Every finding on record at Oak Glen Post Acute

Based on observation, interview and record review, the facility failed to provide supervision and interventions for one of three residents reviewed for elopement (incident when a resident leaves the facility without authorization or supervision necessary for safety) (Resident 1), after the resident was identified as being at risk for wandering and elopement upon admission. This failure resulted in Resident 1 leaving the facility undetected on June 14, 2026, placing the resident at risk for accidents, serious injury, or death. Findings: On June 30, 2026, at 9:30 a.m., an unannounced visit was conducted at the facility to investigate an incident of elopement. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnosis which included, anxiety disorder (nervousness), bipolar disorder (mental disorder), acquired absence of right leg above knee, and Nicotine dependence (cigarettes, uncomplicated). A review of Resident 1's Elopement and wandering risk observation/assessment dated June 5, 2026, indicated, .Score of 14.If the total score is 10 or greater, the resident would be considered at risk for wandering or elopement.Mobility.resident is able to move propel themselves in a wheelchair with some assistance.Cognitive status.resident is disoriented or has period of confusion and or impaired attention but does not wander .Mood and Behaviors:.requires frequent reminder/reorientation.other conditions that may impact wandering behavior or risk for elopement. Yes.change in environment, infection.has family or resident representative expressed concerns about the residents wandering tendencies? Yes is checked.verbalized resident will wander and ask others if they have cigarettes.IDT.interventions.has the care plan been initiated/updated to reflect interventions aimed at reducing the risk of unsafe wandering or an elopement? .Yes is checked.Use of wander alarm.No.a wander alarm is NOT indicated.Behavior modification.does not exhibit unsafe wandering or elopement attempts. The Baseline Care Plan dated June 5, 2026, indicated, .health and safety concerns.alert.episodes of confusion.elopement risk.not checked (indicating there was no acknowledgment of the elopement risk). Further review of Resident 1's baseline care plan indicated that the June 5, 2026, assessment identified Resident 1 as being at risk for wandering and elopement. There was no documented evidence that individualized interventions, including increased monitoring or other preventive measures, had been implemented before the June 14, 2026, incident. The History and Physical Examination, dated June 7, 2026, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's progress notes dated June 14, 2026, at 8:45 p.m., indicated, .Resident was observed outside the facility grounds after leaving her room without staff assistance. Resident was noted approaching a vehicle parked near the facility and requesting a cigarette from an individual inside the vehicle. Prior to the incident resident had attended a supervised smoke break and was escorted back to her room by staff and assisted into bed. Nursing staff re-directed resident back to facility. Resident was calm and amenable with re-direction and returned to her room without incident Resident with close visual monitoring q (every) 30 mins (minutes) by all staff. On June 30, 2026, at 1:39 p.m., an interview and record review was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 was assigned to Resident 1, and stated Resident 1 was identified as a wander risk. LVN 1 stated Resident 1's elopement risk assessment was 14 which indicated the resident was at risk for wandering/elopement. LVN 1 stated a care plan should be implemented after an evaluation was conducted to indicate the proper interventions were in place. LVN 1 stated no care plan was initially implemented due to no prior elopement history. LVN 1 stated Resident 1's sister noted possible elopement behavior upon admission, leading to increased monitoring per facility standards. LVN 1 stated an elopement attempt did occur on June 14, 2026, which prompted a care plan and wander guard use (a device which causes an alarm to trigger when a resident wanders close to exit doors). On June 30, 2026, at 2:10 p.m., an interview was conducted with Certified Nursing Assistant (CNA 1). CNA 1 stated Resident 1 was at risk for wandering and currently had a wander guard. CNA 1 stated a 30-minute monitoring log was initiated on June 30, 2026, per supervisor instruction and was unsure why it had not been started earlier. On June 30, 2026, at 2:47 p.m., an interview was conducted with LVN 2, the charge nurse on duty during the June 14, 2026, incident. LVN 2 explained that elopement risks were communicated during nurse huddles (shift reports). LVN 2 stated, before his 7:30 p.m. lunch break, he asked the assigned CNA to watch Resident 1 to prevent wandering. Upon return around 8:00 p.m., he was informed Resident 1 was found outside and returned safely. Resident 1 had no injuries and no prior elopement attempts. LVN 2 was unsure if the CNA sought help monitoring Resident 1 after assisting other residents. LVN 2 indicated he did not review elopement care plan interventions before the incident and learned of a new plan post-incident requiring close monitoring and wander guard use. On June 30, 2026, at 3:22 p.m., an interview was conducted with CNA 2. CNA 2 stated Resident 1 returned from a smoke break at 5:30 p.m., and went to her room were she was last seen before 7:30 p.m. CNA 2 stated she learned from the desk nurse that Resident 1 was outside and responded immediately. CNA 2 stated she found Resident 1 in the east parking lot in a wheelchair, asking for a cigarette, with no one else nearby and away from the main road. CNA 2 stated She was unaware Resident 1 required increased supervision and she was not informed of previous wandering concerns. On June 30, 2026, at 3:57 p.m., an interview was conducted with CNA 3. CNA 3 stated she was assigned to Resident 1 on June 14, 2026, and she was asked to watch Resident 1 while the charge nurse was on break. CNA 3 stated she later learned Resident 1 had again been found outside. CNA 3 stated she was unaware Resident 1 had wandering behaviors or required additional supervision. On June 30, 2026, at 4:24 p.m., an interview and record review was conducted with the Director of Nursing (DON). The DON stated resident are monitored at least every two hours, with increased monitoring based on identified wandering or elopement risk. The DON stated Resident 1's June 5, 2026, elopement evaluation identified the resident as being at risk for wandering and elopement with a score of 14 and that a care plan should have been initiated at that time. the DON stated the care plan was not implemented until after the June 14, 2026, incident. The DON stated there was no alarm sounded when the resident exited the building. the DON stated the lack of a care plan and corresponding interventions created a risk that Resident 1's wandering behaviors would not be appropriately addressed. A review of the policy and procedure titled, Wandering and Elopements dated March 2019, indicated, .the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety .

Based on interview and record review, the facility failed to ensure the residents' room temperatures were monitored and recorded for three days in July 2025.This failure had the potential to prevent the facility from identifying whether the air conditioning system was functioning properly, which could result in residents experiencing discomfort or unsafe heat-related conditions. Findings:A review of the facility documents titled, Room and Hallway Temperature Log, Month of July 2025, indicated missing temperature entries on the following dates:- July 4, 2025- July 5, 2025; and- July 6, 2025On July 15, 2025, at 10:10 a.m., an interview was conducted with the Maintenance Director (MTD). The MTD stated the compressor for the facility's air conditioning (AC) system broke down on July 11, 2025. The MTD stated this was the only day the AC unit had malfunctioned. The MTD stated he immediately placed a call with their vendor who helped with their AC maintenance, and they came to check the units that same day and provided an estimate of cost for the replacement of the compressors. The MTD stated, meanwhile, he placed fans in each resident room and an industrial cooling unit in the hallway.On July 15, 2025, at 10:29 a.m., an interview was conducted with Resident 3. Resident 3 stated on July 5, 2025, she noticed the building temperature felt warmer than usual and suspected the AC unit had broken down. Resident 3 further stated she notified staff but wasn't sure if repairs were being made.On July 15, 2025, at 3:34 p.m., a concurrent interview and record review of the facility's resident room temperature logs was conducted with the Maintenance Director (MTD). The MTD stated the facility's protocol was to monitor resident room temperatures daily, including on weekends. The MTD stated he did not work from July 4, 2025, to July 6, 2025, and in his absence, the temperatures were not checked on those days. The MTD stated the room temperatures should have been checked to ensure they were not too high as elevated temperatures could cause discomfort and place residents at risk of unsafe heat related conditions.On July 15, 2025, at 4:45 p.m., a concurrent interview and record review of the facility's resident room temperature logs was conducted with the Administrator (ADM). The ADM stated to ensure resident safety, MTD staff were responsible for monitoring and recording resident room temperatures daily, including weekends. The ADM further stated, MTD staff should have checked and logged the temperatures on July 4 to 6, 2025, to ensure the AC was functioning properly and that the room temperatures were not elevated, to prevent residents from experiencing discomfort or conditions such as heat stroke or dehydration. A review of facility's policy and procedure titled, Homelike Environment, dated 2001, indicated, .residents are provided with a safe, clean, comfortable and homelike environment and.the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.these characteristics include.comfortable and safe temperatures (71 -81 F (Fahrenheit [temperature scale]).A review of facility's policy and procedure titled, Maintenance Service, dated 2001, indicated, .maintenance service shall be provided to all areas of the building, grounds, and equipment .functions of the maintenance personnel include, but are not limited to .maintaining the heat/cooling system .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Crumbs and debris were found on the floor under the storage shelves in the storeroom; 2. Four clear food storage container had white debris on the top lid; 3. Four multiple canned goods white residue on it; 4. A walk- in refrigerator had dried dark red residue, crumbs and grime were on the floor; 5. The freezer in the disaster supply room had crumbs, and grime on its side and back; 6. Crumbs and debris found under the shelves in the disaster supply room; 7. One fan that was used in the kitchen had white debris on the blades and cover; and 8. Three Cutting boards were found without a smooth surface. These failures had the potential to cause food contamination and pest infestation leading to food borne illness (stomach illness acquired from ingesting contaminated food) in a vulnerable population of 57 residents who received food prepared in the kitchen. Findings: On May 19, 2025, between 8:20 a.m. and 8:40 a.m., a concurrent observation and interview was conducted with the Director of Dietary Services (DDS) in the kitchen. The following areas were discussed: A. Crumbs, white debris, and trash were found under the storage shelves in the store room. The DDS stated the storeroom should be kept clean to prevent pest infestations. B. Four clear storage container lids had white debris. The DDS stated the food storage containers should not be dusty to prevent cross-contamination, which could lead to food borne illness to the residents. C. Multiple can goods on the shelf had white residues on it. The DDS stated the white residue was a cake mix that spilled and should be wiped clean immediately to prevent cross-contamination, which could lead to food borne illness to the residents. D. Inside the walk-in refrigerator, dried dark red residue, crumbs and grime where on the floor. The DDS stated the floor should be kept clean to prevent cross-contamination, which could lead to food borne illness to the residents. E. The freezer had crumbs, debris, and grime on its sides and back. The DDS stated it should be kept clean to prevent pest infestation which could lead to food borne illness to the residents. F. Crumbs, debris were found under the shelves on the floor in the disaster supply room. The DDS stated it should be kept clean to prevent pest infestation which could lead to food borne illness to the residents. G. One black fan was observed to have white debris on the blades and cover. The DDS stated the fan had dust buildup and should be cleaned more frequently to avoid cross-contamination of food which could cause food borne illness. A review of the facility's policy and procedure titled, Sanitization, dated 2008, indicated, .1 .all kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish .2 all utensils, counters, shelves and equipment shall be kept clean .18 .The Food services staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task . On May 21, 2025, at 8:50 a.m., a concurrent observation and interview was conducted with the Director of Dietary Services (DDS) in the kitchen. Three cutting boards (brown, green and red color measuring at 24 inches [(a unit measurement of length)] in width and 18 inches in length) were observed with deep indentations and rough surfaces. The DDS stated, the cutting boards had indentations and should have had smooth surfaces to prevent microorganisms (germs) from growing in the grooves, which could lead to foodborne illness among residents. A review of the U.S FDA Food Code 2022, Section 4-501.12 Cutting Surfaces, indicated, .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces . On May 22, 2025, at 10:30 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the storage shelves in the storage rooms, walk-in refrigerator and freezer should not have any grime, white buildup, dirt and should be kept clean to prevent cross-contamination which could cause food borne illness. The RD further stated the cutting boards should not have deep scratches and the fans should not have dust buildup, to prevent cross-contamination, which could cause food borne illness. A review of the facility's policy and procedure titled, Sanitization, dated 2008, indicated, .1 .all kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish .2 all utensils, counters, shelves and equipment shall be kept clean .18 .The Food services staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task .

Based on interview and record review the facility failed to ensure multiple unused non-controlled medications were disposed in accordance with the policy and procedure. The medication disposition was not witnessed by two staff. This failure had the potential for medication diversion (the removal of a prescription drug from its intended path from the manufacturer to the patient). Findings: On May 21, 2025, at 12:21 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated the medication will be destroyed in a designated white receptacle and this will be witnessed by two staff. The DON further stated there was a potential for staff to use it for themselves and diversion to occur if theses procedure was not followed. The DON stated for the disposition on May 20, 2025, the disposition of the following non- controlled medications (medications not considered to have a significant potential for abuse or dependence), was not witnessed by two staff. a. 3 - carvedilol 25 mg tab (tablet); b. 31- potassium cl (chloride) ER (extended- release) 20 meq (milliequivalent, a unit of measurement); c. 11- metformin 500 mg tabs; d. 13- pantoprazole dr 40 mg (milligram, a unit of measurement) tab; e. 30- amiodarone 200 mg tab; f. 155- divalproex dr (delayed- release) 125 mg cap; g. 31- sertraline 25 mg tab; h. 19- tamsulosin 0,4 mg cap; A review of the facility policy and procedure titled, Discarding and Destroying Medications, dated April 2019, indicated .Medications will be destroyed in accordance federal, state, and local regulations of non- hazardous pharmaceuticals .controlled substance .for unused non hazardous .take the medication .mix the medication with either liquid or solid undesirable substance .place the waste mixture in a sealable bag .dispose .in the presence of two witness .

2. On May 19, 2025 at 10:45 a.m., during observation, two empty antibiotic (ceftriaxone and vancomycin ) bags labeled May 14, 2025, were left hanging on an IV (intravenous) pole. In a concurrent interview and observation with LVN 4, LVN 4 stated that the empty bags and IV lines should have been removed immediately after they were consumed and discarded properly. LVN 4 further stated there was a potential for cross contamination. On May 22, 2025, at 8:39 a.m., during an interview with the IP, the IP stated empty IV antibiotics should be removed from the IV pole and from the room and discarded in an appropriate way. The IP stated empty antibiotic bags could be a source of infection gathering more bacteria. 3. On May 19, 2025, at 1:04 p.m., in front of Resident 107's room, two transporter, non-staff, entered a room with EBP signage without wearing proper PPE when attempting to transfer a resident. A concurrent interview was conducted with the IP, the IP stated the the transporter should have worn the proper PPE when transferring a resident. A review of Resident 107's admission Record indicated Resident 107 was admitted to the facility May 4, 2025, with diagnoses which included ESRD (end stage renal disease-inability of the kidney to make urine and remove waste from the blood). A review of Resident 107's care Plan titled Enhanced Barrier Precautions (EBP), dated May 5, 2025, indicated .EBP during high contact resident care due to preesence of indwelling catheter .Place EBP notification/signage to alert staff/visitors of precautions .Utilize PPE (gloves, gown , etc) .during high contact resident care activities (when transferring) . A review of the facility policy and procedure titled, Isolation-Categories of Transmission-Based Precautions, dated 2022, indicated, .transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected .appropriate notification is placed on the room entrance door and on the front of the cart so that personnel and visitors are aware of the need for and the type of precaution .the signage informs the staff of the type of precautions, instruction for use of PPE, and /or instructions to see a nurse before entering the room .Enhanced Barrier Precautions .visitors should wear gowns and gloves if participating in high-contact care activities .assistance with bathing , toileting .transferring .especially if interacting with multiple residents . Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. There was no signage for Enhanced Barrier Precaution (EBP) posted near Resident 40's room. In addition, there was no available personal protective equipment (PPE) supplies for the staff near the resident's room on EBP. 2. Two empty medication bags were not discarded in accordance with the standard of practice; and 3. Two non-staff transporters did not follow the proper isolation precautions for Resident 107. These failures had the potential to result in cross contamination which could cause illnesses to a vulnerable population. Findings: 1. On May 19, 2025, at 11:11 a.m., a concurrent interview and record review, was conducted with Licensed Vocational Nurse (LVN) 4 stated Resident 40 was on EBP, and there was no signage of what PPE to wear, and there was no PPE cart by the doorway. LVN 4 stated if there is no signage, staff and non staff would not know what PPE to wear prior to entering the room. A review of Resident 40's admission Record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included paraplegia (inability to voluntarily move the lower parts of the body). A review of Resident 40's Care Plan titled, Enhanced Barrier Precautions (EBP), dated April 30, 2025, indicated .EBP during high contact resident care due to presence of indwelling catheter .Place EBP notification/signage near resident room .items for following EBP are in place (gloves, gown , etc) . On May 21, 2025, at 9:15 a.m., a concurrent observation and interview was conducted with LVN 3. LVN 3 stated the staff should wear the appropriate PPE (gown, gloves, and face mask) before entering the room to conduct wound care, because the residents receiving wound care were at risk for infection. On May 21, 2025, at 9:48 a.m., a follow up interview was conducted with LVN 3. LVN 3 was asked how the staff were made aware of a resident on EBP precautions. LVN 3 stated a sign indicating EBP should be placed near the door frame that indicates the bed number of the resident on EBP and the type of PPE to wear. LVN 3 observed there was no signage posted on the door frame for the resident on EBP and stated you would not know because there is no signage posted. LVN 3 further stated if a sign was not posted within view the resident could be at risk for infection if no PPE was worn. On May 21, 2025, at 10:06 a.m., with the infection preventionist (IP). The IP observed there was no sign for EBP within view for a resident on EBP precautions. The IP stated all isolation precautions including EBP should have a sign posted within view so that all staff and non-staff could be aware of the necessary PPE to wear prior to entry into the room. The IP further stated if there were no sign posted indicating the proper PPE then a resident could be at risk for infection. On May 21, 2025, at 10:33 a.m., during a concurrent interview and observation of Resident 40's doorframe with the IP, the IP stated the EBP signage should have been posted, along with the required PPE on the doorframe for the staff and non staff to see before they enter the room.

Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of two residents reviewed for nutrition (Resident 41). This failure had the potential for the resident to continue having weight loss due to the delay in provision of appropriate intervention. Findings: On May 20, 2025, at 2:57 p.m. an interview was conducted with Resident 41. Resident 41 stated she only enjoyed a small portion of the meals provided and that she had lost weight because of it. Resident 41 could not recall her current weight. A review of Resident 41's record was conducted. Resident 41 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (the inability to regulate sugar in the body), and muscle wasting and atrophy (decreased strength of the muscles causing weakness). Resident 41's history and physical dated April 7, 2025, indicated she did have the capacity to understand and make decisions. A review of the dietary notes dated April 21, 2025, indicated, .residents weight loss of -4 lbs (pounds - a unit of measure) within 1 week. Recommendations to change diet to fortified. Referred to (physicians name) and agreed with orders to change diet to fortified. Orders noted and carried out . A review of the change of condition notice dated April 25, 2025, indicated, .Resident with a -4 lb weight loss in 1 week. Resident had a -4 lb weigh loss on 4/18/25. Seen by RD (Registered Dietitian) Resident's average intake is <75%, HS snack offered daily. Resident has a preference of small portions. RD previous recommendation to add fortified foods to current diet order. MD (physician) .Will monitor resident and encourage meals with any supplemental meals offered if refuses meals . A review of the weekly weights indicated on May 2, 2025, Resident 41 weighed 110 lbs. On May 9, 2025, and on May 16, 2025, the resident weighed 105 pounds which is a -5 lbs Loss. A review of the care plan initiated April 9, 2025, indicated, .Resident has Type 2 diabetes mellitus without complications. interventions .monitor for signs of hyper/hypoglycemia (i.e weight loss). A review of the care plan initiated April 16, 2025, indicated, .Resident has nutritional problem or potential nutritional problem r/t anxiety, T2DM interventions .Monitor record/report to MD PRN s/sx of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss >5% in 1 month .provide and serve diet as ordered (Registered Dietitian) RD to evaluate and make diet change recommendations PRN . A review of the progress notes, dietary notes, nutritional notes, did not indicate discussion on the weight loss of the resident from May 9 to May 16, 2025. On May 22, 2025, at 10:31 a.m., an interview and record review was conducted with the RD. The RD stated the weight for Resident 41 was addressed on April 28, 2025. The RD stated she would do monthly notes for residents with BMI and age related weight loss and that she did not make a note for Resident 41. The RD stated she was not aware of the weight loss for Resident 41 in May and that the DS should bring to her attention any concerns for residents and communicate any changes. On May 22, 2025, at 2:51 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was not aware of the 5 lbs. weight loss for Resident 41. The DON stated a change of condition should have been made for Resident 41 from May 2 to the May 9, 2025 weight change and the RD and the DS should have been made aware. The DON further stated the nurse aide and nurse assigned to the resident should have documented and communicated a weight change with the RD, the DS, and the charge nurse. On May 22, 2025, at 2:57 p.m. an interview was conducted with the DS. The DS stated she would consider a weight loss of 5 lbs in one week to be reportable to the RD so an evaluation could be made. The DS stated changes in weight should be communicated to the RD, so the RD could conduct an evaluation and a weight variance meeting. The DS stated she was not made aware of the recent weight loss for Resident 41 and the nursing staff should have informed her when it was identified on May 9, 2025. A review of the facility policy and procedure titled, Weight Assessment and Intervention, dated 2008, indicated, .the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .negative trends will be evaluated by the treatment team .care planning shall address .identified causes of weight loss .monitoring and reassessment . A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated 2017, indicated, .nurse will notify the resident's attending physician on call when there has been .significant change in the resident's physical/emotional/mental condition .impacts more than one area of the residents health status .a comprehensive assessment of the resident's condition will be conducted . A review of the facility policy and procedure titled, Charting and Documentation, dated 2022, indicated, .changes in the residents condition .the assessment data and/or any unusual findings obtained .notification of family, physician, or other staff .

2. A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included aphasia (a language disorder that affects a person's ability to communicate) following non-traumatic intracerebral hemorrhage (bleeding inside the brain that does not result from trauma or injury). On May 22, 2025, at 9:41a.m., in a concurrent interview and record review with the Social Services Director (SSD), the SSD stated a review of Resident 15's Advance Directive Acknowledgement Report indicated, Resident 15 had executed an Advance Directive on admission, however; the SSD stated a copy of the AD was not found in Resident 15's record. The SSD further stated the AD should be in the resident's record available for nurses and physician to access to have information how the resident wants to be cared for when he is held unconscious. The SSD stated if the AD was not available there is a potential that interventions provided would go against his wish. A review of the facility policy and procedure titled, Advance Directives, dated 2016, indicated, .Social service director or designee will inquires of the resident .about the existence of any written advance directive .If a resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .Staff will document in the medical record the offer to assist and the resident decision to accept of decline assistance . Based on interview and record review, the facility failed to ensure the following for two of six residents (Residents 5 and 15) reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment): 1. For Resident 5, the resident or the resident's representative had been provided information and education regarding the formulation of an AD; and 2. For Resident 15, a copy of the AD was available in the resident's record. These failures had the potential to lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. A review of Resident 5's admission Record, indicated Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's History and Physical dated April 29, 2025, indicated Resident 5 has fluctuating capacity to understand and make decisions. On May 20, 2025 at 1:46 p.m., during an interview with Resident 5, he stated he did not know if he has an AD or what is the AD. On May 22, 2025, at 9:49 a.m., during a concurrent interview and review of Resident 5's medical record with the Social Service Director (SSD), she stated if a resident did not have an AD, she would offer resources and education to the resident or the resident representative. The SSD stated it was important for residents to be educated and have the opportunity to formulate an AD in the event the resident were unable to make decisions in the future. The SSD stated Resident 5 had no AD, was not provided education, and was not reviewed for AD. The SSD further stated she should have followed up and provided AD education to Resident 5 or the resident's representative.

Based on observation, interview, and record review, the facility failed to ensure one of three residents reviewed for respiratory care (Resident 159) , received respiratory treatment in accordance with the physician order. This failure has the potential to result in Resident 159 not to receive the necessary oxygen treatment which could negatively impact the resident's already compromised health. Findings: On May 19, 2025, at 10:06 a.m., a concurrent observation and interview was conducted with Resident 159. Resident 159 was alert and sitting up in bed. She was observed to be using oxygen through a nasal canula (NC - a device to deliver oxygen using a plastic tubing placed in the nostrils) at four liters per minute (LPM - unit of measurement). Oxygen tubing was observed to have a label, dated May 18, 2025. Resident 159 stated she had been using oxygen since she was admitted . Resident 159 was observed turning off the oxygen concentrator after an alarm had sounded. Resident 159 stated, oh that happens a few times a day, and if I turn it off and back on it will stop. Resident 159 stated she was unsure if four liters of oxygen was the correct amount she needed. On May 20, 2025, at 10:30 a.m., a follow up observation and interview was conducted with Resident 159. Resident 159 was alert and sitting up in bed. The oxygen concentrator was observed to be turned off and the NC was not on the nostrils. Resident 159 stated oh I turned it off because it made a noise, but you can turn it back on if you want. On May 20, 2025, at 10:35 a.m., a concurrent observation, interview and record review was conducted with LVN 1 at the bedside of Resident 159. LVN 1 stated it was the nurses responsibility to conduct morning rounds for the residents on oxygen to check the oxygen flow rates, dates of the tubing and assess for adverse signs and symptoms and that she checks to see if Resident 159 was using her oxygen or at what rate. A review of the physicians order with LVN 1 indicated Resident 159 was to receive oxygen at a rate of two LPM continuously and as needed. LVN 1 stated it can be either one. LVN 1 stated Resident 159 should be receiving oxygen at a rate of two LPM. LVN 1 observed the oxygen concentrator at the bedside of Resident 159 and noted the oxygen concentrator was turned off. LVN 1 stated Resident 159 had a behavior of turning the machine on and off and was able to 'reset it' on her own without the assistance of staff. LVN 1 further stated that Resident 159 had the ability to tell when she needed the oxygen. LVN 1 turned the oxygen concentrator on and observed the rate was set to four LPM. LVN 1 stated she should not be on four but she should be on two. LVN 1 further stated staff should have checked the rate of oxygen and followed the physicians orders. On May 22, 2025, at 1:41 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the physicians order for oxygen administration should have been clarified by the nurse to indicate the proper flow rate, and the frequency and that it should not have read both continuous and as needed. The DON stated nurses should be checking the oxygen flow rates each shift. The DON stated the nurses should be assessing for the oxygen use to make sure the correct setting for the oxygen is in place each shift. The DON further stated the nurses should have followed the orders and conducted assessments so that there are no risks of the residents to not receive the inadequate oxygen levels. A review of Resident 159's record, indicated she was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (shortness of breath, associated with a weakening of the lungs capacity to produce oxygen). Resident 159's history and physical dated May 12, 2025, indicated she did have the capacity to understand and make decisions. A review of the physicians order dated May 11, 2025, indicated, .Oxygen at ___2liters / min (a unit of measure) or__90_% via [specify delivery system] Nasal Cannula (NC) , Humidification: [specify] Yes Frequency: [Continuously] - every shift for CHF AND as needed . A review of the nursing weekly summary dated May 19, 2025, indicated, .Oxygen saturation .Method .Oxygen via Nasal .Respiratory .Continuous .liters per minute .2 .route .NC . A review of the nursing weekly summary dated May 21, 2025, indicated, .Oxygen use .any changes in oxygen use .NO . A revieww of Resident 159's Care plan: Oxygen: Resident requires the use of oxygen r/t congestive heart failure. Start date. May 11, 2025 .Goal .will be compliant with oxygen therapy .Intervention .monitor oxygen saturation via pulse oximetry every (specify) .administer oxygen at___L via (specify) . A review of the facility policy and procedure titled, Oxygen Administration, dated 2010 indicated, .verify that there is a physician's order for this procedure .review the physician's orders or facility protocol for oxygen administration .review the resident's care plan to assess for any special needs of the resident .the nasal cannula is a tube that is placed .into the residents nose, held in place by an elastic band placed around the resident's head .while the resident is receiving oxygen therapy, assess for the following .oxygen saturation .documentation .the rate of oxygen flow, rout, and rationale .frequency and duration of the treatment .if the resident refused the procedure, the reason(s) why and the intervention taken .report other information in accordance with facility policy and professional standards of practice .

Based on observation, interview, and record review, the facility failed to ensure one of two residents reviewed (Resident 159), was receiving oxygen treatment in accordance with the care plan developed by the facility. This failure had the potential for the staff to be unaware whether the resident is consistently receiving the appropriate supplemental oxygen which could negatively impact the resident's overall health. Findings: On May 19, 2025, at 10:06 a.m., Resident 159 was observed turning off the oxygen concentrator after an alarm had sounded. Resident 159 stated, oh that happens a few times a day, and if I turn it off and back on it will stop. On May 19, 2025, between 9:45 a.m. to 11:45 a.m., Resident 159 was observed to have turned the oxygen concentrator on and off on two occasions, and again between 1:45 p.m. to 3:45 p.m., for a total of four occasions. At no time during the observations were staff observed to enter the room to address Resident 159 about the oxygen concentrator or the need for use of the oxygen. On May 20, 2025, at 10:30 a.m., an observation and interview was conducted with Resident 159. Resident 159 was alert and sitting up in bed. The oxygen concentrator was observed to be turned off and the nasal cannula (a plastic tubing that delivers oxygen) was not placed in the appropriate area, along the face and nasal passage. Resident 159 stated, oh I turned it off because it made a noise, but you can turn it back on if you want. A review of Resident 159's record, indicated she was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (shortness of breath, associated with a weakening of the lungs capacity to produce oxygen), and heart failure (a weakend ability of the heart to pump blood throughout the body) Resident 159's history and physical dated May 12, 2025, indicated she did have the capacity to understand and make decisions. A review of the physicians order dated May 11, 2025, indicated, .Oxygen at ___2liters / min (a unit of measure) or__90_% via [specify delivery system] Nasal Cannula, Humidification: [specify] Yes Frequency: [Continuously] - every shift for CHF AND as needed . A review of Resident 159's Care Plan indicated, .Care plan: Oxygen: Resident requires the use of oxygen r/t (related too) congestive heart failure. Start date. May 11, 2025 .Goal .will be compliant with oxygen therapy .Intervention .monitor oxygen saturation via pulse oximetry every (specify) .administer oxygen at___L via (specify) . On May 20, 2025, at 10:35 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated it was the nurses responsibility to conduct morning rounds for the residents on oxygen to check the oxygen flow rates, dates of the tubing and assess the residents for shortness of breath. LVN 1 stated she did not check on Resident 159 today and she was not aware if Resident 159 was receiving oxygen or at what rate. LVN 1 stated Resident 159 had a behavior of turning the machine on and off and was able to 'reset it' on her own without the assistance of staff. LVN 1 further stated Resident 159 had the ability to tell when she needed the oxygen. On May 22, 2025, at 1:41 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated there should be a care plan developed for Resident 159's behaviors of turning off the oxygen concentrator and the nurses should be checking the oxygen rate, tubing, and should be assessing the residents each shift. The DON further stated there was a risk for the resident not to receive the necessary oxygen needed which could cause unwanted signs and symptoms such as shortness of breath. A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered dated 2016, indicated, .the comprehensive, person-centered care plan will .incorporate identified problem areas .incorporate risk factors associate with identified problems .aid in preventing or reducing decline in the resident's functional status and/or functional levels .identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process .

Based on interview and record review, the facility failed to: 1. Complete baseline care plans (Initial care plans, including mental, physical & psychosocial care needs, based on current health status) within 48 hours of admission for two out of three sampled residents (Residents 1 and 2), and 2. Provide resident and/or resident representative a copy of their baseline care plans, for two out of three sampled residents (Residents 1 and 3). This failure had the potential to result in a lack of communication between staff and residents, leading to inconsistencies in delivery of care. Findings: On December 6, 2024, an unannounced visit was made to the facility for a quality-of-care issue. 1. On December 9, 2024, at 6:09 p.m., an interview was conducted with the Director of Nursing (DON), who stated, baseline care plans were to be completed, within 48 hours of the resident ' s admission. The DON further stated, the members of the IDT, (Interdisciplinary team -Social Services, Rehabilitation, Dietary & Activity department supervisors) completed their portions of the baseline care plans separately, within the 48-hour time frame. a. A review of Resident 1's medical records, titled, Resident Information, dated, December 11, 2024, indicated, the resident was admitted to the facility on [DATE], with a diagnosis of muscle wasting, and a Brief Interview for Mental Status ({BIMS}- A cognitive assessment) score of 10 (Moderate cognitive impairment). Further review indicated, a representative was legally appointed to make Resident 1's medical care decisions. A review of Resident 1's Baseline Care Plans, initiated on November 25, 2024, at 10:10 p.m., indicated, the care plans were not completed within 48-hours of admission, as Rehabilitation and Dietary services, had not completed their baseline care plans, until November 30, 2024. On December 10, 2024, at 8:19 a.m., a concurrent interview with the Rehabilitation Director (RD), and review of Resident 1's rehabilitation evaluation, & baseline care plans were conducted. The RD stated, it was the facility policy to complete baseline care plans within 48 hours of a resident ' s admission. The RD stated, his process for completing his portion of a resident's baseline care plans involved completing a rehabilitation evaluation within 24 hours of admission and then using the evaluation to complete the baseline care plans within 48 hours. The RD stated, Resident 1 was admitted to the facility on [DATE], and he did not complete Resident 1's baseline care plans until November 30, 2024. The RD stated he should have completed the resident ' s baseline care plan within 48 hours. On November 10, 2024, a concurrent interview with the Dietary Supervisor (DS), and review of Resident 1's baseline care plans were conducted. The DS stated, it was the facilities policy to complete baseline care plans within 48 hours. The DS stated, her process involved completing a dietary evaluation within 24 hours of a resident ' s admission and then using that information to complete the baseline care plans. The DS stated, she completed Resident 1 ' s baseline care plans late, as the resident was admitted on [DATE], and the care plan was not completed until November 30, 2024. The DS stated, she completed the baseline care plan past the 48-hour time frame. b. A review of Resident 2's medical records, titled, Resident Information, dated, December 11, 2024, indicated, resident was admitted to the facility on [DATE], with a diagnosis of history of falling. A review of Resident 2's, Baseline Care Plans, initiated on, December 4, 2024, at 9:44 p.m., indicated, the RD and the Social Service Director had not completed the baseline care plan within 48 hours. On December 10, 2024, at 8:19 a.m., a concurrent interview with the RD, and review of Resident 2's rehabilitation evaluation, & baseline care plans were conducted. The RD stated, it was the facility policy to complete baseline care plans, within 48 hours of admission. The RD stated, his process for completing baseline care plans included completing a rehabilitation evaluation within 24 hours and then using the evaluation to complete the baseline care plans within 48 hours. The RD stated, Resident 2 was admitted to the facility on [DATE] and Resident 2's baseline care plans were not completed until December 7, 2024 (past the 48 hour time frame). On December 10, 2024, at 9:21 a.m., a concurrent interview with SSD, and review of Resident 2's baseline care plans were conducted. The SSD stated, it was the facility's policy to complete baseline care plans within 48 hours of a resident's admission. The SSD further stated, she meets with the resident/representative within 48 hours of their admission, then uses that information to complete the baseline care plans. The SSD stated, Resident 2 was admitted to the facility on [DATE], and she had not yet completed resident ' s baseline care plans. A review of the facility Policy, titled, Care Plans - Baseline, revised, March 2022, indicated, . A baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . 2. On December 9, 2024, at 6:09 p.m., an interview was conducted with the DON, who stated, it is her expectations all IDT members to give a copy of their completed portion of the resident ' s baseline care plans, to the resident/representative at their initial IDT conference. The DON stated, the process of the initial IDT conference includes, being held within 7-days of the resident 's admission, at which time, the resident 's care plans & goals are discussed. DON further stated, she would expect IDT members to document in a progress note, if a copy of the resident 's baseline care plans were given, and/or offered to the resident/representative, during their initial IDT conference. a. A review of Resident 1's medical records, titled, Resident Information, dated, December 11, 2024, indicated, the resident was admitted to the facility on [DATE], with a diagnosis of muscle wasting, and a BIMS score of 10 (Moderate cognitive impairment). Further review indicated, a Representative was legally appointed to make Resident 1's medical care decisions. A review of Resident 1's initial, IDT meeting, dated, November 27, 2024, at 5:16 p.m., indicated, IDT met to discuss plan of care . Further review of Resident 1's records indicated, there was no documentation, verifying a copy of the residents baseline care plans, was provided/offered to resident/representative during the IDT meeting. b. A review of Resident 3's medical record titled, Resident Information, dated, December 11, 2024, indicated, resident was admitted to the facility on [DATE], with a diagnosis of a fractured left (Hip), and a BIMS score of 12 (moderate cognitive impairment). A review of Resident 3's, initial IDT meeting, dated, November 21, 2024, at 2:35 p.m., indicated, . IDT meeting held with resident . (Plan of care) reviewed . Further review indicated, there was no documentation, verifying a copy of the residents baseline care plans were provided/offered to resident/representative during the IDT meeting. On December 10, 2024, at 8:02 a.m., an interview was conducted with the Activities Director (AD), who stated, she evaluates a resident within 24 hours of their admission, then she uses the information to complete the activities portion of the resident's baseline care plans. AD verified, she does not provide a copy of the activities baseline care plans to the resident/representative and does not provide a copy at their initial IDT conference. On December 10, 2024, at 8:19 a.m., an interview was conducted with the RD, who stated, he does not provide a copy of the rehabilitation's portion of the resident's baseline care plans to the resident/representative, and does not provide a copy at their initial IDT conference. On December 10, 2024, at 8:52 a.m., an interview was conducted with the DS, who stated, the dietary portion of the resident's baseline care plans, are reviewed at the resident's initial IDT meeting, and she does not provide a copy of the baseline care plans to the resident/representative and does not provide a copy at their initial IDT conference. On December 10, 2024, at 9:21 a.m., an interview was conducted with the SSD, who stated, the Social Services portion of the resident's baseline care plans are reviewed at the resident ' s initial IDT meeting. SSD further stated, she does not provide a copy of the resident baseline care plans to the resident/representative at their initial IDT meeting. On December 10, 2024, 3:41 p.m., an interview was conducted with the DON, who verified, a copy of the resident's baseline care plans, is currently not being given/offered to the resident/representative, during the resident's initial IDT conference. A facility Policy, titled, Care Plans - Baseline, revised, March 2022, indicated, . 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standard of quality care and must include the minimum healthcare information necessary to properly care for the resident . 4. The resident and /or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) . 5. Provision of the summary to the resident/and or resident representative is documented in the medical record .

Based on interview and record review, the facility failed to ensure a copy of the transfer/discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman (LTC Ombudsman) for one of three sampled residents (Resident 1). This failure has the potential for the Ombudsman not to be able to advocate for the resident in protecting his rights from inappropriate transfer and discharge. Findings: On September 4, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle wasting (loss of muscle strength) and atrophy (thinning of muscles). A review of Resident 1 ' s History and Physical, dated April 4, 2024, indicated Resident 1 can make decisions. A review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated June 27, 2024, indicated, Resident 1 had Brief Interview of Mental Status (BIMS-a tool to measure cognitive function in older adults), score of 14 (cognitively intact). A review of Resident 1 ' s SNF/NF to Hospital Transfer Form, dated July 15, 2024, indicated, .Sent to (name of hospital) .Reinsertion of dislodged suprapubic catheter (medical device that drains urine from bladder) . There was no documented evidence indicating the facility mailed or faxed a copy of the transfer notice to the LTC Ombudsman. On September 4, 2024, at 2:36 p.m., during a concurrent interview and review of Resident 1 ' s medical records with the Director of Nursing (DON), she stated the process for transfer or discharge was the resident would be given the notice upon transfer or discharge from the facility and the Social Service Director (SSD) will send the discharge notice to the LTC Ombudsman within 30 days. The DON stated Resident 1 was transferred to the hospital on July 15, 2024, and the discharge notice was not sent to the LTC Ombudsman. The DON further stated the SSD should have sent the notice to the Ombudsman. On September 4, 2024, at 2:56 p.m., during a concurrent interview and review of Resident 1 ' s medical records with the SSD, she stated for residents who transferred or discharged from the facility, the LTC Ombudsman is sent a letter to notify of the resident discharge within 30 days. The SSD further stated notification is important for resident safety and continuity of care. The SSD stated Resident 1 was transferred to the hospital on July 15, 2024, and was discharged from the facility. The SSD further stated she did not send the discharge notice to the LTC Ombudsman, she further stated I did not know I have to send it when a resident is transferred. The SSD stated she should have sent Resident 1 ' s transfer/discharge notice to the LTC Ombudsman. A review of the facility policy and procedure titled, Transfer or Discharge Notice, dated March 2021, indicated, .Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty days (30) days prior to a transfer or discharge .A copy of the notice is sent to the Office of the State Long -Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .If the information in the notice changes prior to the transfer or discharge, the recipients of the notice are updated as soon as practicable .

Based on observation, interview, and record review, the facility failed to provide a comfortable environment for the residents, when the temperature level for one of the four residents' rooms and in the facility hallway was above 81 degrees Fahrenheit ( F -temperature scale). This failure had the potential to cause discomfort, irritability, sleep disruption, and could lead to health problems. Findings: On July 9, 2024, at 4:15 p.m., an unannounced visit to the facility was conducted to investigate a physical environment issue. On July 9, 2024, at 4:20 p.m., the Resident Representative (RR) was interviewed. The RR stated, on July 6, 2024, the air conditioning was not functioning and the staff had indicated it would be fixed. The RR, who visits the facility daily, stated, facility was hot. The RR stated, last night Resident A woke up soaking wet. The RR stated, the facility air conditioning unit was in poor condition. On July 9, 2024, at 4:30 p.m., the Maintenance Director (MD) was interviewed. The MD stated he was unaware that the air conditioning was not working last Saturday (July 6, 2024). The MD stated he checked the airconditioning this morning and found the airconditioning system lacking sufficient freon (essential for cooling process).The MD further stated the regular comfortable temperature ranges from 71- 81 F (Fahrenheit). On July 9, 2024, at 4:45 p.m., the Maintenance Assistant (MA) was interviewed. The MA stated, the staff did not report to him on Saturday (July 6, 2024) that the airconditioning was not working. The MA stated the staff should have called him. On July 9, 2024, at 5:15 p.m., a concurrent observation of the hallway and Resident A's room was conducted with the MD. The MD stated, the temperature for the hallway and Resident A's room was 83 F. The MD further stated the temperature was high. On July 9, 2024, at 5:40 p.m., the Certified Nursing Assistant (CNA) was interviewed. The CNA stated he would report to Maintenance immediately if the facility temperature was hot. The CNA stated he would ensure the resident's comfort. On July 9, 2024, at 6:15 p.m., a concurrent observation and interview with the DON were conducted. The DON stated, the temperature in the hallway was 83 F. The DON stated the comfortable temperature should be 71- 81 F . A review of the facility policy and procedure titled, Quality of Life- Homelike Environment, dated May 2017, indicated .Comfortable and safe temperature- (71 F to 81 F) .

Based on observation, interview, and record review, the facility failed to ensure food items were stored, prepared, and served under sanitary conditions when: 1. The fifteen pounds of bacon were thawed and were refrozen; and 2. There was no thawing log available for review in accordance to the facility's policy and procedure. These failures had the potential to result in food borne illnesses (illness that comes from eating contaminated food) to 56 medically vulnerable residents. Findings: 1. On April 8, 2024 at 9:08 a.m., during initial tour of the kitchen with the Food and Nutrition Service Director (FNSD), inside the freezer, four-one-gallon plastic bags containing bacon were observed not frozen solid. A concurrent interview was conducted with the FNSD, FNSD stated the bags of bacon were not in their original container. The FNSD further stated the bacon should be frozen solid, when stored in the freezer. On April 10, 2024, at 8:06 a.m., during an interview with the FNSD, the FNSD stated, the fifteen pound bacon in original container was thawed and placed in the walk-in refrigerator. The FNSD stated, the cook took a portion of the thawed bacon and placed the remaining portion of the thawed bacon back in the freezer. The FNSD stated, the cook should have thawed only the necessary portion of bacon, and the remaining portion should have been placed back in the freezer. The FNSD stated, once the meat was thawed, the meat should not be refrozen, to prevent bacterial growth that could cause food borne illness. A review of the U.S FDA (Food and Drug Administration) Food Code 2022, Annex 3 Section 3-501.11 Frozen Food, the Food Code indicated, Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. 2. On April 10, 2024, at 8:16 a.m., the Cook was interviewed. The Cook was asked about the facility's thawing process. The Cook stated when thawing meat, the frozen meat would be placed inside the walk-in refrigerator for 3 days. The Cook stated, the thawed meat should have a pull out date and use-by date. The Cook further stated, they did not have a thawing log. The Cook stated there should be a thawing log, to keep track of food being thawed, to ensure the food stay within safe range (out of Danger Zone- 41-135 degree F). During a review of the facility policy and procedure titled, FOOD PREPARATION .FOOD DEFROSTING METHODS, dated 2018, indicated .The preferable method of defrosting frozen perishable food is to defrost in the refrigerator and kept refrigerated until completely thawed. Food must be labeled and dated with item name, pull date and use-by date no more than three days past use by date .

Based on observation, interview, and record review, the facility failed to ensure the dietary staff performed testing of the sanitizing solution according to manufacturer's instructions. This failure had the potential to cause foodborne illness (illness that comes from eating contaminated food) among the 56 vulnerable residents in the facility. Findings: During a concurrent observation, interview, and review of the manufacturer's instruction for testing QUAT concentration, on April 10, 2024, at 8:26 a.m., the Cook was observed to had dipped the strip into sanitizing solution for five seconds, then compare the strip to a color scale found on the strip container. The Cook stated according to the manufacturer's instruction, dip the test strip for 1-2 seconds, and then compare within 10 seconds the strip with the color scale. The Cook stated he dipped the strip for five seconds and did not follow the manufacturer's instruction. The Cook further stated he should have followed the manufacturer's instruction. The Cook stated, otherwise it would not reveal an accurate result and would promote the growth of bacteria that could cause food borne illness. A review of the manufacturer's instruction in testing the QUAT concentration of the sanitizer, indicated, .CONTROL TESTING .QAC QR Test Strip .Dip test strip into test solution for 1-2 seconds. Within 10 seconds, compare the test pad with color scale . During a review of the facility policy titled, QUATERNARY AMMONIUM LOG POLICY, dated 2018, indicated, .Follow container and test strip instructions .A high concentration may be potentially hazardous and may be a chemical contaminate of food .

Based on observation, interview, and record review, the facility failed to follow up Level II Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) evaluation from the appropriate State-Designated Authority (SDA) upon admission, for two of four residents (Residents 42 and 44). This failure had the potential for Residents 42 and 44 not to receive the services required in an appropriate setting as determined by the SDA. Findings: 1. On April 10, 2024, Resident 42's record was reviewed. Resident 42 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder and mild neuro cognitive disorder (types of mental disorders). A review of Resident 42's PASARR Level 1 Screening document dated March 21, 2024, indicated, .Level 1 - Positive .Result: Positive for suspected MI (sic) (Mental Illness) .Level II Mental Health Evaluation Referral: Required . Further review of Resident 42's record indicated there was no documented evidence the PASARR Level II was followed up as required by PASARR Level 1 screening. On April 10, 2024, at 9:28 a.m., during a concurrent interview and review of Resident 42's PASARR with the Director of Nursing (DON), the DON stated all residents admitted to the facility should be screened for PASARR. The DON stated, nursing should follow up if the screening indicated positive for PASARR Level I. The DON stated Resident 42's initial PASARR Level 1 screening resulted positive and a PASARR Level II is required. The DON further stated, Resident 42's PASARR Level II was not followed up as indicated. 2. On April 10, 2024, Resident 44's record was reviewed. Resident 44 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (type of mental disorder). A review of Resident 44's PASARR Level 1 Screening document dated December 6, 2022, indicated, .Level 1 - Positive .Result: Positive for suspected MI .Level II Mental Health Evaluation Referral: Required . Further review of Resident 44's record indicated, there was no documented evidence the PASARR Level II was followed up as required by PASARR Level 1 screening. On April 10, 2024, at 10:04 a.m., during a concurrent interview and review of Resident 44's PASARR with the DON, she stated Resident 44's initial PASARR Level 1 Screening resulted positive and a PASARR Level II is required. The DON further stated, Resident 44's PASARR Level II was not followed up as indicated. The DON stated the facility and nursing should have followed up for Resident 42 and 44's PASARR Level II screening. The DON further stated it is important for PASARR Level II to be followed up to determine the appropriate care and setting for residents with mental disorders and for the safety of the other residents in the facility. The facility's policy and procedure titled, Admission Criteria, dated March 2019, indicated, .All new admission and readmissions are screened for Mental Disorders (MD) .per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process .If level 1 screen indicates that the individual may meet the criteria for MD .he or she is referred to the state PASARR representative for Level II (evaluation and determination) screening process .

Based on observation, interview, and record review, the facility failed for one of seven residents (Resident 159), to accommodate Resident 159's food preference for no fish, when Resident 159 was served fish. This failure resulted in Resident 159's food preference not being honored, potentially leading to the resident not consuming the food served and having the potential for weight loss. Findings: A review of the facility document titled, Cooks Spreadsheet, for Week 3 Wednesday, indicated, .SPRING MENUS .Garden Fresh Meatloaf . A review of the facility document titled, Good For Your Health Menus, for April 8-14, 2024, indicated, .Wednesday April 10 .Garden Fresh Meatloaf . During tray line observation in the kitchen on April 10, 2024, at 12:45 p.m., the ktichen was observed to run out of meatloaf while serving meal trays. The Cook was observed preparing chicken and fish replacing meatloaf. Seven residents were not served meatloaf. In a concurrent interview with the Cook, the Cook stated, the facility ran out of meat loaf. The Cook stated, seven residents were not served meatloaf and were served fish or chicken instead. On April 11, 2024, at 9:33 a.m., Resident 159 was interviewed. Resident 159 stated she was served fish for lunch. Resident 159 stated, she had food preference of no fish. During a concurrent interview and review of Resident 159's meal service card, on April 11, 2024, at 11:09 a.m., with the Food and Nutrition Service Director (FNSD), the FNSD stated, on the dietary meal service card, Resident 159 dislikes fish. The FNSD stated she should not have been served fish for lunch. During a review of the facility policy and procedure titled FOOD PREFERENCES, dated 2018, indicated .Resident Food preferences will be adhered to within reason .Substitutes for all food disliked will be given from the appropriate food group .

Based on observation, interview, and record review, the facility failed to follow the menu for a Fortified (a food that has extra nutrients added to it or has nutrients added that are not normally there) NAS (no added salt) Mechanical Soft with chopped meat- diet, for one of 16 residents (Resident 33). This failure had the potential to not meet the resident's nutritional needs. Findings: On April 10, 2024, at 11:54 a.m., the FNSD was interviewed. The FNSD stated for fortified diet, the Cook should add extra gravy to make it fortified. A review of Resident 33's meal tray card, for lunch, indicated Mechanical Soft/chopped meats, Fortified NAS. During a concurrent observation and interview, on April 10, 2024, at 12:14 p.m., during lunch tray line in the kitchen with the Cook, the Cook was observed not adding extra gravy to Resident 33's lunch meal tray. The Cook placed Resident 33's lunch meal tray onto the meal delivery cart, ready to serve. The Cook was asked about Resident 33's lunch meal tray, the Cook stated he did not add another scoop of gravy to Resident 33's meal tray. The Cook stated, Resident 33's meal tray card indicated, Mechanical Soft/chopped meats, Fortified NAS. The Cook stated adding another scoop of gravy would make it a fortified diet. During a review of Resident 33's Weight Change Note, dated January 16, 2024, indicated .RD (Registered Dietician) NOTE .CBW 205 # (pounds- unit of measurement) Weight Change-8# /3.7% x 1 week .RD Recs. (sic) (recommendations) Fortify current diet order . A review of Resident 33's Order Summary Report, dated March 5, 2024, indicated, .Fortified NAS diet Mechanical Soft with chopped meat texture . During a review of the facility's policy and procedure (P&P) titled, FORTIFICATION OF FOOD, dated 2018, the P&P indicated, The goal is to increase the calorie and /or protein of the foods commonly consumed by the resident to promote improvement in their nutrition status .EXTRA GRAVY AND SAUCES .Adds 20-50 calories/item .

Based on observation, interview, and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record readily accessible to the staff, for one of three residents reviewed for AD (Resident 49). This failure had the potential for Resident 49's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents' wishes regarding their medical treatment. Findings: On April 10, 2024, Resident 49's record was reviewed. Resident 49 was admitted to the facility on [DATE]. A review of Resident 49's Minimum Data Set (an assessment tool), dated March 14, 2024, indicated Resident 49 had severe cognitive impairment. A review of Resident 49's Advance Directive Acknowledgement, dated January 22, 2024, indicated Resident 49 had executed an Advance Directive. There was no documented evidence a copy of the AD was provided in Residents 49's medical record. On April 10, 2024, at 09:40 a.m., during a concurrent interview and review of Resident 49's record with the Social Service Director (SSD), the SSD stated if a resident had an AD, a copy of the AD would be obtained and placed in the resident's record. The SSD stated, Resident 49's AD was not available in the resident's record. The SSD further stated, Resident 49 had an AD that should have been available and accessible to the staff and physician. The facility Policy and Procedure titled, Advance Directive, dated December 2016, indicated .Prior to or upon admission of a resident, the Social Service Director .Will inquire of the resident .family members .legal representative .about existence of any written advance directive .Information about .an advance directive shall be displayed prominently in the medical record .

Based on observation, interview, and record review, the facility failed for one of 16 residents reviewed for quality of care (Resident 10) to ensure resident was monitored for signs and symptoms of bleeding or bruising (discoloration and tenderness of the skin resulting from pooling of blood beneath the skin) and the physician was notified. This failure had the potential for delayed treatment and management. Findings: On April 9, 2024, at 8:51 a.m., a concurrent observation and interview with Resident 10, in his room, was conducted. Resident 10 was observed with skin discoloration (bruising) approximately three centimeters (cm) by 0.5 cm. on the right upper arm. Resident 10 stated she could not remember when she got it. Resident 10 stated she could have gotten it from wheeling her wheelchair. A review of Resident 10's Admission Record, indicated , she was admitted to the facility on [DATE], with diagnoses which included cerebro-vascular accident (stroke- a result of disrupted blood flow to the brain). A review of Resident 10's Physician Order, dated February 26, 2024, indicated: - Clopidogrel Bisulfate (Plavix- anticoagulant) Oral Tablet 75 MG (milligram- unit of measurement) Give 1 tablet by mouth two times a day for CVA . - Eliquis (Apixaban- anticoagulant) Oral Tablet 5 MG (unit of measurement) Give 1 tablet by mouth two times a day for CVA . A review of Resident 10's Care Plan, dated March 14, 2024, indicated, .Focus: Medication-anticoagulant - Resident is at risk for potential bleeding and bruising due to anticoagulant therapy secondary to history of CVA .Interventions .Administer medication as ordered .Monitor for bruising or bleeding .Report abnormal findings to physician . During a concurrent observation in Resident 10's room and interview with Certified Nurse Assistant (CNA) 1 on April 12, 2024, at 9:21 a.m., CNA 1 stated Resident 10 had a discoloration (bruise) on her right upper arm. CNA 1 stated she was not aware of the resident's bruise. CNA 1 stated, if she observed the bruise she should have reported it to the licensed nurse. During an interview with Licensed Vocational Nurse (LVN) 1 on April 12, 2024, at 9:27 a.m., LVN 1 stated the CNA should report to the licensed nurse any skin changes. LVN 1 further stated the licensed nurse should assessed any skin issue. During an interview with LVN 2, on April 12, 2024, at 9:42 a.m., LVN 2 stated, if a resident developed bruise, the resident should have been monitored and the physician should have been notified. During a concurrent interview and review of Resident 10's record with LVN 2 on April 12, 2024, at 9:52 a.m., LVN 2 stated, the resident is at increased risk for bruises, bleeding, skin discoloration and should have been monitored every shift. LVN 2 stated, there were no documentation Resident 10 was monitored for signs and symptoms of bleeding or bruising for the past two weeks. During a concurrent interview and observation of Resident 10's right upper arm with LVN 2 on April 12, 2024, at 9:56 a.m., LVN 2 stated Resident had a right upper arm discoloration measuring 0.5 x 3 cm (centimeter- unit of measurement). LVN 2 stated Resident 10 should have been monitored for bruising and bleeding and the licensed nurse should have notified the physician.

Based on observation, interview, and record review, the facility failed to ensure for one of 16 sampled residents (Resident 54), the call light was within the resident's reach. This failure had the potential to result in Resident 54 not being able to call for staff assistance when needed. Findings: On April 9, 2024, at 8:01 a.m., Resident 54 was lying in bed. The call light was observed not within reach by Resident 54, it was on his right side hanging in between the floor and the bed. Resident 54 stated he could not call for assistance. Resident 54 stated, the call light was not by his side. On April 9, 2024, at 8:33 a.m., during a concurrent interview and observation in Resident 54's room with CNA 1, CNA 1 stated, Resident 54's call light was not within reach. CNA 1 further stated, the call light should be placed within easy reach of the resident. A review of Resident 54's Admission Record, dated April 10, 2024, indicated the resident was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke- occurs as a result of disrupted blood flow to the brain) and left hemiplegia (left sided paralysis). A review of Resident 54's Minimum Data Set (MDS- an assessment tool), dated March 6, 2024, indicated, Resident 54 had a Brief Interview of Mental Status (used to assess cognitive status in elderly) score 14 (cognitively intact). A review of the facility policy and procedure titled, Answering the Call Light, dated October 2010, indicated, .When the resident is in bed or confined to a chair be sure the call is within easy reach to the resident .

Based on interview and record review, the facility failed to protect the resident's rights to be free from sexual abuse (non-consensual sexual contact of any type such as unwanted touching, groping or any other sexual activity forced upon a person without their consent) by a resident (Resident 1), for four of five sampled residents, (Residents 2, 3, 4, and 5), when the facility failed to reevaluate existing interventions to address Resident 1's inappropriate sexual behavior. This failure resulted in repeated incidents of inappropriate sexual behavior of Resident 1 towards multiple residents (Residents 2, 3, 4, and 5). Findings: On January 10, 2024, at 10:50 a.m., an unannounced visit was conducted to investigate an allegation of sexual abuse. A review of Resident 1's document titled ADMISSION RECORD, undated, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (persistent feeling of sadness, hopelessness, and loss of interest). A review of Resident 1's Progress Notes, indicated: - Dated September 27, 2023, at 7:13 p.m., .Resident was seen kissing resident (Resident 3) who is confused . - Dated September 29, 2023, at 2:48 p.m., .he was noted to walk up and down the halls and was seen by the CN (charge nurse) looking into a female room (Resident 6 and 7's room) . - Dated October 8, 2023, at 10:18 p.m., .@ 1612 hrs. (at 4:12 pm.) Resident had a (sic) episode of inappropriate behavior of kissing resident (Resident 4) early this shift. CNA (Certified Nursing Assistant) saw resident by the lobby caught in the act of about kissing another resident (Resident 4) . - Dated October 13, 2023, at 2:12 p.m., .Res (resident) was seen attempting to touch a female resident (Resident 5) by the nursing station . - Dated October 17, 2023, at 2:02 p.m., .Monitoring res for sexually inappropriate behavior. 1 (one) episode noted this shift. Res was seen by staff almost about to pull down his pants and show his private area to another res (Resident 5) . - Dated October 19, 2023, at 4:14 p.m., .resident was seen and heard asking a different female resident (Resident 3) if she wants a kiss . - Dated December 28, 2023, at 3:30 p.m., .Resident seen by staff at nurse ' s station standing over another resident (Resident 5) who was sitting in a wheelchair. Resident was seen kissing resident (Resident 5) and inappropriately touching on the outside of her clothes . - Dated January 5, 2024, at 12:15 p.m., .this CN (charge nurse) was walking past room (Resident 1's) when this CN saw through the crack in the door, (name of Resident 1) was bent over his roommates bed .saw (name of Resident 1)'s hand on his roommates (Resident 2) penis and (name of Resident 1) was stroking his roommates penis .His roommate was laying in bed with his underwear on, pants off, and his eyes were closed . A review of Resident 1's Psychiatry Note, indicated the following: - Dated October 10, 2023, at 10:10 a.m., .discussed incident in which pt (patient) witnessed kissing another female peer (Resident 3) .During the incident, pt's pers (sic) was noted wandering the hall and entering his room. Staff followed peer and witnessed pt kissing female peer (Resident 3). Staff also reported pt masturbating in the restroom and smearing semen on the walls and doorknobs . - Dated January 3, 2024, at 3:40 p.m., .Pt disclosed kissing a female peer (Resident 5) and admitted that it was unwanted .I don ' t know why I kissed her. I just did it and I knew it was wrong but I just didn't (did not) care. It's no big deal . On January 10, 2024, at 1:50 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, she witnessed the incident between Resident 1 and Resident 2 on January 5, 2024. LVN 1 stated, she saw Resident 1 leaning over Resident 2, and rubbing Resident 2 ' s private area, while Resident 2 was sleeping. LVN 1 stated, Resident 1 had previous incidents with two female residents (Residents 3 and 5), where Resident 1 kissed both female residents, on September 27, 2023 and December 28, 2023. LVN 1 stated Resident 3 was incoherent, and Resident 5 had dementia (memory loss). On January 10, 2024, at 2:20 p.m., the Social Service Director (SSD) was interviewed. The SSD stated, she was familiar with Resident 1. The SSD stated, Resident 1 was caught kissing a female resident (Resident 5) on December 28, 2023. The SSD stated, it was not the first time, Resident 1 had previous incidents, where Resident 1 kissed a female resident (Residents 3), few months ago (September 27, 2023). The SSD stated, Resident 1 had another incident with a male resident, Resident 2, on January 5, 2024. The SSD stated the staff were monitoring Resident 1 every hour. During a review of Resident 1 ' s Care Plan (CP), the CP indicated: - Dated September 27, 2023, .Problem .Exhibits inappropriate behavioral symptoms .CNA (Certified Nursing Assistant)/SSA (Social Service Assistant) observed resident (Resident 1) kissing another resident (Resident 3) in his room .Monitoring whereabouts every 15 mins (minutes) x (for) 72 hrs (hours) then re-eval (re-evaluate) . - Dated January 5, 2024, .Problem .Exhibits behavioral symptoms of allegedly inappropriate sexual touching and kissing of male resident (Resident 2) .Intervention .Administer medication as ordered. Monitor for side effects and notify the physician if observed .Observed and document changes in behavior, including frequency of occurrence and potential triggers . Further review of Resident 1's Care Plan, indicated Resident 1's care plan did not reflect appropriate intervention to prevent Resident 1's inappropriate behavior. There was no documentation the Interdisciplinary Team (IDT - team members from different discipline working together to assess, coordinate, and manage each resident's care) re-evaluated Resident 1's frequency monitoring. On January 10, 2024, at 4:20 p.m., during a concurrent interview and review of Resident 1's Care Plan, dated September 27, 2023, with the Interim Director of Nursing (IDON), the IDON stated, when the current interventions were not working, the IDT had to reevaluate and changed the interventions. The IDON stated, Resident 1's care plan should have been updated to reflect the changes in resident's condition. The IDON stated, the IDT was responsible for making sure the interventions were implemented and reevaluated. On January 11, 2024, at 11:12 a.m., the Mental Health Doctor (MHD) was interviewed. The MHD stated, he was familiar with Resident 1. The MHD stated, he told the staff to keep an eye on him for risk of Resident 1 doing inappropriate behaviors to other residents. On January 11, 2024, at 11:39 a.m., CNA 2 was interviewed. CNA2 stated, she cared for Resident 1 and she monitored the resident every hour. CNA2 stated, she would not know what the resident was doing in between each hour and when she was doing care to other residents. CNA2 stated, Resident 1 walked around the facility. CNA2 stated, when Resident 2 (who was kissed by Resident 1 on September 27, 2023) passed away in December 2023 (December 11, 2023), we stopped monitoring Resident 1. On January 19, 2024, at 2:50 p.m., during a concurrent interview and review of Resident 1's Care Plan, dated September 28, 2023 and January 5, 2024, with the Minimum Data Set Nurse (MDSN), the MDSN stated, she was part of the IDT. The MDSN stated, Resident 1 ' s care plan did not reflect the appropriate interventions for resident 's inappropriate behavior. The MDSN stated, the interventions implemented were not effective since Resident 1 had repeated inappropriate behavior which affected two female residents (Residents 3 and 5) on September 27, 2023, and December 28, 2023, and one male resident (Resident 2) on January 5, 2024. The MDSN stated, the IDT should have revised the care plan if the interventions were not effective. On February 20, 2024, at 1:11 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, she observed Resident 1 trying to peek at female residents' rooms, watching female residents (Residents 6 and 7). On February 20, 2024, at 3:11 p.m., CNA 3 was interviewed. CNA 3 stated, Resident 1 was keeping an eye on all the ladies, following the female residents. CNA 3 stated, Resident 1 would sneak when the staff were not watching. CNA 3 stated, Resident 4 reported that Resident 1 was trying to kiss her. On February 20, 2024, at 4 p.m., LVN 2 was interviewed. LVN 2 stated, Resident 1 was like a ticking time bomb, taking opportunities to attack. LVN 2 stated, even though the staff was monitoring Resident 1's behavior, they could not control the resident. LVN 2 stated, he noticed the gap with the monitoring, which could give opportunities for the resident to do his inappropriate behavior. A review of Resident 1 ' s Monitoring Log, indicated the following: - From September 27 to September 30, 2023, Resident 1 was monitored every 15 minutes - From September 30 to October 31, 2023, Resident 1 was monitored every hour - From December 28, 2023, to January 3, 2024, Resident 1 was monitored every hour. Further review of Resident 1's Monitoring Log, indicated there was no documented evidence Resident 1 was monitored from November 1, 2023, to December 28, 2023. On February 20, 2024, at 4:30 p.m., during a concurrent interview and review of Resident 1's Monitoring log, the IDON stated, there was no documentation Resident 1's whereabouts were monitored from November 1, 2023, to December 27, 2023. The IDON stated, the IDT should think of an approach for the resident's inappropriate behavior. The IDON stated, if the resident had behavior, the frequency of monitoring should be adjusted. A review of the facility policy and procedure titled, Resident to Resident Altercations, dated September 2022, indicated, .All altercations, including those that may represent resident to resident abuse, are investigated and reported .Behaviors that may provoke a reaction by resident or others include .sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing .If two residents are involved in an altercation, staff .make any necessary changes in the care plan approaches to any or all of the involved individuals .document in the resident's clinical record all interventions and their effectiveness . A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, indicated, .Residents have the right to be free from abuse Protect resident from abuse .by anyone including but not necessarily limited to .other residents .

Based on interview and record review the facility failed to ensure that one of seven sampled residents (Resident A) received necessary treatment and care in accordance with professional standards of practice. This failure occurred when the facility: 1. Did not ensure Resident A received the physician ordered insulin (medication that lowers the level of glucose [sugar] in the blood) after admission to the facility, and 2. Did not provide Resident A with necessary blood sugar monitoring. These failures resulted in Resident A's unmonitored and uncontrolled blood sugar to rise throughout the night, which necessitated Resident A to be sent out via 911 to the acute care hospital in the morning where she expired shortly after arrival at the hospital's emergency room (ER). Findings: On [DATE], at 11:20 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment. On [DATE], a review of Resident A's facility electronic medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a document for Resident A titled, SNF (skilled nursing facility) Supplemental Orders, dated, [DATE], indicated, Patient is NOT capable of giving informed consent and/or is unable to participate in the treatment plan. A review of a record for Resident A from the discharging hospital titled, Physician Discharge Summary, dated [DATE], indicated, Discharge medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -insulin [MEDICATION(S)] 100 unit/mL (milliliter) injection Commonly known as [MEDICATION(S)]. Instructions: Inject 0.17 mLs (17 Units total) into the skin 2 (two) times daily. Dose: 17 Units What changed: *how much to take *how to take this *when to take this *additional instructions A review of Lexicomp, a nationally recognized drug reference indicated, Insulin [MEDICATION(S)] ([MEDICATION(S)]) is used to lower blood sugar in patients with high blood sugar (diabetes) and is a long-acting insulin. Insulin requirements vary dramatically between patients and dictates frequent monitoring and close medical supervision. Insulin [MEDICATION(S)] must be used concomitantly (in combination) with rapid or short-acting insulins i.e., multiple daily injection regimen. -insulin [MEDICATION(S)] 100 unit/mL injection Commonly known as: [MEDICATION(S)] Instructions: Inject 8 units subcutaneously (under the skin) TIDAC (Three times a day before meals) meals if eating > (greater than) 25% of meal. What changed: additional instructions -insulin [MEDICATION(S)] 100 unit/mL injection Commonly known as: [MEDICATION(S)] Instructions: Inject ,d+[DATE] units three times daily before meals as needed per sliding scale: BG (blood glucose) <70 = hold rapid-acting insulin and see [CONDITION(S)] (low blood sugar) measures. ,d+[DATE] = No correction ,d+[DATE] = 1 unit, ,d+[DATE] = 2 units, ,d+[DATE] = 3 units, ,d+[DATE] = 4 units, > 350 = 5 units and notify provider on call. What changed: You were already taking a medication with the same name, and this prescription was added. Make sure you understand how and when to take each . Further review of Resident A's facility medical record included a copy of the discharging hospital's Medication Administration Report (MAR), dated, [DATE]. This MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - insulin [MEDICATION(S)] ([MEDICATION(S)]) (medication to control high blood sugar) inject 17 units Dose: 17 units Freq: (frequency) 2 times daily Route: SubQ (subcutaneously-under the skin). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - insulin [MEDICATION(S)] ([MEDICATION(S)], ADMELOG) Inject 8 Units Dose: 8 units Freq: 3 times daily before meals Route: SubQ (subcutaneous - under the skin) Admin (administration) Instructions: Give within 15 min (minutes) prior to meal . Further review of Lexicomp indicated, Insulin [MEDICATION(S)] ([MEDICATION(S)]) is a rapid-acting insulin analog .Insulin requirements vary dramatically between patients and dictate frequent monitoring and close medical supervision. Diabetes mellitus, type 1, treatment: SubQ: Insulin [MEDICATION(S)] must be used concomitantly with intermediate or long-acting insulin. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident A's facility record included a document titled, Order Summary Report, which indicated the following order dated [DATE]: - Admit to (initials of facility) [DATE] under the services of (name of doctor) with the following Dx (diagnosis) .Insulin dependent Type 1 DM (diabetes mellitus) . Further review of Resident A's facility document titled, Order Summary Report, indicated two orders for the insulin [MEDICATION(S)] dated [DATE]: - [MEDICATION(S)] solution 100 Unit/ML (milliliter) (Insulin [MEDICATION(S)]) Inject 8 unit subcutaneously before meals for diabetes mellitus give within 15 minutes prior to meal. Hold if not eating > (greater than) 25% of meals. - [MEDICATION(S)] Solution 100 Unit/ML (Insulin [MEDICATION(S)]) Inject 8 units subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals. Review of Resident A's facility document titled, Order Summary Report, indicated an order also dated [DATE], for, [MEDICATION(S)] Solution 100 Unit/ML (insulin [MEDICATION(S)]) Inject 17 unit subcutaneously two times a day for diabetes mellitus. Review of a document from the discharging hospital titled, Summary of Care, dated [DATE], for Resident A indicated that the resident had two blood sugar tests prior to discharge from the hospital to the facility. One at 6:15 a.m., on [DATE], with a blood sugar level of 192, and the last test prior to discharge at 11:44 a.m., with a level of 100. No orders were found in Resident A's facility record to monitor blood sugar levels. Review of Resident A's Admission Summary, dated, [DATE], at 6:40 p.m., indicated, admitted to (initials of facility) at 2pm [DATE], this 67 yo (sic) (year old) lady from (name of discharging hospital) under the service of (doctor's name) .Resident is alert, able to make needs known, not in respiratory distress .Resident ate 25% for supper .(name of doctor) made aware of this admission . A review of Resident A's facility document titled, Admit/Re-Admit Nursing Evaluation, dated, [DATE], indicated, Verification: 1. Attending Physician Notified, Orders Read Back and Verified? a. Yes 2. If Yes, Indicate Date and Time of Notification, Orders Verification: [DATE]. Review of Resident A's facility care plans indicated the following care plan dated, [DATE], Focus- The resident has Diabetes Mellitus Type 1(insulin dependent) .Goal - The resident will be free from any s/s (signs or symptoms) of [CONDITION(S)] (high blood sugar levels) through the review date .The resident will have no complications related to diabetes through the review date. Interventions .Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness .Educate regarding medications and importance of compliance . A review of Resident A's facility MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the facility MAR for Resident A indicated the physician ordered administration of [MEDICATION(S)] Solution scheduled for 9:00 p.m. on [DATE], was not given. The record indicated that Resident A failed to receive any physician ordered insulins on [DATE], after admission to the facility. A review of Resident A's facility Progress Notes, indicated the following entry dated, [DATE], at 9:38 p.m., Orders- Administration Note: [MEDICATION(S)] Solution 100 Unit/ml. Inject 17 unit subcutaneously two times a day for diabetes mellitus. New admit, awaiting pharmacy for delivery will endorse. This progress note was authored by a license vocation nurse (LVN 1). Further review of Resident A's facility Progress Notes, indicated the following entry dated, [DATE], at 6:33 a.m., Heath Status Note .Resident remains alert, oriented and verbally responsive. Able to make needs known .No adverse drug reactions noted at this time. No n/v (nausea and vomiting) . A review of Resident A's MAR for [DATE], indicated that the physician ordered administration of the insulin [MEDICATION(S)] scheduled for 6:45 a.m., was not given. Further review of Resident A's facility Progress Notes, indicated the following entry, Orders- Administration Note, dated, [DATE], at 10:03 a.m., [MEDICATION(S)] Solution 100 Unit/ml. Inject 8 unit subcutaneously with meals for diabetes mellitus Hold if not eating > 25% of meals (sic) resident vomited all she ate. A review of Resident A's MAR for [DATE], indicated that Resident A did not receive the physician ordered insulin, [MEDICATION(S)], on [DATE]. Further review of Resident A's facility medical record found no documentation that indicated the resident's physician was notified that the ordered insulins had not been given on [DATE]th or 13th, 2020. A review of Resident A's facility Progress Notes, indicated the following entry, Health Status Note, dated [DATE], at 11:30 a.m., At 10:17 this morning resident was noted to be sweating and breathing fast. She was able to respond to her husband who was on the phone at the time. Blood sugar was checked and showed HI. (A review of the leading provider of blood sugar monitoring systems, Accu-Chek indicated, If the letters HI are displayed on the screen, the blood glucose may be higher than the measuring range of the system. The meter is designed to provide a numerical value for blood glucose in the range of ,d+[DATE] mg/dL (milligram/deciliter). CNA (certified nursing assistant) reported to this writer earlier that resident vomited breakfast food (sic) .(name of doctor) and husband informed .Husband was updated of residents' (sic) condition and at 10:54am (sic) agreed that resident be transferred to hospital preferably to (name of discharged hospital). Call to 911 was placed and they arrived about 11:15. This writer went to check on the resident at about this time and found her to be unresponsive (unconscious, possibly dead or dying) .Resident was transferred out of the facility around 11:25am (sic). Further review of Resident A's facility medical record found no documentation that any blood sugar check had been done prior to 10:00 a.m., on [DATE], 20 hours after admission to the facility. Per the American Diabetes Association (ADA), Blood glucose (blood sugar) monitoring is the primary tool to find out if blood glucose levels are within a targeted range. It is important for blood glucose levels to stay in a healthy range. The ADA indicated that the recommended blood sugar levels should be between 70 and 130 mg/dL before meals, less than 180 mg/dL after meals. The American Diabetes Association further indicated; [CONDITION(S)] is the technical term for high blood sugar. [CONDITION(S)] occurs when the body has too little insulin or when the body cannot use insulin properly. A few of the causes .Not enough insulin or oral diabetes medications . The ADA further indicated, [CONDITION(S)] (high blood sugar) can be a serious problem if left untreated. It is important to treat as soon as detected. Failure to treat [CONDITION(S)], can result in ketoacidosis (diabetic coma) . A review of Resident A's emergency transport's, Patient Care Report, dated, [DATE], indicated the paramedics were called at 10:56 a.m., and were with the resident by 11:12 a.m. Further review of Resident A's emergency transport's, Patient Care Report, indicated, Narrative: .To (name of facility) SNF (skilled nursing facility) for Difficulty breathing, high blood sugar, To be greeted at entrance by staff. Staff stopped (number of transport) crew for COVID screening procedures. During procedures, staff member appeared stating, Hurry, she's unresponsive now. (number of transport) proceded (sic) as quickly as possible to room directed by staff. All staff members outside of PT's (patient) room. (Number of transport) found PT laying semi-fowlers (positioned on the back with the head and trunk raised to between 15 and 45 degrees) in bed, unresponsive with agonal breathing (medical term for the gasping or struggling to breathe) PT immediately moved to gurney for transport due to PT condition .staff stated PT had High Blood Sugar and was found with difficulty breathing prior to calling 911 .PT arrived yesterday from (name of discharging hospital) for rehabilitation .PT moved to ambulance and loaded. Upon loading PT became pulseless (absence of heart beat) .Chest compressions started . A review of Resident A's hospital record titled, ED (emergency department) Aware Note, dated [DATE], indicated, History or Presenting Illness: The patient is a [AGE] year(s) old female complaining of [CONDITION(S)] (sudden, unexpected loss of heart function, breathing, and consciousness). (Name of Resident A) was seen by me at Oct-,d+[DATE] 11:33. The patient's chief complaint quote was full arrest (abrupt loss of heart function) . Resident A's, ED Aware Note, further indicated, .Pt arrived pulseless in asystole (state of total cessation of electrical activity from the heart) after prolonged downtime with delayed initiation of CPR (Cardiopulmonary resuscitation- emergency procedure that combines chest compressions with artificial ventilation) . Further review of Resident A's hospital, ED Aware Note, dated, [DATE], indicated, [NAME] (time of death) called 1140 .Dx (diagnosis) asystole, cardiopulmonary arrest, [CONDITION(S)] .blood glucose 477 . A review of Resident A's hospital record titled, Discharge Diagnosis, indicated, asystole, [CONDITION(S)] and [CONDITION(S)]. A review of Resident A's Certificate of Death, dated, [DATE], indicated, Immediate Cause- final disease or condition resulting in death: (A). [CONDITION(S)] . Review of a journal titled, Cardiovascular Complications of Ketoacidosis, in the national publication, U.S. Pharmacist, dated, February 17, 2016, indicated, Ketoacidosis is a serious medical emergency requiring hospitalization .It is most commonly associated with several cardiovascular (relating to the heart) complications (per the Mayo Clinic complications of the heart include sudden [CONDITION(S)]) .Ketoacidosis most commonly occurs in insulin-dependent diabetes with omission (left out or excluded) of insulin . On [DATE], at 3:09 p.m., a phone interview was conducted with a licensed vocational nurse (LVN 2). LVN 2 confirmed that he had provided care for Resident A on the morning of [DATE]. LVN 2 was asked if he had administered the physician ordered insulins during his shift. LVN 2 stated that he could not remember exactly which insulin he had given but stated after the doctor was notified, he believed that he had given the [MEDICATION(S)]. LVN 2 continued that his supervisor had contacted the doctor to get an order to check the resident's blood sugar level. LVN 2 stated when he checked the blood glucose monitor it kept reading, high. LVN 2 was asked if there had been an order to monitor or check Resident A's blood sugar or an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 2 stated, I guess not. LVN 2 continued that there was no order to check the resident's blood sugar. LVN 2 stated that his supervisor had called the physician to get the order to have the resident's blood sugar checked on [DATE]. On [DATE], at 4:07 p.m., a phone interview was conducted with Resident A's attending physician (AP) at the facility. The AP was asked if she had been notified that Resident A had failed to receive her ordered insulins [DATE]th and [DATE]th. The AP stated that she had not been notified that the resident had not received her medications. The AP continued that she does not always get notified for things like that. The AP was then asked for a resident with diabetes would it be expected to have an order to check the resident's blood sugar and have a sliding scale. The AP stated, Yes, of course, there should have been an order. On [DATE], at 10:16 a.m., a phone interview was conducted with the facility's Director of Nursing (DON). The DON was asked the facility's expectation to notify the physician if medications were not available to be given at the ordered time. The DON stated that if medications were not delivered or not available to be given, the staff should have called the physician and informed the physician that the medications were late or not available to get new orders. The DON was asked if the facility had an E-kit (emergency medication kit). The DON confirmed that the facility had an E-kit. After checking the facility E-kit the DON stated that the E-kit had [MEDICATION(S)] and a regular acting insulin but not the [MEDICATION(S)]. The DON was asked the expectation for an order to check the blood sugar levels. The DON stated that even though there was no order, the blood sugar should have been monitored. The DON continued that with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the physician should have been called to obtain an order to check the blood sugar levels. On [DATE], at 10:30 a.m., a phone interview was conducted with LVN 1. LVN 1 confirmed that she had provided care for Resident A on [DATE]. LVN 1 stated she had worked a double shift that day from 6:30 a.m. to 11:00 p.m. LVN 1 was asked if she had administered Resident A's insulins. LVN 1 stated, No. LVN 1 further stated that the medications had not been delivered from the pharmacy to the facility during her shift. LVN 1 continued that she had not had the medications at that time to administer. LVN 1 was asked if she had called to inform the physician that the medications were not available to give. LVN 1 stated, I didn't call personally. LVN 1 stated that she was unaware if anyone had called the physician to notify them that the medications were not available to give at the ordered times. LVN 1 was then asked if it was expected for the physician to be notified if a medication was not available to be given at the ordered time. LVN 1 stated, Yes, it would be expected to have notified the physician. LVN 1 was asked if she had monitored Resident A's blood sugar levels. LVN 1 stated, No. LVN 1 continued, There was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a facility policy titled, Diabetes Mellitus: Monitoring and Management Protocol, undated indicated, .Type 1 DM (diabetes Mellitus) .Residents with type 1 DM using a multiple-dose insulin regimen may test before meals and at bedtime. Requires injections of insulin to control diabetes and prevent Ketoacidosis . On [DATE], at 2:04 p.m., a phone interview with conducted with one of the facility's registered nurses (RN 1). RN 1 confirmed that she had been Resident A's admitting nurse on [DATE]. RN 1 stated that she had input Resident A's facility orders from the discharge orders received from the discharging hospital. RN 1 was asked that given Resident A's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ? RN 1 stated, I agree. RN 1 continued, Yes, there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated there should have been an order to monitor the blood sugar. RN 1 stated that she had spoken with the nurses at the facility the next day and informed them that if a resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Vocational Nursing Practice Act indicated, Scope of Vocational Nursing Practice: The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan . It further indicated, .Performance Standards: (a) A licensed vocational nurse shall safeguard patients'/clients' health and safety by actions that include but are not limited to the following: .(2) Documenting patient/client care in accordance with standards of the profession . Review of the Business and Professions Code, Division 2, Chapter 6. Nursing, Article 2. Scope of Regulation, amended 1974, indicated, .(b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: (1) Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician .

Based on interview and record review, the facility staff failed to report sexual and physical abuse incidents of two staff members, a male Certified Nursing Assistant 1 (CNA 1), and a female Certified Nursing Assistant 2 (CNA 2), to three residents (Resident 1, Resident 2, and Resident 3), to the Administrator immediately. Additionally, the facility Administrator failed to follow his policy and procedure to report the sexual and physical abuse to the police. This failed practice had the potential to subject residents at the facility to further sexual and physical harm, by allowing the Certified Nursing Assistants (CNAs) to continue to work in the facility. Findings: On June 17, 2014, at 9:30 a.m., an unannounced visit was made to the facility to investigate an entity reported incident. During the interview with the Administrator, he stated on June 13, 2014, at 10 a.m., he met with the Activity Director (AD), regarding incidents of inappropriate sexual behaviors by two Certified Nursing Assistants (CNA 1 and CNA 2). The Administrator stated, the AD, Rehabilitative Nursing Assistant (RNA), Activity Aide 1 (AA 1), Activity Aide 2 (AA 2), and Activity Aide 3 (AA 3), reported they saw the two CNAs tweaking, pinching and rubbing residents' nipples or chests. The Administrator stated the CNAs have been put on administrative leave since June 13, 2014. The Administrator stated these staff had submitted written statements of their observations. On June 17, 2014, a review of these written statements of sexual and physical abuse incidents was conducted. The AD documented in her written statement dated June 11, 2014, that she had observed CNA 2 circling the nipples of Resident 2 with her fingers in the dining room on May 5, 2014. The AD documented AA 2 was standing next to her, and had also witnessed the incident. The staff members had failed to report the incident until June 13, 2014, which was 39 days later. On June 24, 2014, at 10:30 a.m., the AD was interviewed. The AD confirmed her written statement, dated June 11, 2014. She stated, she attended a mandatory sexual harassment meeting on June 3, 2014, and began to realize she should report her observations of CNA 2 inappropriately touching Resident 2's chest area, which occurred on May 5, 2014, but failed to report the incident to the Administrator until June 12, 2014. On June 30, 2014, the AD notes were reviewed. The AD documented, in her written statement, she reported the sexual and physical abuse to the facilities corporate nurse consultant, on June 11, 2014, and not the Administrator, due to feeling more supported and less intimidated by her corporate representative. The facility corporate nurse consultant advised the AD that she should compose her written statement, and to collect written statements from her staff. The AD then collected the written statements from the RNA, AA 1, AA 2, and AA 3. On June 12, 2014, the AD spoke to the facilities corporate nurse consultant, who said he had notified the Administrator of the incidents, at approximately 12 noon. The AD documented she contacted the Administrator on June 12, 2014, by phone, since the Administrator was at his other facility, to confirm he received the information reported to him by the facilities corporate nurse consultant on June 12, 2014. The AD spoke to the Administrator who said to leave the paperwork on his desk, and he would discuss the information on June 13, 2014. On June 24, 2014, at 12:30 p.m., AA 2 was interviewed. She submitted a written statement to the AD, on June 11, 2014, regarding witnessing intermittent observations of sexual and physical abuse, by CNA 1 and CNA 2, tweaking the nipples of Resident 1, Resident 2, and Resident 3. AA 2 stated she cannot recall the actual date of the incidents, but stated it occurred intermittently prior to lunch and dinner. She stated she did not report her observations to the Administrator, but submitted a written statement to the AD because she is afraid of retaliation. AA 2 stated she found it difficult to report her observations due to the Administrator's door being shut, so she reported the incidents to the AD who was her immediate supervisor. AA 2 stated on June 13, 2014, when she met with the Administrator, the Administrator asked her, "Have they slashed your tires, or scratched the paint on your car?" AA 2 stated she did not feel supported by the Administrator or safe at the facility. On June 24, 2014, at 11 a.m., AA 1 was interviewed. AA 1 confirmed her written statement, dated June 12, 2014. She witnessed CNA 2 inappropriately rubbing Resident 2's chest, and twisting the nipples of Resident 2 a few times, in the dining room, on June 10, 2014, at approximately 4:45 p.m. AA 1 submitted a written report to the AD, her supervisor, on June 12, 2014, and did not say anything to the Administrator because she felt she would be retaliated against, and management would ignore and belittle her. On June 24, 2014, at 11:30 a.m., the RNA was interviewed. She stated she and AA 3 witnessed CNA 1 touching Resident 2's nipples on June 9, 2014, but the incident was not reported to the AD until June 11, 2014, which was two days later. Additionally, the RNA stated when she met with the Administrator, on June 13, 2014, she felt "lamb blasted" by him and retaliated against. The RNA stated the work environment is uncomfortable, and she is not receiving the support from the Administrator. On June 24, 2014, a review of the written statement documented by AA 3, dated June 13, 2014, indicated that she had witnessed the CNAs rubbing the chest of Resident 1 and Resident 2, and also pinching their nipples. AA 3 did not have definitive dates and times, and did not report the incidents to the AD until June 13, 2014. AA 3 was afraid and felt she would be retaliated against to speak out by having her name known, and being identified as someone who reported her co-workers. During the interview with the facility Administrator, on June 24, 2014, at 3:15 p.m., the Administrator stated he has completed a Resident Abuse Investigation Report on June 13, 2014. The Administrator stated he does not feel the CNAs touched the residents' nipples or chest inappropriately because he felt it calms the residents down; therefore, he did not report the two CNAs to the CNA board, the Department of Justice, nor the police, because the incident had not gone beyond playfulness by the two CNAs. On July 31, 2014, the facility policy and procedure titled, "Resident Abuse, Neglect, or Mistreatment," dated July 24, 2013, was reviewed. The policy indicated, "Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source...1. Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation, or neglect of a resident shall be immediately reported to the Administrator, Director of Nursing, or designee(s)...3. The Administrator or designee will notify the resident's representative, and any State or Federal agencies of allegations within 24 hours...9. The Administrator shall take the following actions to assure that the investigation is conducted timely and effectively:...b. The Administrator or designee shall immediately call local police when assault, sexual abuse, homicide, forgery, or wanton neglect are suspected or have occurred...The investigative report will include:...k. Names of people outside the facility who were notified of the incident, including the police..." On July 31, 2014, the facility policy and procedure titled, "Resident/Staff/Family Abuse Reporting," dated July 24, 2013, was reviewed. The policy indicated, "It is the policy of the facility to encourage and support all residents, staff, and families in feeling free to report any suspected acts of abuse,...The facility will take all measures possible to assure residents, staff and families are free from fear of retribution if reports or incidents are reported to the facility...1. Any person(s) witnessing or having knowledge of potential or actual abuse must report the incident to the Administrator and/or designee immediately...Everyone is required to make a report of known or suspected abuse to the local ombudsman or the local law enforcement agency..."

Based on interview, and record review, the facility failed to ensure three residents (Resident 1, Resident 2, and Resident 3) were free from sexual and physical abuse by two staff members, when a male Certified Nursing Assistant 1 (CNA 1) twisted Resident 1 and Resident 2's nipples, and a female Certified Nursing Assistant 2 (CNA 2) inappropriately rubbed Resident 1, Resident 2, and Resident 3's chest and twisted the Residents' nipples. This failed practice resulted in Resident 1 feeling angry, agitated, and humiliated. The potential of Resident 2 and Resident 3 having worsened mood swings, becoming less trusting of staff members, and having increased anxiety. Findings: An unannounced visit was made to the facility on [DATE], at 9:30 a.m., to investigate an entity reported incident. During the interview with the Administrator, he stated on June 13, 2014, at 10 a.m., he met with the Activity Director (AD), regarding incidents of inappropriate sexual behaviors by two Certified Nursing Assistants (CNA 1 and CNA 2). The Administrator stated, the AD, Rehabilitative Nursing Assistant (RNA), Activity Aide 1 (AA 1), Activity Aide 2 (AA 2), and Activity Aide 3 (AA 3), reported they saw the two CNAs tweaking, pinching and rubbing residents' nipples or chests. The Administrator stated the CNAs have been put on administrative leave since June 13, 2014. The Administrator stated these staff had submitted written statements of their observations. On June 17, 2014, a review of these written statements of sexual and physical abuse incidents was conducted. The AD documented in her written statement dated June 11, 2014, that she had observed CNA 2 circling the nipples of Resident 2 with her fingers in the dining room on May 5, 2014. The AD documented AA 2 was standing next to her. CNA 2 stated, "I can get him to behave and do whatever I want, when I do this." On June 24, 2014, at 10:30 a.m., the AD was interviewed. The AD confirmed her written statement, dated June 11, 2014. She stated, she attended a mandatory sexual harassment meeting on June 3, 2014, and began to realize she should report her observations of CNA 2 inappropriately touching Resident 2's chest area, which occurred on May 5, 2014. On June 24, 2014, at 12:10 p.m., AA 2 was interviewed. She stated, the abuse incidents occurred intermittently prior to lunch time and dinner time in the dining room. AA 2 witnessed CNA 2 stimulating Resident 1's nipples and stating, "Look he is getting sexually aroused, because his nipples are getting hard." AA 2 told CNA 2 to stop, but CNA 2 laughed and said Resident 1 likes it. AA 2 also stated she witnessed CNA 2 stimulate Resident 3's nipples and stated, "I can get them to do what I want them to do." AA 2, stated she saw CNA 1 tweak the nipples of Resident 1 and Resident 2, after coming up behind the Residents, who were in their wheelchairs. AA 2 states this occurs intermittently prior to lunch and dinner time, in the dining room. On June 24, 2014, at 11 a.m., AA 1 was interviewed. She stated she witnessed CNA 2 inappropriately rubbing Resident 2's chest, and twisting the nipples of Resident 2 a few times, in the dining room, on June 10, 2014, at approximately 4:45 p.m. On June 24, 2014, at 11:30 a.m., the RNA was interviewed. The RNA confirmed her written statement, dated June 11, 2014. She stated, "On Monday, June 9, 2014, AA 3 and myself witnessed CNA 1 touching Resident 2's nipples inappropriately, by rubbing and pinching Resident 2's nipples in an erotic nature, at the same time blowing in his ear and rubbing his arm in a sensual nature, between 10 a.m. and 12 p.m." AA 3 documented, in her written statement, dated June 13, 2014, "I have seen many times the CNAs rubbing the chest of Resident 1 and Resident 2, and also pinching their nipples." On June 17, 2014, a review of Resident 1's record indicated, the resident was a [AGE] year-old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized, primary screening and assessment tool of resident health status) dated May 23, 2014, described Resident 1 as being alert with fluctuations in behavior. Resident 1 requires extensive assistance for bed mobility, transferring, and toilet use. Resident 1 has weakness in his lower extremities, and requires a wheelchair for transportation. On June 17, 2014, at 9:50 a.m., Resident 1 was interviewed. Resident 1 was observed to be agitated while talking about the incidents. Resident 1 stated, the two CNAs have rubbed his chest area persistently. He stated it made him upset since this happened all the time. He stated he was going to report them, but the CNAs thought it was a joke, and the staff did not take Resident 1 seriously. On June 17, 2014, at 10:45 a.m., during an interview with the Medical Social Worker (MSW), she stated she had contacted and spoke with the wife of Resident 1, who stated she does not want inappropriate playfulness by the CNA toward her husband. On June 17, 2014, a review of Resident 2's record indicated the resident was a [AGE] year-old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], described Resident 2 as having short term and long term memory problems, being alert with moderate cognitive impairment, and could recall location of his own room and staff names and faces. Resident 2 requires extensive assistance for all Activities of Daily Living (ADL), and requires a wheelchair for transportation. On June 17, 2014, a review of Resident 3's record indicated, the resident was a [AGE] year-old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], described Resident 3 as having short term and long term memory problems, being alert with moderate cognitive impairment. Resident 3 requires extensive assistance with ADL, and has weakness in his lower extremities, so requires a wheelchair for transportation. When attempted to interview Resident 2 and Resident 3, on June 17, 2014, at 10:15 a.m., they were not interviewable. Resident 2 was forgetful, and Resident 3 could only make facial gestures, and was unable to verbalize. During the interview with the facility Administrator, on June 24, 2014, at 3:15 p.m., the Administrator stated he has completed a Resident Abuse Investigation Report on June 13, 2014. The Administrator stated he does not feel the CNAs touched the residents' nipples or chest inappropriately because he felt it calms the residents down; therefore, he did not report the two CNAs to the CNA board, the Department of Justice, nor the police, because the incident had not gone beyond playfulness by the two CNAs. On June 24, 2014, the facility policy and procedure titled, "Abuse Program," dated July 24, 2013, was reviewed. The policy indicated, "It is the policy of the facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals."

Based on interview and record review, the facility failed, affecting 450f 45 reviewed past and present facility residents (Residents A-Z and AA-SS) to: 1 Ensure the safe keeping and security of the residents' trust fund accounts. 2. Implement a policy of prevention and prohibition of financial abuse with resident monies. 3. Demonstrate a check and balance protocol to prevent widespread resident financial abuse of resident trust funds. 4. Reconcile (verify) trust funds for residents family members/responsible parties who had passed away at the facility. The facility's failure to safeguard the resident trust funds had the potential to cause misappropriation of resident property- which means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. These failed practices placed the safety and security of resident trust funds in jeopardy; resulting in the theft of $36,703.64 by the former Business Office Manager (BOM) from [DATE], to [DATE]. Findings: During an interview conducted with the facility administrator (ADM) on [DATE], at 2 p.m., the ADM stated that she had employed a BOM whom she had, "suspicion of an employee who may have done fraud.." The BOM was hired [DATE], and her last day of employment was [DATE], in which the BOM did not show up for work. The ADM continued to state that it was reported to her by a nearby facility manager (owned by the same company as this facility), where the BOM had also worked, that there was speculation that something had happened in the payroll department regarding financial inconsistencies at that facility. The ADM stated on [DATE], at 2:45 p.m., "We were doing bank reconciliation (verification) on [DATE]...some checks were questionable...something was irregular with the (trust) funds." The ADM stated, "I immediately contacted a third party auditor to research the matter." The Governing Body (people who represent the facility) was then alerted to this information. The ADM continued to communicate, "On [DATE], at 2:45 p.m., a report was made to the Riverside District Office (Licensing and Certification) and a police report was made." The same day the ADM continued to state, "The main bank (Name Withheld) that handles the Resident Trust fund ...the account was put on hold." During the interview with the ADM on [DATE], at 2:50 p.m., a phone call was placed on speaker phone by the ADM. A lawyer representing the facility governing body was on the phone and stated that the BOM was in his office and confessed to misappropriation of resident trust funds. The lawyer stated, "She (the BOM) confided to me she acted alone in the misappropriation of funds from the resident trust account...she is to come up with her own accounting of what may be missing on our (facility's) end. "The lawyer stated he was working with the former BOM to come to an agreement to return the resident trust funds. During an interview with the ADM, conducted on [DATE], at 10 a.m., the ADM was questioned about the BOM's duties in the facility business office. The ADM handed over the job description of the former BOM. A review of the Business Office Manager's-Biller's job description was conducted concerning the former BOM's duties at the facility on [DATE]. The listed duties included: "1. Performs all billing functions... 2. Follows up on delinquent payment... 3. Does monthly bank reconciliation of Resident Trust Fund a. Receives Social Security & Pension checks and makes deposit b. Post deposits & disbursements in system (Add-On) c. Sends Quarterly statements to responsible parties. 4. Maintains necessary files... 5. Performs other office-related tasks as directed by the administrator..." On page four of the Business Office Manager/Biller's job description, the document indicated, "The Administrator is ultimately responsible for the timely collection of resident account balances. The Business Office Manager must meet once each week with the Administrator to review and discuss delinquent accounts and the status of collection efforts to date." During an interview with the ADM on [DATE], at 11 a.m., the ADM stated, "I did not know where she (former BOM) got the money from...a signature stamp was used to make the check(s)." "There was a questionable check... number 2374 dated [DATE], for the amount of $1,790.67 written out to her (the BOM)." The ADM stated that the signature on the check, "Was not my signature." In further discussion the ADM stated, "The protocol for the ADM signature stamp was it was only to be used for payroll and emergency situations... if I was not present...the stamp was supposed to be kept locked up." The ADM acknowledged that the stamp was freely used by the former BOM and not kept secured at the facility. The ADM continued to state that the Governing Body directed her to turn over the signature stamp to the Governing Body. The ADM stated, "I did not see any of those checks." During an interview with the facility's contracted auditor on [DATE], at 1:20 p.m., the auditor stated the company auditors that the facility utilized were not responsible for validating the individual resident trust accounts. She stated, "We (auditors) mostly recommend related to trust and accounts and balances...we are not responsible for overseeing accounts on a month to month basis." The auditor stated she was recently hired on [DATE] to complete the audit of the facility's resident trust funds and stated, "So far most of the resident's trust fund accounts were transferred to a (Name Withheld) personal bank account belonging to the former BOM." The auditor continued to state, "Look at the discharge date s...(there) were multiple residents who expired she (BOM) took money from." The auditor further stated the former BOM also took the residents' interest from the trust fund accounts. A record review of the auditor's final report was conducted on [DATE]. The auditor listed 45 residents in spread sheet format in which the former BOM had conducted financial abuse. There were originally 17 checks made out to the personal bank account of the former BOM, while she was employed at the facility, from [DATE] and to [DATE]. Additional checks were found by the auditor and were listed on the final spread sheet dated [DATE]. Of the 45 residents in which the former BOM took funds from, 12 passed away at the facility. The families and or responsible person of the deceased did not receive their refunds within 30 days of the former residents' death. During an interview conducted with Resident H's daughter on [DATE], at 3:30 p.m., the daughter stated, "I did not receive any trust statements from the facility and was not reimbursed within thirty days after my mother's death." A record review of the auditor's final report/spread sheet was conducted on [DATE], of the residents affected by the alleged financial abuse, conducted at the facility, by the former BOM. Of the 45 residents affected with the alleged financial abuse, 12 had a psychiatric diagnosis, 11 residents had dementia (brain decay), or [MEDICAL CONDITION] (progressive loss of mental capacity), and three residents had mental disorders consisting of mental [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Affected Residents are listed below with letter format identifiers. The corresponding letter(s) add up to the individual checks the BOM wrote. The dates correspond to the date a check was written by the former BOM. The residents are identified by the letter A -Z and AA - SS. A: $17 ([DATE]) Expired Resident [DATE] B: $348 ([DATE]), $261 ([DATE]) C: $.13 ([DATE]) Expired Resident [DATE] D: $790 ([DATE]), $308 ([DATE]), $215 ([DATE]), $262 ([DATE]) E: $3 ([DATE]) F: $150 ([DATE]), $290 ([DATE]) G: $115.01 ([DATE]) Expired Resident [DATE] H: $403 ([DATE]), $606 ([DATE]), $564.89([DATE]) Expired Resident [DATE] I: $1,348 ([DATE]), $735.67 ([DATE]), $778.01 ([DATE]) Expired Resident [DATE] J: $250 ([DATE]), $150([DATE]), $100 ([DATE]) K: $667 ([DATE]) L: $40 ([DATE]) M: $40 ([DATE]) N: $.03 ([DATE]) Expired Resident [DATE] O: $550 ([DATE]), $550 ([DATE]), $1,142 ([DATE]), $947.36 ([DATE]) Expired Resident [DATE] P: $42.98 ([DATE]) Q: $554 ([DATE]), $607 ([DATE]), $312 ([DATE]), $250 ([DATE]), $160 ([DATE]) R: $35.07 ([DATE]) Expired Resident [DATE] S: $771 ([DATE]), $401 ([DATE]), $204 ([DATE]), $205 ([DATE]), $200 ([DATE]) T: $.01 ([DATE]) U: $150([DATE]), $150 ([DATE]),$100 ([DATE]) V: $176.80 ([DATE]) W: $1,090 ([DATE]), $754 ([DATE]), $402 ([DATE]), $201 ([DATE]), $207 ([DATE]), $250 ([DATE]), $207 ([DATE]), $100 ([DATE]), $260.95 ([DATE]) X: $5.00 ([DATE]) Y: 35.40 ([DATE]) Expired Resident [DATE] Z: $.11 ([DATE]) AA: $207([DATE]), $1,592([DATE]), $939 ([DATE]), $150 ([DATE]), $250 ([DATE]), $300 ([DATE]), $1992 ([DATE]) BB: $306 ([DATE])., $380.10 ([DATE]), $276.10 ([DATE]) Expired Resident [DATE] CC: $819 ([DATE]), $400 ([DATE]), $204 ([DATE]), $100 ([DATE]), $100 ([DATE]), $379 ([DATE]) DD: $63.10 ([DATE]) EE: $984 ([DATE]), $1,004 ([DATE]), $1074.54 ([DATE]) FF: $436 ([DATE]), $889 ([DATE]) Expired Resident [DATE] GG: $1,440 ([DATE]), $340 ([DATE]), $.02 ([DATE]) Expired Resident [DATE] HH: $355.67 ([DATE]), $274.59 ([DATE]) II: $.05 ([DATE]) JJ: $0.16 ([DATE]) KK: $52.69 ([DATE]) LL: $20.51 ([DATE]) MM: $433.27 ([DATE]) NN: $0.03 ([DATE]) OO: $8.62 ([DATE]) PP: $30.00 ([DATE]) QQ: $60 ([DATE]) RR: $17.67 ([DATE]) SS: $1363.10 ([DATE]) Total: $36,703.64 During an interview with Business Office Worker 1, on [DATE], at 12:40 p.m., the worker stated, "The monthly reconciliation (verification of accounts) was done by the ADM and forwarded to the accounting office." She stated, "All the numbers added up" (with the resident trust fund). She stated, "We put too much trust in (Name Withheld). The worker stated the facility," Did not follow through with a (formal) month to month reconciliation (verification) of the residents' trust accounts." Worker 1 acknowledged individual ledgers to reconcile (verify) with patient trust control accounts were not taking place in the facility's business office. Worker 1 also acknowledged that the families of deceased residents did not receive their refunded trust fund money. There were no formal one to one meetings with the Administrator and staff, as per facility policy. There was no documentation brought to the surveyor to show there were meetings that took place with time and date of reconciliation (verification) of the trust accounts. Office Worker 1 acknowledged the facility's business office was now printing out on a monthly basis, all monthly checks made. She continued to stated, "The checks now have to match the monthly reconciliation statement." Office Worker 1 further stated (there) is no authorization (now) by any employee except the administrator, to sign any checks or to use a check (signature) stamp. The facility policy and procedure titled,"Policies and Procedures in Handling Patient Trust Fund," indicated the following: 3. "A custodian shall be designated by the Facility/Administrator to handle petty cash withdrawals, withdrawals by checks, and to make deposits tot he account. All checks will be signed by the custodian and administrator... c. Recordings and postings to the trust fund ledgers should be done daily. d. Postings should be reconciled with the Control account (on -going accounting sheet) immediately after postings." Under Disbursements the policy indicated: "...b. Patient refunds should be made payable to the resident. Refunds other than for residents should be authorized & supported. 4. Bank Reconciliation a. Monthly Bank reconciliation should be prepared. b. Bank balance to reconcile with controller/ledger account. c. Individual ledgers to reconcile with Patient Trust control Account. d. Monthly interest income earned should be posted/accrued to the individual ledgers of the Residents." The policy further indicated, "6. When a resident is discharged , refunds should be made within three (3) days upon discharge and within (30) days upon death. Upon discharge, residents/authorized representative should be given a current statement of their trust account balance..." Under Residents Moneys or Valuables: "...2. Should be adequately safeguarded and accurately accounted for and documented... ...6. Of dead residents without a representative or known heirs (relatives), are given to the County Public Administrator and a copy of notice is given to the Department of Health."