being abandoned upon admission to the facility. She agreed it was not addressed on the resident's care plan. b) Resident #6 On 06/08/26, an observation and interview with Resident #6 at 11:18 am found she had just returned from dialysis. She stated, They got me back on time today thank goodness because the girl this morning did not put my cushion in my wheelchair. The surveyor observed the resident's wheelchair, in which she was still sitting, and noted the cushion was not present. The cushion was located in Resident #6's room on the floor. Resident #6 stated, This chair hurts when the cushion is not in it. Nurse Aide #73 was present during this interview and observation and agreed the cushion was not in Resident #6's chair. A review of Resident #6's care plan found the following focus statement: : (First Name of Resident #6) is a long-term care resident and requires assistance with their ADL's related to chronic health conditions, muscle weakness, COPD, difficulty in walking, lack of coordination. The goal associated with this practice statement read as follows: (First name of Resident #6 will maintain her current level of function as able through review period. The interventions included: Pressure reduction cushion to wheelchair at all times. Observe proper placement Q shift. Replace as indicated. This intervention was added to the care plan on 12/14/24. c) Resident #98 An interview with Resident #98 on the afternoon of 06/01/26 found he was waiting on a bed at another Skilled Nursing Facility which would be closer to his family. He indicated this has been his plan since he was admitted to the facility. An interview with Social Worker #100 on the afternoon of 06/09/26 confirmed she had sent a referral to the other Skilled Nursing Facility on 03/19/26 and was just waiting for them to have a bed for him. A review of Resident #98's care plan found the following care plan related to discharge: Focus Statement: LONG TERM DISCHARGE PLAN: (First name of Resident #98) is expected to remain in the facility long term and has no plans to discharge at this time This was initiated on 02/02/26. Goal: (First Name of Resident #98)/resident representative will have their needs met thru the review period This was also initiated on 02/02/26. Interventions Included: -- assess for the resident's preference to return to the community and refer if needed Date Initiated: 02/02/26-- refer the resident to the local contact agency if indicated by the resident Date Initiated: 02/02/26-- review and update discharge plans with the resident when needed Date Initiated: 02/02/26 On the afternoon of 06/09/26 the care plan was reviewed with Nurse Consultant #131, who agreed it should have been updated to reflect the resident's desire to transfer to another facility.

Based on record review, resident interviews, and staff interviews, the facility failed to provide Dialysis services in accordance with professional standards of practice. Resident #1 did not receive dinner meals when returning from Dialyses. Resident #6 did not receive timely transportation back from Dialyses. This failed practice was found true for (2) two of (2) two residents reviewed for Dialysis services during the Long-Term Care Survey Process. Resident identifier: #1. Facility Census: 109. Findings include: a) Resident #1 During the initial interview on 06/01/2026 at 12:15 PM, Resident #1 stated, I go to dialysis three times a week. Two of those days are in the evening. They don't always save my dinner. Sometimes I just have to eat something I have in my room. I do not know why they can't just put it in the fridge and then heat it up. A record review on 06/03/26 at 1:42 PM, revealed an order for Resident #1 that reads as follows:Dialysis at (Local Dialysis center named) Q Monday and Friday; have ready for transport by 3:00 PM for scheduled chair time at 3:30 PM; facility to transport. (Address and phone number of Dialysis center). Further record review of the meal percentages for Resident #1 from 03/03/26 to present shows that there are 24 possible Monday and Friday dinner (Resident was out to the hospital from [DATE] to 04/09/26). Out of the possible 24 suppers, 15 are not recorded or are recorded as Resident not available. During an interview on 06/03/26 at 2:15 PM, The Director of Nursing (DON) confirmed that by looking at the documentation it does appear that Resident #1 did not receive dinner meals on the dates above, which correlate with her dialysis schedule.

Based on record review and staff interview the facility failed to ensure all residents were afforded the opportunity to formulate their own advance directive and to have their wishes honored after an advance directive is formulated. This was true for two (2) of seven (7) residents reviewed for the care area of advance directives during the long term care survey process. Resident identifiers: #11 and #124. Facility Census: 109. a) Resident #11 A review of Resident #11's medical record on the morning of [DATE] found a physician determination of capacity completed by Resident #11's attending physician on [DATE]. This form indicated Resident #11 had capacity to make medical decisions. This was the most recent capacity form located in Resident #11's medical record. Further review of the medical record found a Physician Order for Scope of Treatment (POST) form dated [DATE]. The medical record revealed Resident #11 was admitted to the facility on 11/22. This POST form was the most recent in the resident's medical record and indicated the resident was to be a full code. Further review of the post form found it was signed by someone other than Resident #11. Social Worker #100 confirmed during an interview at 12:57 pm on [DATE] that the POST form was not signed by Resident #11. When asked if Resident #11 should have been given the opportunity to complete a new post form when she regained capacity on [DATE] she stated, Yes she should have. b) Resident #124 A review of Resident #124's medical record found a POST form signed by Resident #124 on [DATE], indicating the resident wished to not receive CPR and wanted only comfort focused treatments. A review of the physician's orders entered into Resident #124's medical record found the following order entered on [DATE], ADC: Full Code/ Full treatments/no artificial means of nutrition desired/has capacity. An interview with Nurse Consultant #131 and the Nursing Home Administrator on the after noon of [DATE] confirmed the order entered into the physician's orders did not match Resident #124's expressed wishes and needed correction.

Based on record review, staff interviews and resident interviews the facility failed to treat each resident with respect and dignity by not recognizing their individuality. This failed practice was found true for (2) two of (3) three residents reviewed for dignity during the Long-Term Care Survey. Resident identifiers: #88 and #101. Facility census: 109. Findings Include: a) Resident #88 During an interview on 06/02/26 at 3:10 PM, Resident #88, who has a Brief Interview for Mental Status (BIMS) score of 15 stated, Last night an agency CNA came into my room at 1:00 in the morning and woke me up and said she needed to put my name on my personal stuff. I told her no and to get out. That is ridiculous. I think she went into other rooms and did the same thing. b) Resident #101 During an interview on 06/02/26 at 3:20 PM, Resident #101, who has a BIMS score of 12 stated, A CNA came in my room last night about 2 in the morning and wanted to put my name on some stuff. She said she had to go get something but then didn't come back. Do they have to do that at 2 in the morning? c) Staff interview During an interview on 06/02/26 at 3:55 PM, the Director of Nursing (DON) stated, I am not sure if they were labeling personal items, or if the direction came from the nurse. But no, they should not do that at that time of the morning.

Based on record review and resident and staff interviews, the facility failed to ensure Resident #49 was free from abuse. This was true for one (1) of five (5) residents sampled for abuse during the Long-Term Care survey process. Census: 109 Resident identifier: #49a) Resident #49 A policy titled Resident-To-Resident Altercations defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. During an interview with Resident #49 on 06/03/26 at 3:40PM, she stated she was yelled at and called names over a man and it made me feel degraded. Upon further investigation, a nursing note dated 02/17/26 at 6:27 PM revealed, It was reported to this nurse that resident 94036643 verbally threatened to kick resident 94036540's but. Resident 94036540 reported that she didn't want resident 94036643 to kick her but. Resident 94036643 put on 1:1 [one-on-one]. PCP [primary care physician] and RP [responsible party] notified. A review of the facility reported incident (FRI) showed the resident who yelled at Resident #49 was supposed to be placed on one-on-one (1:1) observation at 2:30 PM on 02/17/26. A review of the Medication Administration Record (MAR) for 02/17/26 shows the other resident was not put on one-on-one (1:1) observation until 7:00 PM on 02/17/26. The FRI also showed that the incident was unverified despite both parties admitting it happened.In an interview with Social Services #100 on 06/03/26 at 3:00PM, she confirmed the offending resident was not on one-on-one (1:1) at the time of the incident with Resident #49. During an interview with Corporate Registered Nurse #131 on 06/03/26 at 3:50PM, she confirmed, per documentation, Resident #49 was yelled at by another resident who was supposed to be on one-on-one (1:1) observations.

Based on record review, family interview and staff interview the facility failed ensure Resident #63 maintained privacy of her medical record. The facility sent excerpts from the residents medical record to an out of state facility without the permission of the healthcare decision maker. This was true for one (1) of one (1) residents reviewed for the care area of privacy during the long term care survey process. Resident Identifier: 63. Facility Census: 109. a) Resident #63 On 06/02/26 at 8:28 am an interview with the Medical Power of Attorney (MPOA) for Resident #63 revealed that the facility sent excerpts of the medical record to another facility without the MPOA's permission. She stated, Things are better now but they did do that last year. A review of Resident #63's medical record found the following Social Service Progress note: -- Not Dated 05/07/25 ar 9:23 AM read as follows: (Name of out of state faiclity) contacted social services with an inquire of additional notes. 7 days of notes sent per request. Awaiting response. --Note dated 05/07/25 at 12:08 pm read as follows: SS (Social Services) submitted 60 days worth of note to (Name of Out of State nursing facility) per their request. Will continue to follow up. --Note Dated 10/29/25 at 2:42 PM read as follows: (First name of Resident #63) daughter declined the transfer to the psychological facility, after SW (social worker) got her a bed. An interview with Nurse Consultant #131 at 1:15 pm on 06/09/26 confirmed that excerpts of Resident #63's medical record were sent to an out of state facility. She further confirmed the medical record contained no evidence that the MPOA gave permission for the records to be sent.

Based on record review, observation, staff interview and resident interview, the facility failed to ensure a resident's call light was within reach. This was a random opportunity for discovery. Resident Identifier: #52. Facility Census: 109. Findings include:a) Resident #52 The Hill Valley Healthcare policy titled Answering the Call Light states under general guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. On 06/01/26 at 3:47 PM, this surveyor interviewed Resident #52. The only concern she had was that she could not find her call light. She stated, I tried to find it earlier. This surveyor found the call light behind her pillow and pressed the button. At 3:49 PM Certified Nurse Aide (CNA) #82 entered the room and asked Resident #52 if she needed anything? I told CNA #82 that I was the one who pushed the call light and asked her if the call light was within Resident #52's reach? CNA #82 stated, It was not within her reach and I will fix it.

Based on observation, record review, resident interview, and staff interview, the facility failed to provide each resident with a nourishing diet in a form prepared to meet their individual needs. This failed practice created an immediate jeopardy sitaution. There was an immediate risk of choking for residents who were supposed to be served mechanical soft diets. This immediate jeopardy situation had the potentail to affect more than an isolated number of residents. Resident identifiers: #86, #42, #36, #48, #19, #57, #53, #16, #60, #75 and #7. Facility census: 106. Findings included: a) During lunch pass, on 02/16/25 at 11:55 AM, Resident #86, #42, #36, and #48 with physician-ordered mechanical soft diets were noted to have whole meatballs and whole penne pasta. These These residents were consuming the meatballs and pasta. On 02/16/25 at 11:55 AM, [NAME] #74 said They (the meatballs) are whole today, but they are cutting them (the meatballs) for them (the residents) now. The residents had plastic utensils due to a broken dishwasher and were observed having difficulty cutting their food. On 02/16/25 at 12:05 PM, the Dietary Manager in training said either the kitchen or the nursing assistants can chop the food. She said most of the the kitchen chops the meals for mechanical soft diets. On 02/17/25 at 11:30 AM, the Certified Dietary Manager said the meatballs probably should have been ground, and fork-tender. He stated all meat for mechanical soft diets should be ground, unless they have an order for regular, chopped meat. The policy and procedure for Swedish meatballs over noodles with date 02/16/25 stated the chopped process for entrees was to process meatballs and noodles separately in a food processor until even ground texture is achieved with no pieces larger than 1/8 inch. The menu extension for baked penne and meat sauce was to ground meat sauce #10 with chopped pasta in six (6) ounce sauce. According to the menu extension, Swedish meatballs over noodles should have chopped Swedish meatballs sauce #8 over noodles. However, penne pasta was used instead of noodles. According to other recipes in the meal extension, penne pasta should be chopped for a mechanical soft diet. On 02/18/25 at 12:25 PM, NA #108 handed Resident #42 non-thickened chocolate milk. The resident took a drink. NA #88 stated the resident needed thickened liquids. The resident had an order for nectar-thickened liquids. During lunch meal pass on 02/18/25, residents with physician-ordered mechanical soft diets were served baked penne and meat sauce. The pasta was served whole. Nursing Assistant (NA) #108 confirmed residents on mechanical soft diets had received whole pasta today. She stated, We (the NAs) always chop it. Resident #42 was observed eating the pasta whole. During dinner meal pass, on 02/18/25 at 5:40 PM, four (4) residents with physician-ordered mechanical soft diets were served French Fries. These residents were Residents #19, #57, #53, and #42. These residents ate the French Fries. Additionally, Resident #35, #36, #42, and #86 had physician- ordered mechanical soft diets and were served ground meat without gravy. All these residents consumed some of the ground meat with no gravy. These were random opportunities for discovery. According to the facility's policy and procedure for mechanical soft diet with date 02/07/25, French fries on mechanical soft diet must be baked and soft, with no crisp edges. Instructions were given to follow the extension/production sheet for process or substitution. According to the facility's policy and procedure for mechanical soft diet with date June 2023, The addition of gravies or sauces may be needed to increase moisture content of meats to promote ease in swallowing. The policy also stated food characteristics should be soft, tender and moist throughout. The menu extension stated French fries must be baked and soft with no crisp edges. The menu extension also stated Salisbury steak with mushroom gravy should be chopped 1/2 inch #8 with pureed gravy . On 02/18/24, the Activities Director verified there was no gravy on the meat and obtained gravy for the meats. On 02/18/24 at 5:25 PM, a surveyor observed French fries in the deep-fryer. On 02/18/24 at 6:10 PM, Nurse Aide in Training #108 stated Resident #42 eats French fries all the time. Additionally, on 02/18/24 at 6:20 PM, Dietary Aide #104 stated the French fries were deep- fried. On 02/18/25 at 5:45 PM, Resident #58 was observed attempting to drink chocolate milk that was spoon thick. He had an order for nectar thick liquid. The resident nonverbally communicated that he could not drink the chocolate milk. Dietary Aide #104 said he was the one who did the drinks today. He stated, that is way too thick. He stated he used the wrong scoop in thickening the liquid. On 02/18/25 at 9:00 PM the facility was informed of the above interviews and observations and that an immediate jeopardy (IJ) siatatuion exisited due to the risk of residents choking. On 02/18/25 at 11:18 PM the following plan of correction for the IJ was accepted by the survey team. Immediate Actions Taken to Remove the Immediate Jeopardy 1.Resident Safety and Corrective Actions: As of 02/18/25, all residents on physician-ordered mechanical altered diets were immediately assessed by the assigned nurse for adverse effects related to improper texture-modified meals. Residents identified with incorrect liquid consistency (Resident #42 and Resident #58) were immediately provided with properly thickened liquids per physician order. Dietary staff and licensed nurses will be educated on proper thickening agent usage and correct measuring techniques to ensure appropriate liquid consistency. Nurses currently working have been educated on proper thickening agent usage and correct measuring techniques to ensure appropriate liquid consistency. Immediate discontinuation of serving deep-fried French fries for mechanical soft diets. Medical Director and resident responsible parties were notified of the diet inconsistencies by the nurse managers on 02/18/25. 2. Staff Education and Re-Training: Dietary Staff: Immediately or upon arrival to their next worked shift received in-service training conducted on 02/19/25 by the Dietary Manager and/or designee on: Proper preparation of mechanical soft diets, including the correct chopping and grinding procedures. Proper menu extension adherence and use of production sheets. Thickened liquid consistency for residents requiring nectar or pudding-thick liquids. Nursing Staff and CNAs: Re-educated on proper meal modifications and verifying consistency of food and beverages before serving. In-service was provided by the DON/designee. 3. Monitoring and Quality Assurance Measures: Daily Meal Audits: Beginning 02/19/25, the Dietary Manager and Nursing Supervisor will conduct meal service audits daily to ensure proper diet consistency compliance. Any discrepancies in meal preparation are immediately corrected, documented, and reviewed in daily safety huddles. Weekly audits of meal service by the Dietary Manager and Director of Nursing (DON) for four weeks, then ongoing monthly audits. QAPI Committee will review compliance data and discuss any identified trends or issues. Administrator and Medical Director notified of all corrective actions and ongoing monitoring efforts. 02/18/25 at 9:25 AM, the State Surveyor met with the Registered Dietician, Director of Nursing, Speech Language Pathologist (SLP) and Registered Nurse (RN) #145. The Hormel Thick and Easy Instant Food and Beverage Thickening Powder packet was reviewed for both nectar and honey liquid consistencies. The packet instructions stated to add one packet of food thickener to 4oz of liquid for nectar-like to honey-like consistency. The SLP reported they used to use gel, but the packets are new. The SLP uses one packet in 4 oz and uses the fork test. The SLP stated, I personally like the gel. RN #145 reported the facility will discontinue the use of the Hormel packets, educate the staff and will order the gel thickener. The nurse's will thicken liquids on the floor and dietary will thicken liquids for meals. On 02/19/25 at 12:20 PM, Resident #7 with a pureed diet order was served the wrong meal ( mechanical soft diet with coleslaw). Resident #7 began eating food off the tray before it was taken away. The Activity Director noted this herself with no surveyor intervention, but the resident had eaten some. Two additional resident's with mechanical soft diets were served coleslaw. After surveyor intervention and the residents starting to eating, the coleslaw was switched out for green beans. The residents were Residents #16, #60, #75, #7. The facility's menu extension, provided by the Registered Dietician,showed residents on mechanical soft diets should have received green beans and not creamy coleslaw. Coleslaw on the resident's trays was verified by Activities Assistant #34.

Based on resident interview, observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #47 expressed to the surveyor he smoked at the facility without staff supervision and kept his own cigarettes and lighter. An interview with the Resident's Licensed Practical Nurse (LPN) #37 confirmed the Resident had asked her earlier in the day to take him out to smoke. The LPN's only response was, you know you are not allowed to smoke. Twenty seven (27) additional residents were identified as lacking capacity and being able to ambulate/wander throughout the facility. Any of the 27 residents could have obtained access to the cigarettes or lighter, potentially causing serious harm and/or death to self or others due to their cognitive impairments and decreased safety awareness. In addition, Resident #47 was at risk of serious harm and/or death from possible burns resulting from smoking off the premises without staff supervision. The state agency (SA) determined this to be an immediate jeopardy (IJ) which placed Resident #47 and all 27 cognitively impaired and ambulatory residents at risk for serious harm and/or death. The facility was notified of the IJ on 06/26/23 at 6:26 PM. The facility submitted a Plan of Correction (POC) that was accepted by the SA on 06/26/23 at 9:31 PM. The plan of Correction read as follows: Upon reassessment by the Director of Nursing on 6/26/2023, Resident: #78, #97, #554, #11, #354, #72, #20, #40, #56, #32, #60, #80, #89, #63, #31, #53, #39, #42, #52, #98, #74, #84, #76, #81, #62, #28, and # 85 were asked if they currently had any smoking materials including lighters in their rooms. All residents of the facility could be affected. A letter was sent by the Administrator\designee on 6/26/23 to residents and families regarding the facility non-smoking policy. All staff will be reeducated on or before 6/26/23 regarding ensuring the resident's environment remains as free of accident hazards as is possible including providing re-education on facility non-smoking policy with a posttest to validate understanding. Center staff not available during this timeframe will be provided reeducation including posttest by the Administrator\designee upon return to work. New staff will be provided with education and posttests during orientation by the Administrator\designee. New residents and/or responsible parties will be provided information regarding the facilities smoking policy and sign acknowledgement by the Admission Director/designee at the time of admission. The Administrator/designee will conduct random observations daily 4 X weeks then 3 x per week x 2 weeks then randomly thereafter to ensure residents are abiding by facility non-smoking per the center policy. Any trends identified will be reported monthly by the Administrator\designee to the Quality Improvement Committee (QIC) for any additional follow-up and\or in servicing until the issue is resolved then randomly thereafter as determined by the QIC committee. Upon return to the facility at 10:30 AM on 06/27/23, nurse aide (NA) #36 confirmed she clocked in at 7:00 AM on 06/27/23 and had not received any in - services since she began her shift. At 10:35 AM on 06/27/23, Social Worker (SW) #109 confirmed NA #36 had not received any in-services. SW #109 provided a list of employees who had been in -serviced and NA #36's name was not on the list. At 10:50 AM on 06/27/23, the above situation was presented to the Administrator, the Director of Nursing (DON), and a corporate Nurse #139. The Corporate Nurse #139 confirmed the facility's plan of correction directed that all staff present at the building would be in-serviced on 06/26/23. Any staff not currently working would receive in-servicing prior to beginning their next shift. The immediate jeopardy (IJ) could not be abated at this time because the plan of correction submitted by the facility was not completed. At 3:40 PM on 06/27/23, the Corporate Nurse stated the facility had in-serviced and educated all of their staff for POC. On 06/27/23, the SA interviewed all staff in the building and reviewed the in-service training. Observation and tour of the facility found no further issues. The IJ was abated on 06/27/23 at 4:10 PM. The IJ began at 6:26 PM on 06/26/23 and ended on 06/27/23 at 4:10 PM when the SA abated the immediacy. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #47, #354, #78, #97, #554, #11, #72, #20, #40, #56, #32, #60, #80, #89, #63, #31, #53, #39, #42, #52, #98, #74, #84, #76, #81, #62, #28, and #85. Facility census: 109. Findings included: a) Resident #47 Resident #47 was interviewed on 06/26/23 at 11:53 AM, he stated he doesn't like the smoking situation here. The surveyor asked if he smoked. He said, yes he goes off the property to smoke. Surveyor asked if anyone helped him and he said staff used to help him but they got in trouble so they don't anymore. The surveyor asked where he keeps his lighter and cigarettes. He stated he can't say. Then he laughed and said, I know I'm not supposed to, but I keep them in my murse. (He defined a murse as a man's purse). He held up what appeared to be a black, leather fanny pack, he had attached to his wheelchair. A followup interview with resident #47 on 06/26/23 1:00 PM, was conducted. Resident #47 stated the old administrator, (administrator's name), had a conversation with him previously about not being allowed to smoke at the facility. He said he signs out, wheels himself passing the gazebo onto the paved pathway to a store lot next door which houses storage buildings. He said he signs back in when he is done and keeps his cigarettes and lighter in his murse He said he has had two (2) falls outside in the past but that was when he had his scooter. Resident stated that a few weeks ago his roommate woke him up in the middle of the night because a wandering resident (Resident #84) was in their bathroom smoking a cigarette. They told the resident to leave before he gets them in trouble and he left. He does not know where Resident #84 got the cigarettes from. Record review on 06/26/23 indicated the facility had a Smoking Policy that prohibited residents to smoke or possess any smoking paraphernalia. Resident #47 had signed this smoking policy on admission, dated 12/29/21. The surveyor was provided copies of the Sign Out forms that Resident #47 signed out when he was going off the property. It appeared the form was inconsistent. Sometimes he did not sign back in and sometimes a witness did not sign, and at times his condition was not documented on return. b) Interview with Resident # 57 A resident interview on 6/26/26 at approximately 1:45 PM Resident #47's roommate, Resident #57, who said he was not sure if Resident #47 smoked but he did confirm Resident #84 was in their bathroom smoking a few weeks ago. He did not know where Resident #84 got his smoking materials. c) Twenty-seven (27) residents were identified as lacking capacity and being able to ambulate/wander throughout the facility. Any of the 27 residents could have obtained access to the cigarettes or lighter, potentially causing serious harm and/or death to self or others due to their cognitive impairments. Resident #84 was identified as fitting this criteria and had been identified by Resident #47 as already having came into his room and gotten into the smoking materials. Resident #47 found Resident #84 smoking a cigarette in his bathroom. Out of the 27 residents the facility identified as having a cognitive deficit and having the ability to wander, seven (7) have a history of smoking. These residents were identified as Resident: #42, #56, #78, #84, #89, #97, and #354. The 27 residents identified and their most recent Brief Interview for Mental Status (BIMS) (BIMS scores are listed below: 13-15 suggests the resident is cognitively intact, 8 to 12 suggests the resident is moderately impaired, and 0-7 suggests severe impairment) are as follows: Resident #354 with a BIMS score of nine (9) on 06/25/23 Resident #78 did not have a BIMS score but her Annual Minimal Data Set (MDS), dated [DATE], indicated that her cognitive skills for daily decision making are severely impaired Resident #97 did not have a BIMS score but his Admission MDS, dated [DATE], indicated that his cognitive skills for daily decision making are severely impaired Resident #554 did not have a completed BIMS/MDS yet, however, documentation in the medical record indicated the resident was cognitively impaired. Resident #11 with a BIMS score of five (5) on 05/01/23 Resident #72 with a BIMS score of six (6) on 06/06/23 Resident #20 with a BIMS score of zero (0) on 06/05/23 Resident #40 with a BIMS score of four (4) on 06/13/23 Resident #56 with a BIMS score of eight (8) on 04/05/23 Resident #32 with a BIMS score of three (3) on 06/11/23 Resident #60 with a BIMS score of six (6) on 05/10/23 Resident #80 with a BIMS score of three (3) on 06/01/23 Resident #89 with a BIMS score of two (2) on 06/21/23 Resident #63 with a BIMS score of seven (7) on 06/19/23 Resident #31 with a BIMS score of 10 on 06/20/23 Resident #53 with a BIMS score of four (4) on 06/06/23 Resident #39 with a BIMS score of 11 on 05/09/23 Resident #42 with a BIMS score of four (4) on 03/28/23 Resident #52 with a BIMS score of six (6) on 05/16/23 Resident #98 with a BIMS score of four (4) on 06/09/23 Resident #74 did not have a BIMS score but her Quarterly MDS, dated [DATE], indicated that her cognitive skills for daily decision making are severely impaired Resident #84 with a BIMS score of eight (8) on 03/22/23 Resident #76 with a BIMS score of five (5) on 06/01/23 Resident #81 with a BIMS score of 12 on 04/01/23 Resident #62 with a BIMS score of five (5) on 06/19/23 Resident #28 with a BIMS score of two (2) on 05/12/23 Resident #85 with a BIMS score of six (6) on 06/12/23 d) Staff interviews During a staff interview on 06/26/23 at 1:57 PM, with NA #133 the NA stated she did not know where the resident was supposed to go if he wanted to smoke. He signed himself out and back in. He would have to go off property. She was not sure where he would keep cigarettes and lighter if he were smoking. During a staff interview on 06/26/23 at 2:02 PM, with LPN #37 the LPN stated the resident was not supposed to smoke. She said she was not sure where the property perimeter was or what was considered off property. If a resident had capacity they were able to sign themselves out. LPN #37 said they only have to sign out if they are leaving the property, not if they are going to sit right out front. LPN #37 stated this resident asked her to take him out to smoke this morning but she told him no because he was not supposed to be smoking. She did not investigate any further to determine how the resident planned to smoke or if he had smoking materials in his possession. -Staff interview on 06/26/23 at 2:03 PM, with the DON revealed if a resident had capacity they could sign themselves out and leave the property. She said no resident was supposed to be in possession of smoking materials. She said previously there was an issue with a resident who had been discharged . This resident was smoking and other residents started smoking too. At that time they re-educated the staff through employee meetings, one on one education, new hires were educated on the smoking policy, and they were educated via the communication book. The DON stated if an employee had reasonable suspicion that a resident had smoking materials then they should report this to administration so administration could handle the situation. She said, I would think staff would be able to notice if a resident was smoking in the bathroom and they should notify the DON if so. The residents are allowed to leave the property if they have a physician order stating they can safely leave the property by themselves and they have to sign out. The DON denied knowing the Resident was smoking. When the interview with LPN #37 was presented, the DON stated that the staff should notify administration immediately if they have reason to believe that a resident has cigarettes or a lighter. On 06/26/23 at 2:18 PM the surveyors notified the Director of Nursing (DON) that the resident stated he had smoking materials on him. On 06/26/23 at 2:48 PM, SW #109 was looking for Resident #47 and staff told her he signed himself out. The SW found the resident sitting outside the main entrance. She approached him and asked if he had cigarettes. He said yes. She asked for them and assured him she would lock them up in the safe and have his family pick them up. He gave her a pack of Marlboros and a red lighter out of his murse. She asked him if he had any more in his room and he responded no. On 06/26/23 at 7:10 PM, SW #109 brought the surveyor a copy of a progress note written on 09/13/22 at 8:28 AM, by this SW. The note described when SW #109 talked to Resident #47 about the facility's smoking policy. She also brought the surveyor a copy of a care plan for history of alcoholism and tobacco use, with an intervention of educating the resident of smoking policy. Surveyor explained that nowhere in the behavior care plan or history of tobacco care plan did it mention the resident was non compliant with the smoking policy and what interventions to provide if he was non compliant with this policy. The SW confirmed Resident #47 did not have a behavior care plan in place for his history of non compliance with the facility's smoking policy. On 06/27/23, the facility provided a list/audit of residents they identified as having a history of smoking. They interviewed and searched the residents' rooms for smoking paraphernalia. They identified the following residents: #553, #78, #354, #47, #17, #56, #556, #89, #68, #358, #103, #42, #88, #23, #38, #44, #91, #25, #57, #84, #27, #94, #357, and #97. The facility smoking policy revealed the residents were not allowed to smoke but staff are allowed to smoke. Resident #47 signed acknowledgment of this policy upon his admission. Record review failed to show Resident #47 had been assessed to be an indepednet/safe smoker.

Based on record review, staff interview and observations the facility failed to ensure the residents environment over which it had control was as free from accident hazards as possible. This was true for four (4) of eight (8) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey (QIS). Resident #9 rolled from bed on 05/25/17 while one (1) nurse aide was providing incontinence care. Resident #9's care plan did not clearly define the amount of assistance Resident #9 needed for bed mobility. This failure resulted in the Nurse Aides (NAs) assessing and determining the safest way to care for the resident. Assessment is outside of the NAs scope of practice and this information should have been clearly represented in the care plan so that each NA would know how much assistance Resident #9 needed when moving her in the bed. Additionally, Resident #9 was to have bed bolsters to her bed and there was no evidence those were in place at the time of the fall on 05/25/17. The fall on 05/25/17 resulted in Resident #9 suffering bilateral femur fractures which represents actual harm to resident #9 due to the facility's failures. For Resident #65 and #53 the care plan did not clearly define the level assistance by each resident to enable them to complete their Activities of Daily Living in the safest environment possible. This failure resulted in the Nurse Aides (NAs) assessing and determining the safest way to care for each resident. Assessment is outside of the NAs scope of practice and this information should have been clearly represented in the care plan so that each NA would know how much assistance was needed to safely care for each resident. Finally, Resident #123's interventions for fall prevention were not in place upon observation. Resident identifiers: #9, #65, #53 and #123. Facility Census: 100. Findings include: a) Resident #9 A review of Resident #9's medical record beginning at 12:00 p.m. on 07/11/17 found Resident #9 rolled out of bed on 05/25/17 at 6:30 a.m. Review of the incident report found the following: Under the heading Nursing Description: Resident rolled out of bed and unto floor mat bed in lowest position. Under the heading Resident description: Resident did not hit her head against any object or floor. resident stated that she has one of her normal headaches and her arthritis in her legs is acting up. resident transferred to bed with hoyer lift. resident tolerated well Daughter (first name of daughter) notified wants mother to have side rails explained the process to her Daughter will be here this morning physician aware and nurse on call aware resident refuses to go to hospital elects to have x rays done in house at facility. both resident and daughter stated they are pleased with residents care and staff. The incident report indicated there was no witnesses to this fall, however there was a reportable incident filed with the state agency which read as follows: To whom it may concern, I am reporting and unusual occurrence at Eldercare Health and Rehabilitation. Resident, (first and last name of Resident #9), had a fall. Residents fall was witnessed, as staff was providing care for this resident. The residents' legs slid off the bed while having care provided, and at this time the resident was assisted to the floor by staff. The residents legs made contact with the floor first, as staff lowered her to the floor. The CNA (Certified Nursing Assistant) was unable to prevent the fall, however was able to lower/assist the resident to the floor. Resident did not hit her head against any objects during her fall. At the time of the incident the resident refused to go out of the facility for further evaluation. Please notes the resident does have capacity to make her own medical decisions. However, resident did wish to have X-rays done in facility for further evaluation. X-ray results show acute right femur fracture. At this time the resident was sent out of facility to (name of local hospital) for further evaluation. Resident was agreeable with plan of care. After further evaluation at (Name of local hospital), results show left femur fracture. Resident is currently out of facility, however facility will treat per physicians order upon returning to this facility. This report was written by the Social Service Director, and was reported to the state agency on 05/30/17. Along with this report was several statements from staff members who were working the morning of 05/25/17 the statements were as follows: --Statement from Nurse Aide (NA) # 61, Name of Resident #9 will squirm herself across the bed a lot of the time she laying across the mattress. It takes two (2) people to put back in the middle of the bed. Always (sic) asked (sic) her why she does that. Her comment her back is itching. Her legs does not straighten all the way out it is always in a bend. I always tell her she is going to end up on the floor laying across the mattress. She alway (sic) reply she will not be on the floor. --Statement for Licensed Practical Nurse (LPN) (the statement is signed but the name is not legible), CNA called for this nurse Resident sitting on her buttocks CNA stated they were cleaning resident up and she rolled out of bed. Residents bed in low position. Bed in locked position. --Statement from Registered Nurse (RN) #12, (First name of NA #87) stated he had entered room to change resident. He positioned resident in center of bed. After speaking to her and telling her he was going to change her brief. He stated he lowered the bed to lowest position. Floor mats in place. He turned resident and rolled her over out of bed onto the floor mats. He called for his nurse and called for this nurse. --Statement from NA #35, I have taken care of (Name of Resident #9) every time I went into the room she had squirmed to the edge of the bed I straighten her up in bed every time I went back in to do a bed check and she would be back on the edge of the bed. --Statement from NA #87, the nurse aide providing care at the time of the incident, I , (first and last name of NA #87 was providing care for (Resident #9). While providing care her legs slid off of the bed. She did not roll out of bed. When her legs slid off, I assisted her to the floor. Her legs hit the floor first. I did not witness her to his her head on anything. It was more of a guided fallen. She does have a tendency to lean in her bed. Further review of the record found resident had previously fallen on 05/23/17. Review of the incident report for the 05/23/17 fall found the resident was yelling for help at 10:52 p.m. on 05/23/17. Upon entering the room the nurse found Resident #9 laying in the floor beside her bed on her left side. The incident report noted the resident kept saying she had rolled out of bed and hit her head. No visible injury was noted. Resident was not moved from her position until the Ambulance arrived and she was transported to a local hospital. Further, review of the residents medical record found that the resident had a fall on 05/23/17 the resident rolled out of bed and hit her head. She was sent to the ER for eval and returned with no injuries noted. The Director of Nursing provided a fast alert form on 07/12/17, in regards to the fall on 05/23/17. Under the section titled Follow Up Plan of Action facility staff wrote the following, Resident sent to ED (emergency department) for evaluation, returned back to facility with no new orders. ER reports negative findings for resident on CT scan. New intervention: Bolsters to bed. BIMS 14 - has capacity. The DON also provided a nursing interventions form used by the facility which pertained to Resident #9's fall on 05/25/17, under the section titled, Current Interventions in place, was the following, use call light for assistance, bed in lowest position, beri bed, bolster mattress to bed, call light within reach. Both forms provided by the DON indicated the resident should have had bed bolsters to her mattress. However, the incident report and statements from facility staff only mention the interventions of, bed in lowest position and floor mats on the floor beside her bed. No staff statements, mention the bed bolsters being in place at the time of the fall on 05/25/17. A review of the complaints and concerns for the previous 12 months found that on 02/15/17, Resident #9 complained of inadequate peri care. Under the section titled Investigation and Response. the following was documented by the Social Worker, Daughter present when resident was changed, understands resident is hard to clean and turn. A review of Resident #9's care plan found the following intervention in regards to impaired ability to complete her own ADL's, Bed mobility: The resident requires 1 - 2 staff participation to reposition and turn in bed. An interview with the DON at 2:23 p.m. on 7/11/17 found, the care plan is worded as a one (1) to two (2) person assist because sometimes it may just take one person to help the resident depending on the size of the Aide, and if the resident is tired or not. She stated she would personally ask the resident if she was able to help with turning in the bed and if she said she was not then she would go and get someone to help her. She agreed that Nurse Aides are not supposed to assess, however she felt they would be able to make this judgement call and care for the resident safely. An additional interview with the DON, at 10:31 a.m. on 07/12/17, confirmed that bed bolsters were to be in place after the resident fell on [DATE]. She indicated, she did not know why none of the statements nor the incident report mentioned them being in place at the time of the fall. An interview with NA # 87 at 12:27 p.m. on 07/13/17, confirmed he was the NA working with Resident #9 on 05/25/17 when she fell from the bed. When asked what happened that morning he stated, I was in the middle of changing her and she kind of jolted forward for some reason. I had her bed in the low position and she slid to the floor with my assistance. He was then asked why he was changing the resident by himself and he stated, The care plan says to use a one to two person assist. He stated that it was just the aides judgement if they felt comfortable doing it by themselves or not and she had never gave him any indication that she could not help with bed mobility. When asked if the resident had bed bolsters on her bed at the time of the fall, he replied, I can't remember if she did or not. Resident #9 rolled from bed on 05/25/17 while one (1) nurse aide was providing incontinence care. Resident #9's care plan did not clearly define the amount of assistance Resident #9 needed for bed mobility. This failure resulted in the Nurse Aides (NAs) assessing and determining the safest way to care for the resident. Assessment is outside of the NAs scope of practice and this information should have been clearly represented in the care plan so that each NA would know how much assistance Resident #9 needed when moving her in the bed. Additionally, Resident #9 was to have bed bolsters to her bed and there was no evidence those were in place at the time of the fall on 05/25/17. The fall on 05/25/17 resulted in Resident #9 suffering bilateral femur fractures which represents actual harm to resident #9 due to the facility's failures. b) Resident #65 A review of resident #65's care plan at 3:05 p.m. on 07/12/17 found the following interventions related to his ADL self deficit: --Toilet Use: The resident requires (1-2) staff participation to use toilet. -- Bed Mobility: The resident requires (1 -2) staff participation to reposition and turn in bed. -- Bathing: The resident requires (1 - 2) staff participation with bathing. -- Personal Hygiene/Oral Care: The resident requires (1-2) staff participation with person hygiene and oral care. -- Dressing: The resident requires (1-2) staff participation to dress. An interview with the DON at 2:23 p.m. on 7/11/17 found, the care plan is worded as a one (1) to two (2) person assist because sometimes it may just take one person to help the resident depending on the size of the Aide, and if the resident is tired or not. She stated she would personally ask the resident if he was able to help with turning in the bed and if he said he was not then she would go and get someone to help her. She agreed that Nurse Aides are not supposed to assess, however she felt they would be able to make this judgement call and care for the resident safely. c) Resident #123 Record review on 07/12/17, at 8:10 a.m., revealed the resident had three (3) falls in the last six (6) months. On 02/17/17, the resident was observed seated on the side of the bed. Three (3) minutes later the resident was observed sitting in the floor after taking right shoe off to replace with a slipper. The resident slid off the bed while trying to fit slipper onto right foot. The resident had no injuries. On 05/23/17, the resident was found on the floor on her stomach with arms in front of her and legs behind. The residents head is up and looking forward at end of bed at foot board facing the door. A small scratch was noted to the right hand. Resident had shoes on and walker within reach to the left of the resident. She had a small scratch to the right hand. The resident fell again on 07/10/17. The resident was found on the floor beside her bed. The resident was wearing shoes and had her left shoe lace untied. She had bruising to her left hand. A fall risk screen, completed on 07/09/17, noted the fall risk preventions in place: --Nonskid footwear, --Bed in lowest position, --Call light within reach, --Offer toileting, and --Fluids and snacks. Review of the resident's care plan found the following problem: --Resident is at risk for falls related to malaise, impaired mobility, cognition, and ataxic gait. The goal associated with the problem was: --The resident will be free of falls through the review date. Approaches included: --Perimeter border to bed. Review of the physician's orders [REDACTED]. Observation of the resident at 9:22 a.m. on 07/12/17, found she was in bed sleeping. Her bed was not in a low position. No perimeter border was on the bed. A second observation at 10:21 a.m. on 07/12/17, found she was still sleeping and bed was not in lowest position. No perimeter border was on the bed At 10:45 a.m., plant operations manager #22, was in the hallway just outside the resident's room. He was asked if the residents bed was in the lowest position. He stated the bed was electric and he believed the bed could be lower to the floor. At 10:46 a.m., the Registered Nurse (RN), unit manager #53, was asked to observe the resident in her bed. RN #53 verified the bed was not in the lowest position and verified the bed did not have a perimeter border mattress as ordered by the physician. On 07/17/17 at 1:40 p.m., the director of nursing (DON) was advised of the above situation. She confirmed her staff had told about the situation and a perimeter border was added to the resident's bed. She resident's care plan was reviewed with the DON who confirmed the care plan had not been implemented as directed. d) Resident #53 Review of the communication to the nure aides for providing activities of daily living (ADL's) care to Resident #53 found the following instructions: --Bathing: The resident requires assistance with bathing/showers of 1-2 as needed and as necessary. --Bed mobility: The resident requires 1-2 staff participation to reposition and turn in bed. --Dressing: The resident requires 1-2 staff participation to dress. --Personal Hygiene/oral care: The resident requires 1-2 staff participation with personal hygiene and oral care. --Toilet Use: The resident requires 1-2 staff participation to use toilet. --Transfers: The resident requires 1-2 staff participation with transfers. At 9:46 a.m. on 07/18/17, the director of nursing (DON) said she just became aware nurse aides (NA)can not assess a resident to determine how much assistance is need to complete ADL care. She said, I am changing this information now. She confirmed the instructions are not clear as to how many NA's are required to complete ADL care.

Based on resident interview, staff interview, record review and policy review, the facility failed to ensure residents were free from verbal, mental and/or physical abuse by another resident. Residents were fearful of harm to themselves or others related to Resident #145's behaviors. In addition, the resident's foul language was upsetting to some of the residents. Three (3) sample residents and one (1) resident identified through a random opportunity for identification were affected; however, the situation had the potential to affect more than an isolated number of residents. At the time of of the resident's admission, the facility had knowledge the resident had a severe mental disorder, was disoriented, displayed inappropriate social behavior, had seriously impaired judgment, and was verbally abusive. There was no evidence the facility developed a plan of care or implemented interventions, when the resident was admitted , to protect other residents and ensure a safe living environment. Between 10/18/13 and the date of review on 11/06/13 (nineteen (19) days), the resident exhibited aggressive behaviors affecting others. These included cursing, threatening behaviors, physical aggression with staff, intrusions on the privacy of others, and significant disruption of resident care and the living environment. The facility failed to identify the impact this resident's behaviors had on other residents. The resident's comprehensive minimum data set (MDS) assessment did not accurately reflect and assess the behaviors. The care plan did not contain interventions related to preventing harm to himself or others, or interventions to protect other residents' privacy. Resident #145 created an environment which four (4) residents interviewed believed was unsafe. No actual harm had occurred at the time this was identified; however the potential existed for this resident to cause harm to more than an isolated number of residents. The administrator was notified an immediate jeopardy situation existed on 11/06/13 at 1:40 p.m., as the residents had the potential to suffer from harm if interventions were not immediately implemented to protect the other residents from Resident #145. The administrator presented an Immediate Plan of Action, in which Resident #145 would receive one-on-one 24 hour supervision. It was also confirmed this would be a daily assignment. This plan was immediately put in to action and was observed by the surveyor. The plan was relayed to the Office of Health Facility Licensure and Certification. The immediate jeopardy at F223 was removed at 2:30 p.m. on 11/06/13. The scope and severity was reduced from a "K" to an "E" at that time. Resident identifiers: #5, # 87, #66, and #83. Facility Census: 107. Findings include: a) Resident #5 During an interview with the Resident Council President (Resident #5) on 11/06/13 at 10:00 a.m., he immediately stated to the surveyor upon entering his room, "I guess you know about the big problems we have here." When told the survey team was not aware of a big problem, he said, "Well everyone knows about it." The resident stated there was a resident (he named Resident #145) of whom people were afraid. Resident #5 said, " He is beating people up." He said he was not aware of anyone being hurt yet, but Resident #145 had grabbed him and other people. He stated if something was not done about this man, he was afraid one of the helpless residents who "can't defend themselves" would be hurt. Resident #5 said Resident #145 was admitted after the last council meeting, but everyone had been talking about it and something "needs to be done." When asked if he had talked to any of the staff, he stated, "Yes, the administrator and the nurses." He stated the resident wandered into everyone's rooms at night and "used cuss words that you should not have to listen to." Resident #5 reiterated he was afraid if something was not done, Resident #145 was going to hurt someone. He said the ladies got upset with Resident #145's language and they should not have to be exposed to the things he said to them. Resident #5 said he rings his light when he (Resident #145) comes in his room, but worries about the residents who are helpless and not able to yell for help. He stated Resident #145 "Was walking and grabbed him from behind while he was in his wheelchair and twisted his arm." b) Resident #87 During an interview on 11/06/13 at 11:05 a.m., Resident #87 stated Resident #145 was "inappropriate." When asked if she felt afraid, she stated, "Yes, everyone is." Resident #87 referred to Resident #145 as "mean." She said he came in her room one night and sat on her bed and it scared her. She said none of the residents want him around because they are afraid of him. Resident #87 said there were three (3) ladies who have a snack together every night whom the resident "bothers." She said, "Something should be done." When asked if Resident #145 made her feel her environment was not safe, she stated "Yes". c) Resident #83 During an interview with Resident #83, on 11/05/13 at 1:00 p.m., he said, "A resident on C hall is mean. The girls are afraid of him." He identified "girls" as staff. The resident said he did not know the individual's name, but knew the resident resided on C hall. He said the resident would "Push people up the hall, and when the staff tried to stop him, he threw staff against the wall and twisted their arms." Resident #83 said the resident had put a staff member in the bathroom, locked the door and would not let him out. He added, "It isn't right. He is mean and someone could get hurt." During another interview on 11/06/13 at 11:00 a.m., Resident #83 identified the resident he described as Resident #145. d) Resident #66 An interview with Resident #66, on 11/05/13 at 8:30 a.m., revealed Resident #145 had entered her room, grabbed her foot, and asked, "Do you want to do it?" She said when she responded, "Do it?", Resident #145 said, "Do you want to f_ _ _?" Resident #66 denied abuse, but said she was fearful for other residents who could not protect themselves. During another interview on 11/06/13 at 11:05 a.m., Resident #66 said she could not remember the date or time of that incident because "time runs together here." She reiterated the resident had grabbed her foot while she was in bed and it startled her. She added, "I don't like that dirty talk." e) Resident #145 A review of the medical record for Resident #145 revealed he was an [AGE] year old male admitted to the facility on [DATE]. His pre-admission screening (PAS) revealed his mental disorder was "severe." The data on his PAS stated he had been disoriented, displayed inappropriate social behavior, had seriously impaired judgment, was verbally abusive, and had [MEDICAL CONDITION]. This information was on the resident's PAS prior to admission to the nursing home, confirming the facility was made aware of the resident's condition and behaviors prior to his admission. The admission minimum data set (MDS), with an assessment reference date (ARD) of 10/29/13 was reviewed. -- Item E0200B noted, "This resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)" -- Item E0200C noted, "Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual act, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming , disruptive sounds)." Both E0200B and E0200C were coded "1," indicating the behaviors of this type occurred one (1) to three (3) days during the seven (7) day look back period. -- Section E0300 stated if there were any behavioral symptoms in questions E0300 coded one (1), two (2) or three (3), considering all of the behavioral symptoms, answer E0500 and E0600. -- E0500 was coded as follows: E0500.A Did the identified symptoms put the resident at significant risk for physical illness or injury? This was coded zero (0) to reflect "no." E0500.B Significantly interfere with the resident's care? This was coded "1 " to reflect "yes." E0500.C Significantly interfere with resident's participation in activities or social interactions? This was coded "1" to reflect "yes." -- Section E0600 asks questions to identify the impact on others the resident's behaviors have. The questions were as follows: Did any of the identified symptoms put others at significant risk for physical injury? The answer to this question was coded as "No " . Significantly intrude on the privacy or activity of others? This question was answered "No". Significantly disrupt care or living environment? The answer to this question was "No". f) The Care Area Assessment (CAA) notes for behavioral symptoms, which are intended to be a detailed assessment of the problem identified, contained a section titled "analysis of findings." In this section, the behavioral symptoms were not determined to be an immediate threat to self or to others. The care plan considerations stated the care plan would be to "minimize risk." The CAA note stated, "Care plan will be developed to minimize injury to self and others as well as increase compliance with daily care. " The interdisciplinary care plan was dated as last revised 10/25/13. This care plan was written prior to the comprehensive assessment date. There was no evidence the facility utilized the CAA to develop a care plan to minimize injury to self and others as stated. This care plan was written as follows: Problem/focus: "Wandering/Behavior - The resident is an elopement risk/wanderer, has potential for physically verbally disruptive behaviors as evidenced by decreased personal safety awareness, wandering, episodes of physical/verbal aggression. (Has history of farming, coal mining, and electrician at (name of entity) working night shift, and has a known history of frequent fighting as a boy)." Goals: "The resident will not leave the facility unattended daily and through the review date. The resident will demonstrate happiness with daily routine through the review date as evidenced by no more than one physical/verbal outburst per week. The resident's safety will be maintained daily and through the review date." Interventions included: document episodes of leaving facility unattended, notify doctor of aggressive behaviors, offer redirection (snack, drink, activity of choice) to quiet area during episodes of physical aggression, offer redirection during episodes of exiting unattended, picture on file, report to the nurse episodes of physical / verbal aggression, wander guard to body. There were no care plan interventions to address the risk of injury to self and others as described in the CAA note. In addition, there were no interventions to protect other residents or keep Resident #145 from intruding in other residents' rooms. g) The facility's nursing notes were reviewed. These notes identified the resident was admitted in the evening at 17:45 (5:45 p.m.) on 10/18/13. It was noted the behaviors started the day after his admission. The notes were as follows: -- 10/19/13 - 04:40 - "Resident pushing another resident in wheelchair into his room. Staff attempted to get resident and wheelchair from room. Resident began to get agitated and yell at staff. Staff members were able to get resident in wheelchair out of room. Neither resident or staff was injured. " -- 10/19/13 - 05:41 - "Staff members attempted to assist resident with toileting and resident became aggressive. Resident grabbed male CNA (certified nursing assistant) by the arm and wrist while yelling at him. After convincing resident to let the CNA go the resident then came out of the restroom and shut the door trying to hold the bathroom door shut with the CNA inside. Redirected the resident and took him for a walk with this nurse. Staff member denies any injuries. Will continue to observe." -- 10/19/13 - 16:33 - "Resident has been wandering within facility. No attempt to exit noted. He has been generally pleasant but becomes agitated easily. Cursing and swearing at times. CNA report that resident went over to roommate in room and showed him his fist, saying 'I'll hit you!' then walked away. Will monitor closely. " -- 10/19/13 - 18:45 "Dr. .... In to see resident with new order noted for [MEDICATION NAME] 5 mg po (by mouth) daily for dementia." -- 10/20/13 - 16:12 - "Night shift staff reported that resident was up during the night wandering in and out of rooms, pushing other residents in w/c (wheelchairs), yelling at other residents/staff etc. Resident has been resting in bed quietly much of the day. His wife sat with him at lunch. Resident appeared pleasantly confused. Will continue to monitor. " -- 10/21/13 - 01:17 - "Resident awake at this time. Standing by roommates bed yelling at him stating "go to sleep!" Assisted resident back to his bed. Will continue to observe." -- 10/21/13 - 18:42 - "Resident exhibited wandering for most of the shift. Resident was redirected easily out of others rooms." -- 10/21/13 - 19:44 - "Resident being very aggressive this evening. He grabbed a guests arm and attempted to pull her down the hall. RN (registered nurse) intervened and redirected resident. Resident has attempted to close the door when LPN (license practical nurse) was in the room and told her to get into his bed. He also attempted to get another resident into his room. Staff is monitoring frequently." -- 10/22/13 - 01:50 - "Resident continues to be awake ambulating in the hallways. He is easily agitated with staff and other residents. Continuing to monitor." -- 10/22/13 - 05:17 - "Resident has been awake all night. Physically aggressive behaviors noted. He has pushed staff and yelled down the hallways. He walks into other residents rooms trying to lay in other bed. Resident has been shown his bed and assisted to bed but gets back up in a few minutes yelling at staff. He attempted to pull his roommate out of the bed. Frequent monitoring continues." -- 10/22/13 - 07:16 - "Resident very combative and refused medication." -- 10/22/13 13:21 - "Resident refused a.m. care until 12:30 p.m. Resident has wandered all shift and he has been easy to redirect. Resident does get agitated around other residents at times." -- 10/22/13 - 14:51 - "Attending physician notified via fax regarding behaviors since admission and current meds. Awaiting response" -- 10/22/13 - 18:11 - Medication administration Note - Resident refused. "I do not need a d_ _ _ shot." -- 10/22/13 - 22:50 - "Resident very agitated and aggressive this evening. He continues to attempt to uncover his room mate and stated 'lets tear him apart'. He sneezed in the hallway and CNA (certified nursing assistant) said 'bless you' and resident responded with 'F_ _ _ you'. He has sexually inappropriate behaviors with staff. He has yelled out in the hallways and attempted to enter other rooms becomes very angry when staff is attempting to redirect." -- 10/23/13 - 06:56 "Resident was assisted to bed around 2:00 a.m. and has slept well throughout the night." -- 10/23/13 - 12:04 - "Resident has exhibited sexually inappropriate behaviors towards staff several times so far this shift. While CNA assisted resident with his a.m. care resident stated to CNA 'you want this. Come on touch it.' Resident was pointing to his penis while talking. The resident was educated about behavior. CNA was walking resident to the dining room for lunch. As resident walked by me at my med cart he grabbed my buttock and stated 'woo hoo'. I educated resident about behavior. Resident has made several comments when female staff entered his room. 'Come get in bed with me good looking. I wished you were in my bed. I can't wait to get you in my bed.' Will continue to observe." -- 10/24/13 - 02:04 - "CNA assisted resident in to bed and resident stated 'You better not come in here with your pants off. I will stick it in you then feel you up and you will float like a balloon.' Spoke with resident about behaviors. Will continue to observe." -- 10/25/13 - 04:18 - "Resident has made sexually inappropriate comments to the CNA this shift. Resident stated 'come on baby lay down with me.' Resident also has been trying to go into other female resident's rooms. Resident gets very agitated when staff tries to redirect him out of other resident's rooms and combative at times. This nurse tried to offer snack or to sit down this seems to help some with behaviors." -- 10/25/13 -16:17 - "Resident has spent much of the day sitting near nurses desk calling out to staff and other residents saying 'Hey come here! You need some help? I got what you need' etc. No combativeness notes so far this shift. Will continue to monitor." -- 10/25/14 - 20:25 - "Resident was in a female resident's room. When CNA went to try and get resident out of room resident jumped out of the wheelchair and begin to hit CNA. Wheelchair was in between resident and CNA. CNA denies any injuries." -- 10/26/13 - 05:12 - "Resident entered the hall way and voided in the hall way. Staff guided him check him and lead him back to bed. The LPN (licensed practical nurse) mopped the floor." -- 10/26/13 - 12:49 - "Resident exhibited verbal and physical aggression with staff during care. Resident refused his shower and all a.m. care. I knocked on residents door because his room mate had his call light on. As I knocked on the door the resident screamed out 'Don't be beating on my d_ _ _ door.' I explained to the resident I was knocking before entering out of courtesy. Resident yelled 'Get the h_ _ _ out of here before I knock your d_ _ _ head off.' When the staff took resident to the shower CNA started to assist resident remove his shirt and resident stated 'Don't take my p_ _ _ _ _ off. CNA tried to explain she was trying to assist him in taking a shower. Resident pushed CNA and stated 'you let me out of here or I will kill myself and you too.' Will continue to monitor." -- 10/27/13 - 05:29 - "Resident wandered from room to room disturbing several residents until staff was able to get him in to bed." -- 10/27/13 - 10:59 - "Medication administration note - Resident refused. 'Get those d_ _ _ things out of here. I don't take medicine.'" -- 10/27/13 18:32 - "Resident has exhibited wandering into other residents rooms, verbally and physically aggressive when staff attempt to redirect resident from other resident's rooms, sexually inappropriate by making comments to female staff during care 'You want to f_ _ _ me?' Resident has been educated throughout the shift regarding behaviors. Resident has also voided in roommates clothes hamper, and a plant in the front lobby and in his hallway." -- 10/28/13 - 01:50 - "Resident stated 'I' d like to pat that a_ _ for 30 min . . . Your pretty, I really like to pat your a_ _ .' ' I got something I like you to massage' 'boy let me tell you what I'd like to pat that b_ _ _ Won't you let me pat it?' Staff politely declined." -- 10/28/13 -14:30 - "Fax sent to Dr.(name) re: increased behaviors and review of home medications with resident previously on [MEDICATION NAME] 23 mg (milligrams) new order to increase [MEDICATION NAME] to 10 mg po (by mouth) daily. Call placed to MPOA (medical power of attorney). aware and agreeable to changes." -- 10/28/13 - 21:31 - "Resident entered another resident's room this evening and family members were in there. Staff observed resident enter room and then observed resident attempt to grab a family member. Resident became very physically aggressive with staff when redirection was attempted. Staff attempted several times to calm resident down without success. Resident was in the hallway and walked past another resident in a chair and placed his hand on her forehead and shoved her had back. Resident was yelling and cursing at staff. Dr. was paged and a new order received for [MEDICATION NAME] 1 mg po (by mouth) times one dose." -- 10/29/13 - 01:24 - "One time dose for [MEDICATION NAME] effective. Resident calmed down and was very pleasant after the medication administration. . . ." -- 10/29/13 08:42 - "Resident exhibiting worsening behaviors at night with wife informing staff that he was [MEDICATION NAME] home due to his inability to sleep. Noted that the resident has increased aggression, inappropriate sexual behaviors, wandering, and exit seeking after he has been awake all day and worsens throughout the evening as he may become increasingly tired. fax sent Dr. (name) requesting trial dose of Ambien. Awaiting response." -- 10/29/13 - 20:55 - "Resident had a bowel movement in roommates trash can and voided in the floor at his roommates bedside. " -- 10/29/13 - 22:57 - "Fax received from Dr. (name) to [MEDICATION NAME] mg by mouth at bedtime as needed." -- 10/29/13 - 22:57 - "Resident was wandering throughout the facility this evening entering resident's rooms. He entered a resident's room on D-Hall and voided in his trash can at his bedside. Resident becomes very aggressive and agitated when staff attempted to redirect. Resident was refusing to lay down for the night and continued wandering. New order [MEDICATION NAME] bedtime noted and administered to resident. Resident assisted to bed shortly after and is currently resting in bed quietly with eyes closed. Call light within reach. Routine toileting and safety checks continue." -- 10/30/13 - 17:46 - "multiple episodes of inappropriate sexual behavior this shift i.e., following staff into rooms making sexual comments. No physically aggressive or combative behaviors noted." -- 10/30/13 - 20:05 - "Resident grabbed another resident's wheelchair from behind. When the resident turned to see who had hold of his chair resident cursed him, grabbed his wrist and attempted to hit resident without success." -- 10/30/13 e 23:09 - "Received order per Dr. (name) for [MEDICATION NAME] 0.5 mg po (by mouth) for behaviors. Pharmacy noticed. POA (power of attorney) to be notified in the a.m." -- 10/31/13 e 15:15 - Care Plan Meeting Note - "Initial Review: Current weight is 187. Is on LCS (low concentrated sweets) Is in use of wander guard for resident's safety. Has had noted physical and verbally aggressive behaviors. At times difficult to redirect. Wife visits often. Has notified staff that he has had increased trouble sleeping over the past few years. At this time resident is expected to have long term placement in facility. " -- 10/31/13 - 18:06 - "yelling at roommate. Wandering in rooms." -- 11/01/13 - 11:05 - Social Service Note - "Resident is in-capacitated. No plans for discharge and resident remains appropriate for placement. His family is supportive and visits on a regular basis. Resident's wife was appointed Health Care Surrogate. Care plan developed regarding resident impaired cognition, wandering and disruptive behaviors. Continue to follow up as needed." -- 11/01/13 - 14:16 - "Refused a.m. care, verbally aggressive with care, wandering." -- 11/01/13 - 10:04 - "Resident exhibited refusing a.m. care, wandering into other residents rooms, verbally aggressive with staff when staff attempts to divert resident from other residents rooms." -- 11/02/13 - 5:47 a.m. - "Resident aggressive with staff members, attempted numerous times to hit staff. Resident went into female residents rooms and became aggressive when staff attempted to redirect." -- 11/02/13 - 17:07 - "yelling at staff and other residents. Resident attempted to wheel a female resident into his room. This nurse was able to remove female. Will continue to observe." -- 11/03/13 - 00:03 - "Resident went in to every resident and staff trying to sell a box of tissues. When they wouldn't buy them he would cuss and move on some times becoming difficult. After he gave up on the tissues he patted the lpn (Licensed Practical Nurse) on the back side and stated I would pat that for an hour. Do you like that? The staff told him no and removed his hand from their bottom." -- 11/03/13 - 19:49 - "Ambien 2.5 mg by mouth administered per order. 1/2 Tablet." -- 11/03/13 - 20:12 - "Family member of residents in another room (named room number) came to this nurse and said this resident was in room (named room) trying to get into the bathroom to use the toilet. Upon entering room, found resident sitting on the trash can in the room (not in the bathroom) having a bowel movement. Attempted to assist the resident by offering my hand to help him stand. Told the resident we needed to go to his room to get cleaned up et (and) resident started swinging his fist yelling saying 'I am trying to s_ _ _ '. Explained to the resident that he needed to go to his room and use his toilet and not the trash can and the resident stated 'I don't give a d_ _ _ what you say. I have to s_ _ _ and I am S _ _ _ _ _ _ _ right here.' This nurse went to side 2 (two) to get the CNAs who work with this resident to see if they could assist him back to his room. CNAs X's (times) 2 (two) came to the room and ask resident if they could help him get cleaned up. Resident was compliant with CNAs letting them assist him back to his room. Room (number named) was cleaned up at this time." -- 11/03/13 - 23:05 - Resident attempting to get into female resident's room. When CNA attempted to redirect resident, resident told CNA 'I am going to knock you on you a _ _ .'" -- 11/04/13 - 08:40 - "[MEDICAL CONDITION] med (medication) assessment [MEDICATION NAME] 0.5 mg BID (twice a day). Comments: Resident was started on the medication r/t (related to) inappropriate behaviors. See behavior notes in behavior folder. Will observe for adverse effects and effectiveness of medication." -- 11/04/13 - 14:03 - "Verbal aggressive with care." -- 11/04/13 - 22:40 - "Resident being sexually inappropriate towards staff and other residents. Threatening to hit staff and other residents. Cussing" -- 11/05/13 - 13:35 "Verbally aggressive with staff during care, wandering into other residents rooms." -- 11/05/13 - 18:46 - "Resident exhibited verbal aggression towards staff during care. 'If you don't get out of here I will kill you. I will kill myself too with an axe and a knife' .CNA (certified nursing assistant) waited aprox. 30 min for resident to calm down then performed a.m. care. " -- 11/06/13 - 00:34 - "Resident was wandering within the facility this evening. He was entering other residents rooms and became aggravated when staff attempted to redirect. Resident is physically aggressive with staff. . . ." h) Employee #34 (nursing assistant) was interviewed at 11:00 a.m. on 11/06/13. It was verified she was the regular caregiver for Resident #145. She also verified most of his behaviors happened in the evenings after she was gone but the resident was combative with them sometimes. She was asked if she had ever heard other residents on that hall verbalize concerns of being afraid of Resident #145. Employee #34 said she heard some of the ladies talk about being concerned with Resident #145. When asked for the names of female residents on that hall who voiced concerns, she identified Residents #87 and #66. i) During an interview with the director of nursing (DON) at 11:30 a.m. 11/06/13, she was asked for the facility's incident and accident reports. The DON provided three (3) months of reports, and verified these were all of the reports. She was asked if there were any incident reports for the incidents identified in the notes (as listed above) of Resident #145. She verified there was only one (1) report for him, and it was dated 10/28/13. Review of the incident report revealed it was related to a fall on 10/28/13. There were no other incident reports Resident #145. The DON verified there were some incidents that required an incident report, but were not completed. When asked about Psychiatric Services for this resident, the DON verified Resident #145 had not had a Psychiatric evaluation since his admission. j) The facility's policy and procedure titled, "Abuse Prevention Policy and Procedure," dated 2012, was provided by the DON on 11/06/13 at 2:30 p.m. Review of the policy revealed the following: 1. Policy Statement "This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agencies service the residents, family members, legal guardians, friends or other individuals. Though it cannot guarantee that such occurrences will not occur at this facility, preventative steps will be taken to reduce the potential for such occurrences." The facility did not take preventative steps for the occurrences of verbal, sexual, mental, and potential physical abuse of residents by Resident E145. There was no evidence the facility identified the abusive behaviors Resident #145 inflicted on others, or established a plan to protect others from the abuse. Even though this resident was confused and did not have capacity, the other residents in the facility suffered from his abusive behaviors. The facility failed to identify the negative impact this had on the residents and their environment. On 11/07/2013 at 8:35 a.m., after an immediate jeopardy was called on 11/06/13 at 1:40 p.m. related to the behaviors of Resident #145, the resident was sent out to the hospital for a psychiatric evaluation due to [MEDICAL CONDITION] and disruptive behaviors. It was verified the resident was admitted for treatment and remained at the hospital as of the time of exit on 11/13/13. .

Based on closed record review and staff interview, the facility failed to develop and implement written policies and procedures to ensure that residents receive care and services necessary to prevent avoidable accidents This was evident for one (1) of six (6) sampled residents whose treatment was changed without a physician's orders [REDACTED]. There was no evidence this resident (who had been identified as being at risk for falls) was first assessed to see if she was a candidate for removal of safety devices while in the dining program and no evidence of care planning for safety interventions to prevent accidents while participating in these programs. Additionally, there were no written guidelines or interventions for staff to follow to assure the resident's safety needs were met. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... "Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)." Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. -- 4. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 5. Interviews with two (2) nursing assistants (Employees #4 and #56), a restorative nursing assistant (Employee #49), and a registered nurse (Employee #27), on [DATE] and [DATE], revealed they were told that residents in the restorative program are to be walked and assisted to sit in the dining room chair without alarms. However, residents who were wheeled to the dining room were allowed to have tab alarms or safety belts if they used them. -- 6. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON agreed that Resident #111 was not using a tab alarm, self-releasing seat belt, or wheelchair at the time of the fall in the dining room on [DATE]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 7. In an interview on [DATE] at 1:45, the social workers (Employees #96 and #108) revealed they did not know whether Resident #111's power of attorney knew, before the resident's fall in the dining room on [DATE], that the resident's tab alarm and safety belt were not being used because of the change to fine dining. Employee #108 stated that, if a letter were sent out to everyone about a resident's transition to fine dining, then everyone would be assured of having been notified, but no letter was sent to families to her knowledge. They said they believed that seat belts were not allowed while residents were seated in regular chairs during fine dining as that would not be dignified. -- 8. During an interview with a member of the activities staff (Employee #35) on [DATE] at 3:20 p.m., she said she was the only staff member in the dining room on [DATE] at the time Resident #111 fell , although she was not assigned to be in the dining room that day at any certain time. She said she went to the kitchen on her own initiative on [DATE], to check if any of the trays were ready or if the dietary staff needed her to start pouring drinks. When asked, she said the noon meal was typically served at 12:10 p.m. in the dining room. She stated that, at 11:45 a.m. on [DATE], she looked up and saw Resident #111 walking and hurried to her, but she could not reach the resident before she fell . She said the resident had no alarm or safety belt in place and she was sitting at the table by herself. -- 9. When asked, during an interview on [DATE] at 4:00 p.m., why Resident #111 was in the dining room so early before the meal, the DON said Resident #111 was one of the easiest residents to walk, so she would have been one of the first brought down to the dining room. She said there was no written safety policy or procedure regarding the use of alarms or seat belts that she could find related to fine dining. Resident #111 had an order for [REDACTED]. .

Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism. Resident #143 had an active infection with a highly contagious organism - [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) - a spore-forming organism from which environmental contamination frequently occurs. Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bouts of diarrhea resulting in bowel incontinence.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Resident #143 was also very active, attended out-of-room activities, and ate in the dining room. He received therapy in the common use therapy room, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propelled his own wheelchair throughout the facility, touching handrails and other common use surfaces in the process. The facility failed to assure Resident #143 (who was alert and oriented) used appropriate hand hygiene measures after toilet use while actively symptomatic, to prevent the spread of this highly infectious organism as he moved independently throughout the entire facility, putting all of the other residents at risk. There was no evidence to reflect staff members considered the surfaces outside of his room, the common areas, or nursing equipment used by this resident to be contaminated. Nursing care staff did not adhere to infection control guidelines when rendering care to Resident #143. Housekeeping staff did not sanitize Resident #143's room with a cleaning product containing sodium hypochlorite (bleach), as recommended by CDC. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010; they did not indicate the presence the infectious organism for Resident #143. There was no evidence the facility had investigated, monitored, and/or assured that measures are being taken to assure there is no spread of this infection to the other residents in the facility. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and director of nursing (DON) were notified of the immediate jeopardy situation. The administrator provided a corrective action plan for removing the immediate jeopardy, including relocating the immunocompromised resident (#89) to another room; providing teaching to Resident #143 and his family member about the infectious organism and the need for appropriate hand hygiene; inservicing staff on appropriate infection control measures to be implemented, including the use of personal protective equipment; disinfecting all resident rooms and common areas with a bleached-based product; and inservicing all housekeeping staff on the proper procedure (and chemicals to be used) for disinfecting the rooms of residents with this infectious organism. The resident with the infection (Resident #143) agreed to stay in his room until his symptoms resolved. The DON developed an infection tracking form for trending patterns, and the infections for March, April, and May 2010 were researched to assure there were no other risks for transmission to a possible compromised roommate. After observing the facility's actions, assuring Resident #89 was safely moved into another room, and assuring the cleaning tasks were completed, the survey team verified all planned actions were implemented to remove the immediate jeopardy at 8:45 p.m. on 05/04/10, and there was no further deficient practice in this requirement. Resident identifiers: #89 and #143. Facility census: 101. Findings include: a) Resident #89 Observation of this resident's room, on 05/03/10, revealed a contact isolation sign posted on the door of this resident's room. Resident #89, a female resident who shared the room with her husband (Resident #143), was observed to be receiving a feeding by her gastrostomy tube ([DEVICE]). The surveyor noted Resident #89 was totally dependent upon staff for all ADLs and that her [DEVICE] offered an open port of entry for infectious organisms. This placed Resident #89 at high risk for contracting a contagious disease. Review of Resident #89's medical record revealed no evidence she had an active infection. Documentation revealed these residents had only moved in the room together in the last few days at the request of the husband (Resident #143). Review of Resident #143's record found he was in contact isolation for [DIAGNOSES REDACTED]. There was no documentation in Resident #89's medical record that her health care decision maker (who was not her husband) was informed of the risks associated with having these two (2) residents share the same room. --- b) Resident #143 1. Review of Resident #143's medical record revealed he was admitted to the facility on [DATE], and that he possessed the capacity to understand and make his own informed health care decisions. He was sent to the hospital on [DATE] and returned on 04/21/10. At that time, he had diarrhea and he tested positive for [DIAGNOSES REDACTED]. He was placed in contact isolation and was treated with [MEDICATION NAME] 500 mg twice a day for seven (7) days. After he finished this course of antibiotics, an order was given on 05/01/10 to obtain a stool specimen to test for the continued presence of [DIAGNOSES REDACTED]. This test came back positive on 05/03/10, and he started another course of [MEDICATION NAME] for seven (7) more days. The resident experienced diarrhea seven (7) times on 05/03/10. He remained in contact isolation at this time. -- 2. Observation found Resident #143 in the dining room area at 11:45 a.m. on 05/03/10. When interviewed, he stated he did not feel well and did not want to eat. He left the dining room independently and was then seen lying in his bed at 12:30 p.m. When interviewed again at that time, he said he just did not "feel good today". When questioned about his abilities to perform his own ADLs, he said, most of the time, he did things himself. He reported having had diarrhea and needing assistance cleaning up, but most of the time he did this himself. He said the diarrhea sometimes made him be incontinent of bowel before he could reach the bathroom. The resident was observed in the front lobby at 11:30 a.m. on 05/04/10. A staff member was looking for him, and when she found him, she stated, "He runs around all the time." Observations throughout the survey event found this resident was very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He also independently propelled his own wheelchair throughout the facility, touching handrails and other common surfaces in his travels. -- 3. In spite of the presence of a contact isolation sign on the door of this resident's room, the nursing assistants and the alert and oriented resident (#143) in that room did not follow contact precautions to prevent spread of the infection. - On 05/04/10 at 9:00 a.m., a very strong, foul odor was detected coming from Resident #143's room. Observation found Resident #143 coming out of the bathroom. This surveyor looked inside the bathroom and saw a raised commode seat with loose stool all over the seat. The resident, when questioned at that time about toileting, said, "Sometimes, I can just go myself." The bathroom, when observed again at 10:00 a.m., had been cleaned. This resident was again observed coming out of his bathroom independently at 11:00 a.m. on 05/04/10. There was no staff in the area at that time. - An interview was conducted with a nursing assistant (Employee #55) at 4:35 p.m. on 05/04/10, regarding Resident #143's toileting habits. Employee #55 stated Resident #143 was mostly continent, but he had diarrhea and was sometimes incontinent. He was also noncompliant and needed assistance, although he took himself to bathroom sometimes. He had a broken leg / knee and needed assistance with transferring. Employee #55 stated, "After you put him on the toilet, he often cleans himself before you come back to help him." At 4:45 p.m., Employee #55 was asked if she would have resident to wash his hands before he went to the dining room, in order for the surveyor to observe the resident's handwashing technique. Employee #55 agreed and entered this resident's room. She leaned over the foot of his bed, placing her bare hands on the resident's bed linens and leaning on the mattress of his bed where he was lying. Employee #55 was not wearing any gloves when her bare hands came into contact with his bed linens, which were likely to be contaminated with [DIAGNOSES REDACTED]. (See also citation at F441.) After asking the resident if he was ready to go wash his hands for dinner, Employee #55 donned a pairs of gloves - prior to assisting Resident #143 to his wheelchair and after touching the resident's bed linens with her bare hands. She assisted the resident in transferring to his wheelchair. He told her, "I can wash my own hands." Employee #55 placed Resident #143 in front of the sink. He turned the water on full blast, and the water splashed all over him and around the sink. He then stuck his hands under the stream of water and rinsed them for seven (7) seconds. He reached up with his wet hands, turned off the water, and obtained a paper towel. He never applied soap to his hands, nor did he use friction when washing his hands. Resident #143 did not effectively wash his hands to prevent the transmission of the [DIAGNOSES REDACTED] throughout the facility. - Observation, on 05/04/10 at 5:30 p.m., found Resident #143 sitting in his bathroom on the toilet by himself. A nursing assistant (Employee #3), who was assigned to care for him, was asked how much assistance she provided to him for personal hygiene after toileting. She stated first he cleans himself up, and then she finishes cleaning him, because he is not totally clean. She said the occupational therapist (OT) was working with him to get him to be able to clean himself. When asked about his handwashing after having a bowel movement, she stated she gives him a disposable wipe to use on his hands after he cleans himself. (There was no mention of the use of soap and water for handwashing.) Observation found Employee #3 did not wear a gown when assisting Resident #143 with personal hygiene after toileting. This employee verified she assisted the resident with cleaning himself after he had a bowel movement. When asked why she did not wear a gown, she stated she only wears a gown if she anticipates coming in contact with stool, and she did not anticipate coming in contact with stool when caring for Resident #143. Facility policy states staff is to wear a gown if it is anticipated that he or she will come in contact with the contaminated body fluids. Given an earlier observation described that found loose stool on Resident #143's toilet seat after he used the bathroom independently, the possibility of a staff member coming into contact with stool, when assisting Resident #143 with personal hygiene after using the toilet, was great. (See also citation at F441.) - Record review found no care plan had been developed to address Resident #143's non-compliance with the contact isolation precautions, including his inadequate handwashing practices. There were no instructions provided (except "assist him to wash his hands") to assure this resident did not spread this infectious organism to his immunocompromised roommate and throughout the entire facility, even though the facility was aware that he often provided his own handwashing and his hand hygiene practices were inadequate to prevent the spread of infection. (See also citation at F279.) -- 4. On 05/04/10 at 2:30 p.m., a housekeeper (Employee #114) was observed coming out of Resident #143's room. When questioned about the process for cleaning a room occupied by a resident in contact isolation, Employee #114 reported the cleaning chemical she used in the bathroom was a heavy duty bathroom cleaner by ECOLAB; she also reported using OASIS 531 to clean the floor and wipe off surfaces, such as the bedside table and the side rails. She was aware this was a contact isolation room and stated she used a different rag and mop and changed her mop water after cleaning such a room, so as to not contaminate other rooms. She said she used OASIS 299 to clean the bathroom and fixtures in the bathroom. When asked if she used anything else to clean this room, she verified these were the only two (2) products she used. She was then asked to get the material safety data sheet (MSDS) for each of these products. Review of the MSDS information found neither of these products contained sodium hypochlorite. - Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: "C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery /manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item." Under the heading "What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?" was found: "Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities.' Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions." (Source: http://www.cdc.gov<http://www.cdc.gov>/ncidod/dhqp/id_CdiffFAQ_HCP.html) - According to the fact sheet provided by the facility as part of its infection control program, the CDC recommended the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], having identified as a special consideration that [DIAGNOSES REDACTED] is a spore-forming organism and environmental contamination frequently occurs. This fact sheet also stated the facility recommended the use of a pre-mixed EPA-registered, hospital-grade sodium hypochlorite-based disinfectant, rather than using a solution of bleach and water mixed daily. - The DON provided literature supporting the use of 10% sodium hypochlorite solution mixed fresh daily (one (1) part house hold chlorine bleach mixed with nine (9) parts tap water). She verified this was what they should have been using to clean Resident #143's room. - During an interview with the maintenance / environmental service director (Employee #44), he could not provide evidence that staff instructed on any specific method of cleaning a room of a resident with [DIAGNOSES REDACTED]. He also could not produce a specific policy and procedure for the cleaning of a room occupied by a resident in contact isolation. At 3:15 p.m., Employee #44 stated he called ECOLAB and was advised they should wipe down Resident #143's room with bleach, then mist the surfaces with the OASIS product, leave it for ten (10) minutes, then wipe it off. There was no evidence this procedure was written anywhere or that these instructions had been provided to the housekeeping staff. -- 5. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. There was no evidence the facility had investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. 5. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. There was no evidence the facility had investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. - The facility's infection control compliance monitoring procedure (last revised July 2008), and the only mechanisms identified for monitor the compliance of the employees with the facility's infection control policies and procedures were self-evaluation by existing employees and observation of each new employee as follows: - Staff Self Evaluation - Each employee may be given a self evaluation form to complete every six (6) months, which will be reviewed by the infection control nurse. This self evaluation, when reviewed, contained basic questions asking staff if they performed the infection control tasks properly. (Examples: Do you decontaminate your hands before resident contact? Do you use gloves, masks, etc?) - Observation - Each new employee will be observed during orientation. The infection control nurse will then prepare a report and present it monthly or at least quarterly to the infection control committee. These methods of compliance monitoring were ineffective for ensuring the employees were following the policies regarding isolation. There was no evidence the facility monitored current employees through direct observation, to ensure they were following the infection control policies and procedures. (See also citation at F441.) -- 6. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and the DON were notified of the immediate jeopardy situation. The administrator provided a corrective action plan for removing the immediate jeopardy, including relocating the immunocompromised resident (#89) to another room; providing teaching to Resident #143 and his family member about the infectious organism and the need for appropriate hand hygiene; inservicing staff on appropriate infection control measures to be implemented, including the use of personal protective equipment; disinfecting all resident rooms and common areas with a bleached-based product; and inservicing all housekeeping staff on the proper procedure (and chemicals to be used) for disinfecting the rooms of residents with this infectious organism. Resident #143 agreed to stay in his room until his symptoms resolved. After observing the facility's actions and assuring that Resident #89 was safely moved into another room, and the cleaning tasks were completed, the survey team verified all planned actions were implemented to remove the immediate jeopardy at 8:45 p.m. on 05/04/10, and there was no further deficient practice in this requirement. .

Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the governing body failed to ensure the facility was administered in such a manner as to provide a safe, sanitary and comfortable environment (to help prevent the development and transmission of disease and infection) and to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism, who did not perform effective handwashing after having episodes of diarrhea, and who independently traveled throughout the facility, entering common areas and touching surfaces used by all residents. The facility's administration failed to develop and maintain an infection control program to effectively prevent the transmission of a highly contagious intestinal infection, [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]), by Resident #143. There were no specific policies for the cleaning of rooms, surfaces, and/or equipment used by this resident infected, and there was no evidence of inservicing to ensure the staff was aware of this resident's infection and the proper techniques to be employed to prevent transmission of the infectious organism throughout the entire building. There was no evidence to reflect the administration provided oversight to the infection control program to ensure infection control policies and procedures were reflective of current standards of practice (in accordance with recommended CDC guidelines) and that staff implemented those policies and procedures as written. These practices placed all residents in the facility in immediate jeopardy for acquiring a [DIAGNOSES REDACTED] infection. (See citation at F224 for specific information related to the immediate jeopardy.) Facility census: 101. Findings include: a) Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism. Resident #143 had an active infection with a highly contagious organism - [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) - a spore-forming organism from which environmental contamination frequently occurs. -- Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: "C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery /manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item." Under the heading "What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?" was found: "Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities.' Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions." (Source: <http://www.cdc.gov<http://www.cdc.gov>/ncidod/dhqp/id_CdiffFAQ_HCP.html>) -- Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bouts of diarrhea.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Resident #143 was also very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propelled his own wheelchair throughout the facility, touching handrails and other common use surfaces in the process. The facility failed to assure Resident #143 (who was alert and oriented) used appropriate hand hygiene measures after toilet use while actively symptomatic, to prevent the spread of this highly infectious organism as he moved independently throughout the entire facility, putting all of the other residents at risk. There was no evidence to reflect staff members considered the surfaces outside of his room, the common areas, or nursing equipment used by this resident to be contaminated. Nursing care staff did not adhere to infection control guidelines when rendering care to Resident #143. Housekeeping staff did not sanitize Resident #143's room with a cleaning product containing sodium hypochlorite (bleach), as recommended by CDC. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010; they did not indicate the presence the infectious organism for Resident #143. There was no evidence the facility had investigated, monitored, and/or assured that measures are being taken to assure there is no spread of this infection to the other residents in the facility. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and director of nursing (DON) were notified of the immediate jeopardy situation. (See also citations at F224 and F441.) -- b) According to the fact sheet provided by the facility as part of its infection control program, the CDC recommended the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], having identified as a special consideration that [DIAGNOSES REDACTED] is a spore-forming organism and environmental contamination frequently occurs. This fact sheet also stated the facility recommended the use of a pre-mixed EPA-registered, hospital-grade sodium hypochlorite-based disinfectant, rather than using a solution of bleach and water mixed daily. The DON provided literature supporting the use of 10% sodium hypochlorite solution mixed fresh daily (one (1) part house hold chlorine bleach mixed with nine (9) parts tap water). She verified this was what they should have been using to clean Resident #143's room. During an interview with the maintenance / environmental service director (Employee #44), he could not provide evidence that staff instructed on any specific method of cleaning a room of a resident with [DIAGNOSES REDACTED]. He also could not produce a specific policy and procedure for the cleaning of a room occupied by a resident in contact isolation. At 3:15 p.m., Employee #44 stated he called ECOLAB and was advised they should wipe down Resident #143's room with bleach, then mist the surfaces with the OASIS product, leave it for ten (10) minutes, then wipe it off. The administration failed to ensure the facility's policies and procedures were established in accordance with current standards of practice (CDC guidelines) and were being utilized to prevent spread of this infectious organism, with respect to sanitizing rooms, surfaces, and equipment used by persons infected with [DIAGNOSES REDACTED]. -- c) Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. Nursing personnel did not employ appropriate infection control measures when rendering assistance with personal hygiene after Resident #143 had a bowel movement, nor did nursing personnel recognize and take appropriate precautions when coming into contact with his bed linens, which should have been viewed as potentially contaminated. Nursing personnel did not ensure Resident #143 effectively sanitized his hands after he performed his own personal hygiene after having a bowel movement, to ensure [DIAGNOSES REDACTED] was not spread to surfaces he touched throughout the facility. The facility's infection control compliance monitoring procedure (last revised July 2008), and the only mechanisms identified for monitor the compliance of the employees with the facility's infection control policies and procedures were self-evaluation by existing employees and observation of each new employee as follows: - Staff Self Evaluation - Each employee may be given a self evaluation form to complete every six (6) months, which will be reviewed by the infection control nurse. This self evaluation, when reviewed, contained basic questions asking staff if they performed the infection control tasks properly. (Examples: Do you decontaminate your hands before resident contact? Do you use gloves, masks, etc?) - Observation - Each new employee will be observed during orientation. The infection control nurse will then prepare a report and present it monthly or at least quarterly to the infection control committee. These methods of compliance monitoring were ineffective for ensuring the employees were following the policies regarding isolation. There was no evidence the facility monitored current employees through direct observation, to ensure they were following the infection control policies and procedures. The administration failed to ensure the facility's infection control program investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. .

Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility's quality and assessment assurance (QAA) committee failed to identify and implement measures to correct quality deficiencies - of which it should have known - to address a system failure with respect to the facility's infection control program. The facility failed to develop and maintain an infection control program to effectively prevent the transmission of a highly contagious intestinal infection, [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) by Resident #143. There were no specific policies for the cleaning of rooms, surfaces, and/or equipment used by Resident #143, and there was no evidence of inservicing to ensure the staff was aware of this resident's infection and the proper techniques to be employed to prevent transmission of the infectious organism throughout the entire building. There was no evidence to reflect the facility ensured its infection control policies and procedures were reflective of current standards of practice (in accordance with recommended CDC guidelines) and that staff implemented those policies and procedures as written. These practices placed all residents in the facility in immediate jeopardy for acquiring a [DIAGNOSES REDACTED] infection. (See citation at F224 for specific information related to the immediate jeopardy.) According to the director of nursing (DON), the facility's QAA committee reviewed the infection control nurse's reports of active infections monthly. Resident #143's [DIAGNOSES REDACTED] infection was not on the March 2010 or April 2010 infection control logs. Although the facility was aware Resident #143 had returned from the hospital with [DIAGNOSES REDACTED] and was being actively treated for [REDACTED]. Facility census: 101. Findings include: a) Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism. Resident #143 had an active infection with a highly contagious organism - [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) - a spore-forming organism from which environmental contamination frequently occurs. -- Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: "C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery /manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item." Under the heading "What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?" was found:"Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities'. Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions." (Source: <http://www.cdc.gov<http://www.cdc.gov>/ncidod/dhqp/id_CdiffFAQ_HCP.html>) -- Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bouts of diarrhea.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Resident #143 was also very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propelled his own wheelchair throughout the facility, touching handrails and other common use surfaces in the process. The facility failed to assure Resident #143 (who was alert and oriented) used appropriate hand hygiene measures after toilet use while actively symptomatic, to prevent the spread of this highly infectious organism as he moved independently throughout the entire facility, putting all of the other residents at risk. There was no evidence to reflect staff members considered the surfaces outside of his room, the common areas, or nursing equipment used by this resident to be contaminated. Nursing care staff did not adhere to infection control guidelines when rendering care to Resident #143. Housekeeping staff did not sanitize Resident #143's room with a cleaning product containing sodium hypochlorite (bleach), as recommended by CDC. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010; they did not indicate the presence the infectious organism for Resident #143. There was no evidence the facility had investigated, monitored, and/or assured that measures are being taken to assure there is no spread of this infection to the other residents in the facility. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and director of nursing (DON) were notified of the immediate jeopardy situation. (See also citations at F224 and F441.) -- b) According to the fact sheet provided by the facility as part of its infection control program, the CDC recommended the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], having identified as a special consideration that [DIAGNOSES REDACTED] is a spore-forming organism and environmental contamination frequently occurs. This fact sheet also stated the facility recommended the use of a pre-mixed EPA-registered, hospital-grade sodium hypochlorite-based disinfectant, rather than using a solution of bleach and water mixed daily. The DON provided literature supporting the use of 10% sodium hypochlorite solution mixed fresh daily (one (1) part house hold chlorine bleach mixed with nine (9) parts tap water). She verified this was what they should have been using to clean Resident #143's room. During an interview with the maintenance / environmental service director (Employee #44), he could not provide evidence that staff instructed on any specific method of cleaning a room of a resident with [DIAGNOSES REDACTED]. He also could not produce a specific policy and procedure for the cleaning of a room occupied by a resident in contact isolation. At 3:15 p.m., Employee #44 stated he called ECOLAB and was advised they should wipe down Resident #143's room with bleach, then mist the surfaces with the OASIS product, leave it for ten (10) minutes, then wipe it off. The facility's policies and procedures were not established in accordance with current standards of practice (CDC guidelines) and were not being utilized to prevent spread of this infectious organism, with respect to sanitizing rooms, surfaces, and equipment used by persons infected with [DIAGNOSES REDACTED]. -- c) Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. Nursing personnel did not employ appropriate infection control measures when rendering assistance with personal hygiene after Resident #143 had a bowel movement, nor did nursing personnel recognize and take appropriate precautions when coming into contact with his bed linens, which should have been viewed as potentially contaminated. Nursing personnel did not ensure Resident #143 effectively sanitized his hands after he performed his own personal hygiene after having a bowel movement, to ensure [DIAGNOSES REDACTED] was not spread to surfaces he touched throughout the facility. The facility's infection control compliance monitoring procedure (last revised July 2008), and the only mechanisms identified for monitor the compliance of the employees with the facility's infection control policies and procedures were self-evaluation by existing employees and observation of each new employee as follows: - Staff Self Evaluation - Each employee may be given a self evaluation form to complete every six (6) months, which will be reviewed by the infection control nurse. This self evaluation, when reviewed, contained basic questions asking staff if they performed the infection control tasks properly. (Examples: Do you decontaminate your hands before resident contact? Do you use gloves, masks, etc?) - Observation - Each new employee will be observed during orientation. The infection control nurse will then prepare a report and present it monthly or at least quarterly to the infection control committee. These methods of compliance monitoring were ineffective for ensuring the employees were following the policies regarding isolation. There was no evidence the facility monitored current employees through direct observation, to ensure they were following the infection control policies and procedures. The facility's infection control program failed to effectively investigate, monitor, and/or implement measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. -- d) During an interview with the DON on 05/05/10 at 3:00 p.m., the facility ' s quality assurance program was discussed. According to the DON, the infection control nurse brings a report to the QAA committee meeting every month and everyone discusses what they were monitoring. It was identified that Resident #143 had recently come from the hospital with [DIAGNOSES REDACTED], and the facility had not identified the need for implementing any special measures to ensure [DIAGNOSES REDACTED] was not spread by Resident #143 throughout the entire facility.

Based on record review, staff interview, observation, and resident interview, the facility failed to assure Resident #143's nutritional status was assessed by a registered dietitian (RD) or that nutritional interventions were implemented for a resident who experienced a severe weight loss of 29 pounds (#) in one (1) month. This was true for one (1) of thirty (30) Stage II sample residents. Resident identifier: #143. Facility census: 101. Findings include: a) Resident #143 1. Resident #143 was admitted to this facility from the hospital on [DATE], after falling and sustaining a fracture of his knee. He was being treated for [REDACTED]. His wife was already a resident at this facility, and he would come in daily to visit her prior being admitted himself. His admission weight, on 03/25/10, was 200#. The second time his weight was measured, on 04/01/10, it was 190#. He had lost 10# in one (1) week. His next weight, on 04/07/10, was 178#. On 4/15/2010, he weighed 171#. On 04/19/10, he complained abdominal pain, nausea, and anorexia and was transferred, then admitted to, the hospital. His weight, upon from the hospital on [DATE], was 171#. The minimum data set assessment, with an assessment reference date of 03/29/10, noted he was leaving greater than twenty-five percent (25%) of his meals uneaten. He was also receiving a therapeutic diet. The resident assessment protocol (RAP) for nutritional status, dated 04/05/10, contained the following recommended interventions: "RD evaluation and Speech Therapy evaluation as needed." 2. An interdisciplinary weight loss meeting was held on 04/09/10, at which time the interdisciplinary team (IDT) noted he had experienced an eleven percent (11%) weight loss in one (1) week. According to an IDT progress note, the physician was notified of this loss. Also noted was the resident had been receiving antibiotics for an upper respiratory tract infection, and the probable cause for the weight change was attributed to the resident having received intravenous (IV) fluids in the acute care setting prior to admission to this facility. The IDT spoke with the resident, and he was quoted as saying, "I don't eat like I used to" and "I don't work like I used to." A nurse (Employee #97) was asked to assess this resident with the surveyor at 11:00 a.m. on 05/04/10. This resident stated to the nurse, "I do not have an appetite anymore." The nurse ask him when this started, and he stated, "When I fell ". There was no evidence that either of these comments was explored further to determine identify possible psychosocial factors that may have been contributing to his loss of appetite. 3. The initial care plan for this resident, established on 04/12/10, identified he had experienced a significant weight loss. Interventions to address the weight loss included: monitoring labs, monitoring bowel sheets, monitoring food intake, weighing the resident, recording his stools, recording his food intake, assisting with eating, encouraging a variety of foods, offering shakes, offering replacement foods, determining food likes and dislikes, and providing the physician-ordered diet. There were no interventions aimed at identifying why this weight loss was occurring. In addition, the care plan did not include interventions such as having the RD assess his weight loss, obtaining an order from the physician for an appetite stimulant, having the social worker further assess to see if he was experiencing depression (as the anorexia could have been linked to depression), asking this alert and oriented resident who is alert and oriented why he was refusing meals, and/or involving him in activities to stimulate his appetite. 4. The resident's dietary progress note, written by the dietary manager (Employee #149) on 04/13/10, stated the resident had a new problem - significant weight loss of eleven percent (11%) in one (1) week, and he was leaving more than twenty-five percent (25%) of his meals uneaten. 5. The next interdisciplinary weight loss meeting was held on 04/15/10. An IDT note written on this date reflected the resident had lost another 9# and acknowledged the total weight loss of 29# in one (1) month. At that time, the resident was recorded as commenting that his appetite wasn't "what it used to be" and stated that, on occasion, he had nausea. The physician was notified of this weight loss via fax, and action taken was to initiate sugar-free mighty shakes with meals, obtain a nutritional panel on 04/16/10, change his food consistency to mechanical soft chopped meat, and continue to offer snacks and substitutes. This note also stated "requesting appetite stimulant" and weigh weekly. 6. Review of the communication form, faxed to the physician on 04/15/10, found: "Resident not eating, (arrow pointing down) 29 pounds in 1 month. Changed diet to mech (mechanical) soft chopped meat, added sugar free supplement tid (three-times-daily), getting labs in the a.m. (morning). At times he complains of stomach upset. Has no stomach meds (medications). Can we try [MEDICATION NAME]?" The physician signed this communication form to indicate he saw it, but there was no date with the signature. The director of nursing (DON) stated the physician did not respond to the request for [MEDICATION NAME] (appetite stimulant). She was unable to find evidence to reflect that anyone followed up on this. The resident was admitted to the hospital on [DATE]. 7. Further review of the resident's dietary records found no evidence that resident, who had been admitted on [DATE], had not been evaluated by the RD as of 05/03/10, when this surveyor reviewed the resident's record. The dietary manager had made a note on 04/29/10, stating, "Initial Re-Admission assessment from the hospital stay. Resident readmitted on [DATE]." This note also contained a recommendation that he receive a multivitamin with iron for nutritional supplementation. This readmission assessment was completed eight (8) days after this resident returned to the nursing home; he had been out in the hospital for three (3) days. The dietary manager (Employee #149), when interviewed on 05/04/10 at 8:30 a.m., confirmed this resident had not been assessed by the RD. She stated she was "not sure why she (the RD) has not seen him yet, but she comes on Thursday, and she will have her look at him this Thursday." NOTE: This surveyor observed the RD had been in the facility on the previous Thursday, 04/29/10. There was no evidence she reviewed this resident's weight loss or assessed his nutritional needs at that time. 8. Further review of the medical record, on 05/04/10, revealed this resident had refused five (5) of the last nine (9) meals served and had consumed less than half of the other four (4) meals. His daily fluid intake for May 2010 had been less than 1000 cc daily, and his total daily fluid intake was very low on the following days: 05/01/10 - 840 cc; 05/02/10 - 960 cc; and 05/03/10 - 600 cc. His bowel elimination records indicated the resident had experienced bouts of diarrhea thirteen (13) times during the first three (3) days of May 2010, as well as three (3) large bowel movements. However, the nursing notes, when reviewed, contained no references to this resident's poor intake of food and fluids, nor of his continual diarrhea during the first three (3) days of May 2010. Employee #97, when questioned about the facility's procedure for identifying abnormal findings such as decreased meal intake and decreased fluid intake as recorded on the nursing assistants' activities of daily living sheets, reported night shift looked at these records then communicated the findings, but that nursing assistants should also communicate these findings to the nurse. She was asked to print a copy of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 9. A therapy screen communication request was completed on 05/04/10, after this surveyor question staff about the resident's poor intake. This request was made to upgrade the consistency of his food. This form stated the resident does not want pureed food, and the family had been bringing in other food items. There was no evidence in the record to reflect staff was aware the family was bringing food to Resident #143 or why. .

Based on observation, record review, resident interview, and staff interview, the facility failed to assess and treat pain for one (1) of thirty (30) Stage II sample residents. Resident #146 complaint of pain daily while receiving physical therapy and during repositioning with daily care, but she was not assessed for and treated with an [MEDICATION NAME] as ordered by the physician. Resident identifier: #146. Facility census: 101. Findings include: a) Resident #146 Medical record review, on 05/04/10 at 8:15 a.m., disclosed a [AGE] year old female resident who was admitted to the facility from an acute care on 04/16/10 with [DIAGNOSES REDACTED]. The initial pain assessment, dated 04/17/10, noted the resident reported having "ache stabbing" pain. Review of the physician orders, dated 04/16/10, reveal the physician had ordered [MEDICATION NAME] 325 mg two (2) tablets every four (4) hours for mild pain and [MEDICATION NAME] 5 mg- 500 mg one (1) tablet every four (4) hour for moderate to severe pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident also received [MEDICATION NAME] two (2) tabs at 8:41 a.m. on 04/28/10. The resident was observed in bed in her room on 04/26/10, 04/27/10, 04/28/10, 04/29/10, 05/03/10, on multiple occasions between the hours of 8:00 a.m. and 6:30 p.m. The resident did not smile, spoke in a soft voice, and had a sad facial expression. The resident did not have any visitors when observed. When interviewed during one (1) of these observations, the resident reported having had a fall at home in December 2009, resulting in a fractured left ankle. The resident also reported she has had multiple admissions to acute care hospitals or long term care facilities since the fall. The registered nurse supervisor (RN - Employee #97), when interviewed on 05/03/10 at 9:00 a.m., reported the resident had not been transferred out of bed due to the resident's refusal and pain in the lower extremities. The RN reviewed the medical record and could not find documentation the resident refused care or was counseled to the health risks of not getting out of bed for extended periods of time. Review of the nurse notes, dated from 04/16/10 through 05/02/10, failed to show written evidence the resident has refused to get out of bed. The MAR indicated [REDACTED] The physical therapist assistant (PTA - Employee #150), when interviewed on 05/04/10 at 10:55 a.m., revealed the resident complained of pain to the lower extremities daily during physical therapy exercises. The PTA stated she was able to provide therapy to the residents's upper extremities daily; however, the resident did not tolerate therapy to the lower extremities due to pain. The PTA, when asked if she reported the resident's daily complaints of pain to the nurse or physician, stated, "No." Observation found Resident #146 in her room at 12:15 p.m. on 05/04/10. When this alert resident was asked if she was in pain, she reported she experienced pain when she was moved or having physical therapy to her lower legs. The resident rated the pain to be an "8" on a scale of "1" to "10", with "10" representing excruciating pain. The resident reported the pain occurred when her lower legs were moved during repositioning and during physical therapy. The care plan coordinator (Employee #41), when interviewed on 05/04/10 at 1:00 p.m., reported the resident's initial care conference was held today and the team did not discuss the resident's daily complaints of pain. The therapy director (Employee #151), when interviewed on 05/04/10 at 2:35 p.m., revealed Employee #150 had reported the resident had "pain a few times" to the therapy director; however, the therapy director stated she was unaware of the resident's "daily complaints of pain" and stated Employee #150 "should have reported the complaints of pain to the nurse". A nurse aide (Employee #42), when interviewed on 05/04/10 at 2:45 p.m., stated Resident #146 had "daily pain" in her lower extremities when care was provided. The nurse aide stated she had reported the pain to the nurse. The licensed practical nurse (LPN - Employee #73), when interviewed on 05/05/10 at 10:00 a.m., stated she was not informed of the resident's complaints of pain by the therapy staff or by the nurse aide. The LPN reported that, when she had assessed the resident for pain, the resident had denied pain, but the resident was resting in bed and not engaged in activity or therapy at those times. The LPN stated she was going to call the doctor to get a "straight order for pain medication daily". Review of the resident's pain assessment, dated 04/17/10 at 11:12 p.m., revealed the resident described her pain as "ache stabbing". Subsequent pain assessments, dated 04/18/10, 04/20/10, and 04/23/10, revealed the resident had pain daily, and this pain occurred "at various times". The pain assessments failed to rate the intensity, location, and/or activity level of the resident. The director of nurses (DON - Employee #127), when interviewed on 05/04/10 at 2:00 p.m., acknowledged the pain assessments documented in the medical record were not comprehensive and reported she was unable to provide any written evidence the resident was assessed and treated for [REDACTED]. .