Every finding on record at Park View Post Acute

Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions and in accordance with professional standards for a census of 116 when:Nonstick pans used in food preparation were visibly scratched, compromising the integrity of the cookware and increasing the risk of nonstick coating flaking into food;A manual can opener had missing metal on the tip, creating a potential physical contaminant hazard during food preparation; andItems in the refrigerators were not marked with an open date or delivery date.These failures had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.1. During a concurrent interview and observation on 3/2/26 at 8:43 a.m., with the Food & Nutrition Director (FND), two large (12 inch) frying pans were observed hanging on the kitchen rack, indicating they were available and ready for use. Both frying pans had severely worn, non-stick coatings, exposed base metal, and carbonized build up on the food contact surfaces. The damaged surfaces were not smooth or easily cleanable. The FND stated both frying pans were no longer supposed to be used.During an interview on 3/3/26 at 11:05 a.m., with the Dietary Resource Consultant (DRC), when shown photos of the frying pans, the DRC stated, the frying pans showed visible excess carbon and buildup on them which could result in food contamination with shavings from the pan.Review of the U.S. FDA Food Code 2022, section 4-201.11 indicated that equipment and utensils must be durable, retain their original characteristics, and remain easily cleanable throughout their intended lifespan. If surfaces deteriorate . they may become difficult to clean and can harbor pathogenic microorganisms. Additionally, equipment must be constructed to prevent parts from breaking off and becoming physical contaminants or injury hazards.Review of the U.S. FDA Food Code 2022, section 4-101.18 indicated that non-stick coatings (e.g. frying pans) were to be used with utensils and cleaners that prevent scratching or scoring.2. During the initial kitchen tour on 3/2/26 at 8:54 a.m., the can opener blade was observed with significant dark discoloration along the cutting edges, consistent with buildup or corrosion.During a concurrent observation and interview on 3/3/26 at 10:59 a.m., in the kitchen with the FND and DRC, the DRC acknowledged the can opener blade was visibly worn down and the FND stated, if area is worn down, it could not be sanitized properly and could cause contamination.Review of the U.S. FDA Food Code 2022, section 4-501.11 indicated that .(C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. It further indicated that The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury.3. During the initial kitchen tour on 3/2/26 at 8:58 a.m., Fridge # 2 contained one partially used pastry bag of whipped topping. The pastry bag was marked with a black ink which was non-legible. There were no other markings on the pastry bag to indicate when it was opened or its use-by date.During the same kitchen tour on 3/2/26 at 9:04 a.m., Fridge # 6 contained a cardboard case of zucchini - the exterior of the box was inspected by surveyor with FND and found no received date.During an interview on 3/3/26 at 11:15 a.m. with the DRC, the DRC stated all foods should be labeled with a received date and labels were used for reference to verify foods were still good to use.A review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Food delivered to facility needs to be marked with a delivery or received date.

Based on observation, interview, and record review, the facility failed to protect resident health information for a census of 116 when dietary tickets were disposed of in the facility's regular trash.This failure decreased the facility's potential to protect and safeguard resident confidentiality and personal privacy.During a concurrent observation and interview on 3/2/26 at 9:17 a.m. with the Food & Nutrition Director (FND), in the kitchen dishwashing area, a dietary aid (DA) was observed removing trays from the soiled tray carts to prepare them to be washed. The DA sorted the tray contents and threw residents' dietary tickets into the garbage can along with scraps of food. The FND stated residents' dietary tickets were thrown into the garbage with food scraps. An observation of the contents of the garbage can included 8 dietary tickets. The FND agreed the residents' name, room number, diet order, allergies, and likes and dislikes were visibly clear to read on the dietary tickets.During an interview on 3/3/26 at 8:58 a.m. with the Director of Nursing (DON), the DON stated any information with residents' identifiers was not to be disposed of in the regular trash. The DON confirmed residents' dietary tickets contained protected health information; therefore, it should have been disposed of in a locked confidential information bin for shredding.During a review of the facility's policy and procedure (P&P) titled, Safeguards for PHI, dated 1/17, the P&P indicated, The covered entity will .When no longer needed or required by law, properly dispose of or destroy PHI, so that it is unrecoverable (shredders or locked shred bins).

Based on observations, interviews, and record review the facility failed to ensure Resident Rights were honored when two of two sampled residents (Resident 82 and Resident 5) were not provided with privacy during routine care and while accommodating the resident's expressed preference for minimal coverings.This failure resulted in exposure of both residents in a state of undress to passers by, undermining dignity and placing residents at risk for psychosocial harm.A review of Resident 82's admission record indicated she was last admitted on 10/25 with the primary diagnosis of Unspecified sequelae of cerebral infarction (long-term health problems caused by a stroke).A review of Resident 82's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/19/26 indicated, an interview could not be conducted with the resident for the resident is rarely/never understood.A review of Resident 5's admission record indicated she was last admitted on 11/22 with the diagnoses of Pneumonia (an infection/inflammation in the lungs), Need for assistance with personal care, and cognitive communication deficit.A review of Resident 5's MDS dated [DATE] indicated, she had no memory impairment and Resident 5's Brief Interview of Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score was 15 (a score of 12-15 indicates intact cognition).During an observation on 3/2/26 at 4:16 p.m., in Resident 82's room, Resident 82 was lying in bed with no clothing on her upper body. A bath towel draped across her chest had slipped, exposing her breasts. A blanket covered only from the waist down. The privacy curtain was not drawn, allowing Resident 82 to be visible from the hallway.During a concurrent observation and interview on 3/2/26 at 4:26 p.m. in Resident 82's room with Licensed Nurse (LN) C, LN C acknowledged Resident 82's breasts were exposed. LN C stated Resident 82 is nonverbal except for saying one word, Uga. LN C stated the resident typically does not like to wear clothes because she becomes hot easily and usually only agrees to wear a hospital gown before bed.During an observation on 3/3/26 at 3:10 p.m., in Resident 82's room, the resident was again observed lying in bed unclothed, with a white bath towel covering the chest and stomach area and blankets covering the lower body.During an observation on 3/4/26 at 3:00 p.m., in Resident 82's room, the privacy curtain was open and Resident 82 was visible from the hallway. Resident 82 was lying in bed with only a bath towel covering her chest and a blanket covering from the feet to the waist.During an observation on 3/5/26 at 11:54 a.m., in Resident 82's room, the resident was lying in bed unclothed with a white bath towel covering her chest and stomach area and blankets covering the lower body.During an observation on 3/5/26 at 11:55 a.m., from the hallway, Resident 5 was observed receiving routine care as she was getting her brief (an adult undergarment) changed in her bed. The privacy curtain inside the room was not closed, and the glass sliding door curtain was open, making the resident visible from both the hallway and the outside patio area.During a concurrent observation and interview on 3/5/26 at 11:58 a.m. with the Director of Nursing (DON), the DON stated she could confirm from the hallway that Resident 5's bottom half was visible from both the hallway and the outside because neither curtain was closed. The DON immediately entered the room to speak with the Certified Nurse Assistant (CNA) providing care to Resident 5. The DON returned to the hallway and stated she had re educated the CNA on maintaining privacy during care. The DON also stated the facility's expectation are for staff to keep [the resident] covered and close the curtain during care and any stage of undress; if coverings fall, staff must replace them as soon as they can.A review of the facility's policy and procedure (P&P) titled, Resident Rights, Subject: Dignity and Privacy, the P&P indicated, .Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by.

Based on observation, interview, and record review, the facility failed to honor the choices and preferences for two out of two residents (Resident 113, and Resident 111) sampled for choices, when,Resident 113 requested to have her emergency inhaler, Albuterol HFA ( an inhaled respiratory medication for shortness of breath), at her bedside on admission for timely use when short of breath and staff did not honor her request.Resident 111 reported stressors related to roommate and requested a room change and staff did not respond.This failure undermined both residents' right to make choices about care and aspects of their life in the facility and contributed to feelings of anxiety and stress.A review of Resident 113's admission record indicated she was admitted on [DATE] with active diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing) and Depression. A review of Resident 113's Minimum Data Set (MDS - a resident assessment tool) conducted on 2/25/26 indicated she had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11 indicating minimal cognitive impairment, and that it was very important to her to take care of her personal belongings. During an interview on 3/2/26 at 11:14 a.m. with Resident 113 in her room, Resident 113 stated, when she needed her emergency inhaler she needed it now, not in 20 to 30 minutes, and felt anxious when she had to wait. Resident 113 further stated she managed her inhaler at home and had asked multiple times to have it at bedside. A review of Resident 113's physician order summary initiated 2/18/26 indicated her Albuterol HFA was ordered to be at bedside on admission. A review of call light response times for Resident 113 indicated on 2/27/26 she hit the call button at 6:55 a.m. and waited 17.23 minutes for a response. A review of an SBAR worksheet (a documentation tool) completed by a Licensed Nurse on 2/27/26 at 7:00 a.m. indicated the resident felt anxious about her COPD condition and was very worried about getting her inhaler on time and requested to have her emergency inhaler in her room in case an attack occurred. During an interview on 3/4/26 at 9:20 a.m. with Licensed Nurse D (LN D), LN D stated, if a resident requested to have a medication at bedside we should assess for capability and obtain a physician order to do so. LN D further stated she could see why a resident would want to have an emergency inhaler at bedside if they were used to managing it on their own and needed it frequently. During an interview on 3/5/26 at 1:30 p.m. with the Director of Nursing (DON), DON stated resident choices and preferences were important to maintain dignity and independence. A review of a facility policy titled, Self-Administration of Medicines, dated 5/2022, indicated, In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team determined that the practice would be safe for the resident and other residents and there is a prescribers order to self-administer. A review of a facility policy titled, Resident Rights and Preferences & Grievance Policy, reviewed 2/12/25, indicated, Honoring patient preferences is an important part of person-centered care, and efforts are made to support individual choices whenever appropriate. 2. A review of Resident 111's admission record indicated she was admitted on [DATE] with diagnoses of a fracture to her left femur ( a break in the bone of her left thigh) , Diabetes type 2 ( (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and ESRD (End Stage Renal Disease-irreversible kidney failure). A review of Resident 111's MDS dated [DATE] indicated she had a BIMS score of 13, with no cognitive impairment. During an interview on 3/2/26 at 11:11 a.m. with Resident 111 in her room, Resident 111 stated, her problem was her roommate because she was loud and liked to, put up her fists, and this made her anxious at times and rest was difficult. Resident 111 further reported she spoke to the Social Services Assistant (SSA) last Saturday and had not heard back. During an interview on 3/5/26 at 8:30 a.m. with Resident 111 in the physical therapy room, Resident 111 stated, her roommate continued to make her uncomfortable because she was very negative and complained all the time and had become hostile, blaming Resident 111 for the room being cold. Resident 111 further stated the issues with her roommate bring her mood way down and she had yet to hear back from any facility staff. During an interview on 3/5/26 at 9:55 a.m. with the Social Services Director (SSD), SSD stated she had no knowledge of Resident 111's grievance and the SSA would have been the one who spoke to Resident 111 and there should have been a note under progress notes if she had. A review of Social Services Progress notes indicated there was no documentation about Resident 111's report of concerns about her roommate. During an interview on 3/5/26 at 11:51 a.m. with the SSA in the social services office, SSA stated she had spoken to Resident 111 last Sunday when her roommate was loud and agitated and disruptive. SSA further stated she had not made a note and should have so all staff would be, on the same page. During an interview on 3/5/26 at 1:30 p.m. with the DON, DON stated if a Resident had concerns about roommate staff should respect and honor their choices and document what their response was. A review of a facility policy titled, Resident Rights and Preferences & Grievance Policy, reviewed 2/12/25, indicated Grievances are concerns that involve alleged violation of resident rights, unresolved or recurring complaints, or issues that require further review and follow-up by facility leadership. Grievances are formally documented, acknowledged, investigated, and resolved in accordance with facility procedures.

Based on interview and record review, the facility failed to ensure an appropriate indication for use of an antipsychotic medication for one of five residents sampled for unnecessary medication review (Resident 48). This failure placed Resident 48 at risk for unnecessary psychotropic medication (any drug that affects behavior, mood, thoughts or perception) use.A review of Resident 48's face sheet (demographics) indicated an admission date of 11/1/22, age in her 90s, and medical diagnoses including a fall with multiple fractures of the spine and Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, among others. A review of Resident 48's physician order, dated 12/24/25, indicated Seroquel (an antipsychotic medication) 12.5 mg (milligrams) by mouth two times a day for dementia with behavioral disturbance. A review of Resident 48's document titled Consent for Treatment: Use of Anti-Psychotic Medication, dated 12/24/25, indicated, Reason for treatment: Agitation/dementia with behavioral disturbance. Review of Resident 48's physician progress notes and psychology progress notes since 12/24/25 revealed no diagnosis of dementia with behavioral disturbance. During a phone interview on 3/5/26 at 1:40 p.m., Pharmacist A reviewed Resident 48's list of medical diagnoses and verified Resident 48 did not have the diagnosis indicated in the physician order for Seroquel of dementia with behavioral disturbance. Review of facility policy Antipsychotic Drugs, last revised 2/2022, indicated, It is the policy of this facility to use antipsychotic drugs based on a comprehensive assessment of a resident, the facility must ensure that: 1. Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.

Based on interview and record review, the facility failed to promptly notify the State Mental Health Authority, Department of Health Care Services (DHCS), for one of two sampled residents (Resident 13), when Resident 13 experienced a significant change in mental health status and received a new diagnosis indicating serious mental illness, requiring referral for Preadmission Screening and Resident Review (PASRR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care).This failure hindered the facility's ability to ensure Resident 13 had an up to date PASRR determination after the new serious mental illness diagnosis, creating the potential for inappropriate placement and delays in identifying and providing necessary specialized behavioral health services.A review of Resident 13's admission record indicated he was last admitted on 1/23 with the diagnoses of Cognitive Communication Deficit, Generalized Muscle Weakness, Need for Assistance with Personal Care, Difficulty in Walking, and Presence of Right Artificial Knee Joint.A review of Resident 13's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/10/26, indicated he had no memory impairment and Resident 13's Brief Interview of Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score indicated a score of 15 (A score of 12 - 15 indicated a resident was cognitively intact).A review of Resident 13's Face Sheet, (front page of the chart that contains a summary of basic information about the resident), dated 3/5/26, the Face Sheet indicated the onset date of Resident 13's Schizophrenia diagnosis was on 2/18/25, and was classified as During Stay.A review of Resident 13's Psych/Evaluation Progress Note, dated 2/18/25, the Progress Note indicated, the resident was diagnosed with schizophrenia. This Progress Note was the first documentation from the contracted psychological services provider indicating Resident 13's schizophrenia diagnosis.During a concurrent interview and record review on 3/4/26 at 11:23 a.m., with Minimum Data Set Coordinator (MDSC), Resident 13's most recently scanned PASRR Level I Screening dated 6/17/24 was reviewed. The PASRR Level I screening indicated, Resident 13 had a serious diagnosed mental disorder of Depression. The MDSC stated, there is no record in the chart for a new PASRR screening after 6/24. The MDSC agreed despite the new schizophrenia diagnosis on 2/18/25, no new PASRR Level I screening was submitted to DHCS.A review of the facility's policy and procedure (P&P) titled, Resident Assessment, revised 11/2019, the P&P indicated, It is the policy of this facility to ensure that each resident is properly screened using the PASSR specified by the state.

Based on observation, interview, and record review, the facility failed to ensure ongoing accurate clinical assessment and documentation for one resident (Resident 78) when no wound assessments for a head wound were documented. This failure made it difficult to determine the wounds progression, response to treatment, and healing trajectory, when there were no assessments available for comparison. This failure had the potential for poor wound response and non- healing to go unnoticed and untreated.A review of Resident 78's admission record indicated he was admitted on [DATE] with diagnoses of Vascular (having to do with the blood vessels and circulation) Dementia (a progressive state of decline in mental abilities), and Dysphagia (difficulty swallowing). A review of Resident 78's Minimum Data Set (MDS-a resident assessment tool) dated 11/27/25 indicated he had a BIMS Score of 14 with no cognitive impairment. During an interview on 3/4/26 at 2:24 p.m. with Resident 78 in his room, Resident 78 stated, the nurses changed his dressing every other day and that he had pain and tenderness with dressing changes. Resident 78 further stated he was concerned because the wound was not healing. A review of Resident 78's Care Plan dated 5/9/25 indicated Resident 78 had a chronic wound to the top of his scalp with orders to monitor/document location, size, and treatment of skin injury and to report any abnormalities, failure to heal, signs or symptoms of infection, or maceration, to the physician. A review of Progress Notes from 2/5/26 through 3/5/26 indicated no documented head wound assessments and no skin issues noted. A review of Resident 78's most recent Interdisciplinary Team notes dated 2/25/26 indicated to continue wound care with no documented discussion of wound assessment or progress towards healing. During an interview on 3/4/26 at 3:24 p.m. with Licensed Nurse E (LN E) and the Director of Nursing (DON), LN E stated she did not document wound assessments when dressing changes were done or periodically. LN E further stated if the wound looked bad they would refer Resident 78 to the Kaiser wound care nurse. The DON confirmed there were no wound assessments documented in the medical record or on paper and the Kaiser wound care nurse had not assessed Resident 78. During an interview on 3/5/26 at 7:55 a.m. with the Assistant Director of Nursing (ADON), ADON stated she could not provide any wound assessments for Resident 78. During an interview on 3/5/26 at 1:30 p.m. with the DON, DON stated, there were no documented wound assessments for Resident 78's head wound and she would be unable to report the current size or characteristics of the wound, and it would be difficult to determine if there was a change in condition. A review of a facility policy titled, Medical Records & Documentation Policy, revised 9/19/25, indicated, Documentation should reflect resident status, care provided, physician orders, and relevant observations. A review of a facility document titled, Licensed Vocational Nurse Job Description, dated 12/17/21, indicated, Chart nurses' notes in a professional and appropriate manner that timely, accurately, and thoroughly reflects the care provided to the resident as well as the resident's response to care. A review of a published article through the Wound Care Education Institute ( A NAWCO-National Alliance of Wound Care and Ostomy, accredited organization for nursing wound care certification and evidenced based standards of care) dated 4/17/2025, titled, Best Practices for Wound Assessment and Documentation, indicated, Wound Documentation is more than record keeping, it is a clinical tool that informs care planning, tracks healing trajectories, and supports regulatory compliance. and lists the foundational elements of wound assessment and documentation as precise anatomical location, wound classification or etiology, accurate measurements, wound bed characteristics, wound edges and margins, exudate characteristics, peri-wound skin status and pain and symptoms reporting.

Based on observation, interview, and record review, the facility failed to implement supervision and monitoring interventions for one of one sampled resident (Resident 6) when the facility did not prevent the resident from exiting beyond the secured patio on 3/2/26 despite her severe cognitive impairment, documented history of exit seeking, and care planned interventions such as door alarms and frequent checks.This failure resulted in Resident 6's elopement beyond the secured patio and exposed Resident 6 to significant hazards with potential for serious injury.A review of Resident 6's admission record indicated she was last admitted 4/25 with the diagnoses of Unspecified Intrascapular Fracture of Left Femur (broken hip on the left side), generalized muscle weakness, unsteadiness on feet, and Alzheimer's Disease with Late Onset.A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/4/26 indicated she had significant deficits in orientation and Resident 6's Brief Interview of Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score indicated a score of 4 (A score of 0-7 indicates severe cognitive impairment).During an observation on 3/2/26 at 9:24 a.m., in the exterior service area near the dumpsters, while with the Food and Nutrition Director (FND), Resident 6 was observed outside the facility's gated patio, walking alone with her walker. During the observation, the resident stated she was running away and expressed a desire to leave the facility.During an interview on 3/4/26 at 8:57 a.m. with the Staffing Coordinator (SC), the SC stated she was aware Resident 6 was an elopement risk and stated any staff member was responsible to check when the resident's sliding door alarm sounded.During an interview on 3/4/26 at 9:39 a.m. with Licensed Nurse (LN) B, LN B stated Resident 6 had previously attempted to leave the facility on several occasions. LN B stated approximately one month earlier, Resident 6 reached the same exterior patio gate. LN B further stated the Resident 6 slipped through the first set of double doors into the lobby after a visitor entered. LN B stated the resident frequently verbalizes wanting to go home, and her exit seeking behavior varies from day to day.During an interview on 3/5/26 at 12:01 p.m. with the Director of Nursing (DON), the DON acknowledged that on 3/2/26 Resident 6 was outside the gate and was no longer in the patio. The DON stated Resident 6 had experienced two or three elopement incidents and described the 3/2/26 incident as a one off, stating it just so happened the surveyor was present when it occurred.During a review of Resident 6's Licensed Nurse (LN) Elopement/Wandering Evaluations, dated 3/11/25, 6/5/25, 7/5/25, and 8/25/25, the evaluations indicated the LN tool uses a scoring system in which 0-8 indicates low risk and 10-99 indicates high risk. The evaluation dated 8/25/25 showed a score of 17, indicating the resident was assessed as high risk for elopement.During a review of Resident 6's Nurse Advanced (N Adv) Elopement Evaluations, dated 10/25/25, 1/8/26, 2/5/26, and 3/2/26, the evaluations indicated this tool identifies any score of 1 or higher as a positive indication of elopement risk. The evaluation dated 3/2/26 showed a score of 2.0, indicating the resident continued to demonstrate behaviors associated with elopement risk.During a review of the facility's policy and procedure titled Elopement, dated 7/25, the policy indicated the facility is committed to maintaining a safe environment and implementing reasonable measures to minimize the risk of resident elopement.

Based on observation, interviews, including a Santa [NAME] Police Department Detective interview, and facility record reviews, the facility failed to protect one resident (Resident 1) of a census of 115 and sample of 77 interviewable residents, to be free from sexual abuse, when Licensed Staff B witnessed Unlicensed Staff A touching his exposed penis against Resident 1's naked body during care.This failure to protect Resident 1 from Unlicensed Staff A resulted in Resident 1 stating she told Unlicensed Staff A to stop, and it made her feel uncomfortable, and would make a reasonable person, who suffered from sexual assault by a facility staff member, to experience fear, guilt, shame, isolation, dehumanization and humiliation as a result of the sexual abuse. A review of Resident 1's medical record document titled Face Sheet, indicated she was admitted [DATE] with diagnoses including Parkinson's Disease (A chronic, progressive brain disorder affecting chemicals in the brain, leading to impaired muscle control) with Dyskinesia (involuntary movements), with fluctuations of Dyskinesia, Dysphonia (a voice disorder characterized by hoarseness, raspiness, breathiness, or strain), and muscle weakness.A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/11/25, indicated Resident 1 had no memory impairment and unclear speech. The MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 13 (13-15 indicate intact cognition, 8-12 suggest moderate impairment, and 0-7 signify severe impairment). During an interview with the Administrator on 1/27/26 at 9:15 a.m., he stated he was informed by his Business Officer Manager (BOM) that Licensed Nurse B walked into Resident's 1's room on 12/29/25 and witnessed Unlicensed Staff A standing behind Resident 1 with his penis own in his hand. The Administrator stated Licensed Nurse B immediately escorted Unlicensed Staff A to meet with the Business Officer Manager.During an interview with Resident 1 on 1/27/26 at 10:30 a.m., in the Administrator's office, Resident 1 was observed sitting in a specialty wheelchair, with her arms and legs contracted up to her chest. Her voice was very quiet. She answered in few words. Resident 1 remembered Unlicensed Staff A. When she was asked if he was inappropriate, she responded Yes. When asked if he did things she did not want him to she stated, It did happen. When asked if he put two - three fingers in her body when he was cleaning her, she stated, It did happen. When asked if he put his penis in her vagina she stated, More than once. She stated she would say No to him.During an interview on 1/27/26 at 11:48 a.m. the Business Operation Manager stated on 12/29/25 around 4 p.m., Licensed Nurse B came into the office with Unlicensed Staff A and stated she had observed Unlicensed Staff A in Resident 1's bedroom, standing beside Resident 1 with his penis exposed, in his hand. The Business Operation Manager stated he asked Unlicensed Staff A if it was true if he had his penis exposed in Resident 1's room and Unlicensed Staff A responded, I don't know and stated whatever she [Licensed Nurse B] said. The Business Operation Manager stated Unlicensed Staff A never denied the allegation. The Business Operation Manager stated he interviewed Licensed Staff B and she stated when she walked into Resident 1's room she observed Resident 1 lying on her back, in her bed, with her limbs contracted towards her leaning to her right side.During an interview on 1/27/26 at 1:35 p.m., Licensed Staff B stated on 12/29/25 between 4 p.m. and 5 p.m. she walked into Resident 1's room and saw Resident 1 lying on her bed with her legs contracted and Unlicensed Staff A had his penis out and touching her [Resident 1's] butt area. She stated Resident 1 was positioned on the right side of the bed, facing the door, with her buttocks on the edge of the left side of the bed, where Unlicensed Staff A was standing. She stated she observed Unlicensed Staff A with his pants were pulled down in the front. She stated, He was holding his penis in his left hand, and his right hand was on Resident 1's left buttock, and his penis was pressed against her left buttock at the gluteal fold (the horizontal skin crease separating the lower buttock from the upper thigh).During an interview on 1/27/26 at 1:50 p.m., Charge Nurse C stated on 12/29/25 after 5 p.m., Licensed Nurse B told her she had seen Unlicensed Staff A touch Resident 1 with his exposed penis. Charge Nurse C went with Licensed Nurse B to Resident 1's room and asked her if she was okay. Charge Nurse C stated Resident 1 stated Boundaries were crossed with the unlicensed staff who had been with her. She stated she spoke with Resident 1 later during the shift, and she stated Unlicensed Staff A had crossed boundaries when he changed her brief. She stated Resident 1 stated sometimes he would push his fingers on her anus and he was rough. She stated Resident 1 felt he lingered too long in her room during personal care.During an interview with the Police Detective on 1/29/26 at 2:32 p.m., he stated Resident 1 indicated during his interviews with her on 12/29/25 and 12/30/25, that Unlicensed Staff A had touched her with his penis, had inserted his penis into her vagina, and had inserted two or three fingers into her vagina on multiple occasions. He stated when he interviewed Unlicensed Staff A he admitted he touched Resident 1 inappropriately with his penis and his fingers on multiple occasions.During a review of a facility Policy and Procedure titled Resident Abuse Prevention Policy, revised 9/19/25, it stipulated The purpose of this policy is to affirm the facility's commitment to preventing.any form of resident abuse.The facility maintains a zero-tolerance stance toward any form of resident abuse.These findings represent past noncompliance with this regulatory requirement. Record review confirmed the alleged perpetrator was removed from the premises, suspended, and consequently terminated. The police were notified and investigated. Staff were in-serviced right away, and the resident's care plan was updated. There was sufficient evidence that the facility corrected the violation as of 12/31/25, and no other occurrences of noncompliance were identified. At the time of the survey the facility was in substantial compliance with the regulatory requirement, and therefore, this violation does not require a plan of correction.

Based on observation, interview, and record review, the facility failed to ensure medications were stored and maintained in accordance with professional standards of practice for one of five residents (Resident 1) when, two medications pills were found left unattended at the bedside of Resident 1 without authorization for bedside storage or self-administration.This deficient practice created the potential for medication errors, diversion, or harm to Resident 1 or other residents.Findings:In a record review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility with diagnoses that included hypertension (high blood pressure), atrial fibrillation (heart rhythm disorder where the heart beats irregularly and rapidly), heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs) and dementia (a progressive state of decline in mental abilities).In an observation and interview on 9/3/25 at 11:00 a.m., Resident 1 was sitting at her bedside table. On the table was a small cup containing two pills: one small white pill and one oval white/cream-colored pill. Resident #1 was unable to identify the pills or state how long they had been there.In an interview on 9/3/25 at 11:39 a.m., Licensed Nurse 1 (LN 1) confirmed two pills had been left on Resident 1's bedside table. LN 1 stated the medications were Resident 1's heart medications that were withheld because Resident 1's heart rate and blood pressure (the force exerted by blood against the walls of the arteries as it circulates throughout the body) were too low to give the medications. LN 1 admitted she accidentally left the medication cup on the bedside table and acknowledged this created a risk for Resident 1, as taking the medications with low blood or heart rate could have caused further cardiovascular compromise, ( a situation where the heart is unable to adequately pump blood to meet the body's needs which can lead to a variety of symptoms and complications, including chest pain, shortness of breath, confusion and loss of consciousness). She also acknowledged the pills could have been ingested by another resident, particularly a confused or wandering resident, resulting in harm to the resident.In an interview on 9/3/25 at 11:50 a.m., with the Director of Nursing (DON), the DON confirmed she was aware LN 1 left medications at Resident 1's bedside. The DON agreed that leaving medications unattended at the bedside was unsafe for the resident and acknowledged that it was possible for another resident to enter Resident 1's room and consume the unattended medications.A review of Resident 1's the Order Summary Report for active orders, did not indicate Resident 1 could take her own medications.A review of Resident 1's active Care (written document outlining a resident's specific health, personal, and social needs, developed after an initial assessment and updated regularly), the plan did not indicate that Resident 1 could take her own medications.Review of facility policy titled, Medication Storage in the Facility - Bedside Medication Storage,, dated May 2022, indicated, .A written order for the bedside storage of medications should be present in the resident's medical record, and the manner of storage should prevent access by other residents.Review of facility policy titled, Medication Administration - General Guidelines, dated May 2022, indicated, .For residents not in their room or otherwise. unavailable to receive medications during the pass, after completing the medication pass, the nurse returns the missed medications to secured storage.

Based on interview and record review, the facility failed to maintain medical records in a complete and accurately documented manner for one resident out of four sampled residents (Resident 1) when vital signs (measurements of the body's functions that include heart rate, the amount of oxygen in the blood, breaths per minute and blood pressure [the force of blood as the heart pumps]), were recorded in the resident's medical record after the resident had been transferred out of the facility.This failure resulted in inaccurate documentation in Resident 1's medical record. Findings:A review of Resident 1's admission record indicated she was an [AGE] year-old admitted to the facility in June 2025 with diagnoses which included pneumonia, (an infection in the lungs), asthma, (a chronic lung disease that inflames and narrows the airways), and chronic obstructive pulmonary disease, (a progressive lung disease that makes it difficult to breathe due to airflow blockage). In an interview on 7/15/25 at 3:34 p.m., the daughter of Resident 1 stated Resident 1 did not return to the facility after she was transferred to the hospital on 6/28/25.In a record review of Resident 1's transfer form, dated 6/26/25, indicated Resident 1 was discharged to the hospital 6/28/25 at 07:32 p.m.A review of Resident 1's vital signs, from 6/29/25, indicated at 12:15 a.m. vital signs were documented for blood pressure, oxygen saturation (the amount of oxygen in the blood), pulse rate (heart rate), and respiration rate (breaths per minute).During a concurrent interview and record review on 7/17/25 at 2:43 p.m. with the Director of Nursing (DON), Resident 1's transfer form from 6/28/25 and vital signs documentation from 6/29/25, was reviewed. The DON confirmed the transfer form indicated that Resident 1 was transferred to the hospital at 7:32 p.m. on July 28, 2025 and there were vital signs documented in the residence records on July 29, 2025, at 12:15 a.m. when Resident 1 was no longer in the facility. The DON stated the vitals signs were an error in documentation.A review of the facility's policy and procedure titled, Vital Signs Monitoring and Reporting, effective date 4/1/2025, indicated, .Vital signs should be obtained recorded and reported in a timely and accurate manner.

Based on interview and record review, the facility failed to develop and implement a resident centered care plan for one resident (Resident 1) out of four sampled residents when licensed nurse staff did not develop a care plan for Resident 1's use of a Bilevel Positive Airway Pressure (BIPAP- therapy for assisted breathing by delivering pressurized air through a mask). This failure decreased the facility's potential to provide resident centered care and ensure safety for Resident 1. Findings: A review of a facility document titled admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia (a severe condition in which the body struggles to remove carbon dioxide from the blood, leading to lung diseases), Sleep Apnea (a sleep disorder where the upper airway collapses, causing pauses with breathing) and Morbid Obesity (a severe disorder which involves too much body fat with co-existing health issues such as Sleep Apnea). A review of a facility document titled Care Plan Report , dated 5/5/25, indicated Resident 1's care plan for Altered Respiratory Status/Difficulty Breathing was not updated to include an intervention for BIPAP therapy. A review of a facility document dated 5/6/25, at 4:26 p.m., indicated a telephone order was placed by Medical Doctor 2 (MD 2) for Resident 1 to receive BIPAP with home settings at bedtime for Obstructive Sleep Apnea (OSA- a condition where breathing repeatedly stops or becomes very shallow during sleep, often due to a blockage in the upper airway). A review of Resident 1's Medication Administration Record (MAR), dated May 2025, indicated Resident 1 did not receive his ordered BIPAP therapy on 5/11/25. A review of Resident 1's progress note dated 5/11/25 at 9:43 p.m., indicated, BIPAP held due to broken part and inoperable. During an interview on 6/2/25 at 12:40 p.m., MD 1 stated if a resident did not receive BIPAP therapy as ordered their sleep would be unmanaged and it had the potential to cause the resident increased confusion due to a carbon dioxide buildup in their blood. MD 1 further stated it could make other blood chemistries elevate, causing the resident's condition to worsen. During a concurrent interview and record review on 6/3/25 at 1:22 p.m., Licensed Nurse 2 (LN 2) stated resident care plans were designed to treat the whole person, and it was necessary to review care plans often to ensure nursing was aware of all changes. LN 2 confirmed Resident 1 did not have any care plans that identified BIPAP therapy. A review of facility policy titled Care and Treatment: Care Planning , revised 6/25, indicated It is the policy of this facility that the Interdisciplinary Team shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental and psychosocial well-being .the care plan will reflect the interdisciplinary approach to Person-Centered Care and considering the different individual needs .identified during the assessment process of the resident.

Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of care for one resident (Resident 1) out of four sampled residents when: 1. A Licensed Nurse (LN) failed to notify the physician when Resident 1's Bilevel Positive Airway Pressure (BIPAP- therapy for assisted breathing by delivering pressurized air through a mask) machine became inoperable; and, 2. An LN did not notify the physician when Resident 1 was not administered an ordered medication. These failures had the potential to cause Resident 1's condition to deteriorate and complicate his clinical condition. Findings: 1. A review of a facility document titled admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia (a severe condition in which the body struggles to remove carbon dioxide from the blood, leading to lung diseases), Type 2 Diabetes (a chronic condition in which the body does not produce enough insulin), Sleep Apnea (a sleep disorder where the upper airway collapses, causing pauses with breathing) and Morbid Obesity (a severe disorder which involves too much body fat with co-existing health issues such as Type 2 Diabetes or Sleep Apnea). A review of Resident 1's physician order, dated 5/6/25, at 4:26 p.m., indicated a telephone order was placed by Medical Doctor 2 (MDS 2) for Resident 1 to receive BIPAP with home settings at bedtime for Obstructive Sleep Apnea (OSA- a condition where breathing repeatedly stops or becomes very shallow during sleep, often due to a blockage in the upper airway). A review of Resident 1's Medication Administration Record (MAR), dated May 2025, indicated Resident 1 did not receive his ordered BIPAP therapy on 5/11/25. A review of Resident 1's progress notes, dated 5/11/25, at 9:43 p.m., indicated, BIPAP held due to broken part and inoperable. PT [Resident 1] agreed to [nasal cannula-medical tubing that provides oxygen]. During an interview on 6/2/25 at 12:40 p.m., MD 1 stated he expected to receive a phone call regarding a resident's broken BIPAP machine. MD 1 stated if a resident did not receive their BIPAP therapy as ordered, their sleep would be unmanaged and had the potential to cause the resident increased confusion due to a carbon dioxide buildup in their blood. MD 1 further stated it also could make other blood chemistries elevate, causing the resident's condition to worsen. During an interview on 6/2/25 at 1:21 p.m., the Director of Nursing (DON) stated, It is not ok that we broke his BIPAP . The expectation for an event of this magnitude is to alert myself, and the MD or ask someone from home to bring in supplies. During a concurrent interview and record review on 6/2/25 at 3:15 p.m., the Assistant Director of Nursing (ADON) confirmed Resident 1 did not receive his BIPAP therapy on the night of 5/11/25. The ADON further confirmed there was no documented evidence the MD was notified of Resident 1's BIPAP being inoperable. During an interview on 6/3/25 at 11:49 a.m., LN 1 stated she understood the importance of maintaining the BIPAP as ordered and if the machine became inoperable, she would immediately notify the physician and escalate the situation to the DON or nursing supervisor. 2. A review of Resident 1's physician order dated 5/3/25 at 10:45 a.m., indicated a telephone order was placed for ,Ozempic® [medication used to control Diabetes Mellitus] 2 mg [milligram- a unit of measure]/dose Subcutaneous [administered under the skin] Solution Pen Injector 8 mg/3 ml [milliliter- a measure of volume]. Inject 2 mg subcutaneously one time a day every Monday for Diabetes Mellitus 2 [Type 2 Diabetes]. A review of a facility document titled Care Plan Report , dated 5/5/25, indicated Resident 1 had Diabetes Mellitus 2 with the goal to experience no complications related to Diabetes. Staff were expected to implement the following interventions to assist Resident 1 meet his goal, Diabetes medication as ordered by doctor . [ensure Resident 1 and family understood]Diabetes is a chronic disease where compliance is essential to prevent complications of the disease. A review of Resident 1's MAR, dated 5/1/25-5/31/25, indicated Resident 1 did not receive his ordered dose of Ozempic® on 5/19/25. A review of Resident 1's progress note, dated 5/19/25, at 10:38 a.m., indicated, Ozempic® .medication not available. During an interview on 6/2/25, at 11:19 a.m., LN 1 stated if medications were missing, she would call the facility pharmacy, look in the E-kit (a collection of medications kept in a secure location to quickly treat residents) and communicate with the physician that the medication was missing. During an interview on 6/2/25, at 12:40 p.m., MD 1 stated he, should always receive a call about missing medications. MD 1 further stated missed doses of diabetic medication could lead to complications in Resident 1's health such as delayed healing and worsening heart disease. During an interview on 6/2/25, at 1:21 p.m., the DON stated staff were expected to notify the physician about missed medications and to escalate the situation to her if needed. The DON also stated, It is not ok .that we lost [Resident 1's] Ozempic® pen. During a concurrent interview and record review on 6/2/25, at 1:53 p.m., the ADON confirmed Resident 1 missed his prescribed dose of Ozempic® on 5/19/25. During an interview on 6/2/25, at 3:30 p.m., the DON stated the facility did not have a policy regarding physician notification for medication errors or medication omissions. During a phone interview on 6/3/25 at 8:10 a.m., the DON acknowledged insulin was a critical, high-risk medication and not receiving prescribed doses of insulin had the potential to result in hyperglycemia (a condition where there is an abnormally high level of glucose (sugar) in the blood) and additional complications such as further kidney damage. The DON clarified she did not direct her nurses not to call the physician until a resident missed two doses of a medication as indicated in the Preparation and General Guidelines policy; however, the DON also stated she left the discretion up to the licensed nurse to notify the physician. A review of the facility's policy titled Administering Medications , dated April 2019, indicated, Medications are administered in accordance with prescriber orders . A review of the facility's policy titled Preparation and General Guidelines , dated October 2019, indicated, If (two consecutive doses) of a vital medication are .not available, the physician is notified.

Based on observation, interview, and record review the facility failed to ensure residents were free of medication errors when one of three sampled residents (Resident 3) was not given the correct dosage of a medication, Uptravi (generic name selexipag) a medication used to treat pulmonary hypertension (high blood pressure in the arteries that carry blood from the heart to the lungs). This failure had the potential for Resident 3 to have a drug overdose causing physical problems ranging from pain, rashes, weakness, organ failure, (when organs in the body such as the heart, lungs, kidneys or liver are unable to perform their critical functions), seizures or even death. Findings: During an interview on [DATE] at 11:55 a.m., Family member of Resident 3 (Family) complained that Resident 3 was given the wrong dose of her medication several times. Family stated they gave the facility a month supply of her medication from home because the medication was not available at all pharmacies. Family stated, I found out that my wife had been getting 4 pills per dose when it should have been 1 pill per dose when the nurse asked for a refill. Family complained We should not be out of the medication, how did it run out, can ' t the nurses read the label! Family stated they were giving her one tablet of Uptravi 800 mcg (microgram, one millionth of a gram) 2 times a day at home. During a record review on [DATE] Resident 3 ' s admission Record (form to show key facts about resident) indicated Resident 3 was admitted on [DATE] and had Diagnosis of End Stage Kidney disease, Diabetes, and Pulmonary Hypertension (HTN.) During a record review on [DATE] Resident 3 ' s Order Summary Report (Doctors orders) the medications for Resident 3 were documented. The order for Uptravi read: Uptravi oral tablet 200 mcg (Selexipag) give 4 tablets by mouth two times a day for Pulmonary HTN (800 mcg). This medication is filled by an outside specialty pharmacy. Start date [DATE]. Four tablets of 200 mcg would equal 800 mcg, which is the desired dosage. During a record review on [DATE] Resident 3 ' s Medication Administration Record (MAR) for [DATE] included Uptravi oral tablet 200 mcg (Selexipag) give 4 tablets by mouth two times a day for Pulmonary HTN (800 mcg). This medication is filled by an outside specialty pharmacy. Start date [DATE]. Nursing had administrated the medication 29 times over 15 days based on the initialing on the MAR indicating a dose was given. The MAR did not have any documentation to indicate that a nurse gave one 800mcg tablet in place of the four 200mcg tablets to be given per the doctor ' s order. During an interview and concurrent observation on [DATE] at 12:25 p.m., Licensed Staff A opened the medication cart to look at the medication bottle. The medication bottle was no longer in the medication cart. Licensed Staff A stated the bottle may have been given to the family because we needed a refill. Licensed Staff A stated she was aware that the medication bottle label indicated that the tablets were 800 mcg, and directions were for one tablet 2 times a day. Licensed Staff A stated, I was giving her 1 tablet per dose not 4 tablets. Licensed Staff A stated, I would tell the next nurse on duty to only give one tablet from the medication bottle to get the correct dose. Licensed Staff A stated the pharmacy label did not get updated to reflect the order on the MAR. During an interview on [DATE] at 1:05 p.m., Director of Nursing (DON) stated she recently learned that Resident 3 ' s medication stock was depleted before expected, and that the label did not reflect the order. DON stated the nurse last evening ([DATE]) requested help to refill Resident 3 ' s prescription for Uptravi. DON stated she was in the process of clarifying the order and needed to investigate how the month ' s supply was finished although the resident had only been at the facility for 2 weeks. During an interview on [DATE] at 1:50 p.m., Licensed Staff B stated, the day shift nurse told me we were almost out of the Uptravi and had asked the family to bring in more of the medication. Licensed Staff B stated I poured her medication and tossed the medication bottle. I administered the medications and asked the Family to bring in more of the medication. Licensed Staff B stated the family voiced concerns that the facility had gone through Resident 3 ' s medication too fast. Licensed Staff B stated she informed the DON that they needed to refill the prescription. Licensed Staff B stated, I did give her the medications on [DATE] in the evening. I read the MAR and poured out 4 pills. I do not know what the label said because I did not read it completely, I only read the MAR. During a review of the facility's policies, The policy titled Medications Brought to the Facility by Physicians or Resident Family Members, dated 5/2022, instructed medications brought to the facility by other than the designated pharmacist or agent can be accepted only if there is current order for use, the medication container is properly labeled, in a proper container, has not expired and has been positively identify by the physician or Pharmacist prior to use. The facility will have documentation that the identification has been made.'

Based on interviews and record reviews, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards of practice when: 1. Resident 1 did not receive her six of her scheduled medications. 2. The physician was not notified when Resident 1 did not receive their scheduled medications. These failures could lead to worsening of condition, hospitalization , seizure (sudden burst of electrical activity in the brain) or even death. Findings: A review of Resident 1 ' s face sheet (demographics) indicated an admitted [DATE] with a diagnosis of Epilepsy (a brain condition that causes recurring seizures) and Restless Leg Syndrome (RLS, a condition that causes a very strong urge to move the legs). A review of Resident 1 ' s electronic medication administration record (EMAR, electronic documentation of medications administered to a resident) with corresponding progress note dated 7/26/24 indicated the following medications where not administered as ordered because it was still awaiting for arrival: Atorvastatin (used to treat high cholesterol) 40 milligram (mg, unit of measure) 1 tablet (tab) by mouth (PO) at bedtime, Latanoprost (used to treat increased eye pressure) eye drops (gtts) to both eyes at bedtime, Dorzolomide (used to treat increased eye pressure) 2 gtts to left eye afternoon dose, Ropinorole (to treat RLS) 1 tab PO at bedtime, Levetiracetam 500 mg 1/2 tab PO afternoon dose and Lubiprostone 2 capsules by mouth afternoon dose. During a concurrent interview and 7/2024 EMAR record review on 1/14/25 at 2:16 p.m., the Director of Nursing (DON) confirmed Resident 1 did not receive the following ordered scheduled medications on 7/26/24: atorvastatin at 8:00 p.m., latanoprost at 8:00 p.m., ropinorole at 8:00 p.m., levetiracetam at 4:00 p.m., Dorzolomide at 4:00 p.m. and Lubiprostone at 4:00 p.m. When asked if Resident 1 should have received these medications as ordered on 7/26/24, the DON stated yes. The DON stated if residents missed multiple medications, staff would notify the physician especially for Levetiracetam which could result to seizure activity. During a telephone interview on 1/15/25 at 10:05 a.m., the pharmacist stated missing a dose of Levetiracetam could result to rebound seizure and risk of seizure build up. A review of the facility ' s policy and procedure (P&P) titled Medication Administration-Oral, revised 11/2019, the P&P indicated, .no medication is to be administered without a physician ' s (MD) written order .accurate and timely administration according to MD order is essential .

Based on observation, interviews and record review, the facility failed to ensure the contact enteric precaution (used when caring for residents with a suspected or confirmed infection caused by bacteria that spreads through fecal-oral transmission) on room [ROOM NUMBER] was followed when a speech therapist: 1.Did not perform hand hygiene (HH, washing hands with soap and water or using an alcohol-based hand sanitizer to prevent the spread of germs) prior to entering room [ROOM NUMBER], 2.Did not put on gloves prior to entering room [ROOM NUMBER], 3.Did not put on gown prior to entering room [ROOM NUMBER], 4.Did not wash hand with soap and water upon leaving room [ROOM NUMBER]. These failures could result to spread of infection between residents. Findings: A review of Resident 3's face sheet (demographics) indicated an admitted [DATE]. A review of Resident 3's Physician's Order's Summary (POS) indicated a diagnoses of Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and Clostridium Difficile (Cdiff, a germ that causes diarrhea and colitis (an inflammation of the colon), highly contagious, and could be life-threatening). room [ROOM NUMBER] was observed to be on contact enteric precaution due to Resident 8's active Cdiff infection. During an observation on 1/14/25 at 12:55 p.m., the speech therapist (ST) was seen going into room [ROOM NUMBER]. The ST did not perform HH, did not wear gown and gloves prior to entering the room. During a concurrent observation, interview and contact enteric precaution signage record review on 1/14/25 at 12:57 p.m., the ST was seen leaving room [ROOM NUMBER] without first washing her hands with soap and water. The ST verified she did not gown up, performed HH nor wore gloves prior to entering room [ROOM NUMBER]. ST also verified she did not wash her hand with soap and water when she left room [ROOM NUMBER]. ST verified the contact enteric precaution posted on the wall prior to entering room [ROOM NUMBER] which indicated staff should wash or gel hands prior to entry, to use soap and water upon leaving the room and to wear a gown and gloves prior to entering the room. During an interview on 1/14/25 at 1:12 p.m., the Infection Preventionist (IP) stated Resident 3 on room [ROOM NUMBER] had an active CDiff infection. The IP stated all staff should follow the contact enteric precaution when entering and leaving room [ROOM NUMBER]. The IP stated staff should perform HH, wear gowns and gloves prior to entering room [ROOM NUMBER] and should was their hand with soap and water upon leaving the room. The IP stated if staff did not follow these steps, it meant a break in infection control and was a safety issue. The IP stated Resident 3 have an active CDiff and was highly contagious. The IP stated it was important staff follow the contact enteric precaution to prevent spread of CDiff infection. During an interview on 1/14/24 at 2:16 p.m. the Director of Nursing (DON) verified that if a room was on contact enteric precaution, all staff must perform HH, wear gown and gloves prior to entering the room and should wash their hands with soap and water upon leaving the room. The DON stated it was important the contact enteric precautions were followed to ensure safety of staff and other residents and to prevent spread/outbreak of CDiff infection. A review of contact enteric precaution signage posted on the wall before entering room [ROOM NUMBER], the precautions included all staff should wash or gel hands prior to entry, to use soap and water upon leaving the room and to wear a gown and gloves prior to entering the room.

Based on observation, interviews, and record reviews, the facility failed to ensure the rights of five (5) unsampled residents (Resident 20, Resident 55, Resident 69, Resident 76 & Resident 63) and three (3) of 24 sampled residents (Resident 3, Resident 51 & Resident 42) were honored and respected, when: 1) facility staff did not answer or respond to call lights or call for assistance, making residents wait for 20 minutes or more; 2) the facility did not follow its Smoking Policy, when Resident 42 wheeled himself across the facility's parking lot to smoke without staff supervision, and; 3) facility staff entered and exited the building using the slider doors in the residents' rooms that opened to the back patio. These failures: 1) caused Resident 20 to feel terrible after she urinated in her bed while waiting, Resident 55 to fear for the safety of his spouse/room mate when she attempted to get out of bed after waiting for a long time, Resident 69 feeling bad after soiling his bed/linen while waiting, Resident 76 to urinate in bed and sleep on a wet bed until he morning shift came; 2) had the potential of Resident 42 being hit by a vehicle or having a smoking accident, and; 3) caused residents to feel that they had no privacy (Residents 63, Resident 3, and Resident 51). Findings: 1. During an interview on 5/13/24, at 1:17 PM, Resident 20 stated, staff working the night shift did not come when called and she had peed in bed and felt terrible about it. A review of Resident 20's quarterly Minimum Data Set (MDS - a federally-mandated clinical assessment of all residents' functional capabilities in Medicare and Medicaid certified nursing homes helping nursing home staff identify health problems), dated 4/16/24, indicated Resident 20 had a Brief Interview for Mental Status score of 13 (BIMS - mandatory tool used to screen and identify the cognitive condition of residents upon admission. A score of 13 to 15 suggests the patient is cognitively intact), and always did not have control of her urination and bowel movement. During an interview on 5/13/24, at 9:28 AM, Resident 55, whose roommate was his wife, stated there were times his wife had to wait 20 minutes to half an hour to get assistance. Resident 55 stated his wife sometimes tried to get up because the wait was too long, and he was afraid she might fall. A review of Resident 55's quarterly MDS, dated [DATE], indicated he had a BIMS of 13. During an interview on 5/13/24, at 11:58 AM, Resident 69 stated wait time for staff assistance was 20 minutes to a half hour. Resident 69 stated sometimes he soiled his bed and did not appreciate soiling himself and felt bad because he had to wait and get cleaned. A review of Resident 69's quarterly MDS, dated [DATE], indicated he had moderately impaired cognition with a BIMS of 10, was occasionally unable to control urination and always unable to control bowel movement. A review of a physician order, dated 1/11/24 indicated to monitor Resident 69's bowel movement every shift every two days and to administer bowel care and make sure Resident 69 had a bowel movement. During an interview on 5/13/24, at 10:46 AM, Resident 76 stated two to three times, a Certified Nursing Assistance (CNA) did not help and left him when he asked to be assisted to use a urinal. Resident 76 stated he had urinated in bed and had gone to sleep lying on his wet bed until the CNA in the morning cleaned him and his bed. Resident 76 stated he had reported the incident to a nurse, who told him she would investigate. A review of Resident 76's admission MDS, dated [DATE], indicated he had a BIMS score of 13, always did not have control of urination and frequently did not have control of bowel movement. A review of the facility's policy, titled: Resident Rights and Dignity, taken from the Nursing Services Policy and Procedure Manual for Long-Term Care 2001, MED-PASS, Inc. revised 2/21, indicated: Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of the facility. The rights include the resident's right to a dignified existence; be treated with respect, kindness, and dignity; among others. 40402 2. During an observation on 5/13/24 at 8:15 a.m., Resident 42 was in a wheelchair smoking alone in the smoking area. No other residents or staff were present in the smoking area. During an interview on 5/13/24 at 8:45 a.m., with Resident 42, Resident 42 was queried if he was aware of the facility's smoking policy. Resident 42 stated he was told that this facility was a non-smoking facility. Resident was queried if he was at the smoking area earlier this morning at 8:15 a.m. Resident 42 stated he was but he had to sit out front of the facility yesterday and bum cigarettes and matches so he could smoke. Resident 42 stated the staff kept trying to force him to take nicotine (stimulant found in tobacco) patches instead of allowing him to go outside to smoke. Resident 42 stated he had refused every nicotine patch that they tried to force on him. Resident 42 stated he told the DON that he would not take the nicotine patches when he was admitted . Resident 42 stated he had been asking how he could obtain cigarettes, since he was admitted , but no one is helping him. Resident 42 was queried if anyone at the facility had ever asked him the amount of tobacco he was smoking prior to him being admitted to the facility. Resident 42 stated he had never been asked how much he was smoking before he came to the facility. During an interview with Licensed Staff C, on 5/13/24 at 9:50 a.m., Licensed Staff C was queried about the facility's smoking policy. Licensed Staff C stated they were a non-smoking facility; We do not have a smoking polic. Licensed Staff C was queried about the facility's Safe Smoking Evaluation assessment and if it was completed on Resident 42 upon admission. Licensed Staff C stated he did not believe the form was completed, due to this facility being a non-smoking building. A Smoking policy and Safe Smoking Evaluation assessment was requested from medical records for Resident 42; only the Smoking policy was received. Review of Resident 42's medical record, revealed a face sheet with an admitted [DATE]. The face sheet also indicated a diagnosis of Nicotine Dependence. Review of Resident 42's Medication Administration Record for May, indicated Resident 42 had refused all nicotine patches offered to him. Resident 42's care plan, reviewed on 5/13/24, indicated Nicotine patches offered on 4/24/24 and patient has been refusing the patches. MD aware. Review of the Entrance Conference Worksheet indicated the facility had, no smokers in the building. In addition, the Team Coordinator indicated the DON informed her there were no smokers in the building. The Facility had no non-smoking waivers. During a review of the facility's policy and procedure titled, Smoking Policy-Resident, dated 10/2023, indicated, This facility has established and maintains safe resident smoking practices Prior to and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences .Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes, a) current level of tobacco consumption b) method of tobacco consumption c) desire to quit smoking d) ability to smoke safely with or without supervision (per completed Safe Smoking Evaluation) .The staff consults with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation .Any smoking-related privileges, restrictions, and concern (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues .Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. During a review of the facility's policy and procedure titled, Resident Rights, dated, 2/2021, indicated, Employees shall treat all residents with kindness, respect, and dignity Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident right to: a dignified existence, be treated with respect, kindness, and dignity, be free from abuse, neglect, self-determination, communication with and access to people and services, both inside and outside the facility, exercise his or her rights as a resident of the facility and as a resident or citizen of the United States, be supported by the facility in exercising his or her rights, exercise his or her rights without interference, coercion, discrimination or reprisal from the facility, be informed about his or her rights and responsibilities, be informed of and participate in, his or her care planning and treatment, participate in decision-making regarding his or her care, voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without, have the facility respond to his or her grievances, examine survey results, communicate with outside agencies (local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations), regarding any matter. During a review of the facility's policy and procedure titled, Governing Body revised 4/2024, indicated, It is the policy of this facility to have a Governing Body, or designated persons functioning as a Governing Body. The Governing Body is responsible for establishing and implementing policies regarding the management and operation of the facility. The Governing Body of the facility is currently comprised of the following individuals: Administrator, DON, Market Leader, Clinical Market Leader, and Medical Director. Procedure: 1) The Governing Body will provide support and direction to the facility as is appropriate and consistent with applicable Federal regulations. 2) The Governing Body will appoint the Administrator who is: 2.1 Licensed by the State 2.2 Responsible for management of the facility 2.3 Reports to and is accountable to the Governing Body. 3. The Governing Body is responsible for and accountable for the QAPI Program, in accordance with applicable Federal regulations. 4. The Governing Body will receive information from the Administrator relative to the operations of the facility on a regular basis and, in any event, no less than quarterly. 38322 3. During a concurrent interview and observation on 5/13/24 at 9:46 a.m., Resident 3 stated facility staff were cutting through her room to enter/exit the facility instead of using the main doors. Resident 3's room had sliding doors that led to the outside patio. Resident 3 stated she had concerns about her privacy when staff used her room to exit or enter the building, as this was a, matter of respect. Record review of Resident 3's MDS (Minimum Data Sheet-An assessment tool), dated 5/01/24, indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 15, which indicated her cognition was intact (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). During an interview on 5/13/24 at 10:37 a.m., Resident 63 stated staff entered and exited the building through her room using the sliding doors. Record review of Resident 63's BIMS score triggered in the LTCSP (Long Term Care Survey Process-Software to perform recertification surveys in nursing facilities, which obtains information directly from the facility's MDS) was 13, which indicated her cognition was intact. During an interview on 5/13/24 at 10:43 a.m., Resident 51 stated staff had been observed entering and exiting the building through the sliding doors in her room, without asking for permission. Record review of Resident 51's MDS, dated [DATE], indicated her BIMS score was 15, which indicated her cognition was intact. During a confidential Resident Council interview on 5/14/24 at 2:43 p.m., five of the 12 residents in attendance stated staff were using their slider doors in their rooms that faced the back patio, to enter and exit the building, passing through their rooms as a short cut, rather than using the exit door at the end of the hall. Anonymous Resident 1 stated it made her feel like she had no privacy. Anonymous Resident 7 stated he did not like it. Anonymous Resident 4 stated his room did not face the back of the building, but his room was the only space he had so it would bother him if the staff did that. During an interview on 5/16/24 at 1:52 p.m., Licensed Staff F stated, if staff needed to get to the back patio from the hall, they were to use the exit door at the end of the hall. When queried, Licensed Staff F stated, out of respect for the residents' privacy, it was not appropriate to pass through residents' rooms to get to the patio. Review of the most recent Minimum Data Sets (MDS, an assessment tool) of the residents in attendance at the confidential interview, revealed three residents were cognitively intact (BIMS (Brief Interview for Mental Status) scores of 13 to 15) and seven had moderate cognitive impairment (BIMS scores between 8 and 12). A review of the facility's policy, titled, Resident Rights, last revised 2/2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: . privacy and confidentiality .

Based on interview and record review, the facility failed to ensure the survey binder was updated for three years, with the results of complaint and facility-reported incident investigations, and failed to ensure the residents were notified of its location. This failure resulted in the facility's residents not having access to the results of the most recent investigations completed by the Department. Findings: During a record review and concurrent interview on 5/14/24 at 2:02 p.m., review of the survey binder in the hallway outside the Administrator's office revealed there were no complaint or facility-reported incident investigation results or plans of correction added to the binder since 2021. When queried, the Director of Nursing verified there were no investigation results added to the binder since 2021. The DON stated the reason was the facility had not had any deficiencies from the Department since the survey in 2021. During a confidential Resident Council interview on 5/14/24 at 2:32 p.m., 12 out of 12 residents did not know where to find the binder with the Department's inspection results. Anonymous Resident 1 stated they reviewed residents rights at the Resident Council meetings, but the location of the survey binder had not been reviewed. Review of Anonymous Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/28/24, indicated a BIMS score of 15 (Brief Interview for Mental Status, a score of 15 indicates cognitively intact). Further review of the most recent BIMS scores of the residents in attendance at the confidential interview revealed two more residents were cognitively intact (for a total of three, including Anonymous Resident 1) and seven had moderate cognitive impairment (BIMS scores between 8 and 12). During a concurrent interview and record review on 5/15/24 at 9:44 a.m., the Administrator and Surveyor reviewed the binder that contained the facility's survey findings from previous years. The binder was right next to the lobby, in a visible area, but only had survey findings from 2018 to 2021. The binder had not been updated since 2021. This was confirmed by the Administrator. The Administrator stated this was his responsibility and confirmed he did not update it. The Administrator stated he would update it as soon as possible. The Administrator confirmed the facility had received deficiencies after 2021 (That were not available in the binder). During an interview on 5/15/24 at 11:08 a.m., the Activities Director confirmed she was the staff member coordinating the Resident Council meetings for the residents. The Activities Director stated they met for the meetings the last Tuesday of every month and went over old business. The Activities Director was asked if she had discussed with the residents where to find the binder with the survey results. The Activities Director stated she had not talked about this information with the residents during the Resident Council meetings. During an interview with the Medical Records Director on 5/15/24 at 3:50 p.m., he was asked to provide the policy on providing residents with the information of where to find the survey binder. This was also written on a piece of paper handed to him, along with other requested documents. The following day, on 5/16/24 at 9:10 a.m., the Medical Records Director stated the facility did not have a policy on this. Review of facility policy, Resident Rights, last revised 2/2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: . w. examine survey results.

Based on interview and record review, the facility did not ensure four of twenty-four sampled residents (Resident 2, Resident 3, Resident 63 & Resident 51) experienced a comfortable noise level at the facility. This finding had the potential to result in inability for the residents to rest and sleep, necessary for the body's renewal and well-being. Findings: During a concurrent interview and observation on 5/13/24 at 9:46 a.m., Resident 3 stated the noise level was too high at all times of the day and night. Resident 3 stated she had heard staff talking loudly and laughing spontaneously as late as 10:30 p.m., disturbing residents. Record review of Resident 3's MDS (Minimum Data Sheet-An assessment tool), dated 5/01/24, indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 15, which indicated her cognition was intact (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). During an interview on 5/13/24 at 10:37 a.m., Resident 63 stated there was a lot of noise at night as staff were too busy talking on their cell phones or laughing. Record review of Resident 63's BIMS score triggered in the LTCSP (Long Term Care Survey Process-Software to perform recertification surveys in nursing facilities, which obtains information directly from the facility's MDS) was 13, which indicated her cognition was intact. During an interview on 5/13/24 at 10:43 a.m., Resident 51 stated experiencing a high noise level during the night. Resident 51 stated the noise was caused by both, staff, and other residents. Record review of Resident 51's MDS, dated [DATE], indicated her BIMS score was 15, which indicated her cognition was intact. During an interview on 5/14/24 at 8:45 a.m., Anonymous Resident 2 stated he had been at the facility for a little over week. He stated his room was noisy, and that last night was the first night in a long time that it had actually been quiet. During an interview on 5/14/24 at 8:48 a.m., Anonymous Resident 3 stated he had been at the facility for a week. He stated he had not slept well since his admission. He stated he was losing sleep because of the noise in the hallway at night. During a record review on 5/13/24 at 3:12 p.m., the past four months of Resident Council meeting minutes were reviewed. All minutes indicated at the top that the notes were taken by the Activities Director. Resident Council Meeting Minutes for April 2024, March 2024, February 2024, and January 2024, revealed complaints of loud staff and students in hallways. Resident Council Meeting Minutes, dated 4/30/24, revealed, New Business: . *IDT (Interdisciplinary Team) is loud when coming out of stand-up morning meeting. Noise level has been improving. NOC shift (typically 11 p.m. to 7 a.m.) still needs some improvements. On NOC one CNA (Certified Nursing Assistant) and a Nurse are very [NAME] [sic] when they are together. Resident Council Meeting Minutes, dated 3/26/24, revealed, New Business: NOC shift is loud and not answering call lights in a timely manner. Burst of loud noise, voices and laughter usually happens at 4-8 a.m. Resident Council Meeting Minutes, dated 2/27/24, revealed, Old business: . Noise at all times all departments (loud outburst). New students are loud. New business: . Noise level has improved somewhat but there seems to be a loud burst of laughter and conversation, and this can happen at any given time of day and night. Students continue to be [NAME] [sic] even after they have been told to lower their voices. Resident Council Meeting Minutes, dated 1/30/24, revealed, Old business . front staff come to visit back staff during NOC shift and will have conversations. New business: . Noise at all times all departments (loud outburst). New students are loud. During a confidential interview with the Resident Council on 5/14/24 at 2:30 p.m., several residents felt the staff were still too noisy even after repeatedly raising this concern in the Resident Council meetings for the last four months. Anonymous Resident 1 stated that at 10:30 p.m., there was too much chatter amongst the staff. Anonymous Resident 4 stated he preferred to keep his door closed because he did not want to hear what was going on at 2:30 a.m. Anonymous Resident 5 stated staff told her she was not permitted to keep her door closed even though she would like to. Anonymous Resident 6 stated last night was bad (the noise) because two men were having a conversation in the hall for 30 minutes, and Anonymous Resident 6 could not go to sleep. Anonymous Resident 6 stated the noise and lack of sleep did not make her feel good. Anonymous Resident 4 stated a person needed two things to sleep, a dark room and a quiet room. Anonymous Resident 4 stated the staff just needed training. During an interview on 5/16/24 at 11:58 a.m., the Activities Director stated she followed-up on issues brought up at Resident Council meetings by bringing the issue up with the IDT. The Activities Director stated they would go over the issues, and then they would develop a QAPI (a Quality Assurance Performance Improvement project) or they passed the issue on to the corresponding department. The Activities Director stated she followed-up with the Resident Council president on whether or not an issue was resolved by having informal conversations outside of the meetings. The Activities Director stated the Resident Council president would sometimes catch her in the hall and tell her, this has or hasn't worked. When asked about the noise level in the facility, the Activities Director stated she had put in the minutes the noise had been improving. The Activities Director stated all the issues that had been brought up at the Resident Council meetings had been continuing, they have continuous work. When asked how she documented an issue had been resolved, the Activities Director stated that in the minutes it was, not brought up anymore. Review of facility policy, Homelike Environment, last revised 2/2021, indicated, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: . comfortable sound levels.

Based on interview and record review, the facility failed to ensure the Resident Council knew how to file a grievance. This failure could potentially result in residents' issues going unresolved. Findings: During a record review on 5/13/24 at 3:12 p.m., the past four months of Resident Council Meeting Minutes were reviewed. All minutes indicated at the top, that the notes were taken by the Activities Director. Resident Council Meeting Minutes, dated 3/26/24, revealed, New Business: . The council has asked for SS (Social Services) department to attend meeting with them and go over theft and loss, grievance an [sic] other SS related question they may have and to meet the news [sic] staff in SS. Section of minutes titled, Department concerns, revealed, Social Service: R.C. (Resident Council) has invited SS to attend next meeting to go over grievances and theft and loss. Resident Council Meeting Minutes, dated 4/30/24, revealed, New Business: *SS still to meet with the resident council. During a confidential interview on 5/14/24 at 2:43 p.m., 10 out of 12 residents in attendance did not know how to file a grievance. Anonymous Resident 1 stated the Social Services Director (SSD) had not been able to attend a Resident Council meeting to explain the grievance process to them because the SSD had to pick up her kids from school at the same time as the Resident Council meetings. During an interview on 5/16/24 at 11:58 a.m., the Activities Director verified the SSD had been invited to the Resident Council meeting but had not been able to attend last month. The Activities Director stated the SSD was planning on scheduling a special meeting with the Resident Council as soon as they could find a time that worked for everyone. Review of Anonymous Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/28/24, indicated a BIMS score of 15 (Brief Interview for Mental Status, a score of 15 indicates cognitively intact). Further review of the most recent BIMS scores of the residents in attendance at the confidential interview revealed two more residents were cognitively intact (for a total of three, including Anonymous Resident 1) and seven had moderate cognitive impairment (BIMS scores between 8 and 12). Review of facility policy, Grievances, last revised/reviewed 1/2022, revealed the grievance official was the SSD. The policy did not address how residents would be informed of their right to file a grievance or how residents would be informed of the grievance process.

Based on observation, interview, and record review, the facility failed to protect two Unsampled Residents (Resident 407 and Resident 411) from verbal and mental abuse, and rough handling by Unlicensed Staff S during toileting when 1) Unlicensed Staff S directed abusive language towards Resident 407 and Resident 411, and 2) Unlicensed Staff S roughly transferred Resident 407 to the commode. This failure negatively impacted the residents' psychosocial well-being. Resident 407 felt upset, uncomfortable and not safe with Unlicensed Staff S taking care of him. Resident 411 felt very bad and that he would anger Unlicensed Staff S if he had to call him again to help with toileting. This failure likely impacted the sense of safety of other residents who witnessed the incident. Findings: 1. Resident 407's admission Minimum Data set (MDS, an assessment tool), dated 10/6/18, indicated that Resident 407 was an [AGE] year old male, who was admitted to the facility on [DATE], from an acute care hospital. Resident 407 needed assistance getting out of bed for toileting or sitting in a chair. During an interview with Resident 407's daughter on 10/12/18 at 10:00 a.m., she stated that the incident occurred the first evening after her father's admission to the facility on [DATE]. She stated her father told her what happened the next day on 10/7/18. She stated her father was very alert and was very upset because he was having diarrhea all night from the medication he had taken in the hospital. Unlicensed Staff S came in to clean-up her father at around 10:00 p.m. About 20 minutes later, her father pressed the call light again because he needed to use the toilet. Unlicensed Staff S came to the room and was angry. She stated her father told her, Unlicensed Staff S just picked him up and roughly placed him on the commode. There was another nurse in the room assisting Unlicensed Staff S with her father. She stated her father, her husband, and she reported the incident to Administrative Staff B. During a concurrent observation and interview on 10/12/18 at 10:15 a.m., Resident 407 was lying in bed awake and alert. When asked what happened, Resident 407 stated that Unlicensed Staff S was angry and said, he had five patients call lights he had to answer. After Unlicensed Staff S helped him to the toilet the first time, he needed to go to the bathroom again about 20 minutes later and pressed the call light. Resident 407 stated no one came and he had an accident. When Unlicensed Staff S came in to help him to the commode, Unlicensed Staff S picked him up and plopped him on the commode like I was a rag doll. A nurse was in the room and assisted Unlicensed Staff S when he was putting him on the commode. Resident 407 stated the nurse witnessed what Unlicensed Staff S did and later came over to him and apologized for the way he was treated. The nurse stayed in the room and finished cleaning him up and helped him to bed. Resident 407 stated he was afraid to have Unlicensed Staff S take care of him again until Administrative Staff A told him and his daughter that Unlicensed Staff S would not take care of him again. During an interview on 10/12/18, at 1:00 p.m., Unlicensed Staff T (who assisted Staff S) stated that Unlicensed Staff S was frustrated because it had been a busy night and many call bells were going off. Unlicensed Staff S came to the nurses station and asked for assistance to put Resident 407 on the commode. Unlicensed Staff T stated Unlicensed Staff S lifted the resident and plopped him on the commode without asking the resident if he was ready. Resident 407 asked Unlicensed Staff S why he handled him so roughly. Unlicensed Staff S asked Unlicensed Staff T if she would finish cleaning up the resident and left the room to answer the other call lights. Unlicensed Staff T stated Unlicensed Staff S did not act like this before, his behavior was building up all night. Unlicensed Staff S lost his patience the last 10-15 minutes of the shift and was yelling in the hallway that he needed help causing residents to wake-up. During an interview on 10/12/18, at 4:00 p.m., Administrative Staff B discussed the events that were reported to him by Resident 407 and his family. Administrative Staff B stated that Resident 407 pressed the call light for assistance to the commode. Unlicensed Staff S and Unlicensed Staff T attended to the call light. Unlicensed Staff T assisted Unlicensed Staff S by prepping the resident. Unlicensed Staff S picked up Resident 407 and plopped him down on the commode, instead of doing a gentle transfer. Resident 407 was upset and felt Unlicensed Staff S was too rough with the transfer. The facility's investigation report titled Follow-Up Self Report of 10/7/18. (Unlicensed Staff S) / (Resident 407) ., dated 10/11/18, indicated from the residents statement that Unlicensed Staff S was very rough and tossed me like a rag doll onto the commode. The investigative report indicated the facility had determined that the rough handling of Resident 407 could have happened and the facility will be terminating Unlicensed Staff S employment. 2. Resident 411's admission Minimum Data set (MDS, an assessment tool), dated 10/6/18, indicated that Resident 411 was an [AGE] year old male, who was admitted to the facility on [DATE], with multiple medical [DIAGNOSES REDACTED]. The admission MDS also indicated Resident 411 had trouble walking and required a one person physical assist for Activities of Daily Living (ADLs). During a concurrent observation and interview on 10/12/18, at 9:30 a.m., Resident 411 was sitting up in his wheelchair, alert and explained what happened when he rang the call bell for assistance to the bathroom on 10/6/18 at approximately 10:30 p.m. Resident 411 stated he was in bed drinking water and rang the call bell for assistance to the bathroom. Resident 411 stated he had been to the bathroom two to three times because he was drinking water. When Unlicensed Staff S came back in the room he appeared angry and raised his voice and told him not to drink water so he would not go to the bathroom. Resident 411 stated he felt very bad because he wanted to drink water, he was thirsty. Resident 411 asked Unlicensed Staff S why he did not want to help him, he had to urinate. Unlicensed Staff S stated, I am not here to take care of only you, I have other patients to take care of and Resident 411 called him too much, again and again, and he had other things to do. Resident 411 told Unlicensed Staff S, when you speak to me in this manner, I don't like that. Resident 411 stated he threw the blankets on the bed like he was mad. Resident 411 reported the incident to his family and his family reported to Licensed Nurse W. During an interview on 10/12/18, at 14:35 p.m., Resident 98, roommate and witness to Resident 411's incident, stated it was a very busy night and lots of call bells were going off. Unlicensed Staff S had come into the room about two to three times to assist Resident 411 to the bathroom. Resident 98 stated he believed Unlicensed Staff S became overwhelmed, something else was going on and when he came in the room he told Resident 411 to stop drinking water. Unlicensed Staff S sounded agitated and raised his voice. Resident 98 heard Unlicensed Staff S yelling in the hallway afterwards for whatever reason. Unlicensed Staff S seemed to reach his frustration point. Resident 98 stated Unlicensed Staff S seemed to be distracted about something. Resident 98 stated he recognized this behavior because he used to be a camp counselor and he knew about mandatory reporting. The facility's investigation report titled Follow-Up Self Report of 10/7/18. (Unlicensed Staff S)/ (Resident 411) ., potential abuse, dated 10/11/18, indicated from the resident's statement that Unlicensed Staff S told Resident 411 to stop drinking water because he could not keep taking him to the bathroom all night long. The investigative report indicated the facility had determined that the verbal abuse likely happened and will be terminating Unlicensed Staff S's employment. The facility's policy/procedure Titled Abuse: Prevention of and Prohibition Against, revised 11/28/17, indicates, The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Section D, Prevention states: The Facility will take action to protect and prevent abuse and neglect from occurring with the Facility by: Supervising staff to identify and correct any inappropriate or unprofessional behaviors.

Based on interview, and record review, the facility failed to ensure the resident environment was as free from accident hazards as possible by failing to ensure residents were properly secured when transporting two residents, Resident 1 and Resident 2, by wheelchair in a van owned and operated by Sister Facility D. While riding in the van on the way back to the facility after an outing on 10/22/15, Resident 1 fell out of her wheelchair and sustained a fracture of the right femur, (thigh bone), and the right tibia, one of the bones in the lower leg, which required surgical repair. At the same time, Resident 2 fell out of her wheelchair and injured her right knee without a fracture. The injuries compromised the residents' ability to maintain an optimum level of physical function and well-being. Findings: During an interview, on 11/10/15 at 2:15 p.m., Resident 1 stated she was seated in her wheelchair in the back of the van on the way back to the facility from an outing on 10/22/15. Resident 1 stated there was a seat belt across her lap but not across her chest. Resident 1 stated she did not think the seat belt was buckled. Resident 1 stated when the van braked suddenly, she fell forward from the wheelchair onto the floor of the van. During a review of Resident 1's medical record, on 10/30/15, the resident's Minimum Data Set (MDS), dated [DATE], indicated Resident 1 was able to understand and be understood and scored 15 out of 15 possible points on the Brief Interview for Mental Status test (BIMS). The MDS is a comprehensive assessment of a resident's physical, mental, and emotional status. The BIMS test evaluates the resident's memory, awareness of surroundings, and understanding of current situation. The note of the Fall Committee of the IDT (Interdisciplinary Team), dated 10/23/15 at 3:47 p.m., written by the Director of Nursing (DON), indicated Resident 1 sustained a fracture of the right distal fibula (one of the bones in the lower leg) and right femur after a fall from her wheelchair while riding in the van on 10/22/15. The Discharge Summary from the acute care hospital, dated 10/26/15, documented Resident 1 was admitted to the acute care hospital from 10/23/15 to 10/26/15. The discharge summary documented Resident 1 had sustained a right fracture of the femur with displacement (the lower third portion of the long bone of the right thigh was broken and not in alignment with the rest of the bone) from a fall out of a wheelchair which required surgery. The surgery to fix the femur fracture, was a post intramedullary nail fixation (a metal rod placed inside the long bone of the femur to hold it in alignment). The Discharge Summary indicated Resident 1 also sustained a nondisplaced right tibial shaft fracture (the lower portion of one of the bones of the lower leg, the tibia, was broken but not out of alignment). The surgery to fix the tibia fracture was to ensure the upper and lower portions of the bone were lined up correctly and to apply a splint to hold the bone in place while it healed. The surgery to repair both bones occurred on 10/23/15. During an interview, on 10/30/15 at 2:30 p.m., Resident 2 stated she sat in her wheelchair in the back of the van on the way back to the facility from an outing on 10/22/15. Resident 2 stated the wheelchair was attached to the floor of the van but she did not remember anything about the seat belt. Resident 2 stated the driver had to brake suddenly, very hard, and she fell forward out of her wheelchair onto the floor of the van. Resident 2 stated she did not remember being buckled into the wheelchair and did not think she had a seat belt on. During a review of Resident 2's medical record, on 1/11/16, the resident's MDS indicated Resident 2 was able to understand and be understood, and scored 14 points out of 15 possible points on the BIMS. The report of the evaluation by the orthopedist on 11/2/15 indicated Resident 2 sustained a diffuse (spread over a large area) bone bruise involving the right medial femoral condyle (a bone in the knee) with no fractures when she fell out of her wheelchair while riding in a van during an outing on 10/22/15. During an interview, on 11/5/15 at 2:30 p.m., Staff A, the Activity Director, stated she accompanied the residents in the van on the way back to the facility from the outing on 10/22/15. Staff A stated the residents who were seated in their wheelchairs in the back of the van had seat belts that went across their chests from the floor. Staff A stated the driver of the van secured the wheelchairs to the floor of the van and the seat belts to the floor of the van. Staff A stated she buckled Resident 1's seat belt and Resident 2's seat belt. Staff A stated she was turned around facing the back talking to Resident 1 and 2, not buckled into her seat which faced forward, when the driver braked suddenly. Staff A stated she was able to move toward Resident 1 and Resident 2 to break their falls. Staff A stated the seat belts for both wheelchairs popped open and both residents fell out of their wheelchairs on top of her. Staff A stated she did not have any formal training by the facility in the use of or buckling of the van seat belts. During an interview, on 11/20/15 at 12 noon, the Administrator stated the facility did not have a policy and procedure that addressed transporting residents in a facility van because the facility did not own a van. The Administrator stated the facility did not provide training to staff in how to secure residents for transportation in a van or bus or personal vehicle. During an interview, on 10/30/15 at 1 p.m., Staff B, the driver from Sister Facility D, stated she showed Staff A, the Activity Director, how to buckle the seat belts for the residents who were in wheelchairs in the back of the van in preparation for the outing on 10/22/15. Staff B stated the seat belt for residents in wheelchairs had a part that goes across the resident's chest as well as a part that goes across the lap. Staff B stated on the return trip from the outing she did not assist Staff A and the other staff with the two residents in wheelchairs. Staff B stated she did not secure the wheelchairs to the floor and did not buckle the wheelchair residents' seat belts in preparation for the return trip to the facility after the outing. Staff B stated she only handled the lift to transfer the residents who were in wheelchairs into the van in preparation for the return trip back to the facility from the outing. During a document review, on 12/3/15, the document from Sister Facility D titled Bus/Van Pre Trip Inspection, dated 10/22/15, and completed by Staff B indicated the following task was completed, :Check seat belts, in good working order, not frayed, cut or torn. Under the section, Notify Maintenance Director of any issues found, the document indicated the following: When leaving Petaluma Pumpkin Patch asked staff if residents were all in seats and if seat belts were on and secure. Staff responded yes. The document was signed by Staff B. During a document review, on 12/18/15, a document from Sister Facility D titled Fleet Safety Program SNF/ALF, (undated), indicated the following: The driver and all occupants are required to wear safety belts at all times when the vehicle is in operation or while riding in the vehicle. The driver is responsible for ensuring all passengers, including residents, wear their safety belts and are properly secured in the vehicle at all times using the exiting harnesses and restraints. During an interview, on 10/30/15 at 11:30 a.m., Staff E, the Activity Assistant, stated all residents were loaded into the van via the lift while sitting in their wheelchairs to go to the outing and on the return trip from the outing on 10/22/15. Staff E stated most residents were transferred from their wheelchairs to regular seats and their wheelchairs were placed in the back of the van. Two residents remained in their wheelchairs in the back of the van and their wheelchairs were attached to the floor. Staff E stated she only buckled the seat belts of the residents who were seated in regular seats and did not buckle in the residents who remained in their wheelchairs. Staff E stated she assisted with buckling in the regular seat residents going to the outing and on the return trip from the outing. Staff E stated she did not ride in the van with the residents, but rode in a private car to and from the outing. During an interview, on 11/12/15 at 12:30 p.m., Staff F stated she was in the van on the return trip from the outing on 10/22/15. Staff F stated she helped buckle in the residents who sat in regular seats for the return trip but did not buckle in the residents who sat in their wheelchairs in the back of the van. Staff F stated she sat in the last seat on the right side of the van. Staff F stated when the van braked suddenly, she looked back and saw both of the residents, Resident 1 and Resident 2, completely on the floor out of their wheelchairs. Staff F stated she and the Activity Director got the residents back in their wheelchairs. Staff F stated she did not buckle the residents seat belts after they were back in their wheelchairs but thought another staff member did.

Based on interview, and review of clinical records and facility policy, the facility failed to provide care necessary to maintain hydration when, 1. Resident 3 was not provided continuous assessment or comprehensively assessed following a change in condition, and 2. Resident 3's Physician order [REDACTED]. Resident 3's response to changes in the plan of care were not monitored and assessed, which resulted in dehydration, kidney failure and contributed to Resident 3's death. Findings: The clinical record for Resident 3 was reviewed on ,[DATE] and [DATE]. Review of physician progress notes [REDACTED]. The progress note indicated Resident 3 was found with her mouth open, eyes closed and dusky skin. The progress notes indicated Resident 3 was observed to have labored, rapid respirations of over 70 per minute, clammy, mottled skin and non-reactive pupils. Resident 3's family requested comfort care for Resident 3. Nurse's Notes, dated [DATE] at 1000, (10 a.m.), indicated Resident 3 was given liquid [MEDICATION NAME] and [MEDICATION NAME] to ease her labored breathing. The oxygen was turned off at the family's request, and Resident 3 died at 1039, (10:39 a.m.). The Admission Record dated [DATE] indicated Resident 3 was admitted to the facility following a fall with a fracture, for rehabilitation. Additional [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS). a resident assessment tool, dated [DATE], indicated Resident 3 required assistance with all activities of daily living, however she had no problems with swallowing. Review of physician progress notes [REDACTED]. The physician progress notes [REDACTED]. Review, of the Dehydration Risk Assessment, dated [DATE], indicted Resident 3's score had increased from a score of 15 on [DATE], (low risk of dehydration), to a score of 25 on [DATE], (moderate risk of dehydration). The increased risk score was due to Resident 3's "change in mental status", with decreased ability to recognize and communicate thirst. Dehydration is lack of adequate fluids in body tissues. Review, of the Hydration Care Plan, dated [DATE], indicated Resident 3's care plan for Hydration was not revised or updated until [DATE], when "offer resident fluids during care rounds" was added as an approach. This was almost one month after the risk had been identified as increased to moderate on [DATE].. During an interview, on [DATE] at 10:35 a.m., and concurrent review of an Interdisciplinary Care Plan Conference Record, dated [DATE], Licensed Staff D indicated Resident 3 had a intake of 47% of her meals and a decline in psychosocial status. Licensed Staff D stated the percentage of meals was calculated over one week of time, and that Resident 3's intake had fluctuated. Concurrent review of a Change of Condition MDS, dated [DATE], indicated Resident 3's speech was no longer understandable, and she coughed and choked during meals and medications. Licensed Staff D stated the swallow assessment had been done by the Dietary Supervisor E. When asked if licensed staff should have followed up on the change in Resident 3's ability to swallow, Licensed Staff D stated, "Yes, immediately. (I) assume nursing would do something about it". During an interview, on [DATE] at 10:55 a.m., Dietary Supervisor E stated that to gather information for Resident 3's Change of Condition MDS, she had spoken with the nursing assistants who fed Resident 3. The nursing assistants indicated to Dietary Supervisor E that Resident 3 had been sleepier, and described Resident 3 as "coughing". During an interview, on [DATE] at 11:50 a.m., Licensed Staff F stated she used prior MDS assessments, Resident 3's history, and a summary of the physician progress notes [REDACTED]. Licensed Staff F stated Resident was "doing OK with pureed food", and hadn't lost any weight. Licensed Staff F stated Resident 3 was lethargic but had a fluctuating level of consciousness. Licensed Staff F did not indicate she had seen Resident 3, as part of the assessment. However, review, of Interdisciplinary Progress Notes, also dated [DATE], indicated Resident 3 was, "continuously declining in function. Not been eating past few days, not opening mouth when attempting to feed her or give medications. She has poor intake and increased sleepiness". Review, of the facility "Nursing 24 Hour Report" for [DATE], indicated Resident 3's change in ability to swallow, and increased sleepiness had not been entered onto the report. The Nursing 24 Hour Report is a communication tool; a written log, used to communicate important information regarding residents' condition and care needs from shift to shift. 2. During an interview, on [DATE] at 10:35 a.m., Licensed Staff D stated that during a care conference with Resident 3's family on [DATE], the family had acknowledged that Resident 3 had declined but that her functioning also fluctuated. Resident 3's Physician order [REDACTED]. The family had confirmed they wanted Resident 3 to receive full treatment, including a defined trial period of artificial nutrition by tube, should the need arise. The Interdisciplinary Care Plan Conference Record also indicated Resident 3 had a intake of 47% of her meals and a decline in psychosocial status. (overall mood and ability to communicate or interface with others) Licensed Staff D stated the percentage of meals was calculated over one week of time, and that Resident 3's intake had fluctuated. Review of Nurse's Notes, dated [DATE], titled weekly summary, indicated Resident 3, "consumes 40% average meals & 100% average snacks." No further Nurse's Notes were written, until [DATE]. "Request for Physician Order", dated [DATE], noted, "Resident is continuously declining in function. For the past few days she's not been eating like her normal function...Doesn't open mouth when you feed her, hard to give med(ication)s...Average meal intake for the week is 30.6%." Review, of Resident 3's POLST, dated [DATE], indicated "Do Not Attempt Resuscitation" if no pulse and no breathing were present, had been checked. However, in the event of a continued pulse and respirations, Resident 3 was to receive "Full Treatment", which included intravenous fluids, antibiotics, intubation, and mechanical ventilation. Section C of the POLST, titled Artificially Administered Nutrition, indicated Resident 3 was to be provided a defined trial period of artifical nutrition by tube. (a means of providing liquid nutrition to a person by way of a tube that is either inserted through the nose to the stomach or is surgically inserted directly into the stomach) Review, of the clinical record for Resident 3 gave no indication that artificial nutrition had been discussed, or offered to Resident 3 and her family. 3. During an interview, on [DATE], Licensed Staff F stated she had updated Resident 3's Plan of Care following the Change of Condition MDS, dated [DATE]. Review, of Resident 3's plan of care for Dysphagia, revealed Approaches dated [DATE]: assist with feeding and check mouth for food and residual, and, prompt resident to swallow food. These Approaches also appeared on Resident 3's Nutrition Care Plan, dated [DATE], and in Physician order [REDACTED]. During interview on [DATE] at 10:35 p.m., Licensed Nurse D stated, that changes in residents' care plans are mentioned at the facility daily stand up meeting, e-mailed to the Director of Nurses, and "told to the nurses". Seven (7) days after the Change of Condition MDS dated [DATE], and changes in the Plan of Care, a "Request for Physician Order", dated [DATE], noted, "Resident is continuously declining in function. For the past few days she's not been eating like her normal function...Doesn't open mouth when you feed her, hard to give med(ication)s...Average meal intake for the week is 30.6%." The Request for Physician order [REDACTED]. The second half of the request contained Nurse Practitioner I's response, dated [DATE], and signed off by the facility staff the following day, on [DATE], which ordered blood and urine tests, the results were to be sent to Nurse Practitioner I. An additional order directed facility staff to request that Nurse Practitioner H see Resident 3 in the morning. There was not a Change of Condition form for this further decline in the Nurse's Notes. During interview, on [DATE], Licensed Staff F stated she had not sent a Change of Condition form on [DATE] because Resident 3 had "waxed and waned", and she, "didn't know if (Resident 3) was still doing that". Review of the Nursing 24 Hour Report revealed that Resident 3's change of condition appeared on the [DATE] night shift report for the first time. During an interview, on [DATE] at 6:45 a.m., Licensed Staff G stated she found the response to the [DATE], Request for Physician order [REDACTED]. Licensed Staff G stated she always checked the fax machine when she started her shift and the orders had not been there at 10 p.m. the previous evening. Licensed Nurse G stated she requested the blood tests be drawn by the phlebotomist in the facility at the time, which was done. Licensed Staff G stated she checked Resident 3's clinical record for a Change of Condition form, but did not find one. Licensed Staff G sent a Certified Nurse Assistant, (CNA) to check Resident 3's vital signs at approximately 6:30 a.m.. The CNA reported Resident 3's vital signs as: blood pressure ,[DATE], temperature 100.2 degrees F(Fahrenheit), heart rate 99, (elevated), respirations 28, (elevated), and oxygen saturation 87%, (oxygen saturation measures the amount of oxygen carried by the red blood cells and is ,[DATE]% in a healthy person). Licensed Staff G stated she telephoned the on-call physician (Physician L) and left a message with the answering service, that Resident 3 had a fever. Licensed Staff G stated she faxed a Change of Condition and Request for Physician order [REDACTED]. Concurrent review of the document indicated Licensed Staff G had reported Resident 3's fever and other vital signs, as well as a narrative regarding Resident 3's continuous decline in function, lack of eating, and sleepiness. Licensed Staff G requested orders for fever reducing medication and oxygen to be administered. Licensed Staff G stated Nurse Practitioner I faxed a response immediately, ordered the requested medication, oxygen, and additionally, ordered a chest X-ray, and that Nurse Practitioner H see Resident 3 Licensed Staff G stated Resident 3's family was at the bedside early and she told them about Resident 3's fever and low oxygen saturation. During an interview, on [DATE] at 3:15 p.m., Nurse Practitioner H stated on [DATE], she found Resident 3 to have a respiratory rate of 70 breaths per minute, mottled skin from the hips to feet, and a slow heart rate. Nurse Practitioner H stated Resident 3's family was weeping at the bedside. Nurse Practitioner H stated the family refused an offered to transfer to an acute care hospital. Nurse Practitioner H stated she ordered pain medication for Resident 3 because she wanted Resident 3 to be comfortable. Resident 3 died 35 minutes later. Review, of laboratory results done [DATE] at 4:52 a.m., and faxed to the facility at 1347 (1:47 p.m.), revealed the following abnormal results for Resident 3: Hemoglobin =17.8 High, normal 4XXX,[DATE].10 g/dL. Hematocrit=55.5 High, normal 36XXX,[DATE].9 %. Blood Urea Nitrogen=100 Critical result, normal ,[DATE] mg/dL Creatinine=3.5 High, normal 0XXX,[DATE].3 mg/dL. eGFR=13 Low, normal ,[DATE]. Interpretation of eGFR <15 = Kidney Failure. Sodium =167 Critical result, normal ,[DATE] mEq/L. Potassium=5.6 High, normal 3XXX,[DATE].1 mEq/L. Chloride =126 H, normal ,[DATE] mEq/L. Additionally, Resident 3 had an elevated white blood cell count, indicative of an infection. The laboratory report indicated the critical values had been called to the facility on [DATE], at 1347, (1:47 p.m.), approxaimately three, (3), hours after Resident 3 died . Abnormal blood values are indicative of certain medical conditions. MedlinePlus, (nlm.nih.gov/medlineplus/article), indicated elevated hemoglobin, hematocrit and chloride are indicative of dehydration, defined as lack of adequate fluid in a body. Elevated potassium, and sodium, are indicative of dehydration as well as kidney failure. Elevated blood urea nitrogen (BUN), and creatinine are indication of kidney failure, as is a low eGFR (estimated glomular filtration rate). One, (pre-renal), cause of kidney failure is dehydration. Review, of the facility Nursing Administration Policy and Procedure titled, Significant Change of Condition, Monitoring For, revised ,[DATE], #NACT04, indicated; "If,...it is recognized ...that the care needs of the resident have changed, the Nursing Supervisor should be made aware, and he/she will monitor." Examples included change in ability to feed or drink, change in intake, and change in behavior. The policy further directed that the resident be placed in the 24 Hour Report and nursing would provide no less than three days of documentation. "An attempt to identify the cause for decline, when it occurs, needed assist and resident behaviors ...will be monitored".

Based on observation, interview and review of the clinical record, the facility failed to recognize excessive dosage of an anticonvulsant, and failed to follow pharmacist recommendation to verify the dose with the prescribing physician, which resulted in Resident 2 experiencing ongoing increased involuntary movement, and confusion, that required transfer an acute care emergency department. Findings: During an observation, and concurrent interview, on 3/13/12 at 2 p.m., Resident 2 sat in a wheelchair in a facility hallway. Resident 2 maneuvered the electric wheelchair into her room. Resident 2 swayed in a circular motion as she sat in the wheelchair, her arms waved sporadically in the air. Resident 2 burst into tears when asked what had brought her to the facility. Resident 2 was unable to maintain the conversation, her weeping stopped, and she complained of pain in her left toe. Review, on 3/13/12, at 2:30 p.m., of the clinical record, for Resident 2 revealed Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was paralyzed from the waist down, and experienced painful muscle spasms treated with [MEDICATION NAME] a muscle relaxer used to treat muscle spasms. Admission Physician Orders, dated 3/2/13 indicated Resident 2 had capacity to make medical decisions regarding medical care. An Assessment of Involuntary Movements, AIMS, completed by facility staff, on 3/2/12, indicated that Resident 2 had no involuntary movements at the time of admission. admission orders [MEDICATION NAME] ([MEDICATION NAME] Sodium Extended) 300 mgm, (milligrams)-1 cap by mouth (po) TID (three times a day) everyday, for [MEDICAL CONDITION] disorder". The total dose per day equaled 900 mgm. The usual maintenance dose range for [MEDICATION NAME], an anticonvulsant (drug used to treat [MEDICAL CONDITION]) medication commonly used for [MEDICAL CONDITION] control, is 300-600 milligrams (mgm.). per day, according to LexicompOnline, a medication resource for medical professionals. During an interview, and concurrent review of the [MEDICATION NAME] orders for Resident 2, on 3/14/12 at 2 p.m., Licensed Staff A did not recognize the [MEDICATION NAME] dosage for Resident 2 as excessive. During an interview, on 3/14/12 at 4:40 p.m., Licensed Staff C stated that the nurse assigned to do new admissions was responsible for reviewing the admission orders [REDACTED]. Licensed Staff C stated the desk nurse was also responsible for reviewing orders. During a telephone interview, on 3/15/12 at 11:20 a.m., Licensed Pharmacist B, stated he remembered the order for [MEDICATION NAME] 300 mgm TID for Resident 2. Pharmacist B stated when the order was received in the pharmacy, he phoned the facility to suggest the staff verify the order with the physician. Pharmacist B stated he also put a written note on the packaged [MEDICATION NAME] for Resident 2, to remind the facility staff to follow up on verification of the dose with the physician. During an observation, on 3/15/12 at 11:40 a.m., on Station 2 of the facility, the packaged [MEDICATION NAME] for Resident 2, was retrieved from the medication room by Licensed Staff C. There was not a note on the package. During a concurrent interview, on 3/15/12 at 11:40, Licensed Staff C reviewed Resident 2's clinical record, and confirmed there was no indication that the [MEDICATION NAME] dosage had been verified with the physician. Licensed Staff C stated he had verified other medications for Resident 2 with the physician, but did not remember getting a phone call from Licensed Pharmacist B in regards to verification of the [MEDICATION NAME] dosage for Resident 2. Licensed Staff C recognized that the ordered [MEDICATION NAME] dosage was "high". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Nurse's Notes, dated 3/7/12, (no time), revealed a Change in Condition form that stated Resident 2 was noted to have involuntary movements of the head and shoulder, described as "wavering body movements". The Change of Condition form noted that Resident 2's DPOA, (Durable Power of Attorney), stated Resident 2 had the movements previously, but they were much more intense. A Request for Physician order, dated 3/7/13, faxed on 3/7/13 at 16:04, (military time for 4:04 p.m.), notified the physician of Resident 2's involuntary movements, noted what medications Resident 2 received, and requested an order for [REDACTED]. Nurse's Notes, dated 3/8/13, indicated facility staff had telephoned the physician at 2:45 p.m., to verbally inform him that Resident 2 had involuntary movements, and could no longer feed herself. The physician replied the jerking movements were part of Resident 2's condition and increased the dosage of Resident 2's anti-spasmodic medication, [MEDICATION NAME] from 30 milligrams three times daily to 30 milligrams four times daily for spasms. physician progress notes [REDACTED]. Nurse's Notes, dated 3/9/13, 12 a.m., indicated facility staff (LVN), received a phone call from the emergency department that indicated Resident 2 had an increased [MEDICATION NAME] level. Review, of Emergency Department discharge notes, dated 3/9/13, indicated Resident 2 had been diagnosed with [REDACTED]. Lexicomp.Online noted sedation, confusion, and cerebellar dysfunction ( loss of coordination) may occur with higher serum concentrations of [MEDICATION NAME]. Symptoms may be exhibited as follows: Serum concentration > 20 mcq/ml=abnormal eye movements called [DIAGNOSES REDACTED]. Serum concentration >30 mcq/ml=increased abnormal eye movements, serum concentration > 40 mcq/ml= ataxia, (uncoordinated movements), and decreased mentation. Serum concentrations >70 mcq/ml, may result in death. Review, of laboratory results, for Resident 2, drawn on 3/12/12, three days after Resident 2's [MEDICATION NAME] was stopped, revealed Resident 2's [MEDICATION NAME] level to be 44.3 mcq/ml, a critical result verified by repeat analysis.

Based on observation, interview, review of clinical records, and review of facility documentation, the facility failed to maintain an effective infection prevention and control program designed to prevent the development and transmission of disease and infection for the residents in the facility, when: 1. Staff did not: a) Implement standard or contact precautions correctly; b) Follow posted infection control instructions; and c) Follow hand washing standards, for three of 19 sampled residents (Residents 1, 7, and 16), one extended survey sampled resident (Resident 21) and one random resident (Resident 20). 2. Staff failed to notify the physician when laboratory results for a urinary tract infection, revealed that the organism was resistant to the antibiotic that had been ordered by the physician, and the antibiotic was continued; and failed to notify the physician that the repeat laboratory test was not carried out as ordered, for Extended Survey Sample Resident 21. 3. Staff failed to maintain a complete and accurate Infection Control Log; the log lacked the essential information required to provide sufficient surveillance and monitoring of the infections. The staff also failed to identify educational requirements or to develop plans to address the infections and prevent recurrence. 4. There were 91 facility-acquired urinary tract infections (UTI's), in the previous thirteen months, with the predominant organisms being intestinal bacteria. When requested, the facility did not provide any documentation of staff training, to prevent facility-acquired urinary tract infections. These failures resulted in a minimum of 209 facility-acquired infections with the potential of cross-contamination and widespread exposure of pathogenic organisms to all residents. (Facility-acquired refers to an infection that generally occurs after 72 hours from the time of admission to a health care facility). IMMEDIATE JEOPARDY was identified, on 8/03/11 at 12:30 p.m., under 483.65 Infection Control. The Administrator, Director of Nursing Services, Quality Consultant Nurse and the Vice President of Operations were present. The IMMEDIATE JEOPARDY was abated, on 08/04/11 at 2:45 p.m. The Administrator was present. Findings: 1a. During the recertification survey, which occurred from 7/25/11 to 8/4/11, the surveyors identified that the facility had 209 facility-acquired infections since the last survey on 6/25/10. (Cross Reference F520) During an observation on the initial tour of the facility, on 7/25/11 at 8:15 a.m., there was a sign at Resident 1's door which indicated an infection control alert, and included instructions to wash hands before and after care and wear gloves when entering the room. During an observation on 7/26/11 at 8 a.m. Unlicensed Staff S was at the bedside assisting Resident 1 with breakfast. Unlicensed Staff S was not wearing a gown or gloves and carried the breakfast tray to the food cart in the hallway. Unlicensed Staff S did not wash hands before or after caring for Resident 1 or after leaving the room, or before going into another resident's room. During an observation, on 7/27/11 at 6:30 p.m., the surveyor observed Unlicensed Staff H at the bedside assisting Resident 1 with eating, without wearing a gown, but wearing gloves. Unlicensed Staff H carried the tray to the food cart in the hallway. Unlicensed Staff H did not wash hands with soap and water before or after using the gloves, while caring for Resident 1, or after leaving the room. Resident 1's clinical record was reviewed on 7/26/11 at 9 a.m., 7/29/11 at 10 a.m., and 8/1/11 at 7:45 a.m., and revealed that Resident 1 had [DIAGNOSES REDACTED]. coli, a bacteria commonly found in the intestines), that required antibiotics. The clinical record revealed Interdisciplinary Team Notes (IDT) notes, dated 5/25/11, indicating a new change of condition for loose stools, and that a stool culture was sent to rule out[DIAGNOSES REDACTED]. A telephone contact summary, dated 5/25/11, revealed, "SNF Nurse (name) reports Pt (patient) had a + (positive)[DIAGNOSES REDACTED] result. Pt has been on Keflex 500 mg TID (three times a day) and completed the course yesterday ....Pt continues to have LBM (loose bowel movements) ...Start [MEDICATION NAME] 250 mg po QID (milligrams by mouth, four times a day) for 3 weeks, then tid (three times a day) for 2 weeks then bid (two times a day) for two weeks then stop." Review of Resident 1's medication administration records (MAR) indicated loose stools on 7/2 -7/4/11, 7/15/11, and 7/20-7/29/11. Resident 1 was totally dependent on staff for all activities of daily living, including eating, bathing, toileting, and hygiene. Review of the Care Plans revealed that there was no care plan for Contact Isolation/precaution for the Resident 1's[DIAGNOSES REDACTED] infection. During a review, on 7/27/11 at 9 a.m., the facility policy, not dated, and noted on the top of the page as, "Sample," indicated: "Subject Infection Control, Section: Clostridium Difficile; Prevention and control: ...#4A Mode of transmission: [DIAGNOSES REDACTED] is present in the feces and the major reservoirs of[DIAGNOSES REDACTED] are infected patients and the items of environmental services contaminated with feces. Clostridium spores are transferred to patients primarily via the hands of healthcare personal who have direct contact with infected patients who have touched a contaminated service or item... "#1. Hand washing: All healthcare workers should wash their hands with soap and water after every contact with resident and his environment who has CDI (clostridium difficile infection). Alcohol gels/rubs are not effective in removing or killing spores whereby the soap and water do provide mechanical removal of this infectious organism from the hands.... #2 Contact Isolation: Residents with active diarrhea diagnosed as having CDI should be placed on contact isolation. They should remain in their room until the diarrhea and the treatment for [REDACTED]. Protective equipment needed: While a resident is in isolation for CDI, gloves and gown should be worn when giving direct care or having contact with the CDI resident's environment. After the equipment is removed (before exiting the pt's (patients) room) hand washing should be preformed immediately." Review of the Infection Control Manual on 7/27/11 at 11 a.m. indicated that some of the policies and procedures within the manual were not dated in the section for Effective Date or any other page and had the word, "Sample," listed at the top of the page. There was a cover sheet to this manual with signatures and was dated 5/6/11. During an interview, on 7/27/11 at 11:00 a.m., Management Staff A stated that the Infection Control Manual had been signed off at the 5/6/11, Infection Control meeting, so all policies contained within that manual were effective. During a review on 8/1/11 at 8 a.m., of Resident 1's clinical record, nursing notes, dated 7/29/11 and 7/30/11, indicated Resident 1 continued to be on contact precautions. During an interview on 8/2/11 at 7:45 a.m., Management Staff B stated that nursing staff confirmed that Resident 1 had continuing loose stools, and that there was no care plan developed for Resident 1's[DIAGNOSES REDACTED] contact precautions. Management Staff B concurred that the intake and output records and the CNA's records of bowel movements did not coincide with the MAR. Management Staff B also stated that she relied solely upon the Infection Control Nurse/Staff Educator (Licensed Staff E) to determine when a resident was to be placed on or off contact precautions. 1b. During an interview on 7/27/11 at 12:30 p.m., the Facility Treatment Nurse, (Licensed Staff J) stated she was very careful not to have contact with the patient or bed. She stated she did not use a gown because she felt that as long as she was careful, she did not need one. She indicated that if she thought she might get something on her, she might put a gown on, but that this did not happen to her. Licensed Staff J stated that as the facility treatment nurse, she was responsible for all wound and pressure ulcer care for the entire facility from Monday through Friday from 8 a.m. to 5 p.m. During clinical review on 7/28/11 at 10:45 a.m., Resident 16's clinical record included a hospital record, dated 4/27/11, which indicated that Resident 16 had an incision and drainage of the right buttock for a 6 x 7 cm area of abscess. Cultures from the abscess, two sets of blood cultures, and a swab of the nares (nostrils) obtained on admission to the hospital on [DATE], revealed that cultures were positive for Methicillin-resistant Staphylococcus Aureus (MRSA) (a bacteria that is resistant to common antibiotics). [DIAGNOSES REDACTED]. Admission physician orders [REDACTED]. Review of the the facility physician admission assessment, dated 5/6/11, revealed ... "MRSA, Vanco (antibiotic-kills bacteria in the intestines), till (until the) 26th (5/26/2011)...MRSA Sepsis/wound." Clinical record review revealed that there was no care plan for Resident 16's Contact Precautions upon admission. During observation and interview on 7/29/2011 at 2:45 p.m., Licensed Staff J (facility treatment nurse) performed a dressing change on Resident 16, after the CNA had informed Licensed Staff J that Resident 16 had large bowel movement, and the dressing had fallen off. While observing Licensed Staff J and the CNA change the dressing, both staff leaned over the bed, and their clothes touched the bed linens . The chuks (2 ft. x 2 ft. waterproof moisture barrier for hospital beds) was rolled up under Resident 16 and had not been changed. Licensed Staff J and the CNA did not wear gowns while performing the dressing change or removing the soiled linens and stool-soiled chuks from the bed. When asked about Contact Precautions, Licensed Staff J stated that this resident (Resident 16) had not been on Contact Precautions since admission. Licensed Staff J stated she did not wear gowns or masks, and she was always very careful to make sure that she did not touch the bed linens with her clothes. 1c. Record review on 7/27/11 at 9:30 a.m., indicated that Resident 7 was admitted with [DIAGNOSES REDACTED]. Resident 7 also had a history of [REDACTED]. A consultation Report, dated 2/23/11, revealed that Resident 7 had history of Methicillin-resistant Staph aureus bacteremia of prepatellar bursitis (inflamed kneecap), and status [REDACTED]. Nurses notes, dated 3/15/11, indicated that during a dressing change of Resident 7's left foot, there was a lot of drainage with bright red blood. Nurses notes, dated 3/16/11 at 10:30 a.m., revealed that Resident 7 had a dressing change on his left foot/toes, and there was a large amount of bloody drainage with odor. Nurses notes, dated 3/17/11 at 8 a.m., indicated that during dressing change on Resident 7's left foot/toes, there was a large amount of bloody drainage with odor. Nurses notes, dated 3/21/11, indicated there was, "necrosis," (the death of most or all of the cells in tissue) of Resident 7's 2nd and 3rd toes on his left foot, and the dressing on his foot was, "saturated with foul smelling," drainage. The Physician Skilled Nursing Facility Progress Note, dated 3/21/11, indicated that Resident 7's left foot, second toe, had...."gangrene with subsequent crush injury, progressive gangrene, with possible MRSA cellulitis..." During concurrent observation and interview, on 7/27/11 at 1:45 p.m., Unlicensed Staff X was performing extensive care of Resident 7 (bathing, dressing, and bathroom). When asked if there were precautions for Resident 7, Unlicensed Staff X stated, "I just use gloves." During interview with Licensed Staff Z on 7/27/11 at 5:20 p.m., and concurrent review of nurses notes, dated 3/21/11 a.m., revealed that the 2nd and 3rd toe necrosis wounds and the dressing were saturated with foul smelling serous drainage (clear liquid). Licensed Staff Z stated that she had been told that Resident 7 had Methicillin-resistant Staphylococcus aureus (MRSA) of the nares (nose) and was not on Contact Precautions. Licensed Staff Z stated that she was upset about not being informed of the full history of Resident 7. Review of, "Enhanced Standard Precautions for Long-Term Facilities" (AFL 10-27), dated September 7, 2010, noted: "The first and most important CDC tier (Center for Disease Control, increasingly complex set of recommendations for preventing the transmission of infectious agents). Standard Precautions, presumes that all moist body fluids from all patients/residents are colonized or infected with one or more transmissible infectious agents. The most common bacterial agents methicillin-sensitive and methicillin -resistant (MRSA), [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE), and the gram negative bacilli such as E-coli...Moist body fluids include blood, excretions (except sweat) and secretions (regardless of whether blood is visible), non-intact skin and mucous membranes. All body fluids are presumed infectious because it is not possible to know whether or not an infectious agent is present... In addition to hand hygiene, Standard Precautions require gowns, gloves, masks, and face shields when health care personnel (HCP) anticipate that their hands, clothes or the mucous membranes of the eyes, nose or mouth or skin on the face will be exposed to blood or other body fluids. Standard precautions are always used in addition to Transmission-Based precautions and Intensified Interventions. ... The second CDC tier Contact Precautions are an extension of Standard Precautions in that gowns and gloves are required for all patient/resident contacts (as opposed to gowns and gloves for anticipated contact with body fluids) as well as contact with environmental surfaces in the patient's/resident's room." During an interview, on 7/29/11 at 11:00 a.m., with Management Staff A, Management Staff B, Management Staff C and Consultant D, when asked why Resident 7 and Resident 16 had not been placed on Contact Precautions when the information from the hospitals had indicated MRSA with draining wounds, Consultant D stated that neither resident had uncontrolled drainage so Contact Precautions were not required. 1d. An observation on 8/1/11 at 7:30 a.m., revealed a sign at Resident 21's door which indicated an infection control alert, and included instructions to wash hands before and after care and wear gloves when entering the room. Unlicensed Staff AA wore gloves upon entering the room to pick up the breakfast tray, when the tray was placed on the food cart in the hallway, Unlicensed Staff AA removed the gloves and discarded them, but did not wash her hands and continued to collect trays from other rooms. 1e. During an observation on 8/1/11 at 9:45 a.m., in resident room [ROOM NUMBER], Unlicensed Staff AB assisted Random Resident 20 to the toilet. After removing her gloves, and without washing her hands, put on a clean pair of gloves to assist with a mechanical lift. During concurrent interview with Unlicensed Staff AB, when asked about hand hygiene, she stated that she was supposed to wash her hands between residents. During an interview, on 8/1/11 at 10:30 a.m., when asked to relay the facility policy for hand washing for contact precautions, Licensed Staff E, the facility Infection Control/Staff Educator, stated that hand washing was not required when the staff did not do direct patient care, such as closing the privacy curtains or picking up a food tray. If doing direct resident care, the policy was to wash hands, put on gloves, care for the resident, take the gloves off and then wash hands again. When asked if washing hands was monitored, Licensed Staff E stated that the facility had a Guardian Angel program that consisted of management staff (including non-nursing staff) that visited rooms to do spot checks, which included verifying that hand hygiene was being done and to check on infection control issues. When asked what the facility process was for isolation, Licensed Staff E stated that he worked with the Admissions Department for residents identified prior to admission with an infection, and they worked together to assign appropriate rooms. When asked if a physician order [REDACTED]. Licensed Staff E stated that if there was a change of condition, with infection symptoms after admission, a licensed nurse could initiate and determine the type of isolation required and notify him. Licensed Staff E then would notify the staff, including the treatment nurse, so appropriate personal protective equipment (PPE) was used. When asked how to stop precautions, such as contact precautions for[DIAGNOSES REDACTED], Licensed Staff E stated that if the resident had[DIAGNOSES REDACTED], the process was that if there were no diarrhea stools for 48 hours, they would discontinue the contact precautions. Housekeeping would then cleaned the room. Licensed Staff E concurred that there were no care plans for Contact Precautions, and stated that the type of precautions could be determined by reviewing the clinical records, and that there were several sections of the clinical record that noted the information. These included the nursing notes, the CNA logs for hydration and output, the activities of daily living abilities, and change of condition forms. When asked if the records were audited for appropriate documentation and follow up, Licensed Staff E stated he was not sure. During an interview, on 8/2/11 at 9:10 a.m., when the observations of unlicensed staff not wearing gloves or washing hands for Resident 1, who was on contact precautions for[DIAGNOSES REDACTED], was relayed, Licensed Staff E stated that the staff could use discretion about washing hands. He stated that the staff knew the residents and would know if a resident was unsanitary, such as touching contaminated briefs (diapers), and if not, then they could remove the food tray or feed the resident without washing hands. On 8/3/11 at 3:10 p.m., when asked about the Immediate Jeopardy regarding Infection Control, the Medical Director stated that he was aware and felt it was a needed change and good for the facility. The director indicated that improvement in any area that was not up to standards was good. The director stated that the facility has made a lot of improvements, but needed to identify where it was failing. The facility policy and procedure titled, "Infection Control Urinary Tract Infection Prevention...," (undated), reflected ... "All healthcare workers should wash their hands before and after every resident contact, before and after donning gloves..." 2) During a clinical review on 8/2/11 at 10 a.m., Resident 21's laboratory results indicated that urine for culture and sensitivity was submitted to the laboratory on 7/9/11. Review of the physician orders [REDACTED]. The laboratory sent a report to the facility on [DATE], identifying that there were 25,000 colonies/milliliter (ml) of [MEDICATION NAME] and noted, "[MEDICATION NAME] RESISTANT," and indicated that the organism was resistant to Cipro. p Review of the medication administration record (MAR) revealed that Resident 21 continued to [MEDICATION NAME] 7/15/11. There was no documentation in the record that the physician was notified that the organism was resistant to Cipro. Resident 21's physician order [REDACTED]. The urine specimen was collected on 8/1/11, and submitted to the laboratory. The laboratory returned a urinalysis, without the culture and sensitivity, on 8/2/11, that revealed 50,000 colonies/ml gram negative rods. During an interview, on 8/2/11 at 12 p.m., Licensed Staff V corroborated the above findings, and stated that she was not aware that the laboratory did not do the culture and sensitivity on the urine submitted on 8/1/11, and stated that it was not logged into the nurse's communication binder. Licensed Staff V stated that she would call the laboratory to ensure that a culture and sensitivity was performed on the urine collected on 8/1/11. During an interview, on 8/2/11 at 3:15 p.m., Management Staff B stated that the licensed staff failed to notify the physician that the 7/13/11, result indicated that the organism was resistant to the antibiotic the physician ordered, that the physician should have been notified so that [MEDICATION NAME] be discontinued. Management Staff B also stated that she concurred with the finding that the laboratory slip on 8/1/11, was not made out correctly, that staff failed to indicate both a urinalysis and culture and sensitivity on the laboratory request. During an interview, on 8/2/11 at 3:40 p.m., Licensed Staff AE stated that it was the responsibility of the nursing staff to notify the physician when a culture and sensitivity report returned and revealed that a resident was on an antibiotic that was resistant to the organism and concurred that this was not done for Resident 21. Surveyor: Carter, Jacquelyn 3) Review of the facilities Infection Control Logs revealed: Resident 1: Review of the facility Infection Control Log, on 8/3/11 at 10 a.m., revealed that Resident 1's UTI with antibiotics ordered on [DATE], was not on the log for July 2011. The June 2011, Infection Control Log listed Resident 1 with an infection, with an onset date of 5/28/11. The site was noted as GI, with no other data, and there were no notations about cultures, antibiotics, or precautions. The May 2011, Infection Control Log listed Resident 1, with the infection site listed as respiratory, with an onset date of 4/18/11, that it was community acquired (community acquired refers to infections that were present or incubating at the time of admission), and with no other data. Resident 7: The Monthly Infection Control Log for April 2011, reviewed on 7/27/11 at 9:30 a.m., indicated that Resident 7 had a community-acquired infection with a date of onset as 4/6/11. The wound site was the left foot, there was no culture taken, there was no organism noted, and that there were no precautions. The log's antibiotic column was blank, and the infection cleared column was blank. Resident 9: Review of the clinical record for Resident 9, on 7/26/11, revealed that she had a history of [REDACTED]. coli) and Proteus mirabilis (bacteria usually found in fecal matter and a common cause of urinary infections). The Monthly Infection Control Log for March 2011, reviewed on 8/2/11 at 4 p.m. and 8/3/11 at 10 a.m., indicated the site of infection as urinary tract infection (UTI) with the date of onset as 3/4/11, that it was a community-acquired infection, with no cultures noted, and the organism column was blank, with no precautions, and the antibiotic listed was [MEDICATION NAME]. The log also indicated that on 3/15/11, Resident 9 had a facility-acquired infection, with the site listed as GI (gastrointestinal), the bacteria was Clostridium difficile (C-diff) with no culture, and with Contact Precautions. The antibiotic was listed is [MEDICATION NAME]. The July 2011, log indicated the site as UTI with catheter and the date of onset as 7/21/11, that the infection was facility acquired, and the culture revealed [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE). The isolation/precaution type column was blank, and the antibiotic was listed as [MEDICATION NAME]. Resident 10: Review of the clinical record for Resident 10 on 7/26/11, revealed that she had a history of [REDACTED]. coli) and Proteus mirabilis. The September 2011, Infection Control Log, reviewed on 8/2/11 at 4 p.m. and 8/3/11 at 10 a.m., indicated the site as UTI, with an onset date of 9/10/10, that the infection was facility acquired, and with no other data. The January 2011, log indicated the site as respiratory, with a date of onset as 1/8/11, that the infection was facility acquired, and with no other data. The July 2011, log indicated a UTI, with an onset date of 7/25/11, that the infection was facility acquired, that the organism was E-coli, and the antibiotic was listed as Keflex. Resident 11: Review of the clinical record for Resident 11 on 7/25/11, revealed that she had a history of [REDACTED]. coli) and Proteus mirabilis. The September 2010, Infection Control Log, reviewed on 8/2/11 at 4 p.m. and 8/3/11 at 10 a.m., indicated a UTI, with an onset date of 9/2/10, that the infection was facility acquired, and with no other data. The October 2010, log indicated a UTI, with an onset date of 10/2/10, that the infection was facility acquired, and with no other data. The March 2011, log indicated a UTI, with an onset date of 3/12/11, that the infection was facility acquired, with no culture, and the antibiotic was [MEDICATION NAME]. . The July 2011, log indicated a UTI, with an onset date of 7/28/11, that the infection was facility acquired, that there was a culture that was noted as Proteus, and the antibiotic was [MEDICATION NAME]. Resident 13: Resident 13's clinical record was reviewed on 7/28/11 at 10 a.m. Acute care physician notes, dated 7/28/11, indicated that Resident 13's blood and urine cultures revealed Proteus. "Blood cultures demonstrate Proteus mirabilis..." Review of the facility Infection Control Log, on 8/3/11 at 10 a.m., revealed that Resident 13 was not on the July 2011, log. Resident 16: The Monthly Infection Control Log for May 2011, reviewed on 7/28/11 at 10:45 a.m., indicated that Resident 16 had community-acquired MRSA, the date of onset was listed as 5/2/11, the date cleared was blank, the culture column was listed as MRSA, the site was listed as wound, and the precautions were listed as, "Contact" (used for infections spread by skin-to-skin contact or contact with other surfaces--gown, gloves, hand-washing), and the antibiotic column was blank. The Monthly Infection Control logs for June and July did not include Resident 16. Resident 21: Review of the facility Infection Control Log for July 2011, reviewed on 8/2/11 at 10 a.m., did not reveal any entry for Resident 21 (who had a UTI). Review of the facility Infection Control Log, on 8/2/11 at 4:30 p.m. and 8/3/11 at 9 a.m., revealed the following: There were a minimum of 209 facility-acquired infections and 166 community-acquired infections since the last survey, June 25, 2011, with infections listed by site, not organism. Site was listed as: Urinary tract (UTI), urinary tract with a Foley catheter, respiratory (resp), skin/wound, gastrointestinal (GI), eye/ear, or other. Residents with more than one facility-acquired infection: Ten residents had two Twelve residents had three Seven residents had four Two residents had five Two residents had six One resident had seven (five urinary tract, one respiratory and one GI) Residents with facility-acquired urinary tract infections since 6/25/11: Fourteen residents with one Four residents with two Four residents with three One resident with five One resident with six During interview, on 7/27/11 at 11:45 a.m., Licensed Staff E was asked to provide copies of what infection control issues were presented to the Infection Control Committee and the type of data that was collected. Licensed Staff E provided copies of recent agendas for Infection Control Meetings. The agendas listed items such as, "Presentation of Infection Surveillance Reports," and, "Respiratory Tract Infections," but there was no data as to what the presentations contained. When asked for specific reports and data, Licensed Staff E stated that there was no other paperwork for the meetings and everything was just discussed. As of 7/28/11 at 5:30 p.m., specific data as to Infection Control Surveillance reports or other issues presented to the Infection Control Committee had not been provided. During an interview, on 8/1/11 at 10:30 a.m., when asked to explain the infection control program at the facility, Licensed Staff E, stated that the Monthly Infection Control log was compared to the laboratory culture reports and presented at the quarterly Infection Control Meetings, and the committee members recommended follow- up. Licensed Staff E stated that a report was then forwarded to the quarterly Quality Assurance Committee. Licensed Staff E stated that at the last Infection Control Committee meeting there was a discussion regarding the need to improve the daily surveillance log - the Infection Control log. When asked who he used as a resource, he stated that Consultant D was used as his resource, and he did not know if Consultant Staff D was certified as an Infection Control Practitioner (ICP). Licensed Staff E stated he was currently working on obtaining his certification for ICP. During an interview, on 8/2/11 at 4:50 p.m., Licensed Staff E was asked to provide information about the Monthly Infection Control Log. Licensed Staff E stated that this log contained his surveillance information and concurred that the log did not contain information in each column. Licensed Staff E stated he was not very good at keeping logs, and that he should have included the organism, symptoms, the type of isolation and the antibiotic given and if and when it was changed. Licensed Staff E stated that he had just recently received some input from an outside resource, who was an infection control nurse. Licensed Staff E stated that he was trying to go back to the previous months' logs and update them with the organism and if the resident was on precautions, but he had limited time to do this. He also stated that he should add all potential infections to the log, and then indicate those that were ruled out for an infection. Licensed Staff E stated that to meet the definition of a facility-acquired infection, for the Infection Control Log, the resident had to have been in the facility more than 48 hours, had not been out of the facility for dialysis or pass, had symptoms of an infection, was placed on antibiotics, and the date of onset would be the day the antibiotics were started. The infection control log lacked information in several columns. The missing information was: Age, date of admission, date infection cleared, signs and symptoms, diagnostic (culture taken y/n, organism/quantity, chest x-ray date, isolation precaution type, antibiotic, and no infection). The format and data columns for the months during the last survey changed formats and added or deleted columns, so that the same data elements were not available for trending or analysis. 4) During interview on 7/27/11 at 9 a.m., when asked what he thought about when there was E-coli in a UTI, the Infection Control Nurse/Staff Educator (Licensed Staff E) responded, "Peri-care" (the cleansing of the pelvic area occupied by genital and urinary passages and the rectum). He stated that he was always providing in-services (classes) to staff regarding peri-care and the correct procedure for catheter insertion and catheter care. He stated that staff did return demonstrations during the classes. He was asked to provide copies of the class outlines and attendance records. During interview, on 7/27/11 at 11:45 a.m., Licensed Staff E stated that 60% of the infections noted in the facility were uri

Based on staff interviews and facility document review, the facility failed to implement effective collaborative strategies to track and trend infection surveillance (the function of observing, gathering, investigating and reviewing information) for residents' safety. This failure had the potential for the development and transmission of disease and epidemic infections in residents who were already at risk for infection, due to a wide range of pre-existing illnesses and functional disabilities. Findings: During an interview on 11/16/11 at 1:40 p.m., Management Staff C indicated that the tools used by the facility to manage the facility's Infection Control Program included: 1. The facility's provider for diagnostic laboratory's, "Monthly Culture Report"; 2. "Infection Control Surveillance Log," (surveillance information/tracking form which included the, 'Resident Name', 'Infection Site', 'Signs and Symptoms', 'Diagnostics', 'Infection Control Nurse Information', and 'Treatment'); 3. The, "Monthly Analysis of Infections"; and 4. The mapping tool (the facility's floor plan that was color coded). Review of the facility Infection Control minutes for the months of September 2011, and October 2011, on 11/15/11 at 4:35 p.m., revealed that skin infections needed to be a focus area in September 2011. When asked why, on 11/16/11 at 1:40 p.m., Management Staff C could not recall. Review of the facility Infection Control logs for the months of September 2011, and October 2011, on 11/15/11 at 4:35 p.m., revealed that the number of facility-acquired infections went up 50%, from 12 in September 2011, to 18 in October 2011. Review of the facility Infection Control logs for the months of August 2011, September 2011, and October 2011, on 11/15/11 at 4:35 p.m., revealed that the data was inconsistent and difficult to track and trend. The diagnostic laboratory that services the facility for collecting, processing and submitting testing results made available a monthly culture report that included the number of cultures by site (blood, eye/ear, skin/wound, etc.) and by organism ([MEDICATION NAME] ([MEDICATION NAME] are part of the normal intestinal flora of humans), E. Coli (a Gram-negative, rod-shaped bacterium that is commonly found in the lower intestines), MRSA (Methicillin-Resistant Staphylococcus Aureus), etc). All of these organisms were potentially responsible for serious infections or death. The laboratory's, "Monthly Culture Reports," for August 2011, September 2011, and October 2011, were difficult to interpret due to color coding which was indistinct, and the names of graphed organisms could not be readily determined. The lab included, "no growth," in its calculation of organisms. According to the, "Monthly Culture Report," for August 2011, E. coli accounted for 25.9% of the cultures. When data regarding no growth was removed then E. coli actually accounted for seven of the 16 identified infections, and the rate was 43.75%. The data was similarly misleading for September 2011, and October 2011. During interview, on 11/16/11 at 1:40 p.m., Management Staff C was queried about why, "no growth organisms," was included in the calculation in determining the percentage of actual organisms. Management Staff C could not give the rationale why the lab included the number in the calculation and concurred the percentages could mislead the reader. Review of the Monthly Culture Reports for August 2011, September 2011, and October 2011, revealed the predominant bacteria's were those found in fecal material. When asked what was specifically being done to decrease the findings, Management Staff C stated, on 11/16/11 at 1:40 p.m., that staff was being educated on proper perineal care. There was no decrease in fecal bacteria causes of infection in the reports. The Infection Control Surveillance logs, for August 2011, September 2011, and October 2011, contained data regarding infections, room numbers of residents, and cultures taken. Residents with cultured infections could not be identified by the surveillance logs. a. Review of the Monthly Culture Report for August 2011, revealed there were two cases of [DIAGNOSES REDACTED] (a bacteria found in the gastrointestinal tract and on caregiver hands). b. Review of the Monthly Culture Report for September 2011, revealed there was one case of Providencia (a rare bacteria found in the gastrointestinal tract). c. Review of the Monthly Culture Report for October 2011, revealed there were three cases of [DIAGNOSES REDACTED] (staph: A bacteria that could cause a variety of infections and could be lethal) infections in the facility. None of the data in the logs identified who the residents were with the staph, [DIAGNOSES REDACTED], or Providencia infections. During an interview on 11/16/11 at 1:40 p.m., Management Staff C did not know who the residents were or what was done to prevent the spread of each of the bacteria. When asked about who were the three residents listed as having the Staphylococcus infections, Management Staff C's responded, "Hmm, I will have to look into that further." Review of the Monthly Analysis of Infections revealed the incident rates by site of infection were not consistent with the facility formula (number of infections divided by total patient days and multiplied by 1000), and data contained on the tool was not consistent with the other tools. Examples included, but not limited to: a. In August 2011, the total number of infections indicated was 29. The documented number of skin infections per 2767 patient days was nine. The analysis indicated that this was 0.36 percent of that month's site infections instead of 3.25%. b. In September 2011, the analysis listed no proteus, but the culture report indicated that there was one proteus infection. c. In October 2011, the analysis listed nine skin infections, but the facility map indicated there were seven. Review of the monthly facility maps used for tracking infections revealed that comparisons could not be readily made since data varied from sites and color coding from month to month. The facility was limited in how quickly they could quantify results and take special precautions for any residents that might be affected. a. In August 2011, there were eight sites of infection listed and color coded: Urinary tract infections with catheter use (purple), urinary tract infection without catheter use (turquoise), ear/eye (red), gastrointestinal (yellow), wound (orange), skin (brown), respiratory (black), and other (green). b. In September 2011, there nine sites of infection listed and the color coding was not the same: Urinary tract infections with catheter use (orange), urinary tract infection without catheter use (pink), ear/eye (black), gastrointestinal (yellow), skin/wound (turquoise), genitalia (purple), respiratory (green), [MEDICATION NAME] (red), and other (penciled gray). c. In October 2011, there were seven sites of infection listed and the color coding was different than that of August 2011, and September 2011. During review of the facility's, "Infection Control Surveillance Log" (surveillance information/tracking form) on 11/16/11 at 1:40 p.m., Management Staff C stated, "Anyone on antibiotics for an infection is counted in the infection rate," however Management Staff C could not explain why Resident 7 (a resident on dialysis), who was being administered antibiotics, was not included in the log. During a continued review of the facility's, "Infection Control Log," on 11/16/11 at 2:40 p.m., Management Staff V was asked to join the group conversation by Management Staff C, who described Management V as one of her resources for infection control issues. Management Staff V concurred, "Maybe, we probably should include residents on dialysis taking antibiotics."

Based on resident and staff interviews and record review, the facility failed to ensure services meeting professional standards of quality were provided for seven of 19 sampled residents (Residents 4, 5, 6, 9, 10, 11,13) and one extended sampled resident (Residents 21), when the facility: 1. Failed to ensure professional standards of practice, including use of the nursing process and standards for documentation, were followed for Resident 13, who had complaints of pain and nausea that were not assessed or documented in a timely manner, leading to vomiting, continuing pain, and transfer to an acute care hospital; 2. Failed to ensure physician orders for bowel care were carried out for Residents 9, 10, 11, and 13, with the potential for pain and constipation; 3. Failed to ensure Resident 11 did not receive bowel care that was not ordered by her physician, with the potential for side effects from the unordered medication; 4. Failed to ensure a physician order for [REDACTED]. 5. Failed to ensure physician orders for insulin were followed for Resident 13, with the potential for blood sugars to be out of range; 6. Failed to notify the physician when laboratory results, for a urinary tract infection, revealed that the organism was resistant to the antibiotic ordered by the physician for Resident 21, and Resident 21 continued on the medication for two more days; 7. Failed to notify the physician that an ordered laboratory test was not carried out for Resident 21, which resulted in a continued urinary tract infection; and 8. Failed to clarify multiple bowel care orders with the physician for Residents 4, 5 and 6, with the potential for pain and constipation Findings: 1. According to the American Nurses Association, 2011, "The essential core of practice," was the nursing process, which includes assessment, diagnosis, planning, implementation, and evaluation. According to Fundamentals of Nursing: Human Health & Function, Third Edition: Documentation is a method of communication and "serves as a legal document of the client's health status and care received." Documentation communicates the nursing process and serves as a permanent record of information and care regarding residents. Resident 13 complained of pain and nausea, during the day on 7/25/11, and had no documented evidence of assessment or evaluation, until her change in condition was noted at 6:30 p.m. that evening, and she was transferred to an acute care hospital. During interview, on 7/26/11 at 8:30 a.m., Resident 12 (identified by facility documentation, received 7/26/11, as alert, oriented, and interviewable) stated that she was concerned about her roommate, Resident 13. Resident 12 stated that Resident 13 complained about, "pain yesterday and no one listened." She stated that Resident 13 was sent out to the hospital yesterday afternoon and no one seemed to know what happened, and Resident 12 was worried. Resident 13's clinical record was reviewed on 7/26/11 at 9:10 a.m. She had [DIAGNOSES REDACTED]. Nurse's notes, dated 7/25/11, beginning at 6:30 p.m., indicated Resident 13 vomited, her skin was cool and clammy, her temperature was elevated, her pulse was rapid, and her blood pressure was low. Resident 13's blood sugar was 274. According to Resident 13's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff was unable to get an oxygen saturation (O2 sat-the level of oxygen carried by red blood cells and delivered throughout the body to keep you alive). Oxygen was administered, and Resident 13 was sent to an acute care hospital at 7:20 p.m. Review of the 24-hour report log, on 7/26/11 at 9:15 a.m., included a note regarding Resident 13, by Unlicensed Staff M for the day shift of 7/25/11. The note indicated Resident 13 complained of pain on her right side, that she did not eat much lunch, and that Licensed Staff K was notified of Resident 13's condition. Concurrent interviews with Resident 12 and Unlicensed Staff M, on 7/27/11 at 9:15 a.m., revealed that Resident 13 informed Unlicensed Staff M and Resident 12 that she was in pain on the morning of 7/25/11 at snack time. Resident 13 was not eating her snack because she did not feel well. Unlicensed Staff M told Licensed Staff K of Resident 13's condition that morning, "and he checked her. She was in pain." According to Unlicensed Staff M, Licensed Staff K did not want to give Resident 13 pain medication secondary to a history of constipation. Resident 13 continued to complain of pain and did not want to eat lunch. Unlicensed Staff M informed Licensed Staff K of Resident 13's condition following lunch. Resident 13 continued to be in pain and feeling nauseated. Unlicensed Staff M again informed Licensed Staff K, at about 2 p.m., on 7/25/11, that Resident 13 had pain and was nauseated. During interview with Licensed Staff K, on 7/27/11 at 3:45 p.m., he stated that he checked out Resident 13 on the morning of 7/25/11, and she was in pain which appeared to be related to gas. He stated that he offered her pain medication but she refused. There was no documented evidence in Resident 13's clinical record that she was assessed, in pain, or nauseated or had any change of condition between her weekly summary, dated 7/20/11, and nurse's notes, dated 7/25/11 at 6:30 p.m. 2. Physician orders were not followed, when residents did not receive bowel care medications as prescribed by their physicians. a. Resident 13's clinical record was reviewed on 7/28/11 at 10 a.m. She had physician orders, dated 8/7/09, for Milk of Magnesia (MOM) to be given for constipation for two days and [MEDICATION NAME] suppository to be given for constipation for three days. Review of Resident 13's bowel records and MAR indicated [REDACTED]. The suppository was administered on day four. Resident 13 had no bowel movements from 7/1/11 through 7/8/11 (eight days), and received no physician ordered bowel care. Resident 13 had no bowel movements for three days, 7/12/11 through 7/15/11 (night), 7/15/11 (evenings) through 7/18/11, and 7/21/11 through 7/24/11, and she did not receive MOM. On 7/25/11, Resident 13 was transferred to an acute care hospital due to kidney stones and was found to be constipated. Acute care physician notes, dated 7/28/11, indicated that, "throughout the 24 hours following her admission she began to develop more significant abdominal pain." Resident 13 was placed on a bowel regimen and her abdominal pain was, "better today after having three bowel movements yesterday." b. Resident 11's clinical record was reviewed on 7/25/11 at 2:30 p.m. She had physician orders, dated 12/29/10, for [MEDICATION NAME] 17 gm to be given every day for constipation/bowel care and orders, dated 8/23/11, for a [MEDICATION NAME] suppository daily as needed for constipation (three or fewer bowel movements in a week) and an enema if the suppository was ineffective. Review of Resident 11's bowel records and MAR indicated [REDACTED]. She did not receive the physician prescribed [MEDICATION NAME] as needed for constipation. c. Resident 10's clinical record was reviewed on 7/26/11 at 7:45 a.m. She had physician orders, dated 12/26/08, for MOM to be given as needed for constipation. Review of Resident 10's bowel records and MAR indicated [REDACTED]. d. Resident 9's clinical record was reviewed on 7/26/11 at 9:40 a.m. She had physician orders, dated 5/26/11, for MOM on the second day without a bowel movement. Her bowel records indicated she did not have a bowel movement from 7/17/11 to 7/20/11. Resident 9 was not offered MOM until 7/20/11. 3. Resident 11's clinical record was reviewed on 7/25/11 at 2:30 p.m. She had physician orders for multiple daily laxatives and orders, dated 8/23/11, for as needed bowel care. There was no physician order for [REDACTED]. 4. Resident 11's clinical record was reviewed on 7/25/11 at 2:30 p.m. Resident 11 had a history of [REDACTED]. She had physician orders, dated 8/24/10, for her heels to be, "floated," (elevated from surfaces) at all times. Observations on 7/26/11 at 7 a.m. and 4 p.m., 7/27/11 at 8:15 a.m., 10 a.m., and 3:45 p.m., and on 7/28/11 at 7:30 a.m., revealed Resident 11 was in bed, and her feet were not elevated off the mattress. Observation, on 7/27/11 at 5:35 p.m., revealed Resident 11 was up in her wheelchair. She was wearing white clogs and no socks. The base of the left clog was under the metal footrest and her bare left heel was trapped directly on top of the metal footrest. 5. Resident 13's clinical record was reviewed on 7/28/11 at 10 a.m. She had [DIAGNOSES REDACTED]. Resident 13 had physician orders, dated 8/7/09, for her blood sugars to be checked four times a day, and insulin was to be given based on the blood sugar (b.s.) levels, as follows: Blood sugar below 150 - no insulin Blood sugar 150-200 - 2 units of insulin Blood sugar 201-250 - 4 units of insulin Blood sugar 251-300 - 6 units of insulin Review of Resident 13's MARs for June 2011 and July 2011, revealed she received incorrect doses of insulin on four occasions. On 6/12/11 at 11:30 a.m., her blood sugar was 214, and she received six units of insulin, two more than ordered. On 7/8/11 at 9 p.m., she received two units of insulin (b.s. 221), two units less than ordered. On 7/10/11 at 4:30 p.m., her b.s. was 217, and she received two unit of insulin, again two units less than ordered. On 7/25/11 at 11:30 a.m., Resident 13's blood sugar was 174, and she was given six units of insulin, four units more than ordered by her physician. 6. Review of laboratory results for Resident 21 indicated that a urine for culture and sensitivity was submitted to the laboratory on 7/9/11. Review of the physician orders indicated an order for [REDACTED]. indicated that the organism was resistant to [MEDICATION NAME](this antibiotic would not work for this bacteria). Review of the MAR indicated [REDACTED]. There was no documentation in the record that the physician was notified that the organism was resistant to Cipro. 7. Review Resident 21's physician order dated 7/25/11, indicated that, "Pt (patient) has VRE based on 7/9/11 cx (culture) U/A (urinalysis) C&S (culture and sensitivity) now, Fax all results to (MD name)..." The laboratory requisition slip submitted by staff indicated an order for [REDACTED]. During an interview, on 8/2/11 at 12 p.m., Licensed Staff V corroborated the above findings, and stated that she was not aware that the laboratory did not do the culture and sensitivity on the urine submitted on 8/1/11, and stated that it was not logged into the nurses' communication binder. Licensed Staff V stated that she would call the laboratory to ensure that a culture and sensitivity was performed on the urine collected on 8/1/11. During an interview, on 8/2/11 at 3:15 p.m., Management Staff B stated that the licensed staff failed to notify the physician that the 7/13/11, result indicated that the organism was resistant to the antibiotic the physician ordered, and that the physician should have been notified so that [MEDICATION NAME] be discontinued and an antibiotic ordered that the organism was sensitive to. Management Staff B also stated that she concurred with the finding that the laboratory slip on 8/1/11, was not made out correctly, and that staff failed to indicate urinalysis and culture and sensitivity on the laboratory request. During an interview, on 8/2/11 at 3:40 p.m., Licensed Staff AE stated that it was the responsibility of the nursing staff to notify the physician when a culture and sensitivity report returned and revealed that a resident was on an antibiotic that was resistant to the organism and concurred that this was not done for Resident 21. 8. During a review, on 7/27/11 at 1:00 p.m., review of physician orders for bowel care revealed the following: A. Review of Resident 6's medication orders indicated the following: 1) Milk of Magnesia 30 milliliters by mouth as needed every day for constipation. 2) [MEDICATION NAME] 10 milligrams one suppository rectal as needed every day if milk of magnesia was not effective for constipation. 3) Senna (laxative tablet) 17.2 milligrams by mouth as needed every day and may increase up to four tablets twice daily as needed for severe constipation. B. Review of Resident 4's medication orders indicated the following: 1) [MEDICATION NAME] 10 milligrams one suppository rectal as needed every day for constipation. 2) Fleet enema one bottle rectal as needed every day for constipation. 3) Milk of magnesia 30 milliliters by mouth as needed every day for constipation. C. Review of Resident 5's medication orders indicated the following: 1) Milk of Magnesia (Magnesia [MEDICATION NAME]) 30 milliliters by mouth as needed every day for constipation. 2) [MEDICATION NAME] 10 milligrams one suppository rectal as needed every day if Milk of Magnesia not effective for constipation. 3) [MEDICATION NAME] 17 grams one packet by mouth as needed for constipation. During an interview with Licensed Staff K on 7/27/11 at 1:35 p.m., when asked how to determine constipation and medication administration for the aforementioned residents, he stated that the orders were not clear and needed clarifying. During an interview with Licensed Staff U on 7/27/11 at 1:45 p.m., when asked how to determine constipation and medication administration for the aforementioned residents, she stated that if a resident had not had a bowel movement in three days that she would let the resident decide which laxative to take. However, she would need to clarify orders with the physician if the resident was not capable of making a decision. During an interview with Management Staff B on 7/28/11 at 11 a.m., a policy and procedure for bowel care was requested. Management Staff B replied that the facility did not have a procedure for bowel care; the standard was to follow the physician's orders. Review of policy and procedure titled, "Medication Orders," dated 5/07, indicated that medications were administered only upon clear, complete signed orders.

Based on observation, staff and resident interview, clinical records, and document review, the facility failed to provide a safe environment free of accident hazards and failed to provide adequate supervision and assistance devices to prevent accidents for three of 19 sampled residents (Resident 7, 10, and 11) and one extended resident (Resident 23) when: 1) A staff person stepped backwards on Resident 7's foot, causing a crushing foot injury, which, along with other factors, contributed to a left below-the-knee amputation; 2) Resident 23 fell six times and sustained a 3-1/2 inch scalp laceration, requiring staples; 3) Resident 11 had seven falls and sustained two pelvic fractures, one impacted femur fracture, and an injury to her forehead; 4) Resident 10 fell four times in less than a year; and 5) Resident 5's bed control cord had frayed, and there were exposed wires, with the wires arcing and smelling of electrical fire. Forty-one of 92 bed control/call bells were wrapped with black electrical tape. This failure resulted in an extended survey on 7/28/11 at 11:20 a.m. Findings: 1. During record review on 7/27/11 at 9:30 a.m., Resident 7 was admitted with an above-the-knee amputation to the hip of the right leg due to severe ischemia (restriction of blood supply), and progressive gangrene of the 2nd toe on left foot. The Minimum Data Set Assessment ((MDS) dated [DATE], indicated that Resident 7 required extensive assistance for transfers and bed mobility. The Activities of Daily Living (ADL) nursing plan of care dated 2/26/11, indicated Resident 7 needed assistance with activities of daily living. The interventions were to provide adaptive/safety equipment that included a wheelchair and to provide only the amount of assistance/supervision that was needed. The goal was to prevent complications related to decreased mobility. Occupational Therapy notes dated 2/26/11, indicated that Resident 7 was a fall risk with diabetic precautions and had multiple falls over the past month due to refusing to wear the cast shoe on his left foot causing his foot to slip out from under him at times. The Occupation Therapy notes did not indicate other alternative measures regarding the cast shoe or specific interventions to protect Resident 7's left foot. There was no nursing plan of care indicating how staff was going to protect Resident 7's left foot with specific interventions. During an interview on 7/28/11 at 9:00 a.m., Resident 7 stated that when the occupational therapist stepped backwards on his left foot, he told the CNA. Resident 7 also reported this to his foot Doctor during an appointment on 3/14/11, "...the rehab lady stepped on my foot last week." Physician Discharge Summary from the facility dated 3/22/11, indicated around 3/14/11, (Resident 7's) left foot was accidently stepped on by one of the staff who was backing up when (Resident 7) unexpectedly stood up at the bedside. The summary indicated that Resident 7's circulation appeared adequate to heal a gangrenous distal second toe, but the physician subsequently did excise the gangrenous distal phalanx (tip of the toe). The note indicated the wound appeared to be healing well, but there was a compression injury noted under complications, and (Resident 7)'s mood had worsened with more proximal ischemia involving the entire second toe, and the distal pad of the second and third metatarsals (bones of foot). The tissue was quite soft and appeared to be breaking down and gangrenous...and (Resident 7) developed progressive gangrene of the left forefoot and subsequently underwent a left below- the-knee amputation. 2. During the recertification survey it was identified that the facility had 244 falls since the last survey on 6/25/10.(Cross Reference F520) During a clinical record review on 8/2/11 at 11 a.m., Resident 23 was admitted with [DIAGNOSES REDACTED]. Records revealed: First Fall Interdisciplinary note (IDT) dated 11/18/10 at 7:15 p.m., indicated that Resident 23 had a fall in the social dining room and sustained a skin tear and bruise to the left elbow. A neurological check (alertness, orientation to name, place, pain, consciousness) was performed. Resident 23 was not to go from the long term care unit (units 2 and 3) to other nursing units (units 1A and 1B). The nursing plan of care did not specifically show how the staff planned to keep Resident 23 in the long term care unit. IDT notes also reflected that Resident 23 was not to go outside of the long term care unit, but without a plan of how to obtain this outcome. Second Fall The IDT note dated 12/21/2010 at 3:45 p.m., revealed that Resident 23 was found lying supine on floor near the activity room. The Activity Director witnessed Resident 23 lose her balance while walking with her daughter. The IDT note indicated that staff was not to leave Resident 23 alone and unattended when out of bed. Staff was to, "standby at all times." The IDT note was reflected on the nursing plan of care. The fall assessment and nursing care plan had no dates when written or when the outcome was to be reassessed. Third Fall Nurses notes dated 4/8/11 at 12:30 p.m., revealed that Resident 23 was found on the floor in the laundry room and was lying on her left side. Resident 23 had a bruised and swollen middle finger and complained of back pain. The laundry room was located beside Unit 1B. The IDT notes dated 4/30/11, indicated that the laundry room door or gate would be closed at all times when the laundry personnel were not present. Resident 23 would be closely watched as she wandered around the facility. The note also indicated that staff would provide frequent visual checks. The nursing plan of care and intervention from the IDT notes did not specify how staff was going to watch Resident 23 to prevent falls and accident hazards. During an interview on 8/3/11 at 9:00 a.m., when asked about the multiple falls and wandering, Licensed Staff Q stated, "that all the staff knew her and were to all watch her." During the course of the survey from 7/25/11 to 7/29/11, and from 8/1/11 to 8/4/11, the surveyor observed the laundry room closed only one day, and on 8/3/11, between 8 a.m. to 10 a.m., there was no gate at the laundry room doorway. The laundry room was observed several times during the survey with the door open, no gate in place and no laundry staff present in the room. Fourth Fall Nurses notes dated 6/2/11 at 7:45 p.m., revealed that Resident 23 was found on the floor in the hallway, and noted the fall was unwitnessed. Resident 23 sustained a skin tear to her right elbow. The IDT note and nursing plan of care indicated that staff were to continue with frequent checks while Resident 23 roamed the hallways and to keep her in visual areas. There was no specific intervention detailing how staff was going to provide frequent checks and keep Resident 23 in visual areas. Fifth Fall Nurses notes dated 7/1/11 at 6:25 p.m., indicated that Resident 23 fell in the central supply doorway from the wheelchair onto the floor, and this fall was unwitnessed. Resident 23 sustained an injury to her forehead, a laceration on the right side of her scalp that measured 3.5 in., requiring 12 staples. Resident 23 bled profusely on the floor and on her face. In addition, Resident 23 sustained a right knee contusion. The IDT note dated 7/5/11, revealed that staff were to provide a wheelchair repositioning and appropriate cushion to help prevent falls. There was a discussion, with the family, of Resident 23 wearing a helmet to protect for further head injuries. The family indicated that they did not want a, "Helmet." The family wanted Resident 23 to be allowed to continue to wander the entire facility and use a walker for more mobility. The IDT felt that a walker was not appropriate considering all the falls. The nursing plan of care did not show that it had been updated to include the IDT recommendations. The facility did not provide specific interventions for adequate protection and supervision to prevent falls and injuries. Sixth Fall Nurses notes dated 7/26/11 at 6:25 p.m., revealed an unwitnessed injury with multiple bruises on both upper arms, both wrists, left mid arm, and purplish discoloration on her chest. There was no evaluation for the cause of the injuries or implementation of a plan to prevent further injuries. 3) During interview, on 7/25/11 at 9:15 a.m., Licensed Staff E identified Resident 11 as confused, being a fall risk, and having a recent fall. Observations, on 7/25/11 at 10 a.m., revealed Resident 11 was in bed on a mattress with raised edges. There were two mattresses, one on top of the other, next to Resident 11's bed. Random observations of Resident 11 (when she was in bed during the day), on 7/26/11, 7/27/11, and 7/28/11, revealed the two mattresses were always on top of each other, causing a distance from the top mattress to the floor. Resident 11's clinical record was reviewed on 7/25/11 at 2:30 p.m. She had [DIAGNOSES REDACTED]. Resident 11 had a history of [REDACTED]. Resident 11 fell seven times in nine months. New interventions to prevent falls were not developed. Three of the falls were unwitnessed, with one of the unwitnessed falls finding the resident face down, on the floor between the bed and the wall. The resident sustained [REDACTED]. Resident 11's, "Fall Risk Assessment - Prevention & Management," care plan (Falls care plan), originally dated 8/26/10, indicated that Resident 11 had a history of [REDACTED]. Interdisciplinary Notes indicated: a. On 9/22/10, Resident 11 was found on the landing pad next to her bed. The plan was to do frequent visual checks. The Falls care plan had an undated intervention for frequent visual checks. There were no directions as to how and when the visual checks were to be done. b. On 9/31/10, Resident 11 rolled from her bed to the landing mattress. There was no documented evidence that the fall was witnessed. The plan was to, "continue with present plan of care and will continue to monitor." There was no plan on how Resident 11 was to be monitored and no new interventions to prevent further falls. c. On 12/21/10, Resident 11 had a second documented unwitnessed fall. She was found face down on the floor between the wall and her bed. The plan was to check that the bed locks were locked. d. On 2/1/11, Resident 11 again rolled out of bed and fell to the floor. "Resident usually rolls over the mattress while sleeping. Will continue with present plan of care." e. On 3/26/11, Resident 11 had discoloration on her hip and pain was noted. On 3/27/11, Resident 11 was admitted to an acute care hospital and was found to have a pelvic fracture. physician progress notes [REDACTED]. The notes indicated Resident 11 had a fall out of bed a week or so earlier. "When I last saw her after that fall 3/22/11," the physician did not note any purplish discoloration. The notes further revealed that Resident 11 had acute left upper and lower fractures of her pubis ramus (bone at the back of the pelvic area near the coccyx (tailbone)). There was, "a question of a pathologic component (fracture caused by disease leading to weakness of the bone) ....but (another physician's name) did not feel that was likely." The physician documented that Resident 11 had severe osteoporosis and when she rolled out of bed, "about one week ago," he suspected that the fall caused her pelvic fractures. Continuing review of Interdisciplinary Notes revealed: f. On 4/19/11, "Resident has declined after hospitalization . This is related to her s/p (status [REDACTED]." The notes indicated that Resident 11 was having pain related to the fractures of her pelvis. g. On 5/28/11, Resident 11 fell from her bed to the landing mattress on the floor. There was no indication that the fall was witnessed, and the current plan of care was to continue. There were no new interventions to prevent further falls. h. On 6/8/11, Resident 11 rolled out of bed onto the landing mattress. The plan was to continue frequent visual checks; this plan was in effect since 9/22/10, and had not prevented five subsequent falls. There was no documented indication on how the visual checks were to be done. i. On 6/22/11, Resident 11 had a third documented, unwitnessed, fall when she was found on the landing mattress. She sustained injuries to her forehead with swelling and bleeding and a 2.5 cm x 1.5 cm abrasion to the bridge of her nose. Two mattresses were placed beside the bed. The notes revealed that Resident's responsible party requested that Resident 11 sleep on the mattress on the floor, but, "will not be possible," because there was no lift available that went, "all the way down to the floor." The notes indicated, "We will continue with current plan of care." Nurses Notes indicated: a. On 6/23/11, the outside of the Resident 11's left lower leg had a skin tear over a, "purplish skin discoloration," and there was blood on Resident 11's sock. The notes indicated, "Routine Tylenol for pain." b. On 6/24/11, Resident 11's injuries were being monitored and, "routine Tylenol was given for pain." c. On 7/1/11, Resident 11 was complaining of right knee and hip pain, and x-rays were ordered. Physician notes, dated 7/5/11, indicated Resident 11 fell on [DATE], and sustained a fractured right hip with an impacted (bone surfaces are crushed together) right femoral neck (neck of the thigh bone where it inserts into the hip socket) fracture. Review of Physician notes, dated 7/25/11, revealed (Resident 11), "continues to recover from unwitnessed fall from bed 6/22," which led to a right, "hip femoral neck fx (fracture)." Resident 11 was treated with bedrest and, "she is now able to sit up in a chair." 4. Resident 10's clinical record was reviewed on 7/26/11 at 7:45 a.m. She was at high risk for falls and had a history of [REDACTED]. a. On 8/15/11, Resident 10 had an unwitnessed fall and was found on the ground, outside on the patio. b. On 10/25/10, Resident 10 fell . c. On 6/20/11, Resident 10 had an, "assisted," fall. d. On 7/14/11, Resident 10 had a second, unwitnessed, fall and was found on the floor. 5. An extended survey was conducted from 7/29/11 through 8/4/11, after a bed control with arcing electrical wires, that smelled of an electrical fire, was identified, and there were 41 bed controls wrapped with black electrical tape. This was a potential fire hazard. During an observation on 7/28/11 at 11 a.m., the surveyor detected the smell of burning wire in the air near bed 26 C, which Resident 5 was occupying at the time. Resident 5 complained that her bed was moving today, without the controls being touched. The surveyor heard the bed control motor and observed the bed moving without activating the bed control. An observation of Resident 5's bed control revealed a repair made by black and red electrical tape (see photos) that had pulled loose and exposed four different colored wires. Two of the wires did not have red tape wrapped around their connection. The orange wire had come apart and the ends were slightly touching. The ends of the orange wire appeared discolored. Resident 5 had an oxygen concentrator (Electrically operated device that draws in room air, separates the oxygen from the other gases in the air and delivers concentrated oxygen. Air from concentrator is more than 90% oxygen) and nebulizer (Electrically operated aerosol compressor that delivers medication to the lungs via tubing). Resident 5's physician orders [REDACTED]. During an interview, on 7/28/11 at 11:15 a.m., Unlicensed Staff AC stated that today at 9:45 a.m., while assisting Resident 5 with morning care, the bed would move on its own or not move when the buttons on the bed control were pushed. Unlicensed Staff AC stated that was when she noticed the exposed wires of the bed control cord and she reported the problem to maintenance. During an interview on 7/28/11 at 11:20 a.m., at Resident 5's bedside, Maintenance Staff F stated that he had just become aware that Resident 5's bed control was not working and was preparing to repair it. When asked if any other cords were repaired by using splicing and using electrical tape Maintenance Staff F stated, "no." Observation on 7/28/11 at 11:30 a.m., revealed that in room 33, the call light for bed 33 C had black electrical tape wrapped around it. After Maintenance Staff F removed the tape, he corroborated that the wires were spliced and taped together (See Photos). During an observation on 7/28/11 at 11:40 a.m., the bed control cords for resident beds: 12B, 3B, 11B, 7A, had areas that were covered with black electrical tape. The surveyor observed two maintenance staff, on unit 1A, removing cords from resident rooms and placing them in buckets. During an observation, on 7/28/11 at 11:45 a.m., the bed control cords for resident beds: 14B, 15B,19A, 20A, 21A, and 22A, had areas that were covered with black electrical tape. During observations, on 7/28/11 at 11:45 a.m., the bed control cords for resident beds: 40A, 42A, 43A, 47A and 47B, had areas that were covered with black electrical tape. During concurrent observations and interviews, on 7/28/11 at 11:53 a.m., Maintenance Staff F removed the electrical tape from the 47A, bed control and pointed out where the wires had been broken and then spliced before the electrical tape was applied. Maintenance Staff F demonstrated how the bed controls could get caught when the side rails were raised and lowered and stated it was a common occurrence. Maintenance Staff F and Maintenance Staff O both stated that the presence of black electrical tape on the cords indicated that the cord wires had been torn. They stated that after the wires had been repaired and spliced, they were covered with black electrical tape. When asked, the facility provided a list of the beds that had the bed control cord removed on 7/28/11 at 2:40 p.m. The beds identified by the facility were: 1A, 1B, 2A, 2B, 3B, 4A, 4C, 8A, 8B, 9A, 10B, 11B, 12B, 13A, 13B, 17A, 17B, 18A, 18B, 19A, 19B, 20A, 20B, 22A, 22B, 24A, 24B, 24C, 25A, 26A, 28B, 30A, 31B, 33B, 34A, 34B, 35A, 35B, 41A, 45A, and 45C (total 41). During an interview on 7/29/11 at 8:15 a.m., Management Staff A stated that a total of 41 beds had cords removed because they had black electrician tape on either the bed control or call bell cord. These beds could be identified by a piece of red tape at the foot of the bed, which alerted staff that they would need to use a hand bed crank, to adjust the beds. During an observation on 7/29/11 at 9 a.m., beds that were marked with red tape at the bottom of the bed, that were not on the facility listing, were: 4B, 7A, 40A, 42A, 43A, 43C, 44B, 47A, 47B, 47C and 48A (total 11). Additionally, beds that were noted by observation on 7/28/11 at 11:40 a.m., that had black electrician tape on the bed control cords, that were not included on the facility list of beds with cords removed were: 14B, 15B, 21A, 26C, 33C and 47A (total six). Review of the facility's document, "physician's orders [REDACTED]. On 7/29/11 at 3:45 p.m., when asked about the cords that were wrapped with black electrical tape, Maintenance Staff F replied that he was not aware of the repairs and believes that his staff probably saw him repair a cord and believed that it was a safe practice. He stated that none of his staff told him that they had repaired cords by using electrical tape. When asked how he supervised his staff, Maintenance Staff F stated by reviewing the, "(facility named) Maintenance Logs" and acknowledged that he did not conduct visual inspections of their work. When asked if he had informed the facility administrator of the cord damage, Maintenance Staff F answered, "no." Review of facility's document, "(facility named) Maintenance Logs," revealed that the hand- held bed control was not included as part of the weekly checks. When asked if he followed the manufacturer's guidelines regarding care and maintenance for the beds, Maintenance Staff F stated that he did not, and has never read a manual for the beds or for any other equipment in the facility. Upon request, Management Staff A located the owner's operator manual for the beds on the Internet and provided a copy. Review of the, "Owner's Operator and Maintenance Manual- Invacare Continuing Care Group Long Term Care Beds IH820DLX, IH820-3MDLX, and SC900DLX," indicated under, Operation Information on page 10 to: ..."Periodically inspect all electrical components for damage and replace if found. Continued use of a damaged component can result in abnormal operation and may present a hazard to some users." During an interview, on 7/29/11 at 1:00 p.m., Invacare Representative AD stated that the company required immediate removal of any cord with any type of damage, and that the company did not condone the practice at the facility, of using black electrician tape to repair exposed wires or damaged cords. Review of the Oxygen Services Manual, provided on 7/29/11, From Interactive Medical Systems, under the Section for, "Safety Precautions," listed: "The National Fire Prevention Assoc. (NFPA) and the Compressed Gas Assoc (CGA) list the following as potential fire hazards in oxygen enriched environments...B. Substances that are normally not considered combustible may burn in the presence of elevated oxygen levels...5. All sources of ignition must be removed from the room where O2 (oxygen) is used...7. No sources of open flame, includes candles, heater, or sparking toys, should be permitted in the room..." Review of the Medline Aeromist Plus User's Manual, provided on 7/29/11, revealed under the section titled, "Important Safeguards...3. Do not place this equipment near hot, sparking or burning objects." Review of the facility's policy and procedure, "Physical Environment/Equipment Maintenance," included the following procedures: 1. Equipment instructions and manuals will be kept in the Maintenance Supervisor's Office... 3. Electrical and hydraulic equipment will be inspected by the maintenance supervisor (M.S.) on a routine basis to ensure that all equipment is working properly... 4. M.S. will carry out routine maintenance on specified equipment, as per manufacturer's recommendation. During an interview with Management Staff A on 7/28/11 at 3:10 p.m., when asked how he supervised the work of Maintenance Staff F, Management Staff A stated by checking the work logs, and that no visual inspections were performed.