Every finding on record at Orchard Post Acute

Based on interview and record review, the facility failed to ensure medication administration services were provided in accordance with professional standards for one of one sampled resident (Resident 1) when the Registered Nurse (RN 1) directed Certified Nursing Assistant (CNA 1) to administer medication to Resident 1. This failure had the potential to result in Resident 1 receiving medications from unlicensed personnel, increasing the risk for medication administration errors and compromising resident safety. Findings: During an interview on 6/9/26 at 11:30 a.m. with CNA 1, CNA 1 stated her current assignment was the low 100 hall. CNA 1 stated she had passed medication to Resident 1 after being asked by a nurse. CNA 1 stated the nurse remained present and observed the administration. CNA 1 stated, She just asked me to take the medication to the Resident 1, and I thought I had to do what my nurse asked of me. CNA 1 stated she did not know what medication was administered. CNA 1 stated she later learned she was not permitted to administer medications because it was outside her scope of practice. CNA 1 stated she notified the facility management of the incident. CNA 1 stated the Development of Staff Director (DSD) educated her regarding her responsibilities and informed her CNAs are not permitted to administer medications. CNA 1 stated she received disciplinary action related to the incident and believed the nurse involved also received disciplinary action.During an interview on 6/9/26 at 12:57 p.m. with RN 1, RN 1 stated she was conducting a medication pass when the incident occurred. RN 1 stated Resident 1 was on isolation precautions (infection prevention measures requiring the use of Personal Protective Equipment [PPE] before entering resident room). RN 1 stated PPE included a gown, gloves, and mask, and was available outside Resident 1's room; however, CNA 1 was already inside the room providing care. RN 1 stated she asked CNA 1 to administer the medication to Resident 1 while RN 1 remained standing in the doorway. RN 1 stated, I did not know a CNA could not pass medication. I thought if I was standing there watching, she could give the resident the medication. RN 1 stated she prepared the medication, which was an antibiotic pill (Vancomycin), and handed the medication cup to CNA 1. RN 1 stated CNA 1 then physically handed the medication to Resident 1 for administration. RN 1 stated she continued administering medications to other residents and was subsequently approached by the DSD regarding the incident. RN 1 stated she received education regarding medication administration responsibilities and received disciplinary action. RN 1 stated it was the first time she had asked another staff member to administer medication on her behalf. RN 1 confirmed she prepared the medication and documented the medication administration in Resident 1's medical record. RN 1 confirmed CNA 1 physically administered the medication to Resident 1 while RN 1 remained outside the room. During a concurrent interview and record review on 6/9/26 at 12:00 p.m. with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR) was reviewed. The MAR indicated, on 6/8/26 for the 12:00 p.m. administration pass, medication Vancomycin was documented as administered by RN 1. The DON stated the facility's medication administration process requires a licensed nurse to identify the resident, verify the medication order, and perform the medication administration process utilizing the rights of medication administration, including the right resident, the right medication, right dose, right route, right time, and right documentation. DON stated the nurse who prepared the medication must be the same nurse who administered and documented the medication. The DON stated, Who pours it, gives it, and signs it. The DON stated CNA's could not administer medications. DON stated an in-service took place the day before. The DON confirmed RN 1 prepared a medication for Resident 1, who resided in room on the low 100 side and was on isolation precautions. DON stated RN 1 did not want to don (put on) PPE and remained outside Resident 1's room. The DON stated RN 1 handed the medication to CNA 1 and observed CNA 1 administer the medication to Resident 1. DON confirmed the statement provided by CNA 1 and RN 1 regarding the incident. DON stated the DSD became aware of the incident while addressing an unrelated matter involving CNA 1. The DON stated CNA 1 disclosed administering the medication at the direction of RN 1. The DON stated she instructed the DSD to immediately remove RN 1 from her duties and an investigation was initiated. The DON stated CNA 1 received education regarding scope of practice, was re-trained, and received disciplinary action related to the incident. The DON stated RN 1 also received education and disciplinary action. During a record review on 6/9/26, a facility document titled, Registered Nurse Job Description, signed by RN 1 on 3/19/26, was reviewed. Under the section titled Nursing care Functions, the job description indicated RN responsibilities included ensuring all Registered Nurses (RNs) and Licensed Practical/Vocational Nurses comply with written procedures for administration, storage, and control of medication passes and treatment. Under the section titled Qualifications, the job description indicated the RN must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines pertaining to nursing care facilities. The document indicated RN 1 acknowledged and understood the responsibilities and qualifications required for the RN position by signing the job description on 3/19/26.During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 3/2026, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The person who prepares the dose for administration is the person who administers the dose.During a review of the Nursing Home Care Standards-CANHR.org Professional Reference titled, Medication, unnecessary Drugs and chemical Restraints, dated 2026 , (Found https://canhr.org/nursing-home-care-standards/) the reference indicated, .medications must be administered by licensed nurses or medical personnel. 22 CCR S72313(a)(5). Unlicensed staff may administer certain laxatives, non-prescription lotions, medicinal shampoos and baths, subject to specific training, demonstrated competence and direct supervision by licensed nursing or medical personnel. 22 CCR S72313(a)(5)(B). The person who administers the drug or treatment must record the date, time, and dosage in the resident's individual medication record. 22 CCR S72313(c).

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one of three sampled residents when certified nursing assistant (CNA) 1 was aware that Resident 1 required two person total dependent assistance with turning and repositioning while in bed and CNA 1 performed the task independently causing Resident 1 to roll off of the raised bed onto the floor. This failure resulted in Resident 1 sustaining an injury to the right eyebrow and transferred to the acute care hospital for further evaluation.Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Alzheimer's disease (disorder that primarily affects memory, thinking, and behavior), adult failure to thrive. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 3/2/26, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 1 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment. During an interview on 4/30/26 at 11:35 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated that Resident 1 had a witnessed fall on 4/10/26 during care. CNA 1 stated she had entered Resident 1's room, approached Resident 1 and raised the bed to initiate care. CNA 1 stated she had removed the pillows that were located on Resident 1's left and right-side providing support and noted Resident 1 was lying close to the edge of the bed to the left. CNA 1 stated she proceeded to turn Resident 1's body to the left side to provide care when Resident 1 suddenly began moving her arms and legs. CNA 1 stated she was attempting to calm Resident 1 by speaking to her but ultimately Resident 1 rolled off the left side of the bed onto the floor. CNA 1 stated Resident 1 was dependent on all care which included toileting, turning and repositioning. CNA 1 stated dependent care was when the staff member completed resident task and resident was not able to participate in task completed. During a concurrent interview and record review on 4/30/26 at 12:01 p.m. with the director of staff development (DSD), Resident 1's document titled, Bed mobility, dated 4/1/26-4/17/26 was reviewed. The document indicated, . Roll left and right, the ability to roll from lying on back to left and right side and return to lying on back on the bed. Dependent. The DSD stated the document indicated Resident 1's ability to perform the task of rolling left to right in bed. The DSD stated the document indicated Resident was dependent on staff to perform task. The DSD stated Resident 1 required two staff member assistance with ADL care including turning and repositioning. During an interview on 4/30/26 at 12:29 p.m. with CNA 2, CNA 2 stated the facility process was for the CNAs or other staff members to read the Kardex (provides resident care information and specific details of resident care), located in the residents' electronic medical record to ensure the residents were receiving appropriate care. CNA 2 stated the residents who were totally dependent on care automatically required two staff members to perform the task that the residents could not complete. CNA 2 stated the process was for two staff members to assist dependent residents to ensure safety and ensure residents were comfortable when tasks were completed. During a concurrent interview and record review on 4/30/26 at 12:50 p.m. with the minimum data set nurse (MDS), Resident 1's document titled, Section GG-Functional Abilities- Mobility, dated 3/2/26 was reviewed. The document indicated, . Safety and Quality of performance, if helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Dependent- Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Dependent- Roll left and right: the ability to roll from lying on back to left and right side and return to lying on back on the bed. Dependent- Sit to lying: the ability to move from sitting on side of bed to lying flat on the bed. The MDS stated Dependent meant the CNAs needed to provide Resident 1 with total care when performing the task. The MDS stated Resident 1 required two-person assistance with turning and repositioning. During an interview on 4/3026 at 12:59 p.m. with LVN 2, lvn2 stated the facility expectation was for the staff to provide residents with assistance they required and needed. LVN 2 stated when a resident was dependent on care, there should have been two staff members assisting the resident to perform the task. LVN 2 stated it was important to ensure two staff members were present during care of a resident who was dependent on staff to ensure the resident was safe and comfortable. During a concurrent interview and record review on 4/30/26 at 1:31 p.m. with the director of nursing (DON), Resident 1's document titled, Section GG-Functional Abilities- Mobility, dated 3/2/26 was reviewed. The document indicated, . Safety and Quality of performance, if helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Dependent- Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Dependent- Roll left and right: the ability to roll from lying on back to left and right side and return to lying on back on the bed. Dependent- Sit to lying: the ability to move from sitting on side of bed to lying flat on the bed. The DON stated that Resident 1 was dependent on staff assistance for turning and repositioning while in bed. The DON stated dependent meant the resident could not perform the task independently. The DON stated the facility process was for Resident 1, who was total dependent on task to turn and reposition, to have two-person assistance unless otherwise specified in the EMR. During an interview on 4/30/36 at 2:10 p.m. with the administrator (ADM), the ADM stated the facility expectation was for the residents to receive the proper level of care that was needed. During a record review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 2001, the P&P indicated, .Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During a record review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Communicating specific interventions to all relevant staff. Providing training as necessary. Bed safety.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for food service safety and sanitary conditions, for one of one ice machine, when the facility did not implement Manufacturer's Limited 3 Year Parts And Labor Warranty (MW) and Air- and Water-Cooled User Manual Cleaning, Sanitation and Maintenance (AWM) and the exterior of the ice machine had white, black and green substance. This failure had the potential for the growth of microorganisms which could increase the risk of foodborne illness for all the residents at the facility.Findings:During a concurrent observation and interview with the Certified Dietary Manager (CDM) on 11/19/2025 at 11:20 a.m. in the kitchen, the ice machine was noted to have some white, black and green substance on the exterior side of the ice machine. The CDM confirmed the presence of the white and green substance on the ice machine. The CDM stated the white substance was calcium buildup. The CDM stated she was unable to confirm what the green substance was. The CDM stated the Maintenance Director (MTD) would be able to explain in more detail what the green substance was.During a concurrent observation and interview with the MTD and CDM on 11/19/2025 at 11:28 a.m. in the kitchen, the ice machine was observed to have some white, black and green substance on the exterior side of the ice machine. The MTD confirmed the presence of the substances. The surveyor wiped the green substance on the side of the ice machine with a clean white paper towel, and a brownish green substance was seen on the paper towel. The MTD ran his finger along the side of the ice machine that had the black substance and had a small quantity of the substance on his finger. The MTD acknowledged the substances and stated it was almost time for his monthly cleaning. The MTD stated the black substance was condensation from the ice machine. The MTD stated the green substance was buildup of water. The MTD stated his main objective was to clean the inside of the machine. The MTD stated he cleaned the inside of the ice machine but did not clean the outside of the ice machine. The CDM stated the front of the machine was the area that was cleaned by the dietary staff. The CDM stated dietary staff always wiped down the front panel/dispensing area only. The CDM stated she thought maintenance did monthly cleaning and they cleaned the whole machine.During an interview with the Dietary Aide (DTA) 1 on 11/19/2025 at 11:40 a.m. in the CDM's office, DTA 1 stated the dietary staff cleaned the front of ice machine every day. DTA 1 stated it was the responsibility of maintenance department to clean the ice machine.During an interview with DTA 2 on 11/19/2025 at 11:54 a.m. in the CDM's office, DTA 2 stated he was unsure how often the ice machine was cleaned. DTA 2 stated a maintenance staff was responsible for cleaning the kitchen floor but was not sure if the maintenance staff was responsible for cleaning the ice machine. DTA 2 stated dietary staff did not know where the cleaning log was because they did not have access to that document.During an interview with DTA 3 on 11/19/2025 at 12:18 p.m. in the CDM's office, DTA 3 stated cleaning the ice machine was a daily responsibility assigned to the aides. DTA3 stated dietary staff were unaware of where the cleaning log was. During an interview with the CDM on 11/19/2025 at 12:40 p.m. in the CDM's office, the CDM stated cleaning the ice machine was a daily responsibility assigned to the aides. The CDM stated she did not realize the dietary staff needed to clean the sides and underneath areas more thoroughly. The CDM stated she did not notice the rust and water buildup on the ice machine. The CDM stated dietary staff, and maintenance should work together to ensure there was no buildup on the ice machine. The CDM stated the ice from the ice machine was served to residents. The CDM stated the expectation from dietary staff was that daily attention was needed for exterior surfaces. The CDM stated cross contamination could occur and residents could get sick. The CDM stated it was important that both the outside and inside of the machine be cleaned regularly.During a concurrent interview and record review with the Administrator (ADM) and the Director of Nursing (DON) on 11/19/2025 at 5:05 p.m. in the DON's office, the pictures of the ice machine showing white, black and green substances on the exterior side of the ice machine, the picture of the clean white paper towel showing a brownish green substance and the picture of the MTD's finger with a small quantity of black substance from running his finger along the side of the ice machine were reviewed. The ADM and DON confirmed the presence of the substances. The DON and the ADM stated they were unaware of the substances on the ice machine. The ADM stated the substance looked like a collection of dirt. The DON stated the outside of the ice machine would not create a concern for her, for the residents or for the ice to get cross contaminated. The DON stated that staff were expected to keep the ice machine clean both inside and outside. The DON stated that cleaning the ice machine was important for maintaining infection control practices and environmental cleanliness, as well as for reducing the potential for bacterial growth, illness, or other health risk. The DON stated a clean environment promotes good health. The DON stated that the facility would initiate plans to add ice machine cleanliness monitoring to the facility's quality assurance and performance improvement (QAPI) programA review of the facility document titled, Job description: Dietary Supervisor (DS), dated 9/2016, the DS indicated, General Purpose. The Dietary Supervisor will . maintain area and equipment in sanitary condition. Essential Duties .Maintain kitchen and food storage area in a safe, orderly, clean and sanitary manner.During a review of the facility's document titled, MW, undated, the MW indicated, {Named} Ice Systems, . User Responsibility: The product must be installed, cleaned and maintained as described in the Manual furnished with the product.It is the User's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained.During a review of the facility's document titled, AWM, 10/2016, the AWM indicated, .Exterior Panels-The front, top and side panels are durable stainless steel. Fingerprints, dust and grease will require cleaning .During the review of the 2022 Food and Drug Administration (FDA) Food Code, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated, .C. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris .

Based on observation, interview, and record review, the facility failed to ensure food storage was stored under sanitary conditions in accordance with professional standards for food service safety when: 1. A large plastic container of rice was in the dry storage pantry without a label and did not have an opened date or an expiration date. 2. Freezer 1 of 2 was observed without an internal thermometer. Refrigerator 1 of 3 was observed without an internal thermometer (a tool used to measure how hot or cold something is). These failures had the potential to contribute to the growth of foodborne pathogens (a tiny organism, like a germ, that could cause disease. Pathogens included things like bacteria, viruses and fungi) and posed a risk of foodborne illness (any illness resulting from eating contaminated/spoiled foods) symptoms which could range from nausea, vomiting, diarrhea, abdominal pain, fever, headache, and confusion to residents who received meals and nourishment from the facility's kitchen. Findings: 1. During a concurrent interview and observation on 5/13/25 at 8:22 a.m. with the Certified Dietary Manager (CDM), in the dry storage pantry, a large clear plastic container of rice had no label, open date or expiration date. The CDM stated, her expectation is that all food in the dry storage should be labeled with what the food item was, the open date and expiration date to prevent residents from receiving old or expired food. During an interview on 5/16/25 at 3:15 p.m. with the Registered Dietitian (RD), the RD stated, all foods in pantry need to label with name of food, open date and expiration date. The RD stated, if the food is not labeled correctly, it increases the risk of residents being served expired food or food, they may have an allergy to resulting in food born illness and possibly death. 2. During a concurrent interview and observation on 5/13/25 at 8:39 a.m. with the CDM in the kitchen , one of two freezers did not have an internal thermometer. The CDM stated, a thermometer was required inside of every freezer. The CDM stated the temperatures were to be taken every morning and documented in a temperature log book to prevent food from going into the Danger Zone (temperatures above 41 degrees Fahrenheit (F - unit of measure) and below 32 degrees F for cold storage. Food that goes into the Danger Zone could spoil, and bacterial growth could begin and expose residents to food borne illness). During a concurrent observation and interview on 5/13/25 at 8:41 a.m. with the CDM in the kitchen, one of three refrigerators did not have an internal thermometer . The CDM stated the refrigerator should have had an internal thermometer to monitor the temperature inside the refrigerator to ensure food is being kept at a temperature to prevent bacterial growth and resident food born illness. During an interview on 5/16/25 at 3:18 p.m. with the RD, the RD stated, every refrigerator and freezer need to have a working internal thermometer that was to be monitored to prevent food from being out of safe food storage temperatures . The RD statd the refrigerator needed to be maintained between 34- to 39-degrees F, and the freezer needs to be maintained below these temperatures, if not the food will lose freshness and will not be safe, resulting in possible food born illness for the residents. During a review of the facility's policy and procedure (P&P), titled Food Preparation and Service, dated 11/2022, indicated, . Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices . thermometers need to be kept clean and calibrated to ensure food safety and to prevent food born illness . During a review of California Code of Regulations, Title 22 - Social Security Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, Chapter 8.5 - Intermediate Care Facilities/Developmentally Disabled-Habilitative Article 3 - Services Section 76888 - Food and Nutrition Services-Food Storage, Universal Citation: 22 CA Code of Regs 76888 dated December 27, 2024, indicated, . All readily perishable foods or beverages shall be maintained at temperatures of 7°C (45°F) or below, or at 60°C (140°F) or above, always, except during necessary periods of preparation and service. Frozen foods shall be always stored at minus 18°C (0°F) or below. There shall be an accurate thermometer in each refrigerator and freezer and in any other storage space used for perishable food .

Based on interview and record review, the facility failed to develop a comprehensive resident-centered care plans for 11 of 24 sampled residents (Residents 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79) when the Activities Director (AD) did not develop resident-centered activity care plans for Residents 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79 since their admission to the facility. These failures resulted in Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79 not having activities they could engage in, which could lead to boredom, loss of interest, inactivity, depression, feelings of isolation and decreased socialization with others while residing in the facility. Findings: During a review of Resident 7's admission Record (AR- a document containing resident profile information) dated 5/16/25, the AR indicated, Resident 7 was admitted to the facility with diagnoses which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dysphagia (difficulty swallowing), and contractures (stiffening/shortening at any point, that reduces the joint's range of motion) of right and left hand. During a review of Resident 12's AR dated 5/16/25, the AR indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dysphagia and contracture of left hand. During a review of Resident 18's AR dated 5/16/25, the AR indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses which included emphysema (long-term lung condition that causes shortness of breath), chronic obstructive pulmonary disease (COPD-chronic lung disease causing difficulty in breathing) and Alzheimer's Disease. During a review of Resident 21's AR dated 5/15/25, the AR indicated, Resident 21 was admitted to the facility on [DATE] with diagnoses which included dysphagia, hemiplegia and hemiparesis, and difficulty in walking. During a review of Resident 32's AR dated 5/16/25, the AR indicated Resident 32 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, epilepsy (recurrent seizures[episodes of abnormal brain activity]) and absence of right and left upper limb, absence of right leg below knee and absence of left leg above knee. During a review of Resident 39's AR dated 5/16/25, the AR indicated, Resident 39 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, difficulty in walking, hemiplegia and hemiparesis. During a review of Resident 45's AR dated 5/16/25, the AR indicated Resident 45 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (decrease muscle size and strength) diabetes mellitus (DM-disorder characterized by difficulty in blood sugar control and poor wound healing). During review of Resident 53's AR dated 5/15/25, the AR indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses which included fracture of right femur (break in the longest bone in the body), muscle weakness and respiratory disorder. During a review of Resident 76's AR dated 5/16/25, the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, muscle weakness and osteoporosis (weak and brittle bone). During a review of Resident 78's AR dated 5/16/25, the AR indicated, Resident 78 was admitted to the facility on [DATE] with diagnoses which included DM, muscle weakness and muscle wasting and atrophy. During a review of Resident 79's AR dated 5/16/25, the AR indicated Resident 79 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), depression (persistent low mood or loss of interest in activities for extended periods) and Alzheimer's Disease. During an interview on 5/16/25 at 8:18 a.m. with Activities Director (AD), the AD stated activities were important because the activities helped resident be active, stimulated their minds and was important for their social well-being. The AD stated other residents who are not able to participate in activities were provided one on one activities by the activity assistant. The AD stated she did not know how often residents were provided one on one activity per week. The AD reviewed Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79's activity care plans and stated Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79's care plans had the same focus, goals, and interventions. The AD stated the care plans were not individualized or person-centered to meet the needs of each resident. The AD stated care plans needed to be personalized and addressed the needs of each resident. The AD stated the activity care plans for Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79 were not individualized to their activity needs. The AD stated she was not sure if they were meeting the activity needs of each resident. During a concurrent interview and record review on 5/16/25 at 9:17 a.m. with Activities Assistant (AA), the AA reviewed activities electronic charting and stated she did not have a list of residents who were needing one on one activities. The AA stated every morning, she went down the hallways to resident rooms and distributed coffee or any beverages and snacks to all residents. The AA stated she provided one on one to residents by spending few minutes with each resident talking with them while distributing snacks/coffee. The AA stated, I think in a week, I visit residents at least once and spent at least five minutes talking with them. The AA stated she thinks activities provided was enough to meet each resident's activity needs. The AA stated she did not know the care plans for each residents, she went around and talked to each resident. During an interview on 5/20/25 at 4:15 p.m. with the Director of Nursing (DON) the DON stated activities care plans were the responsibilities of the AD. The DON stated she talked with the AD regarding care plans and that the care plans had to be individualized and addressed the needs of each residents. The DON stated care plans should be personalized because not all residents are the same. During a review of facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, .A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team [IDT-group of individuals from different backgrounds who collaborate to achieve a common goal], with input from the resident, and his/her family or legal representative . The care plan intervention should be derived from information obtained from the resident and his/her family/responsible party . Includes measurable objectives and times frames . During a review of facility's policy and procedure titled, Activity Programs, dated 8/2006, the P&P indicated, .Our activity programs are designed to encourage maximum participation and are geared to the resident's needs . consist of individual and small and large group activities that are designed to meet the needs and interests of each resident . Activities include but are not limited to, daily coffee social, birthday and holiday parties .

Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of quality of care for seven out of 12 sampled Residents (Residents 24, 27, 29, 48, 56, 58, and 143) when: 1. Resident 24 and Resident 29's oxygen (a colorless, odorless, tasteless gas essential to living organism) flow rate (the amount of oxygen being delivered to the body) were not administered according to their physician order. These failures resulted in Resident 24 and Resident 29 to not received the prescribed amount of oxygen via oxygen concentrator (a machine that pulls in oxygen from the surrounding air) and placed Resident 24 at risk for breathing problems which could include difficulty breathing, headache, and confusion. 2. No Oxygen in Use signage outside of Resident 143's room. This failure had the potential to result in Resident 143's accidental burn. 3. Resident 58 had a physician's order for oxygen at 3 liters per minute (LPM- unit of measurement) and she was receiving 2.5 LPM. This failure had the potential to place Resident 58's safety at risk by developing hypoxia (a condition where the body's tissues do not receive enough oxygen) and her specific needs not being met . 4. The facility failed to follow their policy and procedure (P&P) Change in Resident's Condition or Status for Resident 48 when he had an unwitnessed fall and the physician was not notified, nor a change in condition completed. This failure put Resident 48's safety at risk by not addressing his fall, increasing the risk of additional fallsand his specific needs not met . 5. Resident 27 was high fall risk for falls, had a physician order for a Dycem (a flexible, non-slip material used to stabilize surfaces and objects) device to be placed on the wheelchair which was not in place during observation and was falsely documented as presented by the nursing staff. This failure resulted in wheelchair instability and increased the risk of falls and injury. 6. Resident 27 had a physician order for a Magnetic resonance imaging (MRI - medical imaging used to create detailed, non-invasive images of the body's internal structures, to help doctors diagnose a wide range of conditions and monitor treatment effectiveness.) -due to gait instability and full history which was not scheduled or completed. This failure had the potential to result in delayed diagnosis and treatment for Resident 27. 7. Resident 56 was administered 4 L/min (liters-unit of measurement)/min (minute) of oxygen via Nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 2L/min of oxygen per physician's order. This failure had the potential to put Resident 56 at risk for oxygen toxicity (lung damage that can occur from breathing in too much extra oxygen which can cause coughing and troubled breathing. 8. Resident 56 had a physician order for a left knee X-ray (a type of electromagnetic radiation that can pass through certain objects, including the human body) due to pain which was not completed and marked completed in the electronic charting system without follow up. This failure had the potential to delay treatment for Resident 56. Findings: 1. During a concurrent observation and interview on 5/13/25 at 9:10 a.m. during initial tour in Resident 24's room, Resident 24 was lying in bed, eyes closed and TV on. Resident 24 stated he needed the oxygen to help him breath. Resident 24's oxygen flow rate on the oxygen concentrator indicated 3 l/minute via (through) nasal cannula (NC-a tube used to deliver supplemental oxygen through the nose), During a review of Resident 24's admission Record, (AR-a document with personal identifiable and medical information), dated 5/15/25, the AR indicated Resident 24 was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness and end stage renal disease (ESRD-irreversible kidney failure). During a review of Resident 24's Medication Review Report (MRR) dated 5/15/25, the MRR indicated, .O2 [oxygen] 2 [two] LPM [liters per minute] VIA NASAL CANNULA PRN PER CONCENTRATOR /TANK as needed . During an observation on 5/13/25 at 8:59 a.m. during initial tour in Resident 29's room. Resident 29 observed lying in bed eyes closed and did not answer questions asked. Resident 29's bed was in lowest position and cup of water placed on top of overbed table positioned across the bed. Resident 29 observed with oxygen via NC connected to oxygen concentrator. Resident 29's oxygen flow rate was between 2.5 L and 3L. During a review of Resident 29's oxygen order dated 5/20/25, the order indicated, .O2 2 LPM VIA NASAL CANNULA PER CONCENTRATOR/TANK . During an interview on 5/13/25 at 8:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated oxygen flow rate should be according to physician order. LVN 1 stated, We could not give more than the ordered rate of oxygen. LVN 1 stated giving more oxygen to residents could cause hyperventilation (condition where a person breathes rapidly and deeply, leading to a decrease in the amount of carbon dioxide in the blood) which could result in more serious condition. LVN 1 stated she was the nurse for Resident 24 and Resident 29 and she did not check the flow rate of their oxygen when she administered their medications. During a concurrent interview and record review on 5/13/25 at 9:15 a.m. with Treatment Nurse (TXN), the TXN checked Resident 24's oxygen flow rate and stated, Oxygen is set at 3L/min. TXN reviewed Resident 24's oxygen order and stated Resident 24's oxygen order was 2L/min. TXN checked Resident 29's oxygen flow rate and stated, Oxygen is set between 2.5L/min and 3L/min. TXN reviewed Resident 29's oxygen order and stated, His [Resident 29] oxygen order is 2L/min. TXN stated Resident 24 and Resident 29 were receiving more than the ordered amount of oxygen prescribed by their physician and could lead to more serious respiratory problem. During a concurrent interview and record review on 5/15/25 at 2:15 p.m. with LVN 2, Resident 24's clinical record was reviewed. LVN 2 stated Resident 24's oxygen order was 2L/min via NC. LVN 2 stated licensed nurses were responsible in making sure physician order for oxygen were followed. LVN 2 stated residents receiving more than the ordered oxygen flow rate could, increases the amount of carbon dioxide [CO2-naturally occurring gas in the atmosphere] in the blood and decrease the amount of oxygen into the blood which could lead to delirium [a serious disturbance in a person's mental abilities], lethargy[feeling unusually tired, sluggish, or lacking in energy], cyanotic [bluish or purplish discoloration of the skin, lips, or nail beds caused by a lack of oxygen in the blood] and leads to cardiovascular issues. During an interview on 5/20/25 at 3:58 p.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses to follow physician's orders for oxygen flow rate. The DON stated residents not receiving the correct physician order for oxygen could lead to respiratory problems. During a review of facility policy and procedure (P&P) titled, Physician Orders, Accepting, Transcribing, Carrying Out and Implementing (Noting), undated, the P&P indicated, .Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented . Appropriate dose administration times are established for each medication per facility guidelines . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . 2. During a review of Resident 143's admission Record, undated, the AR indicated, Resident 143 was admitted to facility on 5/3/25 with diagnoses which included muscle weakness, anemia (a condition where the body does not have enough healthy red blood cells), and syncope (fainting or passing out) and colllapse (to fall or cave in). During a review of Resident 143's Order Summary Report, undated, the Order Summary Report, indicated, . O2 2 LPM VIA NASAL CANNULA PER CONCENTRATOR/TANK . During observation on 5/13/25 at 8:30 a.m. during initial tour in Resident 143's room, Resident 143 was lying in bed and observed with oxygen via NC. Resident 143 refused to answer question asked. No signage outside of Resident 143's doorway to indicated use of oxygen in the room. During an interview on 5/13/25 at 8:35 a.m. with TXN, the TXN stated there should have been a signage outside of Resident 143's room to let people (visitors and families) know oxygen was being used in the room. TXN stated it was important to put signage outside the door for safety issues. During an interview on 5/20/25 at 4:05 p.m. with the DON, the DON stated it was important to ensure Oxygen in Use signage was placed outside the doors of residents using oxygen. The DON stated it was for safety issue. The DON stated it was the responsibility of all staff to ensure there was signage outside of each resident using oxygen. The DON stated, It was a team effort, if no signage or if sign fell on the ground to pick up the sign and placed outside residents' door. During a review of facility policy and procedure (P&P) titled Oxygen Administration dated 10/2010, the P&P indicated, . The following equipment and supplies will be necessary when performing this procedure . No Smoking/Oxygen in Use signs . Place an Oxygen in Use sign on the outside of the room entrance door . Place an Oxygen in Use sign in a designated place . 3. During an observation on 5/13/25 at 8:32 a.m., in Resident 58's room, Resident 58 was receiving oxygen from an oxygen concentrator that was set at 2.5 LPM. During a concurrent observation and interview on 5/14/25 at 10:50 a.m., in Resident 58's room with Licensed Vocational Nurse (LVN) 4, Resident 58 was receiving oxygen from an oxygen concentrator that was set at 2.5 LPM. LVN 4 stated Resident 58 had a physician order for her oxygen to be running at 3 LPM, but it was running at 2.5 LPM. LVN 4 stated she was the nurse responsible for Resident 58 and the physician orders should have been followed and they were not. During a review of Resident 58's AR, dated 5/20/25, the AR indicated, Resident 58 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a lung disease that causes chronic inflammation and narrowing of the airways, making it difficult to breathe) with (acute) exacerbation (a flare-up where symptoms become significantly more severe than usual and require immediate attention) and dependence on supplemental oxygen (provides extra oxygen to people who have trouble breathing and are not getting enough oxygen from their lungs alone). During a review of Resident 58's MDS assessment, dated 3/31/25, the MDS assessment indicated Resident 58's BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15. The BIMS assessment indicated Resident 58 was cognitively intact. During a review of Resident 58's Medication Review Report (MRR), dated 5/20/25, the MRR indicated, .Order Summary: . Continuous O2 3L [Liters- unit of measurement] via NC [Nasal Cannula- a simple, flexible tube with two prongs that fit inside your nostrils that is used to deliver extra oxygen] per concentrator/tank related too Diagnosis of Acute Respiratory Failure [a life-threatening emergency your lungs aren't working properly to get enough oxygen into your blood and/or remove carbon dioxide] with Hypoxia [a condition where the body's tissues do not receive enough oxygen] . Active . Order date: 5/13/25 . Start date: 5/13/25 . During an interview on 5/16/25 at 1:55 p.m., with LVN 8, LVN 8 stated that she was Resident 58's nurse on 5/13/25. LVN 8 stated the oxygen was not set at what the physician had ordered (was 3 LPM at that time). LVN 8 stated it was important to follow the physician's order and they did not. LVN 8 stated Resident 58 did not receive the appropriate amount of oxygen and that could have caused respiratory distress, which could have resulted in hospitalization. During an interview on 5/20/25 at 1:38 p.m., with the Director of Nursing (DON), the DON stated it was important to follow the physician's order so their plan of care is supported. The DON stated Resident 58 would have been receiving clinically subtherapeutic oxygen delivery. The DON stated there was potential for Resident 58 to become hypoxic (a condition where the body's tissues do not receive enough oxygen). The DON stated the facility did not follow the policy and procedure Oxygen Administration. During an interview on 5/20/25 at 2:27 p.m., with the Unit Nurse Supervisor (UNS), the UNS stated the expectation for nursing staff was to set the oxygen rate exactly per the physician order. The UNS stated if the oxygen was not set per the physician order than the resident could go into respiratory distress and have complications. The UNS the policy and procedure for Oxygen Administration was not followed. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, dated October 2010, the P&P indicated, .Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . During a review of RegisteredNursing.org professional reference titled, Does a Nurse Always Have to Follow a Doctor's Orders?, dated 1/18/25, (found at https://www.registerednursing.org/articles/does-nurse-always-follow-doctors-orders/#:~:text=Unless%20there%20is%20a%20safety,not%20follow%20a%20doctor's%20order.) the reference indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed neglect. During a review of the National Library of Medicine professional reference titled, Nursing Rights of Medication Administration, dated 9/4/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK560654/) the reference indicated, .Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration . Right Dose . Patient safety and quality of care are essential components of nursing practice and priorities that demand consideration to enable the delivery of high-quality, patient-centered care, and overall well-being. Medical errors are unfortunately very common in clinical practice, and in addition to compromising a patient's personal safety . 4. During a review of Resident 48's Progress Notes (PN), dated 5/2/25 at 1:31 p.m., the PN indicated, . Created by: LVN 4 . Resident [48] found on floor next to his bed at 1 p.m., no injury noted, staff assist resident back to bed, resident stated that he was going to the bathroom, educated resident the use of call light for assistant. Resident thinks that he can walk, writer asked Spanish speaking staff to explain that we can help resident with all needs, resident verbalize understanding. Bed to lowest position, placed floor mats too both sides, Will continue to monitor . During a review of Resident 48's AR, dated 5/20/25, the admission Record indicated, Resident 48 was admitted to the facility on [DATE] with a diagnosis of difficulty in walking, muscle weakness. During a review of Resident 48's MDS assessment, dated 5/2/25, the MDS assessment indicated Resident 48's BIMS assessment score was 7 out of 15. The BIMS assessment indicated Resident 48 was severely cognitively impaired. During an interview on 5/16/25 at 2:05 p.m., with LVN 8, LVN 8 stated if a resident was found on the ground it would be an unwitnessed fall. LVN 8 stated if the resident was found on the ground and has issues communicating, they were to contact the responsible party (RP), notify the DON and the physician. During an interview and record review on 5/20/25 at 1:43 p.m., with the DON, Resident 48's Electronic Medical Record (EMR) was reviewed. The EMR indicated Resident 48 had an unwitnessed fall which occurred on 5/2/25 at 1:31 p.m., but there was no physician notification, nor change of condition completed. The DON stated she was not aware of this fall that was documented in PN. The DON stated the physician was to be made aware of the fall as well and nothing was documented that he was. The DON stated Resident 48 had a fall that same day at 2 a.m. that everyone knew about, but not the 1:31 p.m. fall. The DON stated a change of condition should have been completed for the second fall and it was not per the EMR. The DON stated the P&P Change in Resident's Condition or Status was not followed. The DON stated because it was not followed Resident 48 could have had another fall due to lack of staff support strategies for future fall prevention. During an interview on 5/20/25 at 2:32 p.m., with the Unit Nurse Supervisor (UNS), the UNS stated for an unwitnessed fall a nurse should have notified a physician and completed a change of condition to adjust the plan of care. The UNS stated if this was not done the resident could have an injury from another fall. The UNS stated that a person had a second fall in the same day they would need additional fall interventions put in place. There was an attempt to interview LVN 4 on 5/20/25 at 5 p.m., but she refused to comment on the incident. During a review of the facilities P&P titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, .Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical . and/or status (e.g. [for example] changes in level of care . etc . Policy Interpretation and Implementation . The nurse will notify the resident's attending physician or physician on call when there has been a: a. accident or incident involving the resident .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . there is a significant change in the resident's physical . status . 5. During a review of Resident 27's AR dated 5/16/2025, the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included Polyneuropathy (a condition where multiple nerves become damaged or dysfunctional throughout the body), difficulty in walking and history of falls. During a concurrent observation and interview on 5/16/25 at 9:26 a.m. with Resident 27 in Resident 27's room, Resident 27 sat at the edge of the bed, dressed in shorts and a tee shirt with compression socks on, and Resident 27's wheelchair was next to the bed. Resident 27's wheelchair was noted to have a seat cover with a picture of black and white feathers with red color accents on the feathers, No Dycem slip prevention mat was seen. Resident 27 stated she fell out of her wheelchair, outside the facility on 5/14/25 at night coming back from the market next door. During an interview on 5/16/25 at 10:17 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 27 told her she fell on Wednesday night (5/14/25). CNA 4 acknowledged Resident 27 should have prevention interventions in place, to keep Resident 27 safe from falls. Durning an observation on 5/20/25 at 10:07 a.m. Resident 27 was observed sitting on the wheelchair. Resident 27 stated the Dycem was not on her chair. Durning a concurrent interview and record review on 5/20/25 at 4:16 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 27's Medication Administration Record (MAR), dated 5/20/25 was reviewed. The MAR indicated LVN 3 had document on multiple dates of monitoring for Dycem to prevent resident from sliding off. Monitor placement every shift for fall prevention, start date 10/22/2024. LVN 3 stated she had knowledge of Resident 27's fall on 5/14/25. LVN 3 stated she did document the placement of the Dycem was on the wheelchair, LVN 3 stated she did not see the Dycem and should not have documented falsely. Durning a concurrent interview and record review on 5/20/25 at 4:59 p.m. with the Unit Nurse Supervisor (UNS), Resident 27's MAR dated 5/20/25 was reviewed. The MAR indicated on 5/16/25 for the dayshift time, the UNS confirmed her initials, documented confirmed placement and monitoring of the Dycem. The UNS stated she did not personally see the placement and should not have documented falsely. The UNS stated she was not performing to facility expectation of documentation. Durning an interview on 5/20/25 at 4:34 p.m. with the DON, the DON stated it is the expectation for the facility staff to document accurately and for the physician orders to be fulfilled. During a review of the facility's policy and procedures (P&P) tilted Charting and Documentation, dated April 2008, indicated .All observations, medications administered, services preformed .must be documented in the resident's medical record .Documentation .include at a minimum .assessment data and/or any unusual findings . 6. During a concurrent interview and record review on 5/16/25 at 2:30 p.m. with the DON, Resident 27's Progress notes, dated 5/8/25 were reviewed. The progress notes indicated, .follow up appointment orders .Outpatient referral for MRI due to gait inability . The DON acknowledged this note made on 5/8/25 as orders to follow, author indicated LVN 5. DON indicated the order was not carried out timely, the DON stated the expectation of the nursing staff was to complete the order as soon as possible for the accurate assessment of Resident 27. Durning an interview on 5/20/25 at 4:16 p.m. with LVN 5, LVN 5 was unable to provide a clinical rationale why the physician's orders of an MRI for Resident 27 had not been completed. During a review of the facility's P&P titled Lab and Diagnostic Test results-Clinical Protocol, dated November 2018, the P&P indicated, .physician identify and order diagnostic and lab testing based on the residents' .monitoring needs. The staff will process test requisitions and arrange for test .A nurse will determine whether the test was done . During a review of National Center for Biotechnology Informatiom.gov Professional Reference titled, Legal Implications- Nursing Management and Professional Concepts, dated 2024, (found at https://www.ncbi.nlm.nih.gov/books/NBK610473/#:~:text=A%20nurse%20may%20be%20charged,revocation%20of%20a%20nurse%27s%20license.) the reference indicated, .A nurse may be charged with fraud for documenting interventions not preformed or altering documentation cover up an error. Fraud can result in civil and criminal charges and also suspension or revocation of a nurse's license . During a review of My American Nurse. Com Professional Reference titled, Understand the risk of erroneous and incomplete documentation, dated 8/7/23, (found at https://www.myamericannurse.com/proper-documentation-protects-patients-and-your-license/#:~:text=Takeaways:,or%20licensing%20board%20disciplinary%20action) the reference indicated, .Nursing documentation plays a critical role in healthcare. Errors or incomplete information can affect data accuracy and ultimately best practices. Improper documentation also can contribute to adverse, sometimes fatal, patient outcomes. When you document completely and accurately, you reduce your liability risk and have the strongest legal defense in the event of a malpractice lawsuit or licensing board disciplinary action . 7. During a Review of Resident 56's AR dated 5/20/25, the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and Asthma (a chronic lung condition making it difficult to breathe). During a concurrent observation and interview on 5/13/25 at 8:43 a.m. in Resident 56's room, Resident 56 was sitting in her wheelchair with oxygen via nasal cannula receiving 4L/min. Resident 56 stated she was always feeling short of breath, normally had oxygen on. During a concurrent interview and record review on 5/13/25 at 4:27 p.m. with LVN 3, Resident 56's order summary was reviewed, the order summary indicated Resident 56 should be receiving 2L/min of oxygen via NC ordered by the physician. LVN 3 checked Resident 56's oxygen setting and confirmed the resident was receiving 4 l/min of oxygen via NC. LVN 3 stated Resident 56 should not receive 4 l/min of oxygen that is not the physician order. LVN 3 stated she will monitor Resident 56, and inform the doctor, as well as update the care plan. LVN 3 stated it is important for Resident 56 who has diagnosis of COPD to not over inflate the lungs placing a lot of pressure on her lungs and it can lead to other issues like confusion. During an interview on 5/15/25 at 3:12 p.m. with the DON in the DONs office. The DON stated it was the expectation of the nurses to follow the physician orders as stated. During a review of the facility's policy and procedures (P&P) tilted Oxygen Administration, dated October 2010, indicated .Verify that there is a physician's order .review the physician's orders or facility protocol for oxygen administration .after completing the oxygen setup or adjustment, the following information should be recorded .the rate of oxygen flow . 8. During a record review on 5/15/25 at 9:20 a.m. of Resident 56's Progress notes dated 5/5/25, the progress note indicated the medical doctor gave a telephone order for a 3 view x-ray to the knee of Resident 56, and a copy of the order and face sheet was sent to via fax. During an interview on 5/15/25 at 11:14 a.m. with Resident 56, Resident 56 stated she was unable to bare weight on her left leg. Resident 56 stated she did not fall but did slip and head her left knee pop. Resident 56 stated the facility informed her she would get an x ray and it was not done. Resident 56 expressed frustration on being told something and not being done. During an interview on 5/15/25 at 2:17 p.m. with LVN 1, LVN 1 was unable to provide confirmation the x-ray was completed. LVN 1 stated the order was marked as complete, and results were not found. LVN 1 stated she cannot confirm the order was completed. LVN 1 stated the nurses had to carry out the physican orders as soon as possible and the nurses needed to communicate orders to each other via hand off report (verbal communication between shifts). During an interview on 5/15/25 at 3:12 p.m. with the DON, the DON acknowledged the order was not completed, and the x-ray person did not receive a fax about Resident 56. DON stated it is the expectation of orders to be carried out, this order was missed. During a review of the facility's P&P titled Lab and Diagnostic Test results-Clinical Protocol, dated November 2018, the P&P indicated, .physician identify and order diagnostic and lab testing based on the residents' .monitoring needs. The staff will process test requisitions and arrange for test .A nurse will determine whether the test was done . During a review of the facility's P&P titled Physician orders, accepting, transcribing, carrying out and implementing (Noting) undated, the P&P indicated, Licensed nursing During a review of the facility's P&P titled Physician orders, accepting, transcribing, carrying out and implementing (Noting) undated, the P&P indicated, Licensed nursing personnel will ensure .all physician orders are to be completed and clearly defined to ensure accurate implementation . During a review of Job Description: LPN/LVN dated February 2024, the Charting and Documentation indicated Receive .orders from physicians and record on the Physicians' Order Form. Transcribe physician's order to resident charts, cardex, medication cards, treatment/ care plans, as required .Nursing Care Functions Requisition and arrange for diagnostic and therapeutic services, as order by the physician, and in accordance with our established procedures. Review the resident's chart for specific treatments, medication orders, diets, ect., as necessary. Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotion status .

Based on observation, interview and record review, the facility failed to ensure a hazard free environment and adequate supervision to prevent accidents was provided for two of three sampled residents (Resident 23 and Resident 27) when: 1. Resident 23 was using two phone books covered with duct tape as a step-stool to assist in getting up into bed that were made by therapy staff. This failure put Resident 23's safety at risk by creating a hazardous environment that could have caused an accident or fall. 2. The facility failed to ensure Resident 27 received adequate supervision to prevent accidents despite being identified as a high fall risk. This failure resulted in repeated falls and unsafe situations, with an increased risk of potential bodily harm. Findings: 1. During a current observation and interview on 5/14/25 at 10:08 a.m., with Resident 23, in Resident 23's room, Resident 23 stepped on two blocks made of duct tape (a very strong adhesive tape with a waterproof backing, used to seal home ducts, hoses) to get into her bed. Resident 23 stated rehab made them for her and she needed to step on them to get in and out of bed. Resident 23 stated she was unsure of what they were made of. During a review of Resident 23's admission Record (AR-a document containing resident profile information), dated 5/20/25, the AR indicated, Resident 23 was admitted to the facility on [DATE] with diagnosis of muscle weakness, morbid (severe) obesity (a chronic condition characterized by an excessive accumulation of body fat that can negatively impact health), muscle wasting (when muscles shrink and become weaker) and atrophy (gradual wasting away or shrinking), unsteadiness on feet, ataxic gait (a wobbly, unsteady, and uncoordinated way of walking), chronic pain and other abnormalities of gait and mobility (movement). During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 4/29/25, the MDS assessment indicated Resident 23's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 13 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 23 was cognitively intact. During an interview on 5/15/25 at 3:17 p.m., with the Director of Rehabilitation (DOR), the DOR stated the two blocks were actually phone books covered with duct tape. The DOR stated a facility staff member, Occupational Therapist (OT) 1, made the blocks. The DOR stated the phone books (a physical book that is like a directory or list of names, addresses, and phone numbers of people and businesses in a particular area) were designed to be a therapeutic intervention , but they were not appropriate. The DOR stated the stepping stool made of phone books was a potential safety hazard and could have increased Resident 23's risk for a falls because, she could slip. The DOR stated the facilities policy and procedure Staff Physical Therapist and Clinical Standards of Practice were not followed. During an interview on 5/16/25 at 1:55 p.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 stated she had seen the phone books since January 2025 in Resident 23's room. LVN 8 stated she used them to help her get into bed. LVN 8 stated that Resident 23 could trip on them and they were a safety concern. LVN 8 stated she never said anything to anyone because she used them all the time. During an interview on 5/16/25 at 3:43 p.m., with OT 1, OT 1 stated Resident 23 used them for positioning. OT 1 stated that he did make the blocks and they were phone books wrapped in duct-tape. OT 1 stated the phone books were never intended to be used as an everyday thing and were not made for her to step on the bed. OT 1 stated she needed to be ordered something specifically for stepping on the bed, but that got overlooked. OT 1 stated the way Resident 23 used the blocks would have increased her fall risk During an interview on 5/20/25 at 1:29 p.m., with the Director of Nursing (DON), the DON stated the blocks were not the facilities preferred use for getting up into bed. The DON stated the blocks could have been safer and they were not appropriate. The DON stated the facilities policy and procedures Staff Physical Therapist and Clinical Standards of Practice were not followed. During an interview on 5/20/25 at 2:23 p.m., with the Unit Nurse Supervisor (UNS), the UNS stated the blocks should not have been used by Resident 23. The UNS stated they were a safety issue for the resident and the blocks were not professional. The UNS stated the facilities policy and procedures Staff Physical Therapist and Clinical Standards of Practice were not followed. During a review of the facility's policy and procedure (P&P) titled, Staff Physical Therapist undated, the P&P indicated, .General Purpose: The staff Physical Therapist evaluates and treats patients . Essential Duties: . Recommend and facilitate the ordering of necessary durable medical equipment for patients . Report any problems with department equipment so that it is maintained in good working order . During a review of the facility's P&P titled, Clinical Standards of Practice, undated, the P&P indicated, .All rehab services are delivered in a professional and quality manner . 2. During an interview on 5/15/25 at 3:22 p.m. with the DON, in the DON's office, Resident 27 was observed through a large window, propelling her wheelchair unsupervised out of the facility's parking lot toward the adjacent street. During a review of Resident 27's AR dated 5/16/2025, the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included Polyneuropathy (a condition where multiple nerves become damaged or dysfunctional throughout the body), difficulty in walking and history of falls. During a review of Resident 27 ' s Minimum Data Set assessment, dated 4/7/25, the MDS assessment indicated Resident 27 ' s BIMS assessment score was 14 out of 15. The BIMS assessment indicated Resident 128 was cognitively intact. During an interview on 5/16/25 at 9:26 a.m. with Resident 27, in Resident 27's room. Resident 27 stated she was coming back from the Asian market around the corner. Resident 27 stated it was dark at this time, and she could not get her wheelchair over the bump in the pavement, I flipped over. Resident 27 stated she hit the ground hard and could not get herself back up and into her chair. Resident 27 stated she laid there on the ground, yelling for help. Resident 27 shared her call history on her personal cellphone with multiple calls to the facility and nobody answered, nobody came. Resident 27 stated eventually, she somehow got herself back in the chair and into the facility. Resident 27 stated she reported her fall. Resident expressed frustration with inconsistent support and the feel of needing help. Resident 27 stated, I don't feel I have anyone to advocate for me. During an interview on 5/16/25 at 10:17 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated, Resident 27 does a lot on her own, but when she falls it's bad. She told me she hit her head last time. CNA 4 stated when a resident falls, the resident is checked every 15 minutes, but when Resident 27 outside, I don't know. During an interview on 5/20/25 at 9:57 a.m. with the Receptionist, the receptionist stated, Resident 27 would go three times a day to get her cigarettes. The Receptionist stated he's seen Resident 27 go out front alone. The Receptionist stated each residence has a Leave of Absences (LOA) sheet and they are to sign themselves out. The receptionist reported his shift is over at 5 p.m., when the phone rings anyone can answer the phone, because it will ring throughout the facility. During an interview on 5/20/25 at 10:33 AM with LVN 4, LVN 4 stated, she observed Resident 27 leave the facility. LVN 4 stated Resident 27 signs herself out. LVN 4 could not provide documentation of Resident 27 signing herself out. LVN 4 acknowledged Resident 27 as a high fall risk and not knowing when she was off the property. LVN 4 stated when a resident was a high fall risk they were watched closely. LVN 4 was unable to provide clinical evidence of what watching closely was. LVN 4 acknowledged she was responsible for the residents' well-being and needed to provide adequate supervision for Resident 27 who was at high risk for falls. During a review of Resident 27's Progress Note (PN) dated 5/14/25 and Resident 27's call history, the PN and call history, indicated Resident 27 made calls to the facility on 5/14/25 at 8:34 p.m., 8:37 p.m., 8:39 p.m., and 8:40 p.m., with durations ranging from seventeen seconds to two minutes. No documentation was found indicating that staff were aware of the calls or responded to the resident's request for assistance. During a concurrent interview and record review on 5/20/25 at 3:33 p.m. with the DON, the facility's policy and procedure (P&P) titled Fall Prevention Program and Falling Star Program, undated, was reviewed. The P&P indicated, .residents at high risk .a visual identifier placed on the name plaque outside the door .a yellow armband for further identification . The DON acknowledged the resident had not signed the LOA form, and the team did not always know when she left the building. The DON confirmed consistent individualized interventions should have been in place. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, dated December 2007, the P&P indicated, .staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling .If the resident continues to fall, staff will re-evaluate the situation .staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist . 2. During an interview on 5/15/25 at 3:22 p.m. with the DON, in the DON's office, Resident 27 was observed through a large window, propelling her wheelchair unsupervised out of the facility's parking lot toward the adjacent street. During a review of Resident 27's AR dated 5/16/2025, the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses which included Polyneuropathy (a condition where multiple nerves become damaged or dysfunctional throughout the body), difficulty in walking and history of falls. During a review of Resident 27 ' s Minimum Data Set assessment, dated 4/7/25, the MDS assessment indicated Resident 27 ' s BIMS assessment score was 14 out of 15. The BIMS assessment indicated Resident 128 was cognitively intact. During an interview on 5/16/25 at 9:26 a.m. with Resident 27, in Resident 27's room. Resident 27 stated she was coming back from the Asian market around the corner. Resident 27 stated it was dark at this time, and she could not get her wheelchair over the bump in the pavement, I flipped over. Resident 27 stated she hit the ground hard and could not get herself back up and into her chair. Resident 27 stated she laid there on the ground, yelling for help. Resident 27 shared her call history on her personal cellphone with multiple calls to the facility and nobody answered, nobody came. Resident 27 stated eventually, she somehow got herself back in the chair and into the facility. Resident 27 stated she reported her fall. Resident expressed frustration with inconsistent support and the feel of needing help. Resident 27 stated, I don't feel I have anyone to advocate for me. During an interview on 5/16/25 at 10:17 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated, Resident 27 does a lot on her own, but when she falls it's bad. She told me she hit her head last time. CNA 4 stated when a resident falls, the resident was checked every 15 minutes, but when Resident 27 outside, I don't know. During an interview on 5/20/25 at 9:57 a.m. with the Receptionist, the receptionist stated, Resident 27 would go three times a day to get her cigarettes. The Receptionist stated had seen Resident 27 go out front alone. The Receptionist stated each residence has a Leave of Absences (LOA) sheet and they are to sign themselves out. The receptionist stated his shift was over at 5 p.m., when the phone rings anyone could answer the phone, because it will ring throughout the facility. During an interview on 5/20/25 at 10:33 AM with LVN 4, LVN 4 stated, she observed Resident 27 leave the facility. LVN 4 stated Resident 27 signs herself out. LVN 4 could not provide documentation of Resident 27 signing herself out. LVN 4 acknowledged Resident 27 as a high fall risk and not knowing when she was off the property. LVN 4 stated when a resident was a high fall risk they were watched closely. LVN 4 was unable to provide clinical evidence of what watching closely was. LVN 4 acknowledged she was responsible for the residents' well-being and needed to provide adequate supervision for Resident 27 who was at high risk for falls. During a concurrent interview and record review on 5/20/25 at 3:33 p.m. with the DON, the facility's policy and procedure (P&P) titled Fall Prevention Program and Falling Star Program, undated, was reviewed. The P&P indicated, .Residents at high risk .a visual identifier placed on the name plaque outside the door .a yellow armband for further identification . The DON acknowledged the Resident 27 had not signed the LOA form, and the team did not always know when Resident 27 left the building. The DON confirmed consistent individualized interventions should have been in place. During a review of the facility's P&P titled, Falls and Fall Risk, Managing, dated 12/2007, the P&P indicated, .staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling .If the resident continues to fall, staff will re-evaluate the situation .staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist .

Based on observation, interview, and record review, the facility failed to follow its policy and procedures (P&P) titled, Answering the Call Light, for six of 12 sampled residents (Residents 7, 14, 46, 59, 78, and 293) when the staff did not response to Residents 7, 14, 46, 59, 78, and 293's call lights within 5 minutes. These failures had the potential to result in Residents 7, 14, 46, 59, 78, and 293 not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being. Findings: During a concurrent observation and interview on 5/16/25 at 2:58 p.m. with Resident 7 in her room, Resident 7 was lying in bed, and did not respond to any questions. During a review of Resident 7's admission Record (AR-a document containing resident profile information), dated 5/20/25, the AR indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (progressive brain disorder that gradually damages memory, thinking, and other cognitive functions), dysphagia (difficulty swallowing), essential hypertension (a condition where the force of blood against your artery walls is consistently too high), presence of cardiac pacemaker (a small, battery-operated device that helps regulate the heart's rhythm by providing electrical impulses when the heart's natural sinus node isn't functioning properly), all those symptoms and signs involving cognitive (the mental processes involved in knowing, learning, understanding, and thinking) functions and awareness, muscle weakness generalized, hypotension (a condition where blood pressure drops below normal levels), irritable bowel syndrome (a digestive system disorder characterized by abdominal pain and changes in bowel habits, such as diarrhea or constipation), pain, contracture(a condition where muscles, tendons, ligaments, or skin become tight and shortened, limiting the range of motion in a joint) right hand, contracture of muscle left hand, aphasia (loss of ability to understand or express speech caused by brain damage), anemia (a condition where the body has a lower than normal number of red blood cells, or the red blood cells don't function properly, leading to a reduced ability to carry oxygen). During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical function), dated 5/15/25, the MDS section C indicated, Resident 7 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgment) assessment score was not complete, (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). During a review of Resident 7's MDS assessment dated [DATE], the MDS section GG indicated, Resident 7's Functional Abilities included impairment on both sides to the upper and lower extremities, Resident 7 uses wheelchair, Resident 7 is dependent (helper does all the effort, resident does none of the effort to complete self-care) on eating, oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Resident 7 is dependent on roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed to chair transfer. Sit to stand, toilet transfer and tub/shower transfer was not attempted, and Resident 7 did not perform these activity prior to the current illness . During a review of Resident 7's MDS assessment dated [DATE], the MDS section H indicated, Resident 7's Bladder and Bowel function included Resident 7 is always incontinent (no episodes of continent voiding) for urinary continence. Resident 7 is always incontinent (no episodes of continence bowel movement) for bowel continence. During a review of Resident 7's MDS assessment dated [DATE], the MDS section M indicated, Resident 7's Skin Conditions included Resident 7 uses pressure reducing device for chair, and pressure reducing device for bed. During a concurrent observation and interview on 5/16/25 at 2:50 p.m. with Resident 14 in her room, Resident 14 was sitting in bed, with the head of the bed elevated . Resident 14 stated at night, the staff said it should take them 5-10 minutes to answer the call light, but it took them 30-40 minutes. Resident 14 stated it took the CNAs 4.5 hours to respond to the call light on a particular day last month. Resident 14 stated I was in my own dried stool. Why should it take that long? Resident 14 stated Resident 7 had been in her room for 2-3 years, had contracture and could no longer talk. Resident 14 stated she tried to advocate for Resident 7 and was told Resident 7 was none of her concern. Resident 14 stated I don't feel like I am treated with dignity and respect. During a review of Resident 14's AR dated 5/20/25, the AR indicated, Resident 14, was admitted to the facility on [DATE] with diagnoses which included: partial traumatic amputation (surgical procedure involving the removal of all or part of a limb) of left shoulder and upper arm, type 2 diabetes mellitus (a chronic disease characterized by high blood sugar levels) with diabetic neuropathy (nerve damage caused by high blood sugar levels), acquired absence of right upper limb below elbow, acquired absence of right leg below knee, acquired absence of left leg below knee, pain. During a review of Resident 14's MDS assessment dated [DATE], the MDS section C indicated, Resident 14's BIMS assessment score was 15 out of 15. BIMS scores indicated Resident 14 was cognitively intact. During a review of Resident 14's MDS assessment dated [DATE], the MDS section GG indicated, Resident 14's Functional Abilities included impairment on both sides to the upper and lower extremities, Resident 14 uses wheelchair, Resident 14 is dependent on oral hygiene, toileting hygiene, shower/bath self, lower body dressing and personal hygiene. Resident 14 is partial/moderate assistance (helper does less than half the effort in care) on upper body dressing. Resident 14 is dependent on chair/bed to chair transfer and tub/shower transfer. Resident 14 is partial/moderate assistance on roll left and right, sit to lying, lying to sitting on side of bed. During a review of Resident 14's MDS assessment dated [DATE], the MDS section H indicated, Resident 14's Bladder and Bowel function included Resident 14 is frequently incontinent for urinary continence. Resident 14 is frequently incontinent for bowel continence. During a review of Resident 14's MDS assessment dated [DATE], the MDS section M indicated, Resident 14's Skin Conditions included Resident 14 uses pressure reducing device for chair, and pressure reducing device for bed. During a review of Resident 14's MDS assessment dated [DATE], the MDS section N indicated, Resident 14's Medications included Antiplatelets (medications that work by preventing platelets from sticking together and forming clots ). During a concurrent observation and interview on 5/13/25 at 9:37 a.m. with Resident 46 during the initial tour in Resident 46's room, Resident 46 was sitting in her wheelchair looking through some documents. Resident 46 stated I cannot walk. Resident 46 stated, the facility is short-staffed. Resident 46 stated she wheeled herself to the staff before they attend to her. Resident 46 stated it usually took about 20-30 minutes before staff responded to her call light. During a review of Resident 46's AR dated 5/20/25, the AR indicated, Resident 46, was admitted to the facility on [DATE] from acute care hospital with diagnoses which included: heart failure, adult failure to thrive, essential hypertension, specified osteoarthritis (a degenerative joint disease where cartilage breaks down, leading to pain, stiffness, and decreased range of motion), unequal limp length acquired, pain,, history of falling, unspecified protein calorie malnutrition, muscle weakness generalized. During a review of Resident 46's MDS assessment dated [DATE], the MDS section C indicated, Resident 46's BIMS assessment score was 14 out of 15. BIMS scores indicated Resident 46 was cognitively intact. During a review of Resident 46's MDS assessment dated [DATE], the MDS section GG indicated, Resident 46's Functional Abilities included Resident 46 uses walker and wheelchair. During a review of Resident 46's MDS assessment dated [DATE], the MDS section M indicated, Resident 46's Skin Conditions included Resident 46 uses pressure reducing device for chair, and pressure reducing device for bed. During a review of Resident 46's MDS assessment dated [DATE], the MDS section N indicated, Resident 46's Medications included Diuretics (medications that help the body get rid of excess fluid and salt by increasing urine production). During a concurrent observation and interview on 5/13/25 at 10:10 a.m. with Resident 59 during the initial tour in Resident 59's room, Resident 59 was sitting up in bed with the head of the bed elevated, with contracture of the neck to the right watching television. Resident 59 stated staff took too long to respond to the call light. During a review of Resident 59's AR dated 5/20/25, the AR indicated, Resident 59, was admitted to the facility on [DATE] from acute care hospital with diagnoses which included: other intervertebral disc degeneration (condition where cushions between the bones of the spine break down, wear down, or dry out over time), muscle weakness generalized, chronic obstructive pulmonary disease (a progressive lung disease characterized by difficulty breathing due to persistent airflow obstruction),, primary generalized osteoarthritis , , pain, adult failure to thrive . During a review of Resident 59's MDS assessment dated [DATE], the MDS section C indicated, Resident 59's BIMS assessment score was 15 out of 15. BIMS scores indicated Resident 59 was cognitively intact. During a review of Resident 59's MDS assessment dated [DATE], the MDS section GG indicated, Resident 59's Functional Abilities included impairment on one side to the upper extremity, Resident 59 uses wheelchair. Resident 59 is dependent on eating, oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Resident 59 is dependent on roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer . During a review of Resident 59's MDS assessment dated [DATE], the MDS section H indicated, Resident 59's Bladder and Bowel function included Resident 59 is frequently incontinent for urinary continence. Resident 59 is frequently incontinent for bowel continence. During a review of Resident 59's MDS assessment dated [DATE], the MDS section M indicated, Resident 59's Skin Conditions included Resident 59 has Moisture Associated Skin Damage (MASD). Resident 59 uses pressure reducing device for chair, and pressure reducing device for bed. Resident 59 gets application of ointments/ medications. During a review of Resident 59's MDS assessment dated [DATE], the MDS section N indicated, Resident 59's Medications included Diuretics and Antiplatelets. During a concurrent observation and interview on 5/13/25 at 12:46 p.m. with Family Member (FM) 1 in Resident 78's room, Resident 78 was lying in bed with the head of the bed elevated. FM 1 was sitting in room with Resident 78. FM 1 stated, sometimes the CNAs are standing out there doing nothing. FM 1 stated it takes about 20-30 minutes after the call light was initiated before staff respond. FM 1 stated the facility was short staffed. During a concurrent observation and interview on 5/14/25 at 12:10 p.m. with FM 3 in Resident 78's room, Resident 78 was lying in bed with the head of the bed elevated, eating a burger. FM 3 stated resident did not get adequate supervision when eating. FM 3 stated there was no respect and dignity. FM 3 stated, while visiting Resident 78, FM 3 could hear Resident 78 yelling while coming through the facility doors. FM 3 stated Resident 78 was hungry but was ignored. FM 3 stated on another day, FM 3 saw another resident screaming she had to go to the bathroom; the resident was left alone in the hallway and nobody paid attention to the resident. FM 3 stated some of the CNAs don't like being bugged. FM 3 stated when the family members needed anything for Resident 78, FMs go out to where the staff were and let the staff know what Resident 78 needed, and it took staff about 15- 20 minutes to get resident 78 what was needed. FM 3 stated Resident 59 is Resident 78's roommate. FM 3 stated when Resident 59 uses the call light, and it takes more than 15mins for staff to respond then Resident 59 starts yelling out. FM 3 stated I sometimes go out there and tell them Resident 59 needs help. During a review of Resident 78's AR dated 5/20/25, the AR indicated, Resident 78, was admitted to the facility on [DATE] with diagnoses which included: muscle wasting and atrophy (loss of muscle tissue and is often characterized by decreased muscle size and strength), muscle weakness generalized, unspecified abnormality of gait and mobility, type 2 diabetes mellitus, encounter for palliative care (medical consultations focused on providing comfort and support to patients with serious, life-limiting illnesses),retention of urine. During a review of Resident 78's MDS assessment dated [DATE], the MDS section C indicated, Resident 78's BIMS assessment score was 00 out of 15. BIMS scores indicated Resident 78 had severe cognitive deficit. During a review of Resident 78's MDS assessment dated [DATE], the MDS section GG indicated, Resident 78's Functional Abilities included Resident 78 uses wheelchair. Resident 78 is dependent on lower body dressing and putting on/taking off footwear. Resident 78 needs substantial/ maximal assistance (helper does more than half the effort) on toileting hygiene. Resident 78 needs partial/moderate assistance on oral hygiene, shower/bath self, upper body dressing, and personal hygiene. Resident 78 is dependent on sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. Resident 78 needs partial/moderate assistance on roll left and right, sit to lying, and lying to sitting on side of bed. During a review of Resident 78's MDS assessment dated [DATE], the MDS section H indicated, Resident 78's Bladder and Bowel function included Resident 78 has an indwelling urinary catheter for urinary continence. Resident 78 is always incontinent for bowel continence. During a review of Resident 78's MDS assessment dated [DATE], the MDS section M indicated, Resident 78's Skin Conditions included Resident 78 uses pressure reducing device for chair, and pressure reducing device for bed. During a concurrent observation and interview on 5/13/25 at 3:15 p.m. with Resident 293 during the initial tour in Resident 293's room, Resident 293 was lying in bed. Resident 293 stated it takes staff too long to answer the call light. Resident 293 stated it took about 20 -30 minutes for staff to respond. Resident 293 stated this can be frustrating because when I need help, I don't get it on time. During a review of Resident 293's AR dated 5/20/25, the AR indicated, Resident 293 was admitted to the facility on [DATE] with diagnoses which included: disorder of the autonomic nervous system (a condition where the nerves that regulate involuntary bodily functions (like heart rate, blood pressure, digestion) are not functioning correctly), difficulty in walking, muscle weakness generalized, pain due to vascular prosthetic devices implants and grafts (man-made materials used to replace or repair damaged blood vessels), immunodeficiency (a condition where the immune system is unable to effectively fight off infections and diseases), type 2 diabetes mellitus, anemia, unspecified mood affective disorder (mental health conditions characterized by persistent or severe disturbances in mood and emotions), unspecified hearing loss bilateral (hearing loss affecting both ears), essential hypertension, hypertensive heart disease, chronic ischemic heart disease (a condition where the heart muscle receives less oxygen-rich blood due to narrowed or blocked coronary arteries), foot drop right foot, injury of sciatic nerve at hip and thigh level right leg (results in range of symptoms, including pain, numbness, weakness, and difficulty with movement and sensation in the leg and foot) . During a review of Resident 293's MDS assessment dated [DATE], the MDS section C indicated, Resident 293's BIMS assessment score was 12 out of 15. BIMS scores indicated Resident 293 has moderate cognitive deficit. During a review of Resident 293's MDS assessment dated [DATE], the MDS section GG indicated, Resident 293's Functional Abilities included impairment on one side to the lower extremity, Resident 293 uses wheelchair. Resident 293 needs substantial/ maximal assistance on toileting hygiene, shower/bath self, lower body dressing, and putting on/taking off footwear. Resident 293 is partial/moderate assistance on personal hygiene. Resident 293 is partial/moderate assistance on roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. Resident 293 is partial/moderate assistance on picking up objects. During a review of Resident 293's MDS assessment dated [DATE], the MDS section H indicated, Resident 293's Bladder and Bowel function included Resident 293 is occasionally incontinent for urinary continence. During a review of Resident 293's MDS assessment dated [DATE], the MDS section M indicated, Resident 293's Skin Conditions included Resident 293 has Moisture Associated Skin Damage (MASD). Resident 293 uses pressure reducing device for chair, and pressure reducing device for bed. Resident 293 gets application of ointments/ medications. During a review of Resident 293's MDS assessment dated [DATE], the MDS section N indicated, Resident 293's Medications included Anticoagulant (medications that prevent or reduce blood clot formation), Antiplatelets and Hypoglycemic (drugs used to lower blood sugar levels). During a review of the facility's Resident Council Minutes, dated 1/30/25, the document indicated .Review of past month's issues: .Call lights still take too long to respond .floor staff having attitude when responding to call lights. Concerns: Call lights have not improved on all shifts, still having to wait 30 minutes to be assisted with and CNA are still not assisting residents that are not assigned to that CNA. Call light takes too long to respond Call light is being ignored, and CNA will walk past light and yell back that they will be right back . During a review of the facility's Resident Council Minutes, dated 2/26/25, the document indicated .Concerns: Call lights still take too long to respond CNA limit time assisting with residents so they can get to the next resident. {Unnamed} resident states he/she doesn't get clean .Call lights still waiting 30 to 35 minutes to get assisted. Would like floor staff to acknowledge call lights . During a review of the facility's Resident Council Minutes, dated 3/27/25, the document indicated .Concerns: NOC (Night Shift) CNA are responding to call light with attitude when responding to a 30-to-40-minute wait on call light. CNA tells resident to quit messing with the call light . Residents wants more help and staff on floor at PM and NOC shifts to help with call lights . During a review of the facility's Resident Council Minutes, dated 4/25/25, the document indicated .Concerns: CNA at NOC/PM shift takes too long to respond. One night [resident] had to wait 4 hours for a CNA to respond to call light. CNA stated she was busy. CNAs still has attitude when responding to call light. There is no improvement on call lights Residents would like floor staff to be retrained (for the new hires). Residents feel that new floor staff don't know what they are doing. New CNA on the floor needs more training on how to assist a patient and to know how to change patients Wait 30 minutes on call light on PM shift from 3p.m. to 11p.m Call light takes too long to respond to . During the assigned facility task Resident Council dated 5/15/25 at 10:03 a.m. in the facility's dining room, there were concerns of staff not responding to the call light in a timely manner. Resident 14 stated there was no dignity and respect all the time. Resident 14 stated CNAs, especially the new CNAs, have attitude. Resident 14 stated she was given attitude when she told the CNAs regarding Resident 7's care because Resident 7 is unable to talk. Resident 14 stated the facility tells her complaints will be addressed, but complaints are not addressed. Resident 14 stated They always tell me; everything will be alright. It makes me feel like I am nothing. Resident 14 stated it shouldn't take 30-40 minutes to answer the call light. Resident 14 stated this happens on a regular basis, on the PM and NOC shift. Resident 14 stated she had used the bathroom and had dried stool all up her back and it took a CNA 4.5 hours to respond to her call light. Resident 14 stated she addressed it with the LNs, DSD and DON. Resident 14 stated DSD and DON took a report and there was no feedback. Resident 14 stated I am concerned about the call lights. During an interview on 5/20/25 at 1:39 p.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated the call light policy states call lights should be answered within 15 mins . During an interview on 5/20/25 at 1:43 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated sometimes there were not enough CNAs on PM shifts. CNA 5 stated, sometimes CNAs were unable to get to all the residents. During a concurrent interview and record review on 5/20/25 at 1 :37p.m. with the Director of Staff Development (DSD), the call light policy was reviewed. The DSD stated the expectation was for CNAs to check residents who were unable to call for assistance every 2 hours or as needed. The DSD stated the expectation from staff was that the call lights should be answered within 7 minutes. The DSD stated the expectations were not met. The DSD stated the P&P indicated .Answer immediately, .within 5 minutes. The DSD stated the policy was not followed. During a concurrent interview and record review on 5/20/25 at 3:11 p.m. with the Director of Staff Development (DSD), the resident council minutes for the months of January 2025 - April 2025 were reviewed. The DSD validated there were lots of complaints about call lights from the resident council minutes. The DSD stated the minutes indicated call lights were not answered timely. The DSD confirmed been aware of the complaints. The DSD stated the complaints were not properly addressed by the facility; therefore, residents continue to complain. During a concurrent interview and record review on 5/20/25 at 3 :02 p.m. with the Director of Nursing (DON), the call light policy was reviewed. The DON stated the expectation were when residents turn on their call light, staff should respond and assess the needs of the residents and if unable to meet the needs, staff should refer to another department or discipline if needed. The DON stated staff should answer call light in a timely manner as soon as practically possible. The DON stated the policy was not followed. The DON stated it was important to follow the policy, so the patient gets timely responses to their needs. During a concurrent interview and record review on 5/20/25 at 3:28 p.m. with the Director of Nursing (DON), the resident council minutes for the months of January 2025 - April 2025 were reviewed. The DON stated a 4.5-hour response to the call light was not appropriate. The DON stated potential outcome of not responding to the call light would be that the residents' needs would not be acknowledged. The DON stated she was not aware of the incident of resident in own stool unattended to after initiating call light for 4.5 hours. The DON stated that a resident left unattended in own stool for 4.5 hours was not fair and was not right. During a concurrent interview and record review on 5/20/25 at 3:28 p.m. with the Administrator (ADM), the call light policy and the resident council minutes for the months of January 2025 - April 2025 were reviewed. The ADM stated the resident council minutes were reviewed with the activity's director after the resident council meetings. The ADM stated if there were issues in any department, something should be done about it. The ADM stated he was aware of the call light complaints. The ADM stated staff needed to be educated more on proper call light response time with more of a focus on the afternoon shift night shift. The ADM stated the call light policy was not followed. During a review of the facility's document titled, Job Description, Certified nursing assistant (CNA), dated 2/2024, the document indicated, . General purpose . to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Essential Duties . create and maintain an atmosphere of warmth, personal interest and positive emphasis as well as a calm environment throughout the unit and shift, . ensure that residents who are unable to call for help are checked frequently, answer resident calls promptly, check residents routinely to ensure that their personal care needs are met, . cooperate with . other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents, . assist residents with daily functions (dental and mouth care, bath functions, combing of hair, dressing and undressing as necessary), keep residents dry (change gown, clothing and linens, when it becomes wet or soiled), check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes . During a review of the facility's document titled, Job Description, LPN/LVN, dated 2/2024, the document indicated, . Directs the day-to-day functions of the nursing assistants in accordance with current rules regulations and guidelines ., ensure all nursing personnel assigned to you comply with written policies and procedures ., make daily rounds of your unit/ shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . ensure that personnel providing direct care to residents are providing such care in accordance with the resident care plans and wishes, ensure that residents who are unable to call for help are checked frequently . ensure that your assigned certified nursing assistants (CNAs) are aware of the residents care plan . During a review of the facility's document titled, Job Description, Registered Nurse (RN), dated 2/2024, the document indicated, . Ensure that all nursing service personnels are in compliance with their respective job descriptions ., ensure that a sufficient number of licensed practical and/ or registered nurses are available for your tour of duty to ensure that quality care is maintained, ensure that a sufficient number of certified nursing assistants are available for your tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident, . make daily rounds of nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards, . visit residents on a daily basis in order to observe and evaluate each resident's physical and emotional status, . ensure that residents who are unable to call for help are checked frequently . During a review of Job Description: Director of Staff Development (DSD), dated 2/2024, the document indicated, .General Purpose . is responsible to plan and implement facility orientation, job skill training . for the nursing assistants as required by regulation. Work with the Director of Nursing and Administrator to ensure that the highest degree of quality care is maintained at all times . Essential Duties . plan and conduct meaningful in-service education programs according to requirements for nursing personnel and all facility staff to assure competency in and new skills and as directed by administrator. Make rounds and observe delivery of patient care . During a review of Job Description: Director of Nursing (DON), dated 2/2024, the document indicated, .General Purpose . oversees and supervises the care of all residents . Essential Duties . Develop and implement nursing policies and procedures and ensure compliance. Responsible for ensuring resident safety and that all residents are treated with utmost respect Work closely with all other departments to ensure excellent overall resident care . coordinate MDS and care planning . During a review of the facility's policy and procedure titled, Answering the Call Light, dated 09/2022, indicated, .Policy Statement- The purpose of this procedure is to ensure timely responses to the resident's requests and needs . Steps in the procedure 1. Answer the resident call system immediately .a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. if the resident's request requires another staff member, notify the individual. c. if the resident's request is something you can fulfill, complete the task within five minutes if possible. d. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.2. if assistance is needed when you enter the room, summon help by using the call signal . During a review of the facility's policy and procedure titled, Resident Rights, dated 2/2021, indicated, .Policy Statement- Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: a. a dignified existence. b. be treated with respect, kindness and dignity. c. be free from abuse neglect misappropriation of property and exploitation . u. Voice grievances to the facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. v. Have the facility[TRUNCATED]

Based on observation, interview, and record review, the facility failed to follow the facility's Policy and Procedure (P&P) Medication Storage when two of four sampled medication carts ((Cart 1 and Cart 2) were left unlocked and unattended by Licensed Nurses (LNs). These failures had the potential for residents, staff, and visitors to have unauthorized access to resident medications resulting in theft, overdose, and/or residents not having access to their medications. Findings: During a concurrent observation and interview, on 5/13/25 at 9:47 a.m. with Licensed Vocational Nurse (LVN) 8, in the hall near the nurse station, medication Cart 1 was observed unlocked and unattended. LVN 8 stated the unlocked medication cart was her cart and she should not have left the cart unlocked when she walked away to get supplies. LVN 8 stated a resident, staff member or visitor could have gotten into the medication cart and harmed themselves by taking unprescribed medication. During an interview on 5/13/25 at 10:30 a.m. with the Director of Nursing (DON), the DON stated, the medication carts should always be locked. DON stated it was the responsibility of the nurse that was assigned to the cart to make sure it was always locked. During an observation on 5/20/25 at 4:16 p.m., medication Cart 2 was observed left unattended and unlocked, with the medication keys attached to the medication cart. The nurse assigned to the cart was observed on the opposite side of the nurses' station counter, gathering juices, not keeping the medication cart in her line of vision. Assisstant Director of Nursing (ADON) was observed to approach the cart, remove the keys, lock the medication cart, and discreetly attempt to place the keys into heLVN 5's pocket. During an interview on 5/20/25 at 4:28 p.m. with LVN 5, LVN 5 stated the cart was not left unlocked, it was a pulse oximeter (a small, portable medical device that measures the oxygen saturation in the blood). LVN 5 acknowledged the ADON placed the medication keys in her pocket. LVN 5 stated she should not have lied, and it was important to keep medication cart locked for safety. During an interview on 5/20/25 at 4:31 p.m. with the ADON, at the nurses' station next to medication Cart 2. The ADON acknowledged the observation of her removing the keys from the unlocked medication cart (Caret 2), lock Cart 2 and placed the keys in LVN 5's pocket. The ADON stated LVN 5 should not have walked away from the medication cart with keys left in the lock of Cart 2 and out of her line of sight. The ADON stated the expectation of the nurses was to have the medication carts locked when unattended, to prevent unauthorized access. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication dated 2019, indicated, .The facility stores all drugs and biological in a safely, securely and properly .only licensed nurses .are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by people with authorized access .

3. During a review of Resident 193's admission record (AR), dated 5/20/25, indicated the resident was admitted to the facility on [DATE] with the following diagnosis: Myelodysplastic Syndrome (a group of blood disorders where the bone marrow, responsible for making blood cells, doesn't function properly), leukemia (a type of blood cancer). During a concurrent observation and interview on 5/13/25 at 12:15 p.m. with the REC in the hall outside of Resident 193's room. The REC put on a yellow paper gown and purple gloves and took the lunch tray into Resident 193's room. Resident 193 had a sign outside of her door instructing staff and visitors to put on gloves, mask and gown prior to going into the resident's room. The REC stated that he would have put on a face mask but there were not any face masks in the personal protection equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), bin outside of the resident's room. The REC stated he should have looked for a mask before he entered Resident 193's room. The REC stated, he could have exposed Resident 193 to infections. During an interview on 5/16/25 at 3:42 p.m. with the IP, the IP stated it was her responsibility to check the PPE bins and make sure they are stocked but all staff have access to masks, gloves, and gowns. IP stated her expectation for the REC would have been to go to the supply closet and get more masks or inform her so that she could get another box of masks for the PPE bin. The IP stated the REC should not have gone into Resident 193's room without a mask. IP stated the REC could transmit germs to Resident 193 and cause her to become ill. During an interview on 5/20/25 at 10:20 a.m. with the DON, the DON stated her expectation was for the REC to obtain and wear a face mask prior to going into Resident 193's room. The DON stated Resident 193 was vulnerable and staff not following the rules could put her life at risk. 4. During a concurrent observation and interview on 5/13/25 at 12:15 p.m. with CNA 1, in the hallway outside of the large dining room, a standing lift (is used to transfer residents) was placed against the wall. The standing lift had a white filmy residue, and powdery substance left on the black cushioned pads and on the bottom standing tray of the lift. CNA 1 stated that the lift was not clean, and it should have been cleaned prior to being placed in the hallway. CNA 1 stated the lift could have been contaminated with infectious matter and could spread infection to other residents in the facility. During an interview on 5/16/25 at 3:30 p.m. with the IP, the IP stated it was her expectation for the staff to clean the lift after each use. IP stated the lift has a lot of contact areas and infection could be easily transmitted from resident to resident. During a review of the facility's policy and procedure (P&P), titled Cleaning and Disinfecting Non-Critical Resident Care Items dated 6/2021, indicated, . noncritical care items are those that come into contact with skin but not mucous membranes . reusable items are cleaned and disinfected or sterilized between residents . Based on observation, interview and record review, the facility failed to maintain a clean and sanitary environment for four of 25 sampled residents ( Resident 27, 41, 76, and 193 ) when: 1. Resident 41's urinary catheter bag (a bag attached to a urinary catheter, which is a thin tube inserted into the bladder to drain urine when someone can't urinate normally) and urinary catheter tubing (a thin, flexible tube inserted into the bladder to drain urine) was observed to be on the floor. This failure placed Resident 41 at risk for cross-contamination ( the unintentional transfer of harmful substances from one person, object, or place to another) which could result in infections and illness. 2. LVN 5 did not perform hand hygiene before she went into Resident 27 and 76's room and completed a fingerstick (a finger prick, a way to get a small blood sample from your fingertip) to check their glucose (sugar) levels. This failure placed Residents 27 and 76 at risk of cross-contamination, which could result in infections and illness. 3. The facility failed to follow neutropenic precautions (wearing a face mask, gown, and gloves, when in the room with resident to protect the resident from getting sick because their body's defense against germs is weaker than usual), when Resident 193 was on neutropenic precautions and the Receptionist (REC), went in to Resident 193's room and served a lunch tray without wearing a face mask. This failure had the potential to expose Resident 193 to bacterial and or viral pathogens (a tiny germ that can make you sick), which could lead to illness or death. 4. The facility failed to follow their policy and procedure (P&P), for Cleaning and Disinfecting Non- Critical Resident-Care Items when a standing lift (a device that helps people who can't stand up on their own get from a seated position to a standing position), was left with powder and other visible residue on the lift. This failure had the potential to spread skin infection or other contact infections to other residents in the facility Findings: 1. During an observation on 5/13/25 at 8:29 a.m., in Resident 41's room, Resident 41 was asleep in bed and his urinary catheter bag was on the ground. During a concurrent observation and interview on 5/13/25 at 1 p.m., with Certified Nursing Assistant (CNA) 6, in Resident 41's room, Resident 41 was in his wheelchair and had his urinary catheter tubing touching the floor. CNA 6 stated the catheter tubing should not have been on the ground. During a review of Resident 41's admission Record (AR-a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/20/25, the admission Record indicated, Resident 41 was admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness, overactive bladder (a condition characterized by a sudden, strong urge to urinate, often accompanied by frequent urination and, in some cases, urinary incontinence [loss of bladder control]), obstructive and reflux uropathy (a blockage in the urinary system, preventing urine from flowing properly) and urinary tract infection (an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra). During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 4/29/25, the MDS assessment indicated Resident 41's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 00 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 41 was severely impaired. During a review of Resident 41's Physician Order Summary (POS), dated 4/25/25, the POS indicated, . Order date: 4/25/25 . Communication Method: Phone Order Summary: Indwelling urinary (foley) catheter is in privacy bag and catheter leg strap on at all times During an interview on 5/16/25 at 10:34 a.m., with the Infection Preventionist ( IP- specialists who work to make sure healthcare facilities are safe and free from infections), the IP stated a catheter bag and tubing should never touch the ground because the ground was dirty and carries bacteria. The IP stated the urinary catheter bag and tubing issues put Resident 41 at risk for an infection due to cross-contamination of that bacteria. The IP stated an infection could lead to sepsis (a person's extreme and potentially life-threatening response to an infection) and a hospitalization for Resident 41. The IP stated the facility did not follow the policy and procedure Catheter Care, Urinary. During an interview on 5/16/25 at 11:25 a.m., with CNA 6, CNA 6 stated the catheter tubing was contaminated and it should not have been on the ground. CNA 6 stated this issue would have made the Resident 41 more prone to infection. CNA 6 stated the catheter bag should have been on the side of the bed, off the ground and not on the floor. During an interview on 5/16/25 at 2:05 p.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 stated Resident 41's catheter bag and tubing should not have been on the ground and it was a safety issue. LVN 8 stated bacteria could get on the catheter and could have caused an infection for the Resident 41. LVN 8 stated an infection with Resident 41 could lead to hospitalization. During an interview on 5/20/25 at 1:19 p.m., with the Director of Nursing (DON), the DON stated the expectation would be for the urinary catheter bag and tubing to not have been on the floor. The DON stated this put Resident 41 at risk for infection control issues and cross-contamination of bacteria could have occurred. The DON stated the facility did not follow the policy and procedure Catheter Care, Urinary. During a review of the facility's policy and procedure (P&P) titled Catheter Care, Urinary, dated 9/2014, the P&P indicated, .Purpose: the purpose of this procedure is to prevent catheter associated urinary tract infections . Infection Control: be sure the catheter tubing and drainage bag are kept off the floor . 2. During an observation on 5/15/25 at 11:27 a.m., in Resident 76's room, LVN 5 did not perform hand hygiene before she completed a fingerstick to check Resident 76's glucose level. During an observation on 5/15/25 at 11:40 a.m., in Resident 27's room, LVN 5 did not perform hand hygiene before she completed a fingerstick to check Resident 27's glucose level. During a review of Resident 76's AR, dated 5/20/25, the AR indicated, Resident 76 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (a condition where a body doesn't make enough insulin [a natural hormone that turns food into energy and manages your blood sugar level] or doesn't use insulin well). During a review of Resident 76's MDS assessment, dated 4/14/25, the MDS assessment indicated Resident 76's BIMS assessment score was 12 out of 15. The BIMS assessment indicated Resident 76 was moderately impaired. During a review of Resident 27's admission Record dated 5/20/25, the admission Record indicated, Resident 27 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus. During a review of Resident 27's MDS assessment, dated 4/7/25, the MDS assessment indicated Resident 27's BIMS assessment score was 14 out of 15 The BIMS assessment indicated Resident 27 was cognitively intact. During an interview on 5/15/25 at 11:55 a.m., with LVN 5, LVN 5 stated she did not realize she had not completed hand hygiene before having touched both residents. LVN 5 stated she should have completed hand hygiene before she touched them but did not. LVN 5 stated she put the residents at an increased risk of infection by not doing appropriate hand hygiene. During an interview on 5/16/25 at 10:34 a.m., with the IP, the IP stated by not performing hand hygiene before touching a resident, cross-contamination of bacteria could occur. The IP stated the expectation would be to have performed hand hygiene before having touched a resident. The IP stated as a result of not performing hand hygiene, the residents could have acquired an infection. The IP stated the facility P&P Handwashing/Hand Hygiene was not followed. During an interview on 5/16/25 at 2:05 p.m., with LVN 8, LVN 8 stated appropriate hand hygiene was important to control risk of infections. LVN 8 stated if hand hygiene was not performed before touching a resident, it could have resulted in an infection and ultimately a hospitalization. During an interview on 5/20/25 at 1:54 p.m., with the DON, the DON stated hand hygiene should have been completed before touching a resident. The DON stated the lack of hand hygiene would cause infection control concerns. The DON stated there was potential for an infection that could manifest into an illness. The DON stated the facility P&P Handwashing/Hand Hygiene was not followed. During an interview on 5/20/25 at 4:01 p.m., with the Assistant Director of Nursing (ADON), the ADON stated hand hygiene should have been completed before the resident's received care. The ADON stated by not completing hand hygiene the residents could have been exposed to contamination that could have caused an infection. During a review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene dated 10/2023, the P&P indicated, .Policy Statement: this facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections . Administrative Practices to Promote Hand Hygiene . all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident . Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves .

Based on observation, interview and recorded review, the facility failed to ensure one of two sample residents (Resident 56) received a written notice, including the reason for the room change, prior to being moved to a different room with the facility, when Resident 56 was moved without receiving written communication explaining the change. This failure resulted in Resident 56 being moved without appropriate written communication which had the potential to result in emotional distress and a violation of Resident 56's rights to make informed decision regarding her care and environment. Findings: During a concurrent observation and interview on 5/15/25 at 11:14 a.m. with Resident 56, in Resident 56's room. Resident 56 stated she was moved to a new room on 5/14/25 but did not receive a written notice of change and was not asked to sign anything. Resident 56 stated it was the second time she had to changed rooms. Resident 56 stated she understood the reason given, and she expressed frustrations being relocated multiple times. During a Review of Resident 56's admission Record (AR-a document containing resident profile information) dated 5/16/25, the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and asthma (a chronic lung condition making it difficult to breathe). During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 4/10/25, the MDS assessment indicated Resident 56's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact [a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities], 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 56 was cognitively intact. During a concurrent interview and record review on 5/15/25 at 11:26 a.m. with the Social Services Director (SSD), the facility policy and procedures titled Room change/Roommate Assignment was reviewed. The SSD stated the facility did not provide Resident 56 with a written notice of the room change. The SSD stated the facility's policy required written notice to be provided to residents and/or their representatives which included the reason for the room change and information to assist with the adjustment to a new room or roommate. The SSD stated there was no written documentation or signed notice provided to Resident 56 prior to the move. The SSD stated this communication was important to help Resident 56 adjust and prevent emotional distress. During an interview on 5/15/25 at 3:12 p.m. with the Director of Nursing (DON), the DON stated there was no written notice or supporting documentation provided to Resident 56 prior to the room change. The DON stated the facility policy required a written notice to be provide in advance of a room move, and this communication should have been documented in Residents 56's medical record. The DON stated the expectation was that the communication should have been provided to Resident 56 before the room change. During a review of the facility's policy and procedure (P&P) titled Room Change/Roommate Assignment, dated 3/2021, the P&P indicated, .Prior to changing a room or roommate assignment, all parties involved in the change/assignment .are given .advanced written notice of such change. Advanced written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate .

Based on interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may be paid for Medicare and assume responsibility) for one three sampled residents (Resident 78) when the Medicare coverage was terminated for Resident 78. This deficient practice resulted in not protecting Resident 78's rights and Resident 78's Representative (RR) right to appeal the termination of Medicare Part A and possibly denying Resident 78's needed services. Findings: During observation on 5/13/25 at 10:13 a.m., in Resident 78's room during the initial tour of the facility, Resident 78 was lying in bed. Resident declined to answer questions. During a review of Resident 78's admission Record, (AR- a document containing resident profile information) dated 5/15/25, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy (refers to the shrinking and weakening of muscle tissue due to various causes, including inactivity, aging or certain medical conditions), muscle weakness and retention of urine (unable to empty all urine from the bladder). During a concurrent interview and record review on 5/15/25 at 8:28 a.m. with the Business Office Assistant (BOA), the BOA stated her duties included but not limited to assisting residents to fill up applications for medi-cal (California's name for the federal Medicaid program [joint federal and state program that provides free or low-cost health coverage]). The BOA reviewed Resident 18's medical record titled, Skilled Nursing Facility Beneficiary Protection Notification Review. The BOA stated the SNF-ABN indicated Resident 78 start date was on 9/1/24 and the last covered day of Medicare Part A Services was on 11/29/24. The BOA stated Resident 78 remained in the facility after the last covered day. The BOA stated Resident 78 had Medicare Part A remaining days and a SNF ABN was not issued to Resident 78 because she did not know it was supposed to be issued. The BOA stated the SNF ABN letter should have been issued when the Notice of Medicare Provided Non-Coverage (NOMNC) was issued to Resident 78. The BOA stated the SNF ABN was very important because it provided Resident 78 steps to follow if Resident 78 wanted to continue receiving Medicare A benefits and steps to follow for an appeal. The BOA stated Resident 78 and RR were not able to appeal because they were not given the forms and information. During an interview on 5/20/25 at 4:55 p.m. with the Administrator (ADM), the ADM stated his expectation was to ensure Business Office issues SNF ABN and NOMNC letters to all residents needing the form. The ADM stated SNF ABN and NOMNC letters were supposed to be issued prior to the last covered Medicare part A Day to residents. During a review of facility's document titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS 10055, dated 2024, the document indicated, . Medicare requires Skilled Nursing Facilities [SNFs] to issue the SNF ABN to Original Medicare, also called fee-for-service [FFS] , patients prior to providing care that Medicare usually covers, but may not pay for in this instance . The SNF ABN provides information to the patient so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNF ABN when applicable for SNF Prospective Payment System services (Medicare Part A) .

Based on observation, interview and record review, the facility failed to report unusual occurrences for two of three sampled residents (Residents 28 and 244) when: 1. Resident 28 was attacked by Resident 29 (squeezed his toes and punched him 4 to 6 times in the lower left leg) and the facility did not contact local law enforcement or report the resident-to-resident abuse to the State Survey Agency. This failure put Resident 28's safety at risk, possibly other residents, as well as family and staff members in the facility. 2. Resident 244 was found on the floor by her bed, deceased and the facility did not report this unusual occurrence to the resident's responsible party (RP- a family member of designated person who is the point of contact for the nursing home staff. They can be kept informed about the resident's condition, receive updates, and ask questions) nor the State Survey Agency. This failure placed all residents' well-being and safety at risk residing in the facility due to lack of knowledge of reporting requirements. Findings: 1. During a concurrent observation and interview on [DATE] at 10:33 a.m., with Resident 28, in Resident 28's room, Resident 28 had dark purple bruising on his lower left leg. Resident 28 stated Resident 29 crawled over to his bed, grabbed his toes, started squeezing them and punched his left ankle and leg at least five times. Resident 28 stated Certified Nursing Assistant (CNA) 7 was already at his bedside, but other staff members came in and separated Resident 29 from him and he moved to another room in the facility. Resident 28 stated he had bruising to his leg and the facility had his left leg x-rayed, which were negative. Resident 28 stated he never spoke to the local police department. During a concurrent observation and interview on [DATE] at 8:05 a.m., with Resident 29, in Resident 29's room, a request was made to interview Resident 29 and he refused. During a review of Resident 28's admission Record (AR-a document containing resident profile information), dated [DATE], the AR indicated, Resident 28 was admitted to the facility on [DATE] with diagnosis of muscle weakness, difficulty in walking, morbid obesity (very severe, where someone is significantly overweight, often 100 pounds or more over their ideal weight) due to excess calories, chronic pain, repeated falls, embolism (a blood clot that blocks and stops blood flow) and thrombosis of unspecified artery (when a blood clot [a thrombus] forms inside a blood vessel, blocking the flow of blood). During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated [DATE], the MDS assessment indicated Resident 28's Brief Interview for Mental Status (BIMS -assessment of cognitive (the mental processes involved in gaining knowledge and comprehension) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS assessment indicated Resident 28 was cognitively intact. During a review of Resident 28's Social Services Note (SSN), dated [DATE] at 9:38 a.m. the SSN indicated, .Writer spoke with patient in regard to another patient crawling out of bed and striking patients leg three times . He requested a X-ray be done to his leg as he has prior problems with that leg and he just wants his mind to be cleared with an x-ray. Writer informed nursing to request order from MD [Medical Doctor] . A grievance filed on behalf of patient. Nursing staff to continue to monitor report any changes. Writer sent referral to MD . During a review of Resident 28's Progress Notes (PN), dated [DATE] at 10:52 a.m. the PN indicated, . Resident was moved in the a.m. following his admit due to an alleged altercation with his roommate. X-ray was request and orders carried out Left Knee and Left Tibia 2 view . During a review of Resident 29's admission Record, dated [DATE], the AR indicated, Resident 29 was admitted to the facility on [DATE] with diagnosis of muscle weakness, difficulty in walking and major depressive disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy). During a review of Resident 29's MDS assessment, dated [DATE], the MDS assessment indicated Resident 29's BIMS assessment score was 15 out of 15. The BIMS assessment indicated Resident 29 was cognitively intact. During an interview on [DATE] at 2:05 p.m. with Licensed Vocational Nurse (LVN) 8 stated she was the nurse responsible for Resident 28 at the time of the confrontation. LVN 8 stated Resident 28 was the victim and Resident 29 had hit him. LVN 8 stated Resident 29 had also tried to hit CNA's as well. LVN 8 stated she did not tell the Administrator what occurred but did tell the Director of Nursing (DON). During an interview on [DATE] at 2:50 p.m. with the Abuse Coordinator/Administrator (ACA), the ACA stated he did not believe the punches were abuse but heard Resident 28 was punched. During an interview on [DATE] at 3:15 p.m. with the ACA, the ACA stated he was not sure when he was notified of the incident and he did not document when he was notified. The ACA stated he made the DON responsible for the incident investigation . The ACA stated punching someone would be abuse but had to speak to the DON on why the incident was not reported. The ACA stated after he spoke to the DON about the resident altercation, Yes, we should have reported this. During an interview on [DATE] at 11:46 a.m. with the DON, the DON stated staff called her over the phone and told her about the incident when it occurred. The DON stated she was out of town when this occurred and she did not do an investigation into this incident. The DON stated Resident 28 was attacked and the incident would qualify as resident abuse. The DON stated the expectation would be to report the incident to the State Survey Agency and to local police. The DON stated it did not appear that either of those reports were done. The DON stated the facility did not follow the facilities policy and procedures Unusual Occurrence Reporting, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and Identifying Types of Abuse. During an interview on [DATE] at 2:35 p.m. with the Unit Nurse Supervisor (UNS), the UNS stated a resident getting punched would be physical abuse. The UNS stated the abuse coordinator should have filled out form SOC 341 [Report of Suspected Dependent Adult/Elder Abuse], turn that into the State Survey Agency and notify the police. During an interview on [DATE] at 3:14 p.m. with the ACA, the ACA stated he did not think a call to local police was completed and could not provide proof of notification of the incident. The ACA stated he did not complete a SOC 341 nor report the incident to the State Survey Agency. The ACA stated, I should have done all that and I didn't. The ACA stated the policy and procedures Unusual Occurrence Reporting, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and Identifying Types of Abuse were not followed. The ACA stated a potential outcome of not reporting this incident would be I don't know, you tell me what the outcome could be. The ACA stated, I'm not sure, we report it because we are supposed to. During an interview on [DATE] at 3:45 p.m. with CNA 7, CNA 7 stated she was already in the room speaking to Resident 28 when Resident 29 crawled over, grabbed Resident 28's foot and started punching him. CNA 7 stated she could not recall everything because it all happened so fast. During an interview on [DATE] at 3:54 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the incident qualified as physical abuse toward Resident 28. The ADON stated the incident should have been reported to the State and police because of mandatory reporting laws. The ADON stated something else could have happened to the resident because the reports were not made. The ADON stated the non-reporting put Resident 28's safety at risk. During a review of the facility's policy and procedure (P&P) titled, Identifying Types of Abuse, dated 9/2022, the P&P indicated, . As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents . abuse toward a resident can occur as: a. resident-to-resident abuse . Physical Abuse: 1. Physical abuse includes, but is not limited to hitting . punching . During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated [DATE], the P&P indicated, . all reports of a resident abuse(including injuries of unknown origin) . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . Reporting Allegations to the Administrator and Authorities: 1. If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . law enforcement officials . 3. Immediately is defined as: a. Within two hours of an allegation involving abuse . or . b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury . During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated [DATE], the P&P indicated, . as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors . g. Allegations of abuse . h. Other occurrences that interfere . the welfare, safety, or health of residents . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident or otherwise required by federal and state regulations . 3. A written report detailing the incident and actions taken by the facility after the event shall be sent delivered to the state agency (and other appropriate agency as required by law) within 48 hours of reporting the event or as required by federal and state agencies . 2. During a review of Resident 244 Nurse's Note (NN), dated [DATE] at 4:15 p.m. the NN indicated, . At 2:03 p.m. charge nurse notified unit manager/writer that resident was unresponsive with no RR [respirations] or Pulse. Writer and ADON [Assistant Director of Nursing] responded immediately and verified patient pulseless and non-breathing. Resident noted on floor. Bed in lowest position and on LAL [low air loss] mattress. Writer notified at 2:08 p.m. and DON at bedside assessed resident and no pulses, no respirations, no breath sounds, and no BP [blood pressure] were noted. Skin clear with exception of mottled [caused by decreased blood flow and oxygen to the skin, often due to small blood vessels constricting] skin to RLE [right lower extremity]. No visible signs of injury noted related to rolling on to floor. Resident on Hospice care. Per LN [licensed nurse] earlier in the day pt was noted with COC. Routine morphine administered at 8:20 a.m. to support comfort focus treatment with pain assessment at 10:42 am by LN noting no signs of pain in resident. At 11:15 a.m. LN assessed patient for residuals per order and administered noon medication, all needs met at this time. CNA last checked on resident at 12:50 p.m. and resident was in bed and care was given with no s/sx [signs and symptoms] of distress. [Medical Director] notified and Time of death 2:08 p.m. Two RN's [Registered Nurse] at bedside at the time of confirmation. Family and [Hospice] notified. Postmortem care completed . During a review of Resident 244's admission Record, dated [DATE], the AR indicated, Resident 244 was admitted to the facility on [DATE] with diagnosis of hemiplegia (a medical condition that causes paralysis (a medical condition characterized by the loss or impairment of voluntary movement and muscle function) or weakness on one side of the body) and hemiparesis ( a condition where you have weakness on one side of your body, making it difficult to move or use that side as effectively as the other) following cerebral infarction (a medical emergency called a stroke, when a blood clot or blockage cuts off the blood supply to a part of the brain, leading to brain tissue death affecting non-dominant left side), dementia (a brain disease that causes a decline in thinking, memory, and other cognitive abilities), dysphagia (swallowing difficulty), left hand contracture ( a condition that causes one or more fingers to bend toward the palm of the hand) and muscle weakness. During a review of Resident 244's MDS - assessment, dated [DATE], the MDS assessment indicated Resident 244's BIMS assessment score was 00 out of 15. The BIMS assessment indicated Resident 244 was severely cognitively impaired. During a review of Resident 244's Section GG (GG)- Functional Abilities (assessment of functional abilities), dated [DATE], the GG indicated, . [box checked] Impairment on both sides. Upper extremities (shoulder, elbow, wrist, hand) Lower extremity (hip, knee, ankle, foot) . Code 1= Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity . Code 1 for A. Eating. Code 1 for Oral hygiene. Code 1 for Toileting hygiene. Code 1 for Shower/bathe self. Code 1 for Upper body dressing. Code 1 for Lower body dressing. Code 1 for Putting on/taking off footwear. Code 1 for Personal hygiene . Code 1 for Roll left and right. Code 1 for Sit to lying. Code 1 Lying to sitting on side of bed. Code 1 for Sit to stand. Code 1 for Chair/bed to chair transfer. Code 1 for Tub/shower transfer . During a review of Resident 244's Weights and Vitals Summary (VS), dated [DATE], the VS indicated, XXX[DATE] . Blood Pressure: 122/68 mmHg (millimeters of mercury- unit of measurement) . Pain Level Summary: 2 . Pulse Summary: 68 BPM (beats per minute) . Respiration Summary: 18 breaths per minute . Temperature Summary: 97.8 Forehead non-contact . During a review of Resident 244's Physician/Mid-level Provider Discharge Summary (DS), dated [DATE], the DS indicated, . Pertinent Physical and Laboratory Findings: N/A [Not attempted] . Course of Treatment: Hospice Care, Skilled Nursing . Condition on discharge: [Empty] . Follow-up and Discharge Medication Instructions: Resident Exp-at 2:08 p.m. All personal belongings were given to family . [signed Medical Director] . During a review of Resident 244's Death Certificate (DC), dated [DATE], the DC indicated, . Certificate of Death: [Resident 244] . Immediate Cause: A. Respiratory Failure [sequentially list conditions if any leading to cause on line A] . B. Aspiration Pneumonia C. Cerebral Infarction . Death reported to coroner: No . Biopsy Performed: No . Autopsy Performed: No . During an interview on [DATE] at 9:39 a.m. with Hospice [ a type of medical care that provides comfort and support to people who are nearing the end of their life] Nurse (HN), the HN stated he was Resident 244's hospice nurse. HN stated he was not notified until two and half hours after Resident 244 passed away. HN stated this was unusual and normally they are notified within minutes of one of their residents passing away. During a concurrent interview and record review on [DATE] at 10:33 a.m. with the DON, Resident 244's Electronic Medical Record (EMR) was reviewed. The EMR indicated Resident 244 was found on the floor deceased next to her bed. The DON stated when she walked into Resident 244's room she was on the floor lying on her right side, parallel to her bed. The DON stated she did an assessment and found she was pulseless and not breathing. The DON stated with the help of staff members, they put Resident 244 back in bed and she called the Medical Director. The DON stated over the phone she described her physical assessment and the physician called Resident 244's death a brain bleed that caused her to fall out of bed. The DON stated she spoke with the responsible party/family member (RP/FM) 4. The DON stated she was not sure if she had told the RP/FM 4 that Resident 244 was found on the ground, but she knew that it was not documented what was said. DON stated a person found on the ground would be considered to be a fall and a change of condition should be made. The DON stated again, she told the RP/FM 4 that her mom had died but was not sure if she mentioned the fall or was found on the floor. The DON stated her assessment showed no evidence of trauma so she did not find Resident 244's death to be unusual, even though she was confirmed to be found deceased on the floor. During an interview on [DATE] at 2:39 p.m. with the UNS, the UNS stated LVN 10 went to her office and told her Resident 244 was found on the floor and passed away. The UNS stated she went in the room and Resident 244 was on the floor and staff were scared. The UNS stated she went and got the DON and she came and did an assessment and called the MD. The UNS stated Resident 244 having been found on the floor would be a fall. The UNS stated she did not call the family, the DON did all of that. During an interview on [DATE] at 2:56 p.m. with LVN 10, LVN 10 stated she was the nurse for Resident 244 at the time of her death. LVN 10 stated CNA 9 reported Resident 244 was on the floor, LVN 10 went in Resident 244's room and saw her on the floor, checked Resident 244 for pulse and she had none. LVN 10 stated no one knew how she got on the floor. LVN 10 stated the RP/FM 4 should have been notified and told about the fall because it was unwitnessed. LVN 10 stated a fall was an accident. LVN 10 stated the DON had asked her what happened and when she was telling her she was very emotional and had to leave the facility. LVN 10 stated they didn't ask me any questions when I came back in. During an interview on [DATE] at 4:02 p.m. with the ADON, the ADON stated she went in the room with the UNS and saw Resident 244 on the floor, facing the window. The ADON stated it was an unwitnessed fall and the RP/FM 4 should have been notified of the fall. During an interview on [DATE] at 5:23 p.m. with CNA 9, CNA 9 stated CNA 8 was in Resident 244's room and he had stopped her as she walked by and told her Resident 244 was on the ground. CNA 9 stated she was shocked. CNA 9 stated this was a fall, she was down on the ground. During an interview on [DATE] at 5:33 p.m. with the MD, the MD stated he felt from her medical history that she died from pretty much natural causes, or a bleed. The MD stated he knew Resident 244 was found on the floor, deceased . The MD stated he felt like she died naturally and slid off the bed after. The MD stated it did not trigger a coroners report for him. The MD stated he didn't put it together that a fall was considered an accident. During an interview on [DATE] at 5:33 p.m. with CNA 8, CNA 8 stated he found Resident 244 on the floor. CNA 8 stated he was giving care to Resident 24's roommate, looked over and saw Resident 244's bed was empty. CNA 8 stated he saw Resident 244 and her bed sheets on the floor and was shocked at what happened. CNA 8 stated he was very emotional and he couldn't take seeing her like that. CNA 8 stated that Resident 244 having been found on the floor was an unwitnessed fall and an accident for sure. During an interview on [DATE] at 10:04 a.m. with the RP/FM 4, the RP/FM 4 stated her mom could not communicate, nor move at all in bed. The RP/FM 4 stated she was the responsible party for Resident 244. The RP/FM 4 [very upset and emotional] stated I had no idea she was found on the ground, oh my God, oh my God this is terrible. The RP/FM 4 stated no person from the facility told her or her family Resident 244 was found on the floor deceased it makes a huge difference that she was. The RP/FM 4 stated The DON just lied to us and it would be very unusual for her mother to be on floor. The RP/FM 4 stated the HN told her it was not normal that hospice was not notified timely. The RP/FM 4 stated if she had known she was found on the floor deceased she would have bought an autopsy but did not because she was told by the facility she died naturally. The RP/FM 4 stated she would have needed to know the way her mom was found and would have done things differently. The RP/FM 4 stated the facility withheld vital information that would have been very important to me and what to do next. During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated [DATE], the P&P indicated, . as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors . d. Death of a resident . because of unnatural causes . e.g. [for example] . accidents .h. Other occurrences that interfere . the welfare, safety, or health of residents . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incidents or otherwise required by federal and state regulations . 3. A written report detailing the incident and actions taken by the facility after the event shall be sent delivered to the state agency (and other appropriate agency as required by law) within 48 hours of reporting the event or as required by federal and state agencies . During a review of the facilities P&P titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, .Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical . and/or status (e.g. [for example] changes in level of care . etc . Policy Interpretation and Implementation . The nurse will notify the resident's attending physician or physician on call when there has been a: a. accident or incident involving the resident .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . the resident is involved in any accident or incident that results in an injury including injuries of an unknown source . there is a significant change in the resident's physical . status .

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 21) when Resident 21's deep tissue injury (DTI-localized area of discolored, intact skin, often purple or maroon, or a blood-filled blister due to damage to the underlying tissues) was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 21's care needs not met and the potential for DTI to worsen. Findings: During a concurrent observation and interview on 5/13/25 at 9:40 a.m. during initial tour in Resident 21's room, Resident 21 was lying in bed. Resident 21 observed not able to move left upper extremity and lower extremities, and limited movement of right upper extremity. During a review of Resident 21's admission Record (AR- a document with personal identifiable and medical information) dated 5/15/25, the AR indicated Resident 21 was admitted tot he facility on 4/17/25 with diagnoses which included dysphagia (difficulty swallowing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial or incomplete paralysis or weakness on one side of the body) and Pressure-Induced Deep Tissue Damage of Sacral Region (occurs when sustained pressure restricts blood flow to the tissues over the sacrum, leading to tissue damage During a concurrent observation and interview on 5/15/25 at 9:35 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was familiar with Resident 21's care. CNA 2 stated she took care of Resident 21 and assisted the treatment nurse when providing treatment to Resident 21. CNA 2 stated Resident 21 has a wound on her buttocks area but not sure how big. CNA 2 stated Resident 21 requires extensive assistance with turning and repositioning. CNA 2 stated, She [Resident 21] is not able to move her legs without assistance and her left arm too, she can use her right arm to grab the bar to assist with turning. During a concurrent interview and record review on 5/16/25 at 11:06 a.m. with the Treatment Nurse (TXN), the TXN reviewed Resident 21's progress note dated 4/18/25 and stated Resident 21 was admitted with deep tissue injury to sacrococcyx area (bones at the bottom[base] of the spine). TXN stated he sent a picture of Resident 21's wound to the wound doctor and the wound doctor said to put a diagnosis of DTI of the wound and gave treatment order to be started for Resident 21's DTI. The TXN stated Resident 21's DTI improved and size was smaller compared to the size when Resident 21 was admitted to the facility. During a concurrent interview and record review on 5/20/25 at 10:10 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 21's five day MDS assessment dated [DATE] section M (Skin Conditions), Resident 21's deep tissue injury was not coded in the MDS assessment. The MDSN reviewed Resident 21's treatment orders and stated Resident 21 had treatment order for DTI which was started on 4/18/25. The MDSN stated she did not code Resident 21 as having DTI and she should have. The MDSN stated it was her responsibility to ensure MDS assessments were accurate. During an interview on 5/20/25 at 4:09 p.m. with the Director of Nursing (DON), the DON stated the MDSN reports directly to the Administrator (ADM) and DON. The DON stated her expectation was for the MDSN to ensure accuracy of assessments. The DON stated the assistant director of nursing (ADON) completes the quarterly assessments in the point click care (PCC- software platform specializing in electronic health records [EHRs] and revenue cycle management for long-term care and senior living communities), the MDSN reviews and used the assessment to complete her MDS assessment. The DON stated there was a section of the MDS requiring a bedside assessment but not sure which section. During an interview on 5/20/25 at 4:52 p.m. with ADM, the ADM stated the MDSN reports directly to the administrator. The ADM stated his expectation was, MDSN to code MDS correctly and accurately. During a review of facility policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment dated 11/19, the P&P indicated, . 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation . period for that assessment . During a review of professional reference titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 10/24, indicated. . Definitions . a pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure injury can present as intact skin or an open ulcer and may be painful . Step 1: Determine Deepest Anatomical Stage . At Admission, code based on findings from the first skin assessment that is conducted on or after and as close to the admission as possible . Visualization of the wound bed is necessary for accurate staging .

Based on interviews and record review, the facility failed to follow-up with a positive Preadmission screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level I screening for one of three sampled residents (Resident 52) when Resident 52's PASARR level I screening required PASARR Level II mental health evaluation on 9/24/24 and was not completed. This failure had the potential for Resident 52 to not receive the appropriate services related to her mental disorder. Findings: During a review of Resident 52's admission Record (AR-a document containing resident profile information), dated 5/20/25, the AR indicated, Resident 52 was admitted to the facility on [DATE] with diagnoses which included: unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), major depressive disorder (persistent sadness, loss of interest in activities and difficulty with relationships impacting a person's thinking and behavior), anxiety disorders (a group of conditions characterized by excessive fear, worry, and anxiety that significantly interfere with daily life). During a review of Resident 52's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function), dated 3/25/25, the MDS section C indicated Resident 52 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgment) assessment score of 14 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which indicated Resident 52 was cognitively intact. During a review of Resident 52's PASARR Level I Screening Report (PLISR) dated 9/24/24. The PLISR indicated .Resident Review (RR) (Status Change), .Diagnosed Serious Mental Illness (SMI) .- Yes, Specify the diagnosis .- Unspecified Psychosis . State Use Only comments: Level I - Positive for SMI/Negative for ID (intellectual disability) /DD (developmental disability) /RC (related conditions) . During a review of Resident 52's Notice of PASARR Level I Screening Result (NPSR) dated 9/24/24. The NPSR indicated . A Serious Mental illness (SMI) Level II mental health evaluation is required. Result: Positive for SMI/Negative for ID/DD/RC . During a review of Resident 52's Notice of Attempted Evaluation (NAE) dated 9/24/24. The NAE indicated, . In the event of a possible SMI level I screening, a SMI level II mental health evaluation is required to determine if the individual can benefit from specialized services. However, a SMI level II mental health evaluation was not scheduled for the following reason: facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening During an interview on 5/15/25 at 9:25 a.m. with the admission & Marketing Director (AMD), the AMD stated the facility receives the PASARR level I for residents via file exchange from the hospital. The AMD stated if the PASARR level I screening was positive, the Minimum Data Set Nurse (MDSN ) follows up with PASARR level II evaluation. During a concurrent interview and record review on 5/15/25 at 9:29 a.m. with the MDSN, Resident 52's PLISR dated 9/24/24, NPSR dated 9/24/24, NAE dated 9/24/24 and Progress Notes (PN) were reviewed. The MDSN stated Resident 52's PASARR level I screening was positive for SMI. The MDSN stated communication between MDSN and PASARR representative should be documented in Resident 52's PN. The MDSN validated there was no evidence of communication between MDSN and PASARR representative. The MDSN stated there was no follow up to ensure PASARR level II evaluation was completed for Resident 52. The MDSN stated the MDSN was responsible for the follow up process on the PASARR level II evaluation. The MDSN stated it was important that Resident 52 was assessed for PASARR level II evaluation if Resident 52 was taking antipsychotropic (medication used to treat psychosis, a condition characterized by symptoms like hallucinations, delusions, and disorganized thinking) medication. The MDSN stated it was important to complete the PASARR level II evaluation, so the state agency had accurate records. During a concurrent interview and record review on 5/15/25 at 11:56 a.m. with the Director of Nursing (DON), Resident 52's PLISR dated 9/24/24, NPSR dated 9/24/24, NAE dated 9/24/24 and PN were reviewed. The DON validated a PASARR Level II evaluation was triggered for Resident 52. The DON stated the importance of the PASARR evaluation was to make sure residents were placed appropriately based on their clinical needs and that services were provided based on their diagnosis. The DON validated there was no documentation of communication between MDSN and PASARR representatives. The DON stated the communication should have been documented in a PN in Resident 52's medical records. The DON stated it was important to document the communication between MDSN and PASARR representatives so there was appropriate information to complete the evaluation. The DON validated the NAE indicated .facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening . The DON stated the expectation was to follow up with contracted party/PASARR representative or DHS (Department of Health Services) to make sure the evaluation was completed. The DON stated it was important to follow up on the PASARR Level II evaluation to make sure Resident 52's mental health was supported. The DON stated the PASARR level II evaluation was not completed, therefore the PASARR policy was not followed. The DON stated there was a potential risk for the omission of necessary services for Resident 52. The DON stated Resident 52's mental disorder could have deteriorated if Resident 52 did not have the support needed. During a review of Job Description: Director of Nursing (DON), dated 2/2024, the document indicated, .General Purpose . oversees and supervises the care of all residents . Essential Duties . Develop and implement nursing policies and procedures and ensure compliance. Responsible for ensuring resident safety and that all residents are treated with utmost respect Work closely with all other departments to ensure excellent overall resident care . coordinate MDS and care planning . During a review of the facility's policy and procedure titled, admission Criteria PASARR, dated 03/2019, indicated, .Policy Statement- our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation .9.a. The facility conducts a level I PASARR screen for all potential admission . To determine if the individual meets the criteria for a MD (Mental Disorder), ID (Intellectual Disability/Developmental Disability) or RD (Related Conditions). b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD . is referred to the state PASARR representative for the level II (evaluation and determination) screening process . During a review of professional reference from the California Department of Health Care Services (DHCS) (a government agency that provides healthcare services to low-income and disabled Californians) titled, Preadmission Screening and Resident Review, undated, (found at https://www.dhcs.ca.gov/services/MH/Pages/PASRR.aspx), the reference indicated .The (DHCS), PASRR Section is responsible for determining if individuals with serious mental illness (SMI) and/or intellectual/developmental disability (ID/DD) or related conditions (RC) require: Nursing facility services, considering the least restrictive setting, Specialized services. This is achieved by completing the PASRR process. The PASRR process consists of a Level I Screening, Level II Evaluation, and a final Determination. Level I Screening-The Screening is submitted online by the facility and is a tool that helps identify possible SMI and/or ID/DD/RC. Level II Evaluation- If the Screening is positive for possible SMI and/or ID/DD/RC, then a Level II Evaluation will be performed. The Level II Evaluation helps determine placement and specialized services. The Department of Health Care Services (DHCS) is responsible for SMI Level II Evaluations, which by law must be performed by a third-party contractor

Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan (a plan that provides direction for individualized care of the resident) within 48 hours of resident's admission for one of two sampled residents (Resident 79) when Resident 79's care plans was not created for the oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy per physician's order. This failure had the potential for Resident 79 to not receive oxygen therapy as prescribed by the physician which had the potential to result in hypoxia (a condition where tissues and organs don't receive enough oxygen) and respiratory failure (a condition where the lungs are unable to adequately provide oxygen to the blood or remove carbon dioxide). Findings: During an observation on 5/13/25 at 1:23 p.m. with Resident 79 during the tour in Resident 79's room, Resident 79 was lying in bed with the head of the bed elevated wearing a nasal cannula (NC- thin plastic tube that delivers oxygen directly into the nose through two small prongs) in his nostril. The O2 tubing hung from the resident down the left side of the bed connected to an oxygen concentrator (device that produces oxygen for breathing). The O2 setting was at 2 LPM (liters per minute-unit of measurement). Resident 79 opened his eyes but did not respond to any questions asked. During a review of Resident 79's admission Record (AR-a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/16/25, the AR indicated, Resident 79, was admitted to the facility on [DATE] with diagnoses which included: encounter for palliative care (medical consultations focused on providing comfort and support to patients with serious, life-limiting illnesses), parkinsonism (condition which affects the body's movements), major depressive disorder (persistent sadness, loss of interest in activities and difficulty with relationships impacting a person's thinking and behavior), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), hydrocephalus (buildup of fluid in the brain), . During a review of Resident 79's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 4/11/25, the MDS section C indicated, Resident 79 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which indicated Resident 79 was severely impaired. During a review of Resident 79's MDS assessment dated [DATE], the MDS section O indicated Resident 79's Special Treatment, Procedures, and Programs included Resident 79 on Hospice care (a type of care that focuses on providing comfort and relief to terminally ill patients and their families, rather than focusing on curing the illness). During a review of Resident 79's Order Summary Report (OSR) dated 10/7/24 at 5:01 p.m. The OSR indicated .O2 at 2-5 LPM via NC PRN (as needed) per concentrator /tank as needed for Dyspnea (difficulty or discomfort in breathing) . During a review of Resident 79's Progress Notes (PN) dated 10/8/24 at 10:52 p.m. The PN indicated, .Resident is on monitoring for s/p (status post) new admit to facility under{name}hospice . During a concurrent interview and record review on 5/16/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 79's O2 order and care plans were reviewed. The LVN 6 stated, I do not see any care plan, there should be a care plan if the resident is on O2. LVN 6 stated it was important to have a care plan for O2 because it showed the interventions needed for Resident 79. LVN 6 stated the care plan guided the Licensed Nurses (LNs) and helps LNs know what problems Resident 79 had. LVN 6 stated the care plan should have been initiated when O2 was started on 10/7/24. During a concurrent interview and record review on 5/16/25 at 11:47 a.m. with the Minimum Data Set Nurse (MDSN), Resident 79's O2 order and care plans were reviewed. The MDSN stated there was no care plan for O2. The MDSN stated there should have been a care plan to ensure LNs were providing Resident 79 his O2 needs. The MDSN stated the care plan ensured staff with access to resident 79's care know what interventions the resident needs. The MDSN stated the care plan should have been completed as soon as the O2 was ordered on 10/7/24. During a concurrent interview and record review on 5/16/25 at 1:46 p.m. with the Director of Nursing (DON), the baseline care plan policy, the duties, job description for Registered Nurse (RN) & LVN, Resident 79's O2 order and care plans were reviewed. The DON stated care plans were initiated when residents were admitted to the facility. The DON stated baseline care plans should have been completed based on Resident 79's assessment on admission. The DON stated a baseline care plan should have been completed within 48 hours of admission. The DON stated there was no baseline care plan completed when resident 79 was admitted on [DATE]. The DON stated, It would be appropriate for Resident 79 to have a care plan so that anyone participating in his care would have information regarding the plan of Resident 79's care and other non -physician support can be incorporated in his care. The DON stated having a care plan could improve the care of Resident 79. The DON stated the care plan policy was not followed. The DON stated it was important for staff to follow the policy to ensure adherence to systems that will support residents' care. During a review of the facility's document titled, Job Description, LPN/LVN, dated 2/2024, the document indicated . Charting and Documentation- .Transcribe physician's order to resident . treatment/ care plans as required. Care Plan and Assessment Functions- Review care plans daily to ensure that appropriate care is being rendered . Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs .Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities . During a review of the facility's document titled, Job Description, Registered Nurse (RN), dated 2/2024, the document indicated, . Participate in the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care . Review resident care plans for appropriate resident goals, problems, approaches, revisions based on nursing needs. Ensure that all personnel involved in providing care to the resident are aware of the residents' care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed. Assist the Resident Assessment/ Care Plan Coordinator in planning, scheduling, and revising the MDS . Review resident's medical and nursing treatments to ensure that they are provided in accordance with the resident's care plan and wishes . Must be knowledge able of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities . During a review of Job Description: Director of Nursing (DON), dated 2/2024, the document indicated, .General Purpose . oversees and supervises the care of all residents . Essential Duties . Develop and implement nursing policies and procedures and ensure compliance. Responsible for ensuring resident safety and that all residents are treated with utmost respect Work closely with all other departments to ensure excellent overall resident care . coordinate MDS and care planning . During a review of the facility's policy and procedure titled, Care Plans-Baseline, dated 12/2016, indicated, .Policy Statement- A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation 1. To assure that the resident's immediate care needs are met and maintained .2. The Interdisciplinary Team will review the healthcare practitioner's orders . and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders. b. Physician orders .3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person- centered care plan. 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. the initial goals of the resident . During a review of the facility's policy and procedure titled, Oxygen Administration, dated 10/2010, indicated, .the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation-1. Verify that there is a physician's order for this procedure .2. Review the resident's care plan to assess for any special needs of the resident . During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition .

Based on interview and record review the facility failed to ensure services were provided that met professional standards of quality for one of four sampled Residents (Resident 1), when Licensed Nurses did not document Resident 1 's change of condition for an episode of hypoglycemia (low blood sugar) on 12/16/24 in accordance with facility's policy and procedure on nursing documentation and change of condition. This failure resulted in an incomplete documentation and assessment for Resident 1 and had the potential for delay in care. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for type 2 diabetes mellitus (condition when the body doesn ' t use insulin properly, resulting in high blood sugar). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 12/30/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a record review of Resident 1 ' s, Progress Note (PN), dated 12/16/24, the PN indicated, . Staff reported resident to be sweating and clothes were changed twice within the last 30 minutes of this shift. When writer entered the room resident was found awake but not verbally responsive . fasting blood sugar noted 51 . During a concurrent interview and record review on 1/8/25 at 11:40 a.m. with Registered Nurse (RN) 1, Resident 1 ' s electronic medical record (EMR) was reviewed. The EMR indicated there was no change of condition assessment completed for Resident 1 on 12/16/24. RN 1 stated there should have been a change of condition assessment completed for Resident 1 on 12/16/24 when Resident 1 was sent to the acute care hospital. RN 1 stated it was the facility ' s process to complete a change of condition assessment when there was a change in Residents health status. RN 1 stated it was important to complete a change of condition assessment because it was a form of communication used to document change of residents ' condition for other staff members and physicians. During an interview on 1/8/25 at 12:21 p.m. with the director of nursing (DON), the DON stated it was the facility 's expectation that a change of condition assessment be completed when there was a change in resident health status. The DON stated completing the change of condition assessment was an important form of communication between staff and initiated an appropriate response for Resident 1. During a telephone interview on 1/8/25 at 4:16 p.m. with Licensed vocational nurse (LVN) 1, LVN 1 stated on 12/16/24, Resident 1 experienced a change in condition when his blood sugar was documented at 51. LVN 1 stated the expectation was to complete a change of condition assessment when there was a change in residents ' health status. LVN 1 stated the purpose for completing a change of condition assessment was to effectively communicate the change of condition and interventions completed to other staff. During a review of the facility 's policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status dated 2/2021, the P&P indicated, . A significant change of condition is a major decline or improvement in the residents status that will normally not solve itself without intervention by staff . the nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status. If a significant change in the residents physical or mental condition occurs, a comprehensive assessment of the resident ' s condition will be conducted . During a review of the facility ' s P&P titled, Charting and Documentation, dated 2001 , the P&P indicated, . All services provide to the resident, progress towards the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record . the following information is to be documented in the resident medical record . treatments or services performed, changes in resident ' s condition, events, incidents or accidents involving the resident . documentation in the medical record will be objective, complete and accurate . documentation of procedures and treatments will include care specific details, including . the assessment data and or/any unusual findings obtained . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient ' s chart with clear, concise statements of the nurse ' s decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician ' s orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician ' s . order properly . Based on interview and record review the facility failed to ensure services were provided that met professional standards of quality for one of four sampled Residents (Resident 1), when Licensed Nurses did not document Resident 1 's change of condition for an episode of hypoglycemia (low blood sugar) on 12/16/24 in accordance with facility's policy and procedure on nursing documentation and change of condition. This failure resulted in an incomplete documentation and assessment for Resident 1 and had the potential for delay in care. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for type 2 diabetes mellitus (condition when the body doesn ' t use insulin properly, resulting in high blood sugar). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 12/30/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a record review of Resident 1 ' s, Progress Note (PN), dated 12/16/24, the PN indicated, . Staff reported resident to be sweating and clothes were changed twice within the last 30 minutes of this shift. When writer entered the room resident was found awake but not verbally responsive . fasting blood sugar noted 51 . During a concurrent interview and record review on 1/8/25 at 11:40 a.m. with Registered Nurse (RN) 1, Resident 1 ' s electronic medical record (EMR) was reviewed. The EMR indicated there was no change of condition assessment completed for Resident 1 on 12/16/24. RN 1 stated there should have been a change of condition assessment completed for Resident 1 on 12/16/24 when Resident 1 was sent to the acute care hospital. RN 1 stated it was the facility ' s process to complete a change of condition assessment when there was a change in Residents health status. RN 1 stated it was important to complete a change of condition assessment because it was a form of communication used to document change of residents ' condition for other staff members and physicians. During an interview on 1/8/25 at 12:21 p.m. with the director of nursing (DON), the DON stated it was the facility 's expectation that a change of condition assessment be completed when there was a change in resident health status. The DON stated completing the change of condition assessment was an important form of communication between staff and initiated an appropriate response for Resident 1. During a telephone interview on 1/8/25 at 4:16 p.m. with Licensed vocational nurse (LVN) 1, LVN 1 stated on 12/16/24, Resident 1 experienced a change in condition when his blood sugar was documented at 51. LVN 1 stated the expectation was to complete a change of condition assessment when there was a change in residents ' health status. LVN 1 stated the purpose for completing a change of condition assessment was to effectively communicate the change of condition and interventions completed to other staff. During a review of the facility 's policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status dated 2/2021, the P&P indicated, . A significant change of condition is a major decline or improvement in the residents status that will normally not solve itself without intervention by staff . the nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status. If a significant change in the residents physical or mental condition occurs, a comprehensive assessment of the resident ' s condition will be conducted . During a review of the facility ' s P&P titled, Charting and Documentation, dated 2001 , the P&P indicated, . All services provide to the resident, progress towards the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record . the following information is to be documented in the resident medical record . treatments or services performed, changes in resident ' s condition, events, incidents or accidents involving the resident . documentation in the medical record will be objective, complete and accurate . documentation of procedures and treatments will include care specific details, including . the assessment data and or/any unusual findings obtained . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient ' s chart with clear, concise statements of the nurse ' s decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician ' s orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician ' s . order properly .

Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standard of practice for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 and LVN 2 did not administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) per physician's order. This failure had the potential to cause Resident 1 to experience episodes of unstable blood sugar levels such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that could have a serious outcome affecting resident ' s health and wellness. Finding: During a review of Resident 1's Admission Record (a document containing demographic information), dated, 11/20/2024 the Admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 had the following diagnosis . Partial Traumatic Amputation (loss of a body part) of Left Shoulder and upper Arm .Absence of Right Upper Limb below elbow .Absence of Right Leg Below Knee .Absence of Left Leg Below Knee .Type 2 Diabetes Mellitus (DM) (Chronic Condition that happens when you have persistently high blood sugar). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During an interview on 12/12/2024 at 08:45 a.m. with Resident 1, Resident 1 stated, she has two separate orders for Humalog (fast acting insulin) insulin. Resident 1 stated, she received her 10 units of insulin and a sliding scale (the amount of insulin administered based on current blood sugar level) insulin when needed. Resident 1 stated, staff checked her blood sugar prior to her meals and if her blood sugar was high and she needed insulin from her sliding scale order staff combine both orders for insulin and administer in one shot after her meals. Resident 1 stated, she had received more than 10 units of insulin after her meals. During a concurrent interview and record review on 11/26/24, at 10:10 a.m., with LVN 1, Resident 1's Medication Administration Record (MAR) dated 11/01/2024 and 12/01/2024 were reviewed. LVN 1 stated Resident 1 had two separate insulin orders. The MAR indicated, .physician orders . HumalOG Kwik pen SolutionPen-injector100 UNIT/ML Milliliters (Unit of measure) (Insulin) Lispro Unit Dial) Inject 10 units subcutaneously (under the skin) after meals for DM notify MD if below 60 or higher than 400 . LVN 1 stated, the following was physician ' s order for sliding scale: HumalOG 100 Unit/ML (Insulin Lispro (Human) Inject as per sliding scale: If 0-150=0 units 151-200=2 units 201-250=4 units 251-300=6 units 301-350=8 units 351-400=10 units Subcutaneously before meals for diabetes, Notify MD if below 60 or higher than 400. During an interview on 11/26/24, at 10:10 am with LVN 1. LVN 1 stated, Resident 1 had an order for 10 units of Humalog after every meal and a sliding scale order before meals. LVN 1 stated, we checked her blood sugar about fifteen minutes before her meal arrived. LVN1 stated, physician order for the sliding scale insulin was indicated to be administered before her meals. LVN 1 stated, when Resident 1 needed insulin from her sliding scale order, LVN 1 was combining the required sliding scale insulin with the scheduled order of 10 unit. LVN 1 stated, for example on 11/02/2024, Resident 1 needed four units from her sliding scale and ten units from her scheduled order. LVN 1 stated, she administered fourteen units of Humalog using one insulin pen after Resident 1 was finished eating. LVN 1 stated, she administered the combined units of insulin after meals to Resident 1 on following days: 11/2/24,11/5/24,11/6/24.11/7/24,11/8/24,11/14/24,11/18/24,11/19/24,11/20/24,11/29/24, 11/30/24, and 12/2/24. LVN 1 stated, her signature on the MAR indicated, she administered the insulin. LVN 1 stated, she did not follow physician orders and Resident 1 could have experienced adverse reactions affecting her health and wellness. LVN 1 stated, We were to follow physician orders at all times, and I did not. During a concurrent interview and record review on 11/26/24, at 10:50 a.m., with LVN 2, Resident 1's Medication Administration Record (MAR) dated 11/2024 and 12/11/2024 was reviewed. LVN 2 stated, her signature on the MAR indicated she administered insulin to Resident 1. LVN 2 stated she administered the combined units of insulin using one insulin pen after the meal to Resident 1 on the following dates: 11/3/24,11/4/24,11/9/24, 11/10/24,11/15/24, 11/16/24,11/21/24,11/22/24,11/27/24, 11/28/24, 12/3/24,12/4/24,12/9/24, and 12/10/24. LVN 2 stated, We were not following physician orders for the sliding scale insulin to be administered prior to Resident 1 ' s meals. LVN 2 stated, she was combining the scheduled dose of ten units with the sliding scale units using one insulin pen and administering after Resident 1 ' s meals. During a review of Resident 1's Physician Orders (PO), dated 12/01/2024, the PO indicated, .HumalOG Kwik pen SolutionPen-injector100 UNIT/ML Milliliters (Unit of measure) (Insulin) Lispro Unit Dial) Inject 10 units subcutaneously (under the skin) after meals for DM notify MD if below 60 or higher than 400 . During a review of Resident 1's PO, dated 12/01/2024, the PO indicated, .HumalOG Solution 100 Units/ML (Insulin Lispro(Human) Inject as per sliding scale If 0-150=0 units, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, Subcutaneously before meals for diabetes, Notify MD if below 60 or higher than 400 . During a concurrent interview on 11/26/24, at 11:25 a.m., with Assistant Director on Nursing (ADON), ADON stated, Resident 1 had two separate orders for Humalog insulin. ADON stated, Resident 1 had a scheduled order for ten units of insulin after meals. ADON stated, Resident 1 had a sliding scale order for insulin before meals. ADON stated, the physician order indicated sliding scale Humalog be administered before meals. ADON stated I am aware the LVN ' s are using one insulin pen to administer both insulin orders. ADON stated, LVN ' s were not following physician order to administer sliding scale insulin to Resident 1 prior to meals. ADON stated, Resident 1 could have episodes of hypoglycemia or hyperglycemia if physician orders were not followed. During a concurrent interview on 11/26/24, at 11:45 a.m., with Director of Nursing (DON), [NAME] stated, Resident 1 had two separate orders for insulin. DON stated, LVNs should be administering two separate insulin shots if sliding scale insulin were needed, DON stated, she was not aware LVNs were administering insulin using one insulin pen after meals. DON stated, LVNs were not following physician orders for sliding scale insulin. DON stated, it was out of the scope of the LVNs to deviate from a physician order without consulting the physician. DON stated, Resident 1 ' s blood sugar could become unstable causing harm and affecting her health and wellness. During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration dated 2001, the P&P indicated. Purpose .to provide guidelines for the safe administration of insulin to residents with diabetes .Types of insulin, dosage requirements, strength and method of administration must be verified before administration, to assure that it corresponds with the order on the medication order on the medication sheet and physician ' s order During a review of the facility's document titled Job Description LPN/LVN, dated 02/2024 the job description indicated, .The primary purpose of your job position is to provide direct care to the residents .Prepare and administer medications as ordered by the physician During a review of the facility's (P&P) titled, Administering Medication dated 2001, the P&P indicated, .Medications are administered in a safe and timely manner and as prescribed .Medications are administered in accordance with prescriber orders including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified example before and after meals .The individual administering the medications checks the label THREE(3) times to verify the right resident, right medication, right dosage, right time, and right method(route) of administration before giving the medication . During a professional reference review, retrieved from Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan .

Based on observation, interview and record review, the facility failed to follow professional standards of quality for one of three sampled residents (Resident 1) when Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] and 10/28/24 and no inventory of personal belongings was completed, and the facility did not follow their policy and procedure (P&P) titled Personal Property. These failures resulted in Resident 1's personal belongings not being inventoried and the risk for Residents 1's wallet, checkbook and bankcard getting lost. Findings: During a concurrent observation and interview on 11/5/24 at 12:47 p.m. in Resident 1's room, Resident 1 was lying down in bed awake. Resident 1 stated, he was admitted to the facility about three months ago. Resident 1 stated, when he was admitted , he came to the facility with his checkbook, wallet and bank card. Resident 1 stated, he believed his checkbook, wallet and bankcard was in his bedside cabinet. During a review of Resident 1's Face Sheet (FS-include the patient's name, address, date of birth, insurance information, and emergency contact information.) dated 11/6/24, the FS indicated, Resident 1 was initially admitted to the facility on [DATE] with primary diagnosis of Polyneuropathy (several nerves that malfunction at the same time) and Muscle Weakness. Resident 1's FS indicated he was his own Responsible Party (RP- the person in charge of and responsible for making decisions). During a review of Resident 1's Minimum Data Set [MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment], dated 11/1/24, the MDS section C indicated, Resident 1 had a BIMS (Brief Interview for Mental Status) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 11/5/24 at 12:51 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, the process at the facility was when residents were admitted to the facility, the CNA took inventory of the belongings on paper and gave the belongings and the paper to the Licensed Vocational Nurse (LVN). During a concurrent interview and record review on 11/5/24 at 1:10 p.m. with Medical Records (MR), Resident 1 Electronic Medical Record (EMR) was reviewed. The EMR indicated, Resident 1 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE] and on 10/28/24. MR stated, Resident 1 was admitted to the facility on [DATE]. MR stated, there was no inventory list completed for Resident 1 when he was admitted on [DATE]. MR stated, there was no inventory list in the EMR for the re-admissions on 10/4/24 and 10/28/24. MR stated, Resident 1 should have had an inventory list completed for each admission. MR stated, the CNA was responsible for filling out the inventory paper form, and the LVN was responsible to input the items from the inventory form into the computer and get a signature of the resident or the Residents RP. During a concurrent observation and interview on 11/5/24 at 1:21 p.m. with CNA 1 in Resident 1's room, CNA 1 went through Resident 1's bedside cabinet and was unable to find his wallet, checkbook or bank card. CNA 1 went through Resident 1's pants and jackets that were hung up in the closet and went through Resident 1's closet drawers and was unable to find his check book, wallet or bank card. CNA 1 looked through two pink bags, one white bag and one [retail store] bag that were stored in the closet and was unable to find Resident 1's check book, wallet or bank card. CNA 1 stated, she was not able to find Resident 1's wallet, check book or bank card in his belongings. During an interview on 11/5/24 at 1:48 p.m. with the Social Services Director (SSD), the SSD stated, an outside agency social worker filed a grievance that Resident 1's wallet and check book were missing. The SSD stated, she checked Resident 1's inventory list and did not find the wallet and check book on the inventory list. The SSD stated, Resident 1's wallet, checkbook and bankcard were found in the back of the dining room. The SSD stated, she did not know how Resident 1's items ended up in the dining room. The SSD stated, the CNA and the LVN admitting the resident were responsible for inventorying the resident's belongings. The SSD stated, the LVN was responsible for entering the resident's inventory into the residents EMR. The SSD stated, it was important for resident's belongings to be inventoried to ensure personal items and reimbursement to a resident if something went missing. During an interview on 11/5/24 at 2:54 p.m. with the LVN, the LVN stated, when a resident was admitted to the facility, the CNA or the LVN would make a list of the resident's inventory on paper. LVN stated, it was the LVN's responsibility to enter the inventory into the EMR and make a copy for medical records. LVN stated, if the CNA made the list of items, the LVN had to verify everything on the list was physically present. The LVN stated, the resident or their RP needed to sign the inventory form. The LVN stated when a resident was admitted they had to have an inventory list completed. The LVN stated, if a resident came in with no belongings, they would still had to do an inventory list and document there was no belongings. The LVN stated, it was important to complete an inventory list in case something went missing. During an interview on 11/7/24 at 2:03 p.m. with the Director of Nursing (DON), the DON stated, it was her expectation that an inventory list be completed when a resident was admitted and readmitted to the facility. The DON stated the process of completing the inventory was that the LVN or CNA would fill out the inventory form and the nurse would enter it into the EMR. The DON stated, Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] and 10/28/24. The DON stated, she was unable to find documentation that an inventory list had been completed on 7/12/24, 10/4/24 or 10/28/24 in the EMR or in Resident 1's hard chart (physical medical record). The DON stated, it was important for resident's belongings to be inventoried when they were admitted to ensure their personal belongings were tracked. The DON stated, when inventories were not completed on admission there was a potential for resident's personal belongings to get lost. The DON stated, the facility's P&P for Personal Property required for an inventory to be completed upon admission. The DON stated, the P&P for Personal Property was not followed. During a review of RESIDENT GRIEVANCE FORM, dated 10/14/2024, the RESIDENT GRIEANCE FORM indicated, . [Resident 1] . DESCRIBE THE NATURE OF THE GRIEVANCE: Patient lost items wallet / checkbook Last seen in 8/02/24 per email on 10/14/24 . INVESTIGATION: FINDINGS: . looked for items [at] bedside no findings writer added to communications to be on the look out for items . 10/18/2024 writer put on communications again . 10/21/2024 staff member [initials] looked through all Patient belongings no tracings of items . 10/22/24 Items Found [and] Placed in Social [services] Safe . During a review of the facility's (P&P) titled, Personal Property dated 2001, the P&P indicated, . Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits . The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary . During a review of Job Description LVN dated 2/2024, the Job Description LVN indicated, . Essential Duties . Charting and Documentation . Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge . During a review of Resident 1's Clinical Census (CC) dated, 11/5/24, the CC indicated, Resident 1 was admitted [DATE], discharged on [DATE], readmitted on [DATE], discharged on [DATE] and readmitted on [DATE]. During a review of professional reference from https://canhr.org/nursing-home-admission-agreements/#:~:text=Personal%20Possessions,current%20and%20save%20a%20copy.,titled, NURSING HOME ADMISSION AGREEMENTS dated, 9/4/2024, indicated, . When you are admitted to a nursing home, you will be asked to sign an admission agreement that explains your rights and responsibilities and those of the nursing home . Signing Other Documents at Admission . Personal Possessions . At admission, the nursing home must establish a personal property inventory and give you or your representative a copy. (California Health & Safety Code S1289.4) . During a review of professional reference from https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483 titled REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES dated 11/4/24, indicated, . Resident Rights . Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide . A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings . The facility shall exercise reasonable care for the protection of the resident's property from loss or theft . Admission, transfer, and discharge rights . Admissions policy . The facility must establish and implement an admissions policy .

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for five of 15 sampled residents (Resident 19, Resident 24, Resident 38, Resident 40 and Resident 337) when: 1. Resident 40 was administered 2.5L/min (two point five liter- unit of measurement)/min (minute) oxygen via nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 3L/min of oxygen per physician's order. This failure resulted in Resident 40's oxygen needs going unmet and caused Resident 40 received oxygen at different rate. 2. Resident 38 was started on antibiotic (medicines that fight bacterial infections in people) without obtaining a wound (an injury to the skin) culture (a test to find germs such as bacteria, a virus, or a fungus). This failure had the potential to result in Resident 38 receiving unnecessary antibiotic and had the potential for placing Resident 38 at risk for adverse effects (an undesired harmful effect resulting from a medication or other intervention) and increased antimicrobial (substance that kills bacterial, mold or stops them from growing) resistance. 3. Resident 337 was administered 5L/min oxygen via NC instead of 2L/min per physician's order. This failure had the potential to put Resident 337 at risk for oxygen toxicity (lung damage that can occur from breathing in too much extra [supplemental] oxygen. Symptoms include coughing, trouble breathing, dizziness and death). 4. Oxygen tubing for Resident 337 was not labeled with the date it was changed and the oxygen humidifier (a device designed to increase the moisture level by emitting water droplets or steam into the air) water tank was not labeled with the date the tank was changed. These failures had the potential to put Resident 337 at risk for infection from contaminated oxygen tubing and oxygen humidifier water tank. 5. Resident 24's responsible party (RP-person who can make medical decisions for a resident) was not contacted for updates regarding his low air loss mattress (mattresses designed to distribute the patient's body weight over a broad surface area to help prevent skin breakdown). This failure caused Resident 24's RP to not be informed of changes regarding Resident's 24's care. 6. Resident 19 was listed as her own responsible party (RP-person designated to make decisions and be informed regarding the care of a resident) when she had a Brief Interview of Mental Status (BIMS- assessment which determines the cognitive [the ability to think, learn, and memorize] impairment of a person) score of 11 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment.). This failure resulted in the facility not following their own practices of having an RP in place for Residents with a BIMS score under 13. Findings: 1. During a review of Resident 40's Admission Record (AR-a document containing resident profile information) dated 7/26/24, the AR indicated Resident 40 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and chronic(long term) respiratory failure with hypoxia (absence of enough oxygen in the tissue to sustain bodily functions). During a concurrent observation and interview on 7/22/24 at 9:55 a.m. in Resident 40's room, Resident 40 laid in bed with oxygen via nasal cannula receiving 2.5L/min. Resident 40 stated she was getting 3L/min of oxygen and had been using oxygen for a long time to help her breath. During observation on 7/23/24 at 12:10 p.m. in Resident 40's room, Resident 40 laid in bed watching TV. Resident 40's oxygen was set at 2.5L/min via NC. Resident 40 stated she was supposed to be receiving 3L/min of oxygen to help with her breathing problem. During a concurrent observation and interview on 7/23/24 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 8 in the hallway, LVN 8 checked Resident 40's oxygen and stated Resident 40's oxygen was set at 2.5L/min. LVN 8 stated the oxygen should be set at 3L/min if it was the order. LVN 8 stated Resident 40's oxygen order was not being followed per physician's order. LVN 8 stated Resident 40 was not receiving the amount of oxygen ordered which could lead to respiratory distress. During a concurrent interview and record review on 7/23/24 at 12:25 p.m. with LVN 4, LVN 4 reviewed Resident 40's oxygen order and stated Resident 40 should be recceiving 3L/min of oxygen via NC as ordered by the prhysician. LVN 4 stated she did not checked the oxygen setting in the morning at the start of her shift and she should have. LVN 4 stated all the licensed nurses should have been checking the oxygen setting of residents' receiving oxygen. LVN 4 stated Resident 40 not receiving the correct amount of oxygen could lead to respiratory issues which could result to more serious problem. During an interview on 7/26/24 at 11:03 a.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses checking the oxygen settings and comparing with the order to ensure residents are receiving the correct amount of oxygen. DON stated licensed nurses should be checking residents's oxygen at the start of their shift and throughout their shift making sure residents' were receiving the correct amount of oxygen to prevent respiratory distress. Durimg a review of facility's policy and procedure titled, Oxygen Administration dated 10/10, the P&P indicated, . Verify that there is a physician's order . Review the physician's orders or facility protocol for oxygen administration . After completing the oxygen setup or adjustment, the following informatio should be recorded . The rate of oxygen flow . 49949 2. During a concurrent observation and interview on 7/22/24 at 12:28 p.m., in his room, Resident 38 was lying in bed. Resident 38 stated he was taking an antibiotic and did not know the reason he was taking it. Resident 38 stated he had a wound. During a review of Resident 38 's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 38 was admitted to the facility on [DATE]. Resident 38's diagnosis included muscle weakness, muscle wasting, pressure ulcer (an injury that breaks down the skin and underlying tissue), dysphagia (difficulty swallowing), atrial fibrillation (irregular heartbeat) and hypertension (high blood pressure). During a review of Resident 38's Minimum Date Set (MDS-an evaluation of a resident's cognitive [mental function] and functional status), dated 6/14/24, the MDS indicated the Brief Interview for Mental status (BIMS assessment of a resident's cognitive status for memory recall) score of 11out of 15 (a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment) indicating Resident 38 was cognitively intact. During a concurrent interview and record review on 7/25/24 at 2:27 p.m., with License Vocational Nurse (LVN) 1, Resident 38's [Facility name] Order Summary Report (OSR), dated 7/25/24 was reviewed. The OSR indicated, .Wound culture today 7/25/24 r/t [related to] DTI [a type of tissue damage beneath the skin that results from an external pressure] right 1st toe . LVN 1 stated the wound culture was ordered on 7/25/24. LVN 1 stated Resident 38 started on doxycycline (antibiotic) for deep tissue injury) to the right toe on 7/19/24. During a review of [Facility name] Progress Note (PN) dated 7/19/24, the PN indicated .wound bed has 100% eschar (dead tissue that sheds or falls off from the skin) with no drainage noted, moderate odor present. Peri-wound (tissue surrounding a wound) does not exhibit [display] s/s [signs and symptoms] of infection or complication. Received new order on 7/19/24 doxycycline hyclate [a medication used in the management and treatment of a variety of infections.] tablet 100 mg [milligram-unit of measure] give 1 table via G-tube [a tube inserted through the belly that brings nutrition directly to the stomach]. twice a day for PPX [prophylactically] for 10 days of 1st (first) toe right foot . The PN indicated, no wound culture was ordered on 7/19/24. During an interview on 7/25/24 at 3:13 p.m., with the Infection Preventionist (IP- professionals who make sure staff, residents and visitors are doing all the things they should to prevent infections), the IP stated, she worked as an IP for six months. The IP stated, It is not standard of practice to start antibiotic for DTI. The IP stated she was notified that Resident 38 started on antibiotic on 7/19/24. The IP stated the wound culture was obtained on 7/25/24. During an interview on 7/26/24 at 3:49 p.m., with the Director of Nursing (DON), the DON stated, a wound culture should have been done the same day the antibiotic was started. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcome, Dated revised 12/2016, the P&P indicated, .The IP [infection preventionist] or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consist with the appropriate use of antibiotics .4.Thearpy [a form of treatment] was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics . During a review [NAME] the University of Florida Drug and Therapy title Article, Collect before you treat: obtaining cultures before antibiotic treatment dated 12/2006, retrieved from: chrome extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ufhealth.org/assets/media/Professionals-Bulletins/1006-drugs-therapy-bulletin.pdfthe, the article indicated, .Obtaining appropriate cultures before initiating antimicrobial therapy plays an important role in patient [residents] care .Obtaining culture after antimicrobial therapy has been started can cause inconclusive results because organisms that would otherwise be detected may not necessarily grow after exposure to an antibiotic agent Appropriate antibiotic therapy plays an import role in of antibiotic resistance . The Centers for Disease Control and Prevention (CDC) outlines that in order to help control antibiotic resistance and effectively diagnose and treat infection, it is very important to obtain cultures in order to target antimicrobe therapy to susceptibility results . 48739 3. During an observation on 7/22/24 at 9:56 a.m. in Resident 337's room, Resident 337 was observed dressed, in bed with a nasal cannula in his nostrils. Resident 337 stated he had been in the facility for two weeks. Resident 337's oxygen concentrator (a device that produces high levels of oxygen from the air in the room to supply an oxygen-enriched product gas stream) was observed to be infusing oxygen through Resident 337's nasal cannula at five liters per minute. During a review of Resident 337's Admission Record (AR), dated 7/2/24, the AR indicated Resident 337 was admitted on [DATE] with diagnoses of pneumonia (an infection that affects one or both lungs, causing the air sacs of the lungs to fill with fluid), acute respiratory failure with hypoxia (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), and acute pulmonary edema (a buildup of fluid in the lungs). During a concurrent interview and record review on 7/25/24 at 9:57 a.m. with Licensed Vocational Nurse (LVN) 1, a photograph dated 7/22/24 at 9:56 a.m. of Resident 337's oxygen concentrator was reviewed. LVN 1 verified the photograph indicated Resident 337's oxygen was delivering oxygen at 5 liters per minute. Resident 337's Order Summary Report (Report), dated 7/25/24 was reviewed. The Report indicated Resident 337 had admission orders dated 7/2/24 for oxygen to be administered at 2 liters per minute, via nasal cannula, as needed. LVN 1 stated Resident 337 was admitted on [DATE]. LVN 1 stated there were no physician orders for oxygen to be administered at five liters per minute to Resident 337 prior to 7/22/24 at 11:10 a.m. LVN 1 stated Resident 337's oxygen orders were changed on 7/22/24 at 11:10 a.m. to administer oxygen at five liters per minute. LVN 1 stated on 7/22/24 before 11:10 a.m., Resident 337 should have been receiving oxygen at 2 liters per minute. LVN 1 stated if a resident was given too much oxygen, it could blow out the resident's lungs. LVN 1 stated it was very important for staff to follow physician's orders. During an interview on 7/26/24 at 3:09 p.m. with the Director of Nursing (DON) the DON stated, it was very important for staff to follow physician's orders. The DON stated if staff did not follow physician's orders, it could cause harm to the residents. The DON stated if staff did not follow physician orders for oxygen, it could cause shortness of breath or harm to the resident. The DON stated her expectation was for staff to follow physician's orders. During a review of professional reference retrieved from https://my.clevelandclinic.org/health/treatments/25187-nasal-cannula, dated 8/4/23, indicated, . oxygen therapy has some risks. These risks include: . lung damage or pulmonary oxygen toxicity. This is damage to your lungs and airways from too much oxygen . During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, indicated, . verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . adjust the oxygen delivery device so . the proper flow of oxygen is being administered . 4. During an observation on 7/22/24 at 9:56 a.m. in Resident 337's room, Resident 337 was observed dressed, in bed with an undated nasal cannula in both his nostrils, infusing oxygen at five liters per minute. Resident 337's oxygen humidifier tank was observed to be undated, with water inside the tank. Resident 337 stated he had been in the facility for two weeks. Resident 337 stated he had pneumonia. During a concurrent observation and interview on 7/22/24 at 10:04 a.m. with Certified Nursing Assistant (CNA) 3 in Resident 337's room, Resident 337's oxygen tubing and oxygen humidifier tank were observed. CNA 3 stated the oxygen tubing and oxygen humidifier tank were not dated. CNA 3 stated the oxygen tubing and oxygen humidifier tank should be dated with the date they were last changed. During an interview on 7/25/24 at 2:26 p.m. with LVN 1, LVN 1 stated Resident 337's oxygen tubing should have been dated with the date the tubing was changed. LVN 1 stated Resident 337's oxygen humidifier tank should have been dated with the date the tank was changed. LVN 1 stated dated oxygen tubing and dated humidifier tanks were important for resident infection prevention. LVN 1 stated if the oxygen tubing or the oxygen humidifier tank was not changed, they could have dust or mold growth inside the tank or tubing which could cause infection to Resident 337. During an interview on 7/26/24 at 3:09 p.m. with the DON, the DON stated nurses were responsible for making sure the residents' oxygen tubing and humidifier tanks were changed weekly and dated. The DON stated it was important to change the oxygen tubing and oxygen humidifier tank weekly. The DON stated residents were at an increased risk of infection if the oxygen tubing or oxygen humidifier tank were not changed weekly. During a review of Resident 337's Order Summary Report (Report), dated 7/25/24, the Report indicated, . change humidifier bottle/tubing every day shift every Sun Date & Initial . order date 7/2/24 . During a review of professional reference retrieved from https://www.ucsfhealth.org/education/your-oxygen-equipment, titled, Patient Education Your Oxygen Equipment, dated 2022-2024 indicated, . the nasal cannula should be changed every week . if you are using a humidifier, empty it at least once a day . 48424 5. During a review of Residents 24's Admission Record (AR), dated 1/12/24, the AR indicated, Resident 24 was not his own RP. Resident 24's admitting diagnoses included the following: muscle wasting and atrophy (condition which causes the muscles to diminish and weaken), and muscle weakness. During a review of Resident 24's Minimum Data Set (MDS), dated [DATE], the MDS indicated BIMS score of ten (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 24 had moderate cognitive impairment. During an observation on 7/22/24 at 8:14 a.m. in Resident 24's room. Resident 24 was observed lying on a low air loss mattress. During an interview on 7/25/24 at 4:22 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated a change to Resident 24's low air loss mattress should have been communicated to the RP. CNA 1 stated low air loss mattresses were doctor's orders and doctor's orders needed to be communicated to the RP. CNA 1 stated it was important to communicate to the RP in order to have a cognitively intact person consent to treatments needed. During concurrent interview and record review on 7/26/24 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 24's progress notes, dated 07/22/24 were reviewed. The progress note indicated, .Received new LAL [low air loss mattress] but noted low pressure . ADON [assistant director of nursing] notified. Resident is self RP and made aware. Will [continue] to monitor . LVN 1 stated Resident 24 was not supposed to act as his own RP. LVN 1 stated staff should have contacted his actual RP regarding his mattress. LVN 1 stated it was important to contact Resident 24's RP so appropriate decisions could have been made by a cognitively intact person. During a concurrent interview and record review on 7/26/24 at 2:38 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 24's MDS, dated [DATE] was reviewed. The MDS indicated Resident 24 had a BIMS score of 10. The MDSC stated residents with a BIMS score less than 13 could not serve as their own RP. The MDSC stated Resident 24's BIMS was 10 which indicated he had moderate cognitive impairment. The MDSC stated Resident 24's RP should have been contacted. The MDSC stated if a residents RP was not contacted, the resident would receive inaccurate care. During an interview on 7/26/24 at 3:33 p.m. with the director of nursing (DON), the DON stated Resident 24's RP should have been contacted regarding his mattress. The DON stated the RP would have been unaware of any changes occurring with Resident 24 if he was not contacted. During a review of the facility's policy and procedure (P&P) titled, Informed Consent Policy, dated 4/17, the P&P indicated, . Resident or responsible party will be provided an informed consent whenever applicable . 6. During a review of Resident 19's Admission Record (AR), dated 6/28/24, the AR indicated Resident 19 was her own RP. Resident 19's admitting diagnoses included: Major Depressive Disorder (a mental health disorder characterized by persistently sad mood or loss of interest in activities), Alzheimer's disease (condition which causes memory loss), psychotic disorder with hallucination (condition which causes false beliefs such as hearing or seeing things that are not there). During a review of Resident 19's Minimum Data Set (MDS), dated [DATE], the MDS indicated a BIMS score of 11 indicating Resident 19 had moderate cognitive impairment. During an interview on 7/25/24 at 4:31 p.m. with CNA 1, CNA 1 stated residents with impaired cognitive abilities and confusion could not sign their own consents or serve as their own RP. CNA 1 stated if Resident 19 had a low BIMS score it meant she could not act as her own RP. CNA 1 stated residents with lower BIMS scores should not serve as their own RP because they could have signed consents they would not have understood. During an interview on 7/26/24 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents with a BIMS score between 8-12 were cognitively impaired. LVN 1 stated MDSC was the person who calculated the BIMS scores and determined if residents were able to act as their own RP. During a concurrent interview and record review on 7/26/24 at 2:42 p.m. with the MDSC, Resident 19's MDS Section C, dated 6/1/24, was reviewed. The MDS Section C indicated Resident 19 had a BIMS score of 11. The MDSC stated it was the facility's practice that residents with a BIMS score under 13 could not serve as their own RP. Resident 19 should not have been her own RP with a BIMS score of 11. The MDSC stated a different RP should have been selected at the time of her admission on 6/28/24. The MDSC stated having an appropriate RP was important in order to adequately provide care for residents . During a review of the facility's policy and procedure (P&P) titled, Informed Consent Policy, dated 4/17, the P&P indicated, . Resident or responsible party will be provided an informed consent whenever applicable .

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when the facility failed to have a system in place to control infections and communicable diseases in residents when issues of cross contamination (moving from a dirty area to a clean area) were practiced by staff caring for residents isolated for potential [MEDICAL CONDITION] (C. diff -bacterial infection that causes life threatening diarrhea) and did not provide an effective disinfectant solution used to disinfect equipment. Twenty-nine of 29 sampled residents (Residents 1, 3, 7, 16, 17, 19, 23, 24, 26, 27, 33, 36, 43, 45, 50, 57, 58, 64, 70, 71, 74, 79, 81, 82, 84, 85, 86, 190, 197) were weighed with the same mechanical lift used in the isolation room without disinfecting with an agent that would kill C.diff bacteria; ineffective disinfection was used on the glucometer (machine that checks the blood sugar levels by a skin prick usually for Diabetic (unable to produce enough insulin (hormone) to keep blood sugars within normal range) patients and staff failed to properly perform hand washing after handling infectious equipment and personal protective equipment (PPE). Laundry staff were unable to ensure the washer temperature was high enough to kill the [DIAGNOSES REDACTED] bacteria; environment and other equipment and meal tray carts were not properly disinfected with disinfectant containing bleach, and staff were not trained on infectious disease procedures. Because of these failures and the identified serious potential harm to all residents of the facility related to the serious infection control issues identified with the use of disinfectants that were not effective against [MEDICAL CONDITION] bacteria an Immediate Jeopardy situation (IJ) was called on 3/13/19 at 4:05 p.m., with the facility Administrator (ADM) and the Director of Nursing (DON). These deficient practices resulted in inadequate infection control training, and monitoring and had the potential to result in the spread of [DIAGNOSES REDACTED] infections to residents; inadequate infection control surveillance in the facility and residents to acquire communicable infections, the spread of infectious diseases to all residents requiring blood sugar testing, and inadequate antibiotic surveillance and the unnecessary use of medications in residents and to result in the spread of infections and residents to acquire communicable infections. The facility submitted an Action Plan to address the IJ situation which included the removal of non-chlorine wipes and replacement with Bleach base germicidal wipes that killed [MEDICAL CONDITION] and blood borne pathogens. The bleach wipes would be utilized to clean all surfaces and equipment used by residents. Linens and trash from isolation rooms will be placed in a separate linen bin. Laundry washer water temperature will be monitored on a daily log to ensure the water temperature was at the degree to kill the [MEDICAL CONDITION] bacteria. Designated meal carts for isolation trays will be disinfected with Bleach base germicidal wipes. The facility staff and healthcare service group (HCSG) staff (subcontract) were provided competency education on the use of Bleach base germicidal wipes and PPE removal prior to exiting isolation rooms. The Nurse Practice Educator (NPE) was trained on infection prevention and will be responsible for maintaining infection control surveillance logs as of 3/18/19. The infection control program will be reviewed monthly as part of the Quality Assurance Performance Improvement (QAPI) meeting. The Action Plan was accepted on 3/18/19 at 8:42 a.m. with the ADM. The interventions to address the IJ situation on the Action Plan were fully implemented. The IJ was removed on 3/18/19 at 3:03 p.m., with the ADM. Findings: 1. During an observation on 3/12/19, at 10:10 a.m., in the hallway, Certified Nursing Assistant (CNA 11) was exiting Resident 191's [DIAGNOSES REDACTED] isolation room without removing the potentially [DIAGNOSES REDACTED] infected face mask. CNA 11 walked down the hallway, discarded the face mask in the housekeeper's trash bin located in the hallway and did not wash her hands after handling the potentially [DIAGNOSES REDACTED] infected face mask. CNA 11 then placed her unwashed hands on the hand rails located in the hallway. During an interview with CNA 11, on 3/12/19, at 10:16 a.m., she stated, I was in (Resident 191's room). (Resident name) is on contact precautions for [MEDICAL CONDITION]. I was wearing a mask all day because I have a cough. I threw the mask in the housekeeper's trash bin. CNA 11 stated she should have worn PPE before entering a contact isolation room, washed her hands and removed all PPE prior to exiting the isolation room. During a review of the clinical record for Resident 191's, the Facesheet (document with resident demographic information and medical diagnosis) undated, indicated Resident 191 was admitted on [DATE] to the facility with [DIAGNOSES REDACTED]. During a review of Resident 191's clinical record, the untitled Care plan dated 3/11/19, indicated, Resident exhibits or is at risk for complications of infection related to [DIAGNOSES REDACTED] . Will remain in contact isolation until 3 formed stools . Resident 191's, Order Summary dated 3/8/19 indicated, .Will remain in isolation related to [MEDICAL CONDITION] until patient has three formed stools . During an interview with the DON, on 3/19/19, at 9:14 a.m., she stated all PPE should be discarded prior to exiting an isolation room to prevent surfaces from [DIAGNOSES REDACTED] contamination and spread of infections to residents. During an interview with the Nurse Practice Educator (NPE), on 3/19/19, at 2:21 p.m., she stated, PPE should be removed prior to exiting an isolation room to prevent the spread of [DIAGNOSES REDACTED] infection to residents. Review of professional reference retrieved on 4/2/19, from https://www.cdc.gov/handwashing/why-handwashing.html titled, Handwashing: Clean Hands Save lives dated 9/17/18, indicated, . Keeping hands clean is one of the most important steps we can take to avoid getting sick and spreading germs to others. Many diseases and conditions are spread by not washing hands with soap and clean, running water . Handwashing helps battle the rise in antibiotic resistance . Preventing sickness reduces the amount of antibiotics people use and the likelihood that antibiotic resistance will develop. Handwashing can prevent about 30% of diarrhea-related sicknesses and about 20% of respiratory infections (e.g., colds) . Reducing the number of these infections by washing hands frequently helps prevent the overuse of antibiotics-the single most important factor leading to antibiotic resistance around the world. Handwashing can also prevent people from getting sick with germs that are already resistant to antibiotics and that can be difficult to treat. The facility policy and procedure titled, Contact Precautions dated 11/28/17, indicated, . Before exiting room, remove and bag gown and gloves and wash hands upon exiting room .If use of common equipment is unavoidable, clean and disinfect item before use with another patient . 2. During an observation on 3/12/19, at 4:10 p.m., in the facility hallway, Restorative Nurses Aide (RNA) 2 stood outside of Resident 45's room. Resident 45's room had a sign indicating isolation precautions. RNA 2 handed the bleach free, alcohol free disinfectant wipe to RNA 1, then RNA 1 used the wipe to disinfect the mechanical lift (lift used to assist staff with resident transfers) located inside Resident 45's isolation room. During an interview with RNA 1, on 3/12/19, at 4:16 p.m., she stated Resident 45 was on [MEDICAL CONDITION] isolation precautions. RNA 1 stated the mechanical lift was used to weigh Resident 45 inside the isolation room and the bleach free wipes were used to disinfect the mechanical lift. RNA 1 stated the bleach free wipes were provided by the facility to disinfect equipment used in isolation rooms. RNA 1 stated, The wipes are bactericidal (to kill bacteria), from what I know C- diff is a bacteria and it's ok to use it for [DIAGNOSES REDACTED]. RNA 1 stated the bleach free wipes were the only wipes availed for staff to use to disinfect [DIAGNOSES REDACTED]. RNA 1 stated she was not informed that she needed to use a bleach containing wipe to disinfect or kill [DIAGNOSES REDACTED] infection on equipment. During a review of the clinical record for Resident 45, the Facesheet undated, indicated Resident 45 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 45's, Minimum Data Set assessment (MDS-an assessment tool that identifies resident physical and cognitive abilities) dated 1/30/19, indicated, Resident 45 was frequently incontinent of bowel. Resident 45's untitled, Care plan dated 3/1/19, indicated, Resident exhibits or is at risk for complications of infection related to [DIAGNOSES REDACTED] . Will remain under isolation until patient has 3 consecutive formed stools . Resident 45's, Order Summary dated 3/1/19 indicated, .Patient to remain in isolation related to [MEDICAL CONDITION] until patient has 3 consecutive formed stools . Weigh every day shift . During a concurrent interview and record review with RNA 1, on 3/12/19, at 4:25 p.m., she stated the facility had one mechanical lift that contained a weighing scale. RNA 1 provided the facility document titled, VITAL SIGNS AND WEIGHT FOR THE MONTH OF MARCH 2019. RNA 1 stated residents coded with an L indicated residents that were weighed with the mechanical lift. During a review of the facility document titled, VITAL SIGNS AND WEIGHT FOR THE MONTH OR MARCH 2019 with RNA 1, the document indicated Resident's 1, 3, 7, 16, 17, 19, 23, 24, 26, 27, 33, 36, 43, 45, 50, 57, 58, 64, 70, 71, 74, 79, 81, 82, 84, 85, 86, 190, 197 were coded with an L and weighed with the same potentially [DIAGNOSES REDACTED] infected mechanical lift. During a review of the clinical record for Residents 1, 3, 7, 16, 17, 19, 23, 24, 26, 27, 33, 36, 43, 45, 50, 57, 58, 64, 70, 71, 74, 79, 81, 82, 84, 85, 86, 190, 197 the Order Summary dating from 3/3/17 to 3/14/19 (for 29 residents) indicated, .Weigh every day shift . During an interview with the NPE, on 3/12/19, at 4:20 p.m., she stated bleach free wipes were appropriate to disinfect the mechanical lift used in the [MEDICAL CONDITION] isolation room. The NPE then read the bleach free wipe disinfectant bottle label and stated the wipes did not kill the [MEDICAL CONDITION]. bacteria. During an interview with LVN 12, on 3/12/19, at 4:37 p.m., she stated the bleach free wipes were the only disinfectant wipes used for all isolation rooms including [DIAGNOSES REDACTED]. During an interview with the DON, on 3/13/19, at 9:48 a.m., she stated the Bleach Free wipes had a list of microorganisms that it killed but the wipes did not kill [DIAGNOSES REDACTED] bacteria. The DON stated the facility was using bleach free wipes to disinfect [DIAGNOSES REDACTED] equipment for a long time. The DON did not state how long the facility had used bleach free wipes on potentially [DIAGNOSES REDACTED] infected equipment. During an interview with the DON, on 3/19/19, at 9:14 a.m., she stated the mechanical lift should have been disinfected with bleach to prevent the spread of [DIAGNOSES REDACTED] infection. During an interview with the NPE, on 3/19/19, at 2:21 p.m., she stated all equipment exiting isolation rooms should be sanitized with the appropriate disinfectant to prevent the spread of infection. Review of professional reference retrieved on 4/2/19, from https://www.cdc.gov/cdiff/clinicians/cdi-prevention-strategies.html titled, CDI (C. difficile Infection) Prevention Strategies dated 1/11/19, indicated, .facilitate immediate isolation of patients with suspected or confirmed CDI: . Adhere to recommended hand hygiene practices. Use dedicated patient-care equipment (e.g., blood pressure cuffs, stethoscopes), and use single-use disposable items (e.g., single patient digital thermometer) if possible . Perform daily cleaning using a [DIAGNOSES REDACTED]icile sporicidal (kills spores-dormant bacteria highly resistive to cleaning agents) agent . Clean and disinfect the patient-care environment (including the immediate vicinity (area near or surrounding) around a CDI patient and high touch surfaces) at least once a day, including the toilets. Clean and disinfect all shared equipment prior to use by another patient .Consider the need for cleaning of equipment that is commonly moved between patient rooms (e.g., housekeeping carts, wheelchairs, gurneys) . Review of the CDC (Centers for Disease Control) Professional Reference titled, Isolation precautions guideline dated 9/2018 (https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf) indicated, . since [DIAGNOSES REDACTED]icile may display increased levels of spore production when exposed to non-chlorine-based cleaning agents, and the spores are more resistant than vegetative cells to commonly used surface disinfectants .recommended the use of a 1:10 dilution of 5.25% sodium hypochlorite (household bleach) and water for routine environmental disinfection of rooms of patients with [DIAGNOSES REDACTED]icile . The facility policy and procedure titled, CONTAMINATED ISOLATION ROOM CLEANING: [MEDICAL CONDITION] SPORES dated 6/2016, indicated, Purpose: Review the process of cleaning an Isolation Room and preventing the spread of [MEDICAL CONDITION] disease . To protect the facility . every effort is made to keep the bacteria in the room and isolated in the double bag procedure along with using the EPA (Environmental Protection Agency: an independent federal agency, that sets and enforces rules and standards that protect the environment) approved solution (E.G. Ultra Clorox Disinfectant 1:10 bleach solution . The facility policy and procedure titled, [MEDICAL CONDITION] dated 11/15/18, indicated . 5. Clean and disinfect all use and potentially contaminated equipment. 6. Clean environment daily using a minimum of a 1:10 solution of sodium hypochlorite (nine parts water to one-part bleach) . agent . The facility policy and procedure titled, Cleaning and Disinfecting dated 7/24/18, indicated . PURPOSE: To prevent infectious spread from items or environments to patients and/ or staff. To ensure reusable medical equipment is cleaned and disinfected appropriately . PRACTICE STANDARDS . 5. Perform routine disinfection of items used in daily care practices with EPA registered disinfectant . 5.2 Multi-patient equipment must also be cleaned/ disinfected after patient use . 6. Clean environmental surfaces, floors, walls, furniture . For patients with . [DIAGNOSES REDACTED]icile registered . use minimum of 1:10 dilution of sodium hypochlorite (nine parts water and to one-part bleach) . 3. During a concurrent observation and interview with the Housekeeper/laundry Supervisor (HLS), on 3/13/19, at 11:07 a.m., in the laundry soiled linen room, a large clear plastic bag containing PPE (disposable yellow gown) was inside the soiled linen bin. The HLS stated the large clear plastic bag containing PPE trash should not be stored in the soiled linen bin with other residents soiled linens. The HLS stated, It is an infection control issue. During an interview with CNA 4, on 3/13/19, at 2:23 p.m., CNA 4 stated she placed the trash bag containing PPE (trash) from a [MEDICAL CONDITION] isolation room in the laundry soiled linen bin. CNA 4 stated she was not educated on the proper disposal of trash from an isolation room. During an interview with the DON, on 3/19/19, at 9:14 a.m., she stated waste containing PPE should not be stored in the soiled linen room to prevent cross contamination. During an interview with the NPE, on 3/19/19, at 2:21 p.m., she stated the PPE that was placed inside the laundry soiled linen room was an infection control issue. The facility policy and procedure titled, Contact Precautions dated 11/28/17, indicated, PURPOSE: To reduce the risk of transmission of (infections) by direct or indirect contact . 4.5.1 Removed bagged PPE from room and discard in soiled utility (room storing potentially infectious waste) . 4. During an interview with Laundry staff (LS 2), on 3/13/19, at 10:15 a.m., LS 2 stated she was unable to verbalize the appropriate water temperature range used in the laundry process during the wash cycle for potentially infectious laundry. LS 2 stated the washing machine did not have the capability to display water temperature readings. LS 2 stated the mechanical lift slings (cloth devise placed under residents to lift and transfer resident from one location to another) used on Resident 45 with [DIAGNOSES REDACTED] infection were washed together with other resident laundry. LS 2 stated unless she was verbally notified by staff she would not be able to identify which linens were removed from an isolation room. During an interview with housekeeping (HK 1), on 3/13/19, at 10:31 a.m., he stated the linen from isolation rooms were washed separately. HK 1 stated the facility process for identifying and handling potentially contaminated linens was for staff to take linen from the isolation room and verbally notify the laundry staff to inform them the linen was taken from an isolation room. HK 1 stated he removed soiled linens from one of the isolation [DIAGNOSES REDACTED] room on 3/13/19 and placed the linens (not double bagged) in the soiled laundry bin located in the laundry room. HK 1 stated he placed the linen in the soiled linen bin without notifying laundry staff. During an interview with LS 2, on 3/13/19, at 10:55 a.m., LS 2 stated she had not received soiled linens from an isolation room on 3/13/19 and was not aware if linens needed to be washed at a specific temperature. LS 2 stated she did not know the washing machine water temperature. LS 2 stated she washed all linens in the same manner. During an interview with Housekeeping/Laundry Supervisor (HLS), on 3/13/19, at 11:04 a.m., he stated the washing temperature should be at least 180 degrees Fahrenheit (F). The HLS stated he was unable to demonstrate how to verify the water temperature was at a minimum of 180 F during the washing cycle. Review of professional reference from the California Department of Public Health All Facility Letter (AFL) 10-27, titled, Enhanced Standard Precautions (ESP) for long Term Care Facilities dated 9/7/10, indicated, .Soiled linens such as sheets, towels, incontinence pads and patient gowns are contaminated .even if visible soil in not evident .Laundry wash water temperature should be maintained at or above 160 ° F (170 ° C (Celsius- a scale of temperature). Alternately, low temperature washing at 71-77° F (22-25 ° C) plus 125 parts-per-million (PPM) chlorine bleach rinse . The facility policy and procedure titled, CONTAMINATED ISOLATION ROOM CLEANING: [MEDICAL CONDITION] SPORES dated 6/2016, indicated, Purpose: Review the process of cleaning an Isolation Room and preventing the spread of [MEDICAL CONDITION] disease . To protect the facility from the patient, every effort is made to keep the bacteria in the room and isolated in the double bag procedure along with using the EPA approved solution (E.G. Ultra Clorox Disinfectant 1:10 bleach solution . 4 . linens . b. Double bag bed linens and identify them as isolation room contents for laundry personnel . 8. Exit room . b. Take all double bag linens, mops and curtains to the dirty linen room and let the laundry employees know . 5. During an interview with CNA 4, on 3/13/19, at 2:23 p.m., CNA 4 stated she was told by the DON that meal trays from an isolation room and non-isolation could be placed together in the same meal cart. CNA 4 stated kitchen staff were notified by the nursing staff when meal trays came out of the [DIAGNOSES REDACTED] isolation room. CNA 4 stated she had placed the potentially [DIAGNOSES REDACTED] contaminated meal tray from the [DIAGNOSES REDACTED] isolation room on the meal cart with other resident's trays on 3/13/19 and took the meal cart back to the kitchen. CNA 4 stated she was unable to state if she notified the kitchen staff of the [DIAGNOSES REDACTED] contaminated meal tray. During an interview with Dishwasher (D2), on 3/13/19, at 2:35 p.m., she stated meal trays from an isolation room and non-isolation room were transported to the kitchen on the same meal cart. D2 stated the meal carts were not cleaned with disinfectants containing bleach. D2 stated, I have not received any meal trays from an isolation room today. During a concurrent interview and record review with Dietary District Manager (DDM) on 3/13/19, at 2:42 p.m., he stated the meal cart was sanitized after every use with a pre-mixed solution from (name 146 Multi- quaternary (quat) solution used as a disinfectant). The DDM read the label on (name 146 Multi-Quat) sanitizer bottle and stated the (name 146 Multi-Quat) sanitizer did not contain bleach. Review of professional reference retrieved on 4/2/19, from https://www.cdc.gov/cdiff/clinicians/cdi-prevention-strategies.html titled, CDI (C. difficile Infection) Prevention Strategies dated 1/11/19, indicated, . Create daily and terminal cleaning protocols and checklists for patient-care areas and equipment. Perform daily cleaning using a [DIAGNOSES REDACTED]icile sporicidal (bleach) agent . Clean and disinfect all shared equipment prior to use by another patient .Consider the need for cleaning of equipment that is commonly moved between patient rooms (e.g., housekeeping carts, wheelchairs, gurneys) . The facility policy and procedure titled, [MEDICAL CONDITION] dated 11/15/18, indicated . 5. Clean and disinfect all use and potentially contaminated equipment .using a minimum of a 1:10 solution of sodium hypochlorite (nine parts water to one-part bleach) . 6. During an interview with LVN 2, on 3/12/19, at 4:47 p.m., LVN 2 stated he used hand wipes that did not contain bleach to disinfect the glucometer. LVN 2 stated, That's what I use. (Hand wipes) is used to clean my hands and the glucometer. LVN 2 stated he had been working in the facility for four months and he was trained on orientation to use hand wipes that did not contain bleach to clean his hands and to disinfect the glucometer before and after use. LVN 2 stated one Glucometer device was used for all residents requiring blood sugar testing. LVN 2 stated he used the Glucometer on multiple residents LVN 2 stated the disinfectant wipes that were used to clean the Glucometer after each resident did not contain bleach. LVN 2 stated the potential for a resident to contract an infection was high if the blood on the Glucometer device was not disinfected properly. During a concurrent observation and interview with LVN 2, on 3/12/19, at 5 p.m., in the facility's hallway, LVN 2 opened the bottom drawer of the medication cart and took the hand wipes that did not contain bleach. LVN 2 stated, That's what I use to clean the glucometer. LVN 2 stated there was only one glucometer in each medication cart and the glucometer machine was shared by all residents that required blood sugar testing on his assigned wing. LVN 2 stated the facility process was to disinfect the glucometer machine using hand wipes that did not contain bleach. During a concurrent medication observation and interview with LVN 9 on 3/12/19, at 5:12 p.m., LVN 9 took the glucometer from the medication cart and used (bleach free wipes) to disinfect the glucometer machine. LVN 9 stated, This is what I use to disinfect the glucometer (machine) and it kills (all) blood borne pathogens. During an interview with the DON, on 3/13/19, at 9:48 a.m., she stated the facility (bleach free wipes) had a list of microorganisms that it killed but the bleach free wipes did not kill the [MEDICAL CONDITION] bacteria. During an interview with the DON, on 3/19/19, at 9:14 a.m., she stated the bleach free hand wipes used by LVN 2 and LVN 9 should not be used to disinfect the Glucometer machine. During a medication observation and interview with LVN 11, on 3/13/19, at 11:11 a.m., LVN 11 stated she used (bleach free) wipes that did not contain bleach to disinfect the glucometer. LVN 11 stated, This is what (Licensed Nurses) use to clean the glucometers. During a concurrent interview and record review on 3/13/19, at 3:30 p.m. with the NPE, the glucometer infection control usage competency skill set check list was requested for LVN 2, LVN 10, LVN 11, LVN 13, and LVN 4. The NPE provided the finger stick competency checklist for LVN 11, LVN 10, LVN 13 and LVN 4 but did not provide the competency check list for LVN 2. The NPE stated there was no criteria and method in place to measure glucometer infection control usage competency skills. NPE stated there was no return demonstration documented in the staff competency check list to verify if staff understood the teaching. NPE stated laundry and housekeeping staff were a part of a subcontract company they hired and the facility did not have oversight for their staff competency training. During a concurrent interview and record review with the DON, on 3/13/19, at 4:30 p.m., the DON reviewed the manufacturer's guidelines manual of the glucometer titled, (Brand of glucometer) Blood Glucose Monitoring System User's Guide undated, indicated, . Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease . Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface . The following products are validated for disinfecting the (brand of glucometer) . (brand name) bleach germicidal bleach wipes EPA Registration Number -1 . The DON reviewed the EPA registration number of the disinfecting hand wipes the facility was currently using and stated the EPA Registration Number was 1839-174- and was different from the manufacturer's recommendation. The DON stated bleach wipes should have been used by licensed nurses to disinfect the glucometer before and after resident use. The DON stated the current hand wipes the facility was using were not sufficient to kill blood borne pathogens. During an interview with HK 3, on 3/15/19, at 10:25 a.m., she stated, We work under (name of contracted company). The subcontract company did all our training prior to us starting to work in the facility. The facility never provided us training or anything. When we came here, we were ready to work. We never signed anything for training. HK 3 stated the facility did not perform competencies or training for infection control policies and procedures. During an interview with the DON, on 3/19/19, at 8:51 p.m., she stated, I know (contracted group) has a process to check the laundry and housekeeping staff's competency. The DON stated she was unable to find documentation laundry and housekeeping staff's competencies. The DON stated, the NPE did not have oversight on the laundry and housekeeping staff's training. The DON stated it was important for the facility to have oversight of competency training to all employees of the facility to ensure safe resident processes were used by all staff. The DON was unable to find training documents for the laundry and housekeeping staff. During an interview with the NPE, on 3/19/19, at 2:25 p.m., she stated it was important to have criteria for staff's competency training. The NPE stated, Before the (competency training checklist) evaluation just said met but there was no return demonstration (of compliance or understanding). Return demonstration was important to demonstrate appropriate and competent steps. The NPE stated, The subcontract manager provided training and competency for the laundry and housekeeping (staff) but there was no oversight training and competency. It was through their company. It is important to be on the same page especially with training and competency for all staff that work in the facilities. During an interview with the NPE, on 3/19/19, at 2:54 p.m., NPE stated she reviewed LVN 2's documentation of skills competency on glucometer and was unable to find documentation of competency skill check on orientation. The NPE stated LVN 2 was hired on (MONTH) (YEAR) and should have received his competency skill training before working with residents to ensure he was competent on the skills required, like medication administration and infection control guidelines. The NPE stated LVN 2 should not have used the hand wipes that did not contain bleach to disinfect the glucometer because the bleach free wipes did not kill blood borne pathogens. The NPE stated, If it's not documented then it's not done. The NPE stated the competency check list for staff did not measure staff competencies or how they understood the in-service or training provided. The NPE stated, Without a return demonstration, there is no way to know if nurses or staff understand it. The facility policy and procedure titled, Cleaning and Disinfecting dated 7/24/18, indicated, .To ensure reusable medical equipment is cleaned and disinfected appropriately .Perform routine disinfection of items used in daily care practices with Environmental Protection Agency (EPA) registered disinfectant . .Multi-patient equipment must also be cleaned/disinfected after patient use . Review of the CDC (Centers for Disease Control) Professional Reference titled, Blood Glucose Meters dated 5/2018, (www.cdc.gov.injectionsafety/providers/blood-glucose-monitoring_faqs.html) indicated, . The disinfection solvent you choose should be effective [MEDICAL CONDITION](human immunodeficiency virus, a retrovirus which causes AIDS), [MEDICAL CONDITION] (a form of [MEDICAL CONDITIONS] transmitted in infected blood, causing chronic liver disease), and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] (alcohol) solutions are not effective against [MEDICAL CONDITION] blood borne pathogens . 7. During an interview with the DON, on 3/19/19, at 9:30 a.m., she stated the NPE was the staff member assigned to implement and monitor the facility's Antibiotic (medication used against bacterial infections) (ATB) stewardship and infection control surveillance program. The DON reviewed the ATB stewardship and surveillance program paperwork for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) tracking logs. The DON stated she was unable to find documentation for the three months. The DON stated, I don't know where it is. I can't find it. The DON stated it was important to have complete and accurate documentation of the ATB stewardship and surveillance program to ensure residents were placed on the appropriate ATB. The DON stated the ATB stewardship and surveillance tracking was an important part of the facility's infection prevention and control procedures. During an interview with the NPE, on 3/19/19, at 2:25 p.m., she stated, Antibiotic surveillance is a monthly report to prevent the spread of infection and to make sure (residents) are treated with the correct antibiotic and not treating (residents) with an antibiotic without an infection. We don't have (MONTH) (2018), (MONTH) (2018) and (MONTH) (2018 ATB stewardship and surveillance tracking). The facility policy and procedure titled, Infection Prevention and Control Program Description dated 3/11/19, indicated The Infection Control Program (IPCP) is a comprehensive process that addresses preventing, identifying, reporting, investigating and controlling of infections and communicable disease for patients, staff . and other individuals providing services under a contractual agreement . 1.Surveillance of infection with includes ongoing monitoring to identify possible communicable diseases or infections before they can spread to others in the Center and to whom they should be reported. 2. Process surveillance to review infection prevention and control practices directly related to patient care . 8. During an observation on 3/12/19 at 11:20 a.m. with Resident 64 in his room, the DON and RNA 1 were providing peri(neal)-care (anal area) for Resident 64. RNA 1 removed the so

Based on observation, interview, clinical record and administrative document review, the facility failed to ensure residents with diabetes mellitus (a metabolic disease characterized by higher than normal sugar levels in the blood caused by insulin deficiency) were monitored in accordance with professional standards of quality for 3 of 7 sampled residents (Residents 4, 5, and 7) and 12 of 12 randomly sampled residents (Residents 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19). The facility failed to consistently follow physician orders for obtaining morning finger stick blood sugars (FSBS) and accurately document values. The facility failed to evaluate and appropriately implement interventions meant to address physician ordered measures for unsafe FSBS values (less than 60 mg/dl and greater than 350 mg/dl). Registered Nurses (RN) and Licensed Nurses (LN) did not inform the physician of the FSBS values outside of the acceptable range (above 60 mg/dl and below 350 mg/dl) for diabetic residents. These failures placed Residents 4, 5, and 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19 at risk of unsafe fluctuations in blood sugar levels. Blood sugar finger stick levels lower than 60 mg/dl (milligrams per deciliter, a unit of measure that shows the concentration of a substance in a specific amount of fluid) may lead to nausea, shakiness, dizziness, confusion and loss of consciousness and coma and death if not immediately addressed. Blood sugar levels greater than 350 mg/dl may lead to increased thirst, increased frequency of urination, increased hunger coupled with weight loss, confusion, headaches and if not addressed in a timely manner may lead to dehydration and deposits of glucose in the small blood vessels and peripheral nerves (nerves branching out from brain and spinal cord into all other areas of the body). Due to the serious potential harm related to inadequate monitoring and appropriately intervening for low and high blood sugar levels on 15 Residents, an Immediate Jeopardy (IJ) situation was called on 12/6/16 at 5:25 p.m. with the Administrator (ADM), Director of Nurses (DON) and Regional Resource Nurse Manager (RNM). The facility submitted an approved Action Plan addressing the IJ situation and implemented actions addressing the immediacy and the IJ was removed on 12/8/16 at 10:20 a.m. with the ADM and the DON. Findings: On 11/19/16 at 5:15 a.m., during an observation and interview, LN 9 exited Resident 16's room with the glucometer (an instrument for measuring/checking/monitoring blood for sugar levels) in hand. LN 9 stated Resident 16's FSBS value was 140. LN 9 was asked to display the glucometer reading, which read 198. LN 9 stated, Oops, made a mistake. LN 9 had entered documentation on Resident 16's November 2016 Medication Administration Record (MAR) at 5:15 a.m., in the 6:30 a.m. time space, indicating Resident 16's FSBS value was 140 on 11/19/16. LN 9 went back and wrote over the 140, converting the FSBS value 140 to indicate 198 (the actual value indicated in the glucometer). On 11/19/16 at 5:20 a.m., during an observation and concurrent interview, RN 1 exited Resident 12's room carrying a glucometer. RN 1 stated he would give regular insulin (a quick acting medication, onset within 30 minutes to one hour, used to regulate and lower the amount of sugar in the blood) if needed, at the time he obtained the high FSBS reading. RN 1 stated the morning breakfast meal was served at 7:30 a.m. each day. During this interview, RN 1 did not respond when asked if the time difference between obtaining the FSBS and the serving of breakfast would affect his decision to administer insulin if a resident needed the medication. On 11/19/16 at 5:25 a.m., during a concurrent interview and clinical record review of Resident 12's MAR, RN 1 stated Resident 12's morning FSBS checks were ordered for 6:30 a.m. each morning. When asked the reason RN 1 obtained the scheduled 6:30 a.m. morning FSBS prior to 5:30 a.m., RN 1 stated there were too many FSBS checks ordered at 6:30 a.m. to complete and administer insulin before shift report at 7 a.m. Review of Resident 12's MAR indicated spaces for documenting FSBS entries for 11/6/16 at 9 p.m. and 11/8/16 at 9 p.m. were left blank. RN 1 offered no explanation for the missing documentation of the FSBS values. On 11/19/16 at 8:20 a.m., during a concurrent interview and clinical record review, RN 1 stated it was acceptable to complete FSBS checks and administer insulin as long as it is within an hour before or an hour after the scheduled time printed on the MAR. RN 1 confirmed Resident 5 had physician orders to obtain FSBS at 6:30 a.m. each morning. Review of Resident 5's MAR indicated documentation of FSBS values from 11/10/16 through 11/19/16 at 6:30 a.m. were left blank. When asked about the blank spaces on the MAR for documenting Resident 5's FSBS, RN 1 stated he had documented the 6:30 a.m. FSBS for Resident 5 in the time space below his initial/signature (time space designated for 11:30 a.m. on the MAR). RN 1 stated he documented Resident 5's morning FSBS values and gave no explanation for not documenting in the correct indicated 6:30 a.m. time space (above initial/signature) for Resident 5. On 11/19/16 at 8:25 a.m., during a concurrent interview and clinical record review, RN 1 stated Resident 11's morning blood sugar was 299. RN 1 stated regular insulin was used for residents who were on a sliding scale (progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges) insulin administration. RN 1 stated he would administer regular insulin at the time a high FSBS was obtained. RN 1 stated onset for regular insulin was one hour or less. RN 1 stated morning FSBS for all residents had been completed by 5:30 a.m. and administering regular insulin two hours before resident ate breakfast could put the resident at risk for a low blood sugar. RN 1 stated it was acceptable to [MEDICATION NAME] (as a precaution) give orange juice to residents with low FSBS values. RN 1 stated sweating, shakiness and confusion were symptoms of low blood sugars. RN 1 stated blood sugars are re-checked with or without a physician order when it is suspected a resident has a low blood sugar and after giving a resident orange juice. RN 1 confirmed he did not document FSBS re-check values on Resident 11's or any other Resident's MAR or in their clinical record. On 11/19/16 at 8:35 a.m., during an observation inspection of the glucometer used for residents residing in Hall/Station 100 and a concurrent interview, LN 2 stated the time reading of the glucometer used for Residents in Hall/Station 100 did not match the actual time. When asked about this, LN 2 stated the time reading on the glucometer was off by one hour and had not been re-calibrated (adjusted for accuracy) after day light savings time changed. Review of values stored in the memory of the glucometer indicated there were three values recorded on 11/19/16. The last glucometer reading of 89 indicated a time of 6:15 a.m. (actual time of 5:15 a.m.). The value 89 corresponded to the FSBS value documented in the pre-printed time space on Resident 12's MAR (11/19/16 at 6:30 a.m.) and was not corrected to reflect the actual time the FSBS value 89 was obtained (5:15 a.m.). The second glucometer reading of 81 indicated a recorded date and time of 11/19/16 at 5:58 a.m. (actual time 4:58 a.m.) and did not correspond to any FSBS result documented on the MARs for any Resident on Hall/Station 100. The first glucometer reading of 299 indicated a time of 5:55 a.m. (actual time 4:55 a.m.). The value 299 corresponded to the FSBS value documented in the pre-printed time space on Resident 11's MAR (11/19/16 at 6:30 a.m.) and was not corrected to reflect the actual time the FSBS value 299 was obtained (4:55 a.m.). When asked about the discrepancy between the actual FSBS time and the documented, pre-printed time of 6:30 a.m., LN 2 did not provide an explanation. On 11/19/16 at 8:45 a.m., during an inspection of the glucometer used for residents residing in Hall/Station 300 and a concurrent interview, LN 2 stated the time reading of the glucometer used for Residents in Hall/Station 300 did not match the actual time. When asked about this, LN 2 stated the time reading was off by one hour and had not been re-calibrated after the day light savings time change. Review of the values stored in the memory of the glucometer indicated there were four values for 11/19/16. The last glucometer reading of 136 indicated a date and time of 11/19/16 at 5:58 a.m. (actual time 4:58 a.m.) and did not correspond to any FSBS result documented on the MAR's for any Resident on Hall/Station 300. The third glucometer reading of 90 indicated a time of 5:37 a.m. (actual time 4:37 a.m.) The value 90 corresponded to the FSBS value documented in the pre-printed time space on Resident 9's MAR (11/19/16 at 6:30 a.m.) and was not corrected to reflect the time the FSBS value 90 was actually obtained at 4:37 a.m. The second glucometer reading of 157 indicated a time of 5:31 a.m. rather than the actual time the FSBS was done at 4:31 a.m. The value 157 corresponded to the FSBS value documented in pre-printed time space on Resident 13's MAR for the following day (11/20/16 at 6 a.m.) and was not corrected to reflect the actual date and time the FSBS value 157 was obtained on 11/19/16 at 4:31 a.m. The first glucometer reading of 186 indicated a time of 5:27 a.m. (actual time 4:27 a.m.). The value 186 corresponded to the FSBS value documented on Resident 10's MAR on 11/19/16 at 6:30 a.m. and was not corrected to reflect the actual time the FSBS value of 186 was obtained at 4:27 a.m. On 11/24/16 at 4:58 a.m., during an observation and interview, LN 7 performed an FSBS check on Resident 8 and administered 2 units of regular insulin. LN 7 stated Resident 8's blood sugar was 162. On 11/24/16 at 5:20 a.m., during an interview, when asked about the decision to administer insulin two hours before breakfast was scheduled to be served between 7 a.m. and 7:30 a.m., LN 7 stated it was okay because Resident 8 asks for food and eats in her room. On 11/24/16 at 5:45 a.m., during an interview, LN 3 stated she completed Resident 7's FSBS at 5:00 a.m., administered regular insulin (quick acting) one half hour after the FSBS. LN 3 stated regular insulin is short acting, onset is 30 minutes to one hour and breakfast is served beginning at 7:30 a.m. When asked about the dangers of the practice of administering insulin approximately two hours before breakfast, LN 3 stated, starting FSBS checks at 6:30 a.m. would not allow enough time to administer insulin prior to change of shift at 7 a.m. On 11/24/16 at 5:50 a.m., during a concurrent interview, the DON and LN 3 stated morning FSBS checks were scheduled for 6:30 a.m. Both nurses stated the nurses had an hour before and up to an hour after the printed time on the MAR to administer medication, including insulin. The DON and LN 3 confirmed the facility practice of administering insulin up to two hours prior to breakfast was not appropriate. When asked about the effects of administering insulin approximately two hours before breakfast, the DON responded, [DIAGNOSES REDACTED] (low blood sugar). When asked about the decision to administer insulin two hours before the serving of breakfast, LN 3 stated there was not enough time before change of shift and would continue to do FSBS checks and administer insulin earlier than the scheduled time of 6:30 a.m. because there was not enough time to get all the FSBS checks done before change of shift. On 11/30/16 at 3:30 p.m., during a clinical record review of Resident 5's MAR and concurrent interview with RN 3 and the DON, Resident 5's 11/16 MAR indicated spaces for documenting FSBS values were left blank from 11/10/16 through 11/19/16 at 6:30 a.m. When asked about the blank spaces for Resident 5's FSBS values, RN 3 stated she had documented Resident 5's 11:30 a.m. FSBS value on the MAR in the time space below her initials/signature (time slot designated for 4:30 p.m.). RN 3 and the DON confirmed 6:30 a.m. FSBS values were documented in the 11:30 a.m. time space designated for 11:30 a.m. The FSBS were documented in the space for the 4:30 p.m. time space and 4:30 p.m. blood sugar FSBS values were documented in the 9:00 p.m. time space. The FSBS values for 9:00 p.m. were not documented. RN 3 who worked the day shift stated on five of nine days she documented Resident 5's FSBS in the MAR on the line below her initials (pointed to the 4:30 p.m. time space) and the correct time spot for 11:30 a.m. FSBS values had documentation from the nurse on the previous shift (night shift). RN 3 stated she did not report this to anyone or take any action and continued to document Resident 5's FSBS values in the 4:30 p.m. time space even though the FSBS values were obtained before the noon meal (11:30 a.m.). On 12/6/16 at 4:30 p.m., during a concurrent interview and clinical record review, the DON and Resource Nurse Manager (RNM) discussed the care for Residents 4, 8, 9, 10, 11, 12, 13, 14 and 17. The DON and RNM confirmed Resident 4's MDS indicated a [DIAGNOSES REDACTED]. On 12/6/16 at 4:30 p.m., during a concurrent interview and clinical record review, the DON and RNM confirmed Resident 8's clinical record indicated a [DIAGNOSES REDACTED]. Resident 8's November 2016 MAR indicated, spaces for documenting FSBS values were left blank on 11/2/16 at 4:30 p.m., 11/4/16 at 11:30 a.m. and 11/19/16 at 6:30 a.m. and FSBS values were written over and not legible on 11/1/16 at 11:30 a.m., 11/7/16 at 6:30 a.m. and 11/10/16 at 6:30 a.m. The DON and RNM offered no explanation for the blank spaces and areas of documentation written over FSBS values documented on Resident 8's MAR. On 12/6/16 at 4:30 p.m., during a concurrent interview and clinical record review, the DON and RNM confirmed Resident 9's clinical record indicated [DIAGNOSES REDACTED]. The DON and RNM confirmed the FSBS checks were not performed and no values documented for the following dates and times: 11/12/16 at 11:30 a.m., 11/17/16 at 11:30 a.m. and 11/19/16 at 6:30 a.m. The DON and RNM offered no explanation for missing FSBS values on Resident 9's MAR. On 12/6/16 at 4:30 p.m., during a concurrent interview and clinical record review, the DON and RNM confirmed Resident 10's clinical record indicated a [DIAGNOSES REDACTED]. The first order for diabetes monitoring indicated FSBS checks were to be performed before meals (6:30 a.m., 11:30 a.m. and 4:30 p.m.) with a start date of 11/15/16. The second order on the MAR indicated a physician order for [REDACTED]. There was no physician order or documentation on the MAR indicating FSBS checks in conjunction with the order for Humalog Insulin Mix 75/25 Suspension. FSBS checks for Resident 10 were documented on the MAR as performed at 6:30 a.m. and 7 a.m. each day from 11/15/16 to 11/28/16. Resident 10's November 2016 MAR indicated FSBS values documented on the MAR at 6:30 a.m. did not match the FSBS values documented on the MAR at 7 a.m. on the following days: 11/16/16 6:30 a.m. value was 261, 7 a.m. value was 186, 11/17/16 6:30 a.m. value was 183, 7 a.m. value was 357, 11/18/16 6:30 a.m. value was 106, 7 a.m. value was 330, 11/19/16 6:30 a.m. value was 186, 7 a.m. value was 435, 11/20/16 6:30 a.m. value was 110, 7 a.m. value was 220, 11/21/16 6:30 a.m. value was 210, 7 a.m. value was 212, 11/22/16 6:30 a.m. value was 162, 7 a.m. value was 332, 11/23/16 6:30 a.m. value was 133, 7 a.m. value was 310, 11/24/16 6:30 a.m. time space was blank, 7 a.m. value was 315, and 11/26/16 6:30 a.m. value was 181, 7 a.m. value was 146. Resident 10's November 2016 MARs indicated a hand written notation, duplicate order and blank spaces for FSBS values on 11/29/16 and 11/30/16 at 6:30 a.m., 11:30 a.m. and 4:30 p.m. Resident 10's FSBS values from 11/29/16 to 12/6/16 were documented in spaces on the MAR for Humalog Insulin Mix 75/25 Solution administration at 7 a.m. and 5 p.m. There was no physician order or documentation on the December 2016 MAR indicating FSBS checks in conjunction with the order for Humalog Insulin Mix 75/25 Suspension. Resident 10's December 2016 MAR had a hand written notation, duplicate order in the space for FSBS documentation. The DON and RNM stated each resident should have only one order for FSBS checks on the MAR and did not know the reason Resident 10 had two separate and distinct orders for FSBS. The DON and RNM stated the expectation was that licensed nurses would have determined the reason for the duplicate order and would not have generated two orders for FSBS checks on the MAR. The DON and RNM stated the duplicate order caused Resident 10 to have unnecessary FSBS checks and morning FSBS checks should be performed one time daily at 6:30 a.m. The DON and RNM stated, Licensed Nurses should report to their chain of command when errors in resident records are found. On 12/6/16 at 4:30 p.m., during a concurrent interview and record review, the DON and RNM confirmed Resident 11's clinical record indicated a [DIAGNOSES REDACTED]. The DON and RNM confirmed the FSBS values were less than 70 or greater than 400 for the following dates and times: 11/2/16 at 4:30 p.m. (526), 11/6/16 at 11:30 a.m. (532), 11/11/16 at 11:30 a.m. (471), 11/17/16 at 11:30 a.m. (418), 11/17/16 at 9 p.m. (56), 11/19/16 at 4:30 p.m. (429), 11/23/16 at 6:30 a.m. (484). The DON and RNM confirmed there was no documented evidence the MD was notified of the less than 70 FSBS value 56 and greater than 400 FSBS values 526, 532, 471, 418, and 429. The DON and RNM confirmed the expectation was the licensed nurse was to call the MD with each FSBS value below 70 or greater than 400 and document the reason for all omissions on the back of the MAR or in the nurse's progress notes. On 12/6/16 at 4:30 p.m., during a concurrent interview and record review, the DON and RNM confirmed Resident 12's clinical record indicated a [DIAGNOSES REDACTED]. The DON and RNM confirmed the FSBS checks were not performed and no values were documented for the following dates and times: 11/6/16 at 9 p.m. and 11/8/16 at 9 p.m. On 12/6/16 at 4:30 p.m., during a concurrent interview and record review, the DON and RNM confirmed Resident 13's clinical record indicated a [DIAGNOSES REDACTED]. a day for diabetes with a start date and time 11/15/16 at 11 a.m. Resident 13's MAR indicated documentation of FSBS checks from 11/15/16 to 11/23/16 at 6 a.m. and at 11 a.m. (order was FSBS one time a day). The line on the MAR with the FSBS checks had a hand written time of 6 a.m. scribed over the pre-printed 11 a.m. time. The line on the MAR with the insulin administration had a pre-printed time of 11 a.m. Resident 13's FSBS value of 157 (actual time obtained on 11/19/16 at 4:31 a.m.) scheduled for 11/19/16 at 6 a.m. (hand scribed time) was documented in the space on 11/20/16 at 6 a.m. Resident 13's MAR had values written over and not legible on the following days and times: 11/15/16 at 6 a.m., 11/19/16 at 11 a.m., and 11/20/16 at 11 a.m. On 11/21/16 in the FSBS time space for 6 a.m., a FSBS value of 130 was written and crossed out. (138 was written beneath the 130 FSBS value). On the back of Resident 13's MAR under nurse ' s notes was the following documentation: 11/20/16, 6:25, M, BS 130. The DON and RNM offered no explanation for the value obtained on 11/19/16 which was documented on the MAR as obtained on 11/20/16 at 6 a.m. The DON and RNM confirmed Resident 13 FSBS checks were ordered for one time a day and the hand written time change for FSBS caused Resident 13 to have unnecessary FSBS checks. The DON and RNM stated it was the expectation that licensed nurses document changes on the back of the MAR or in the nurse's progress notes. The back of the MAR indicated headings for documentation of the following: date, time, order change, reason, result, and initials. The DON and RNM confirmed licensed nurses are expected to document accurate information in all Resident's clinical records and on MARs. On 12/6/16 at 4:30 p.m., during a concurrent interview and record review, the DON and RNM confirmed Resident 14's clinical record indicated a [DIAGNOSES REDACTED]. Resident 14's November 2016 MAR indicated three FSBS values equal to or greater than 351 on the following dates and times: 11/29/16 at 11:30 a.m. (351), 11/30/16 at 11:30 a.m. (491) and 11/30/16 at 4:30 p.m. (455). The DON and RNM confirmed there was no documented evidence on the MAR or in the nurse's progress notes the MD was notified of Resident 14's FSBS value on 11/30/16 at 4:30 p.m. (455). The DON and RNM stated the expectation was the licensed nurse was to call the MD for FSBS values greater than 351. On 12/7/16 at 3:25 p.m. during a concurrent interview and record review, RN 2 confirmed Resident 19's MAR indicated FSBS value of 400 documented on 11/25/16 at 4:30 p.m. RN 2 confirmed Resident 19's November 2016 MAR indicated physicians order to administer 15 units regular insulin (sliding scale) for FSBS value of between 351 and 400. RN 2 confirmed documentation on MAR of administration of 18 units of regular insulin. RN 2 stated she gave too much insulin for Resident 19's FSBS value of 400. RN 2 stated she did not know she had made the error and did not notify the MD. On 12/7/16 at 3:40 p.m., during a concurrent interview and record review, LN 5 confirmed she cared for Resident 14 on 11/30/16 on 3 p.m. - 11:30 p.m. shift. LN 5 confirmed her initials in the signature space FSBS value (455) documented on Resident 14's MAR on 11/30/16 at 4:30 p.m. LN 5 confirmed MD was not notified and stated she should have called MD about Resident 14's FSBS greater than 351 On 12/6/16 at 4:30 p.m. during a concurrent interview and record review, the DON and RNM confirmed Resident 17's clinical record indicated a [DIAGNOSES REDACTED]. The DON and RNM confirmed Resident 17's blood sugars FSBS values were greater than 350 for the following dates: 11/21/16 (376), 11/26/16 (392), 11/27/16 (375), 11/28/16 (372), 11/29/16 (368), and 11/30/16 (392). The DON and RNM confirmed there was no documented evidence in Resident 17's clinical record or on the MAR indicating the MD was notified. On 12/8/16 at 2:05 p.m., LN 2 confirmed signature and documentation on Resident 17's MAR of FSBS values on the following dates and times: 11/21/16 (376), 11/26/16 (392), 11/27/16 (375) and 11/28/16 (372). LN 2 confirmed there was no documented evidence the MD was notified. LN 2 stated, I should have notified the doctor. When asked about the timing of the FSBS checks, LN 2 stated Resident 17's blood sugars values would be higher when FSBS checks are done after eating lunch and that was the way it was ordered by the doctor. LN stated she did not consider clarifying the physician's order. On 12/8/16 at 10 a.m., during a concurrent interview and record review, the DON discussed the care for Residents 15, 16 and 18. The DON confirmed Resident 15's clinical record indicated [DIAGNOSES REDACTED]. The DON confirmed the spaces for documenting FSBS checks were left blank for the following dates and times: 11/2/16 at 6:30 a.m., 11/9/16 at 6:30 a.m., 11/16/16 at 6:30 a.m., 11/23/16 at 6:30 a.m. and 11/30/16 at 6:30 a.m. The DON offered no explanation for missing FSBS values on Resident 15's MAR. On 12/8/16 at 10 a.m., during a concurrent interview and clinical record review, the DON confirmed Resident 16's clinical record indicated a [DIAGNOSES REDACTED]. The DON confirmed there was no documented evidence in Resident 16's clinical record or on the MAR indicating the MD was notified of the FSBS values greater than 350 for the following dates and times: 11/13/16 at 4:30 p.m. (380), 11/15/16 at 11:30 a.m. (378), 11/19/16 at 4:30 p.m. (385), 11/25/16 at 4:30 p.m. (448), 11/26/16 at 11:30 a.m. (395), 11/26/16 at 4:30 p.m. (490), 11/27/16 at 4:30 p.m. (388). The DON confirmed the spaces for documenting FSBS checks and insulin administration were left blank on 11/9/16 at 4:30 p.m. The DON confirmed there were written over (not legible) FSBS values on 11/7/16 at 4:30 p.m. and 11/12/16 at 6:30 p.m. The DON offered no explanation for the missing FSBS values and insulin administration documentation on Resident 16's MAR. On 12/8/16 at 10 a.m., during a concurrent interview and clinical record review, the DON confirmed Resident 18's clinical record indicated a [DIAGNOSES REDACTED]. Resident 18's November 2016 MAR indicated FSBS values were written over and not legible on the following dates and times: 11/8/16 at 4:30 p.m., 11/9/16 at 4:30 p.m., 11/10/16 at 4:30 p.m., 11/17/16 at 4:30 p.m., 11/21/16 at 4:30 p.m., and 11/30/16 at 9 p.m. The DON offered no explanation for the written over FSBS values on Resident 8's MAR. On 12/8/16 at 2:50 p.m., during an interview, Resident 18 confirmed a [DIAGNOSES REDACTED]. Through use of hand motions, nodding head up/down or side to side and writing on dry erase board, Resident 18 indicated the nurses were doing FSBS checks between 4 a.m. and 5 a.m. in the morning and would give insulin at that time if needed. Resident indicated breakfast was served at 8 a.m. On 12/8/16 at 4:05 p.m. during a concurrent interview and clinical record review, LN 1 confirmed Resident 19's clinical record indicated a [DIAGNOSES REDACTED]. LN 1 confirmed Resident 19's MAR indicated three FSBS values less than 60 on the following dates and times: 11/28/16 at 11:30 a.m. (48), 11/29/16 at 6:30 a.m. (58) and 11/29/16 at 4:30 p.m. (47). LN 1 confirmed there was no documented evidence in Resident 19's clinical record or on the MAR indicating the MD was notified of the less than 60 FSBS values obtained on 11/28/16 at 11:30 a.m. (48) and 11/29/16 at 6:30 a.m. (58). LN 1 stated she did not notify the physician, the physician should have been notified of the FSBS value of 58. The facility policy and procedure titled, Diabetic Care Protocol revision date 1/2/14, indicated, Perform fingerstick blood glucose monitoring as ordered, Administer insulin/oral hypoglycemic (low blood sugar) medications as ordered . Treat hypoglycemic episode according to Hypoglycemic Protocol . Report blood glucose results to physician/mid-level provider according to ordered parameters. The facility protocol titled, [DIAGNOSES REDACTED] Protocol revision date 1/2/14, indicated documentation of the following: Assessment of the patient's condition, Fingerstick glucose levels, Interventions and patient's response, Physician notification and response, Follow-up, if indicated, Include patient on 24-Hour Summary Report. The facility did not provide a policy and procedure directed at guiding staff on the interval of time for safe administration of insulin and other medications. Review of professional reference, Hold the Insulin! <http://www.nursingcenter.com//upload/static/ 7/Hold.htm> page 30, indicated, Prandial (during or relating to mealtime) and preprandial (before mealtime) insulin is given to prevent postprandial (after mealtime) [MEDICAL CONDITION]. Because rapid-acting prandial or bolus (a single dose of a medication given all at once) insulin mimics the normal pancreatic (a glandin the body, part of the digestive system that produces insulin)response to eating, it's given with each meal. Regular insulin is considered a preprandial insulin because it takes about 30 minutes to start working. Prandial insulins such as Humalog (insulin [MEDICATION NAME]) (a fast acting insulin that starts to work in 15 minutes), [MEDICATION NAME] (insulin [MEDICATION NAME]) (a fast acting insulin that starts to work in 5 to 10 minutes), and [MEDICATION NAME] (insulin glulisine) (a fast acting insulin that starts to work in 15 minutes) start working in 5 to 10 minutes. Administering these insulins at the right time is critical to minimize the patient's risk of [DIAGNOSES REDACTED]. For example, a patient might take 5 units of [MEDICATION NAME] with breakfast, 8 units with lunch, and 10 units with dinner. If the breakfast dose is scheduled for and administered at 0800 (8 a.m.) but breakfast doesn't arrive until 0900 (9 a.m.), the patient is at risk for [DIAGNOSES REDACTED].

Based on observation, interview, clinical record and administrative document review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for two of five residents (Residents 1 and Resident 3) diagnosed with [REDACTED]. 1. Resident 1 had a sudden change in status and subsequently expired in the facility after missing two consecutive [MEDICAL TREATMENT] procedures. Resident 1's Registered Nurses (RNs) and Licensed Vocational Nurses (LNs) failed to provide necessary services which included performing physical assessments, appropriate nurse to physician and nurse to nurse notification regarding the missed [MEDICAL TREATMENT] procedures; of resident care status, and failed to administer critical physician ordered medication in a timely manner. Resident 1's Clinical Record indicated Resident 1 was admitted for rehabilitation following a [MEDICAL CONDITION] on [DATE], and missed two consecutive [MEDICAL TREATMENT] treatments. Resident 1 then died on [DATE]. RN 2 did not inform the physician when Resident 1 missed two [MEDICAL TREATMENT] procedures in a row prior to Resident 1's death. RN 1 did not perform a physical assessment on Resident 1 the night he died . 2a. Resident 3's Central Venous Catheter (a tube inserted through the skin and into a large vein) which served as the [MEDICAL TREATMENT] was inaccurately assessed as having a bruit (a swooshing sound heard with a stethoscope) and thrill (a vibration when felt) which are present with [MEDICAL TREATMENT] access fistula or graft (surgically placed connection between an artery and vein for [MEDICAL TREATMENT] access). 2b. Resident 3's medication [MEDICATION NAME] (used to treat life-threatening high potassium level physician order [REDACTED]. The physician was not notified when administration of the [MEDICATION NAME] was delayed. Licensed Nurses were unable to verbalize the indication for [MEDICATION NAME]'s use and had not communicated pertinent resident care status from one nurse to another or from one shift to another shift. 2c. On [DATE] Resident 3 was returned to the facility after being at the hospital for less than 24 hours and the first three sets of vital signs (blood pressure and pulse) were below the parameters set by the physician, and the physician was not notified. Due to the potential and actual harm of not providing the necessary care and treatment for [REDACTED]. The facility provided an acceptable Action Plan addressing the IJ situation on [DATE] at 9:15 p.m., and implemented all elements of the Action Plan that addressed the immediacy. The IJ was removed on [DATE] at 5:45 p.m. in the presence of the Administrator and the DON. Findings: 1. On [DATE], at 4:30 p.m., a telephone interview with Resident 1's family member (FM), FM 1, was conducted. FM 1 stated Resident 1 was an established [MEDICAL TREATMENT] patient and [MEDICAL TREATMENT] service was to be transferred to a more conveniently located sister [MEDICAL TREATMENT] facility after placement at the skilled nursing facility (SNF). FM 1 stated Resident 1 was returned to the SNF without having had the [MEDICAL TREATMENT] procedure on [DATE]; and a transportation no show caused Resident 1 to also miss a second consecutive (two in a row) [MEDICAL TREATMENT] treatment on [DATE]. FM 1 stated the family member, Resident 1, had been admitted to the facility for rehab (rehabilitation) following his foot amputation, and had not been admitted to hospice (end of life care) services, on [DATE], but died unexpectedly, early in the morning on [DATE], less than four days later. Resident 1's clinical record review indicated Resident 1 was discharged on [DATE], from the Acute Care Hospital following his right below knee amputation (RBKA). The medical record from the hospital indicated [MEDICAL TREATMENT] services had been newly arranged at another (within the same corporation, but a location other than Resident 1 had previously attended) [MEDICAL TREATMENT] clinic for three times per week on a Tuesday (T), Thursday (TH), and Saturday (Sat) schedule. Transportation services had also been arranged with the same company Resident 1 had used before admittance to the SNF. Resident 1's clinical record indicated he was admitted to the SNF on [DATE], at 7 p.m., with [DIAGNOSES REDACTED]. gangrene (localized death and decomposition of body tissue from either obstructed circulation or bacterial infection), and Phantom Limb Syndrome with Pain (perceived pain, often severe, from the amputated limb). According to the record, Resident 1 had not received [MEDICAL TREATMENT] on Thursday [DATE] or Saturday [DATE] as ordered. Resident 1 died on Sunday morning, [DATE] at 4:30 a.m., which was his 4th day at the SNF. The Discharge (D/C) Summary from the acute care hospital indicated, Resident 1 was admitted on [DATE] and discharged thirty-one days later, on [DATE] to the SNF. The D/C summary indicated, discharged to a skilled nursing facility .on [DATE] in stable condition .He needs to continue with outpatient [MEDICAL TREATMENT] . Resident 1's SNF Physician admission orders [REDACTED].) The order also indicated the name, address and contact information of the newly arranged [MEDICAL TREATMENT] center, and the transportation company and phone number. On [DATE] at 12:30 p.m., an interview with Licensed Vocational Nurse (LN) 1 and a concurrent review of Resident 1's clinical record was conducted. In response to Resident 1's clinical status on [DATE], LN 1 stated, I didn't realize the patient was going bad . On [DATE] at 10:45 a.m., an interview and concurrent clinical record review (including the note above) was conducted with RN 2. Nurses Note penned by Registered Nurse (RN) 2, dated [DATE] at 6:33 p.m., indicated the resident was sitting up in a wheelchair waiting for the transportation company to pick him up and take him to the [MEDICAL TREATMENT] center. RN 2 documented she phoned the transportation company at 6 p.m. to find out why no one had come for Resident 1. RN 2's documentation indicated awareness of this being the second consecutive missed [MEDICAL TREATMENT] treatment. RN 2 further documented the transport staff stated all drivers had gone home and no one was available. RN 2 documented she was unable to make contact with the [MEDICAL TREATMENT] center by phone. There was no documentation indicating the physician had been notified. RN 2 stated she was the assigned nurse to care for Resident 1 on the 3 p.m. to 11 p.m. shift, Wed. ,[DATE]; Thurs. ,[DATE]; and Sat ,[DATE]. RN 2 stated, On Saturday, ([DATE]) Resident 1 asked what's the plan? When is transport coming to take me to [MEDICAL TREATMENT]? RN 2 stated, the transport driver didn't show up.RN 2 stated she called the transport company. All the drivers had gone home. [MEDICAL TREATMENT] didn't answer the phone . I didn't contact the physician. I should have . On [DATE] at 8:45 a.m., during an interview, RN 1 stated he was assigned to care for Resident 1 during the night of [DATE], and Resident 1 died on his shift, on [DATE], at 4:30 a.m. When asked about Resident 1's condition, RN 1 stated the only interaction during his shift, was when Resident 1 looked up at him while the resident's vital signs (blood pressure, pulse and respirations) were checked at approximately 12:45 to 1 a.m. RN 1 stated he had not performed a physical assessment, except for the vital signs he obtained. RN 1 stated the documented nurses notes he entered into the computer on [DATE] at 12:33 a.m., were cut and pasted (copied and transferred) from a previous entry made by another nurse. When asked about the accuracy of cut and pasting narrative nurses note entries, RN 1 agreed the cut and paste he had done in the electronic record represented false documentation. RN 1 made the following statement about the night before Resident 1 died , I never spoke to the resident. I did not listen to lung sounds, I did not ask him how he was doing. In response to the request to explain his decision not to perform an assessment on Resident 1, RN 1 stated RN 2 gave him report at the beginning of his shift. RN 1 stated he heard in report Resident 1 had missed [MEDICAL TREATMENT] and RN 2 had made arrangements for a new [MEDICAL TREATMENT] appointment date on Monday ([DATE]). On [DATE] at 11:22 a.m., an interview and concurrent record review were conducted in the Admin office. The Admin reviewed the nurses notes dated [DATE] at 2:15 a.m., [DATE] at 12:28 a.m. and 2:47 p.m., and [DATE] at 12:33 a.m., and admitted the notes were nearly identical and stated they looked cookie cutter (nearly identical). The Admin stated it was unacceptable to copy and paste another nurse's note and all nurses should be performing and charting their own assessments. The Admin admitted she was aware that nurses' notes could be copied and pasted. Internet website titled, http://allnurses.com/[MEDICAL TREATMENT]-renal-urology/bruit-and -thrills- -page2.html indicated, .Patients that have a tunneled [MEDICAL TREATMENT] catheter will NOT have a bruit or thrill unless they also have a fistula or graft. Catheters alone don't have bruits/thrills. This is the feeling and sounds that is created with a fistula and/or graft from the connection of an artery to a vein. 2a. On [DATE] at 5 p.m., during an interview and concurrent clinical record review, the Clinical Nurse Manager (CNM) reviewed the [MEDICAL TREATMENT] Communication Record (HCR) (form used for written communication between the SNF facility and the [MEDICAL TREATMENT] facility) documentation. The clinical record indicated Resident 3 was scheduled for [MEDICAL TREATMENT] every Tuesday, Thursday, and Saturday. There were 13 HCRs dated [DATE] through [DATE]. The SNF documentation Pre-[MEDICAL TREATMENT] form (correctly) did not document a bruit or a thrill on 13 of 13 HCRs. The SNF documentation Post [MEDICAL TREATMENT] form (incorrectly) documented the presence of a bruit and thrill on 7 of the 13 HCRs. These forms were dated ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. The CNM stated she was not aware and could not explain why nurses had not documented bruit and thrill consistently on the form. The CNM stated the Medication Administration Record [REDACTED]. The Monthly MARs for ,[DATE], ,[DATE], and ,[DATE] indicated nurses had documented for each shift (three times each day) they had observed and monitored a bruit and thrill for Resident 3. The hospital record did not indicate a bruit and thrill was documented when Resident 3 was in the hospital [DATE] through [DATE], and the documentation stopped on [DATE]. On [DATE] at 8:45 a.m., during an interview and concurrent observation assessment of Resident 3's [MEDICAL TREATMENT] catheter, LN 6 described the sound and feel of a bruit and thrill as she had documented on Resident 3's record as being assessed on Resident 3's right groin [MEDICAL TREATMENT] catheter. At the bedside, LN 6 was asked to assess Resident 3's right groin [MEDICAL TREATMENT] catheter and was asked if it was the type of line that would have a bruit and thrill. LN 6 stated it was not, and stated she did not know what she was hearing and feeling. On [DATE] at 8:50 a.m., during an interview, the CNM stated Resident 3 had a [MEDICAL TREATMENT] catheter ([MEDICAL TREATMENT] access that does not have a bruit or thrill), not an Arterial Venous (AV) shunt (type of [MEDICAL TREATMENT] access that does have a bruit and thrill). The CNM stated nurses were consistently documenting an assessment that included the presence of a bruit and thrill that was not going to be there. On [DATE] at 4:58 p.m., LN 9 stated Resident 3's right groin [MEDICAL TREATMENT] catheter did not have a bruit or a thrill. LN 9 stated he had checked, and he had listened for both the bruit and the thrill. LN 9 stated, On [DATE], he thought he had determined a bruit and thrill were present, and documented accordingly. Hospital records indicated Resident 3's right groin [MEDICAL TREATMENT] catheter was placed [DATE], and replaced on [DATE], [DATE], and [DATE]. The right groin remained the [MEDICAL TREATMENT] catheter site after each of the replacement procedures. The hospital's Final Report dated [DATE], indicated placement of a [MEDICAL TREATMENT] catheter in the right groin. Final Report dated [DATE], indicated the right groin [MEDICAL TREATMENT] catheter had inadequate blood flow and was replaced with a new catheter. Final Report dated [DATE], indicated the right groin catheter was accidentally withdrawn at least 10 centimeters (a metric measurement) and replaced with a new [MEDICAL TREATMENT] catheter. Final Report dated [DATE], indicated infection was resolved and another [MEDICAL TREATMENT] catheter was placed at the same site in the right groin. The facility policy and procedure (P&P) titled, NSG205 Assessment: Nursing, dated [DATE], indicated, POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed .PURPOSE To determine patient's condition and clinical needs . 4. Notify physician/mid-level provider of assessment results as indicated. 5. Document physician/mid-level provider notification and response if indicated. The facility P&P titled, NSG113 Nursing Documentation, dated [DATE], indicated, POLICY Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate .Nursing staff will not falsify or improperly correct nursing documentation. PURPOSE To communicate patient's status and provide accurate accounting of care and monitoring provided. PRACTICE STANDARDS 1. Nurses will not: 1.1 Document services that were not performed . 2b. Resident 3's Physician telephone order dated [DATE] at 3:52 p.m., indicated [MEDICATION NAME] 15 grams (gm) (a metric measurement) to be given by mouth, one time, one day, for high Potassium level. On [DATE] at 11:30 a.m., during a telephone interview, Resident 3's physician (P) 1 stated he ordered the [MEDICATION NAME] to be given once each day until Resident 3 could have the [MEDICAL TREATMENT] procedure performed. On [DATE] at 11:30 a.m., LN 1 stated she phoned Resident 3's physician, (P) 1 and made him aware Resident 3 was not going to be able to get [MEDICAL TREATMENT] until her [MEDICAL TREATMENT] catheter could be replaced. LN 1 stated she informed P 1 that Resident 3's Potassium level was elevated at 5.7 (normal range is 3.5 - 5.2). LN 1 stated P 1 ordered [MEDICATION NAME] 15 grams to be given one time. On [DATE] at 3:30 p.m., LN 1 stated when she documented P 1's phone order, the medication order entry had not matched the nurses note. LN 1 stated she re-entered the nurses note to match the way the medication order was written. LN 1 stated she should have phoned the physician and clarified whether he intended the [MEDICATION NAME] order to be one time or ONE time each day. Review of Resident 3's clinical record indicated Resident 3's Physician telephone order for [MEDICATION NAME] was dated [DATE] at 3:52 p.m. The Pharmacy order form documented the [MEDICATION NAME] was taken from the Emergency Kit (E-Kit ) (back up pharmacy storage), on [DATE] at 9 p.m. E-kits contained medications stored in the facility and were available to be given immediately. The nurse's note dated [DATE] at 11:37 p.m., indicated Resident 3 had refused to take the medication and wanted to take it in the morning. On [DATE] at 8:45 a.m., during an interview with Resident 3, with LN 6 present, Resident 3 stated she had been told there was a new medication, but it was arriving late, and it would be started in the morning. Resident 3 stated she was not told what it was for. Resident 3 stated she had not refused to take any medication. On [DATE] (Saturday morning) at 6 a.m., during observation, interview, and Resident 3's clinical record review, LN 9 stated, Missing [MEDICAL TREATMENT] even one time is crucial and I would phone the physician. LN 9 stated he should have been told in report Resident 3 would not be going to [MEDICAL TREATMENT] that morning. LN 9 stated he found out by reading nurses notes in the computer and at 4 a.m. he had canceled transport. LN 9 stated today was the first day he knew Resident 3 was going to miss [MEDICAL TREATMENT]. LN 9 stated he saw a new order for [MEDICATION NAME]. LN 9 validated the [MEDICATION NAME] was on the medication cart and stated LN 10 reported Resident 3 had refused the medication. LN 9 validated this on the MAR indicated [REDACTED]I have no idea. LN 9 stated he did not know Resident 3 had missed [MEDICAL TREATMENT] on ,[DATE], and [DATE] would be the second, not the first, missed [MEDICAL TREATMENT] treatment. On [DATE] at 7:27 a.m., LN 6 stated Resident 3 had a new order for [MEDICATION NAME], it came from the e-kit and pointed to the medication on the medicine cart. On [DATE] at 7:45 a.m., LN 6 stated the [MEDICAL TREATMENT] nurse had phoned previously and stated Resident 3's [MEDICAL TREATMENT] catheter was not working and she was unable to be dialyzed on Thursday. LN 6 stated Resident 3 would be missing her second consecutive [MEDICAL TREATMENT] treatment today (Saturday, [DATE]). LN 6 stated the hospital was supposed to be making arrangements to get Resident 3's catheter replaced. LN 6 stated they were waiting for an appointment and it would not be until Monday. On [DATE] at 6 p.m., during a telephone interview, LN 10 stated she did not notify the physician when the [MEDICATION NAME] was not administered as ordered and administration was delayed until the next day. The facility's P&P titled, 6.2 Medication Administration Times, dated [DATE], indicated, POLICY .To provide uniform and efficient practices in safe medication administration . Physician/Prescriber direction and/or the Center's Pharmacy Committee may determine if specific drugs should be administered at designated times . If medication administration times are changed for any medication, consult with physician regarding clinically appropriate timing. 2.1 Document physician consultation in the medical record. 3. Medication administration pass may commence 60 minutes before the designated times of administration but may not exceed 60 minutes after the designated times of administration. 2c. Clinical record review indicated Resident 3's Nurses Note dated [DATE] at 8:30 p.m., penned by LN 9 indicated, Patient came back via ambulance .(from a hospital stay) VSS (vital signs stable) . Resident 3's Nurses Note dated [DATE] at 1:45 a.m., penned by LN 7 indicated, (VS) .(B/P) ,[DATE]. Resident 3's Nurses Note dated [DATE] at 5:49 a.m., penned by LN 7 indicated, (VS) .(B/P) ,[DATE]. On [DATE] at 4 p.m., an interview with the Director of Nurses (DON) and the Administrator (Admin) and concurrent clinical record review of Resident 3's vital signs (listed above) and physician orders [REDACTED]. Resident 3's Physician order [REDACTED]. and to notify the physician if the top number of the B/P was less than 100 or the P was less than 60. The DON stated based on Resident 3's vital signs and the parameters set by the physician, both LN 7 and 9 should have phoned the physician with the information. On [DATE] at 7 p.m., during an interview and concurrent record review, LN 9 stated Resident 3's vital signs were due each shift. LN 9 stated he should have notified the physician. On [DATE] at 5 a.m., during an interview, LN 7 reviewed Resident 3's vital signs and physician's orders [REDACTED]. LN 7 stated the Certified Nurses Assistant (CNA) that took Resident 3's vital signs told him she had checked them twice. LN 7 stated the CNA had rechecked Resident 3's vital signs but did not tell him to look closer at the number values to see if something was outside the parameters. LN 7 stated, I was just doing the task. I didn't see it as an assessment piece. I didn't assess it and I didn't call the MD. The facility policy and procedure titled, NSG205 Assessment: Nursing, dated [DATE], indicated, POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed .PURPOSE To determine patient's condition and clinical needs . 4. Notify physician/mid-level provider of assessment results as indicated . Because of the potential and actual harm of not providing the necessary care and treatment for [REDACTED]. The facility provided an acceptable Action Plan addressing the IJ situation on [DATE] at 9:15 p.m. The IJ was removed on [DATE] at 5:45 p.m., after successful demonstration that all elements of the Action Plan that addressed the immediacy had been implemented, with the Admin and the DON. The facility policy and procedure titled, NSG205 Assessment: Nursing, dated [DATE], indicated, POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed .PURPOSE To determine patient's condition and clinical needs . 4. Notify physician/mid-level provider of assessment results as indicated .

Based on interview, clinical record, administrative document, and the death certificate review, the facility failed to inform 1 of 5 sampled residents (Resident 1's) physician when [MEDICAL TREATMENT] (treatment for [REDACTED]. This failure contributed to the untimely death of Resident 1. Findings: On [DATE], at 4:30 p.m., during a telephone interview, the complainant and family member of Resident 1 (Family (FM 1)) stated Resident 1 was admitted to the facility on the evening of [DATE]. FM 1 stated Resident 1 was an established [MEDICAL TREATMENT] patient and [MEDICAL TREATMENT] service was to be transferred to a more conveniently located sister [MEDICAL TREATMENT] facility after placement at the skilled nursing facility (SNF). FM 1 stated Resident 1 was returned to the SNF without having received the [MEDICAL TREATMENT] treatment on [DATE]. FM 1 stated she didn't understand the reason Resident 1 had not received the [MEDICAL TREATMENT] procedure, but the reason the staff at the [MEDICAL TREATMENT] center gave for sending him back without [MEDICAL TREATMENT] was a needed chest x-ray before starting [MEDICAL TREATMENT]. FM 1 stated Resident 1 missed his second consecutive [MEDICAL TREATMENT] on [DATE], because of a transportation no show. FM 1 stated Resident 1 had been admitted to the facility for rehabilitation after his leg amputation, and stated his death four days after admission was completely unexpected. The admission face sheet and nurses notes indicated Resident 1 was admitted to the facility on [DATE] at 7 p.m. for rehabilitation following a below knee amputation (BKA). Resident 1's [DIAGNOSES REDACTED]. Resident 1's Clinical record review indicated Resident 1 was discharged on [DATE] from the acute care hospital following a RBKA. A non-acute transfer from the acute care hospital indicated [MEDICAL TREATMENT] services had been newly arranged at a sister facility (within the same corporation, but a new location than Resident 1 had previously attended) [MEDICAL TREATMENT] clinic on a weekly Tuesday (T), Thursday (TH), Saturday (Sat) schedule. Transportation services had been arranged with the same company Resident 1 had used before being admitted to the SNF. According to the record, Resident 1 had not received [MEDICAL TREATMENT] on Thursday and/or Saturday as ordered and Resident 1 died early on Sunday morning, which would have been his 4th day at the SNF. The Discharge (D/C) Summary from the acute care hospital indicated Resident 1 was discharged to the SNF on [DATE] in stable condition . FOLLOWUP: The patient will be followed up by the physician at the skilled nursing facility. He needs to continue with outpatient [MEDICAL TREATMENT] . Resident 1's SNF Physician admission orders [REDACTED]. On [DATE] at 11 a.m., during an interview, RN 2 stated she admitted Resident 1 to the facility on [DATE] at approximately 7 p.m. RN 2 stated she also cared for Resident 1 when he was returned to the facility, without getting the [MEDICAL TREATMENT] procedure on [DATE], and when he missed [MEDICAL TREATMENT] again on [DATE]. RN stated she knew Resident 1 missed his second consecutively scheduled [MEDICAL TREATMENT] treatment. RN 2 stated she did not notify Resident 1's physician of the missed [MEDICAL TREATMENT] treatments and she should have. On [DATE] at 9:10 a.m., a telephone interview with Medical Doctor (MD) 1 was conducted. MD 1 stated Resident 1 was a renal patient and was supposed to go to [MEDICAL TREATMENT] 3 times a week. MD 1 stated he did not know why Resident 1 had missed two [MEDICAL TREATMENT] procedures. MD 1 stated, No one let me know he missed [MEDICAL TREATMENT]. They (the nurses) should have called me. MD 1 stated usually if a patient misses [MEDICAL TREATMENT] they need to be sent to the hospital in order to receive the [MEDICAL TREATMENT] procedure. MD 1 stated, Nurses at [MEDICAL TREATMENT] or the SNF should have let me know he did not get [MEDICAL TREATMENT] . The Certificate of Death (COD) from the County Coroner indicated the immediate cause of death was [MEDICAL CONDITION] (breathing cessation) and the underlying cause was documented as [MEDICAL CONDITIONS] (excess fluid in the lungs) and [DIAGNOSES REDACTED] (disease of the heart muscle). The COD indicated the Resident was last seen alive on [DATE]. The facility policy and procedure titled, NSG115 Physician/Mid -level Provider Notification, dated [DATE], indicated, POLICY Upon identification of a patient who has a change in condition .a licensed nurse will perform appropriate clinical observations and data collection and report to physician/mid-level provider, the Medical Director will be contracted .Clinician judgment and patient baseline should always be the primary determinate of the timing of physician/mid-level provider notification .PURPOSE To communicate a change in patient's condition to physician/mid-level provider and initiate interventions as needed/ordered.

Based on interview, clinical record and administrative document review, the facility failed to ensure a system was in place to prohibit neglect for one of five residents (Resident 1) when: Registered Nurse (RN) 1 failed to perform the required physical assessment (a systematic evaluation of the resident's physical, emotional and mental health status for the purpose of providing resident focused nursing services) for Resident 1. Due to the failure to perform a physical assessment, RN 1 had not recognized Resident 1's condition had significantly declined, and as a result RN 1 provided no needed intervention. Resident 2's clinical record entry by RN 1 had not been based on care received from RN 1. Resident 1 was diagnosed with [REDACTED]. RN 2 failed to notify Resident 1's physician when the second of two consecutive scheduled [MEDICAL TREATMENT] treatments were missed. These failures resulted in Resident 1's untimely death which was evidenced by RN 1's failure to perform an assessment and recognize Resident 1's change of condition; provide physician notification, and the provision of possible life-saving intervention. Findings: The admission face sheet and nurses notes indicated Resident 1 was admitted to the facility on [DATE] at 7 p.m. for rehabilitation following a below knee amputation (BKA). Resident 1's [DIAGNOSES REDACTED]. The Certificate of Death indicated Resident 1 died in the facility on [DATE] at 4:30 a.m. The Death Certificate indicated the Immediate cause of death was [MEDICAL CONDITION] (too little oxygen passes from the lungs to the blood); [MEDICAL CONDITIONS] (buildup of fluid in the air sacs of your lungs and [DIAGNOSES REDACTED] (chronic disease of the heart muscle). End Stage [MEDICAL CONDITION] was indicated as other significant conditions contributing to death. On [DATE], at 4:30 p.m., during a telephone interview, Resident 1's family member (Family Member (FM)1) stated Resident 1 was an established [MEDICAL TREATMENT] patient. FM 1 stated Resident 1's [MEDICAL TREATMENT] service was to be transferred to a more conveniently located sister [MEDICAL TREATMENT] facility after placement at the skilled nursing facility (SNF). FM 1 stated Resident 1 was returned to the SNF without having received the [MEDICAL TREATMENT] treatment on [DATE]. FM 1 stated the reason given for sending Resident 1 back to the SNF without first having received [MEDICAL TREATMENT] was because the [MEDICAL TREATMENT] center needed Resident 1 to have a chest x-ray done prior to receiving [MEDICAL TREATMENT]. FM 1 1 stated Resident 1 missed his second consecutive [MEDICAL TREATMENT] on [DATE], because of a transportation no show. FM 1 stated Resident 1's death four days after admission was completely unexpected. On [DATE] at 8:45 a.m., during an interview, RN 1 stated he was assigned to care for Resident 1 the night of [DATE], and stated Resident 1 died on his shift, on [DATE] at 4:30 a.m. RN 1 stated he went out of his way to not disturb Resident 1 the night he died . RN 1 stated he had checked Resident 1's vital signs around 1 a.m. RN 1 stated Resident 1 had looked up at him at the time. RN 1 stated he had not performed a physical assessment on Resident 1 as he had not wanted to disturb him. RN 1 stated the information he entered on Resident 1 into the electronic health record on [DATE] at 12:33 a.m., did not reflect the care he provided to Resident 1. RN 1 stated he cut and pasted (copied and transferred) the documentation from a previous entry made by another nurse rather than information based on a physical assessment by himself. RN 1 stated to enter information regarding an assessment done by a nurse from a previous shift provided false documentation. RN 1 stated he had not spoken to the resident, had not listened to his lung sounds, or ask Resident 1 how he was doing. RN 1 stated RN 2 gave him report at the beginning of his shift. RN 1 stated he had been informed Resident 1 had missed the [MEDICAL TREATMENT] procedure but new arrangements had been made for another day. On [DATE] at 11 a.m., during an interview, RN 2 stated she admitted Resident 1 to the facility on [DATE] at approximately 7 p.m. RN 2 stated she cared for Resident 1 when he returned to the SNF without having received the [MEDICAL TREATMENT] procedure, and again when he missed on [DATE]. RN 2 stated she knew Resident 1 missed his second consecutively scheduled [MEDICAL TREATMENT] treatment. RN 2 stated she had not notified Resident 1's physician and she should have. The facility's policy and procedure (P&P) titled, 2.0 Abuse Prohibition, revision dated [DATE], indicated, (The facility's Corporate name) Residential Care Facilities shall prohibit .neglect .for all residents . Neglect is defined as .deprivation of essential needs . PURPOSE To ensure that the Facility is doing all that is within its control to prevent occurrences of .neglect . The facility's P&P titled, NSG205 Assessment: Nursing, revision dated [DATE], indicated, POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed . The facility's P&P titled, NSG113 Nursing Documentation, revision dated [DATE], indicated, POLICY .Nursing staff will not falsify .nursing documentation. PURPOSE To communicate patient's status and provide accurate accounting of care and monitoring provided.

Based on observation, staff interview, clinical record and administrative document review, the facility failed to ensure 1 of 18 sampled residents (Resident 1) was given assistance with meals. The facility failed to ensure Resident 1 had been provided the dietary supplements ordered to maintain an acceptable weight to avoid unplanned weight loss. This failure resulted in Resident 1's severe weight loss and hunger. Findings: Review of Resident 1's "Monthly Record of Vital Signs, Weights, and Pain" document indicated progressive weight loss over the past eleven months. Recorded monthly weights were as follows: From December 5, 2011 Resident 1's weight was 120 lbs.,and had decreased by June 3, 2012 to 107.6 lbs which was a loss of 13 lbs. From July 1, 2012 the resident's weight was 106.8 lbs., and by October 2, 2012 the resident's weight had decreased to 100.6 lbs for a total loss of 19.4 lbs/19.4 percent loss of body weight within an 11 month time period. Review of annual "Dietary/Nutritional Assessment" dated 10/23/12, indicated Resident 1's "usual weight" had been 123 pounds with the IBW (Ideal Body Weight) 100-120 pounds. Under Nutritional Supplement, "...chocolate health shakes with trays..." The Dietary/Nutritional Assessment indicated, "Needs assistance at meals...supplementation with meals and between...RD (Registered Dietician) plan: Monitor weight..." Review of "Interdisciplinary Team Notes" dated 1/5/12, indicated, "...Recent and continuous weight loss...placed resident on 1/2/12 into RNA dining for all meals for cueing.." On 11/6/12 at 8:15 a.m., during a meal observation in the Restorative Nursing Assistance (RNA) dining room, Resident 1 was observed sitting in her wheelchair facing away from the dining table, with her back to her breakfast tray. Three staff members were observed standing at the perimeter of the room. No feeding assistance or verbal cueing was offered to Resident 1 during this observation. Review of Resident 1's "Dietary Progress Notes" dated 9/12/12, indicated Resident 1 had refused to eat the last 10 meals. The Dietary Progress Notes indicated Resident 1 was to continue 6 ounces of supplement three times per day with meals. Review of Resident 1's physician orders [REDACTED]." Review of Resident 1's "Licensed Nurses Weekly Summary" dated 10/1/12, under Nutritional/Hydration" diet...consumed 25% Nourishment Chocolate health shake all meals...6 ounces TID (three times per day)...under Eating Assist (needed)." On 11/6/12 at 12:40 p.m., during an observation and concurrent interview in the RNA Dining Room Licensed Nurse (LN) 1 was observed checking lunch trays. LN 1 stated, "We randomly check the trays, and then we check them again when we serve them (to ensure served meal is correct)." No assistance or verbal cueing was provided by staff during this meal to Resident 1. Resident 1 did not receive the ordered nutritional supplement. Resident 1 reached for the empty coffee cup, sat it down, then reached for the bread pudding with her left hand. Resident 1 then attempted to bring her hand to her mouth, then placed her hand back on the table without picking up the food item. There was meat observed on the residents plate and there was no assistance from staff to cut up or assist with eating. Resident 1 again reached for the empty coffee cup, then backed away from the table. Resident 1 consumed nothing during this meal. During clinical record review, the facility document entitled, "Food and Fluid Intake," indicated Resident 1 had refused her noon meal on 11/6/12, (rather than identifying that no staff had assisted Resident 1 to eat during the noon meal). On 11/7/12 at 9:00 a.m., during an interview Certified Nursing Assistant (CNA) 3, stated she was aware Resident 1 was assigned to the assisted dining area due to weight loss, but stated she had not assisted Resident 1 with eating. CNA 3 stated, "That's not part of my job." On 11/7/12 at 9:15 a.m., during observation and interview, Resident 1 was observed in the hallway seated in her wheelchair slowly moving down the hall. Resident 1 was holding an empty coffee cup in her hands. Resident 1 stated, "I'm hungry. I'll pay you if you can bring me one of those chocolate shakes." On 11/7/12 at 9:30 a.m., during clinical record review of Resident 1's Minimum Data Set (MDS) assessment, dated 9/10/12, the MDS indicated, Resident 1 required "Limited Assistance with one person physical assist for feeding." On 11/7/12 at 10:00 a.m., during an interview, the Registered Dietician (RD) stated she had not been aware there were missing shakes on Resident 1's last two meal trays and had not been aware staff were not assisting Resident 1 with eating. On 11/7/12 at 12:45 p.m., during observation of the lunch meal, Resident 1 did not receive a nutrition supplement. On 11/8/12 at 9:45 a.m. during interview, the DON (Director of Nursing) stated, "I expect them to cue her (Resident 1) and assist her when she eats" and was not aware staff were not cueing or assisting Resident 1 with her meals and that the resident had not received the ordered supplements. On 11/8/12 at 10:15 a.m., during a concurrent interview and clinical record review and LN 2 verified her signatures on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. LN 2 then stated she had not verified Resident 1 had in fact received the meal supplements on those dates. LN 2 stated she did not provide them, nor did she verify that the resident received them. LN 2 stated, "I just assumed she was getting them." The facility policy and procedure titled, "Meals-Feeding the Resident" undated, indicated, "Standard. A resident is fed to ensure that assistance is provided with eating, if needed.... Procedures, ... Check the meal tray before serving the meal to ensure that everything is on the tray. Correct anything that is wrong.... Encourage the resident to eat all of the meal..." The undated facility policy and procedure titled, "Meals-Preparing and Serving," indicated "Standard. Any resident requiring assistance with meals receives help as needed. Policy. All nursing personnel assist with ... feeding the residents as needed. "