Every finding on record at Poway Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) was protected from abuse when Resident 1's wife was allowed to visit Resident 1 without close monitoring. This failure had the potential to affect Resident 1's safety and well-being. Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition (inadequate intake of nutrients to meet the body's needs) and dementia (an impairment of brain function, such as memory loss and judgment) according to the facility's admission Record. A review of Resident 1's progress notes (PN) in the electronic medical record (EMR) was conducted. The PN dated 8/17/25 at 12:08 P.M. indicated Resident 1 reported to staff that his wife smacked him on his thighs.during assessment, resident told writer [Licensed Nurse 5] the spouse slapped him on the cheek. During an interview on 8/28/25 at 9:33 A.M. with the Administrator, the Administrator stated Resident 1's wife has been limited to visiting Resident 1 in the common areas for close monitoring of the resident. The Administrator stated Resident 1's wife was not allowed to visit Resident 1 in the room alone. An observation and interview with Resident 1 was conducted on 8/28/25 at 10:21 A.M. Resident 1 was lying in bed with oxygen on via nasal cannula (tubing through the nose). Resident 1 stated he just returned from therapy and his wife visited earlier. Resident 1 stated his wife has done unusual things in the past such as throwing a book at him while he and his wife were sitting around the dining table. Resident 1 stated there was some kind of altercation between him and his wife recently. Resident 1 stated he did not remember what happened, but something happened. Resident 1 stated he was unsure if it was safe to be with his wife but it was fine for her to visit. During an interview on 8/28/25 at 10:38 A.M. with Resident 1's assigned certified nurse assistant (CNA) 1, CNA 1 stated she was not aware of the abuse allegation involving Resident 1 and the wife. CNA 1 stated Resident 1's wife arrived around 9 A.M. and assisted Resident 1 with breakfast in Resident 1's room. CNA 1 stated Resident 1's wife was allowed to visit in the room without being closely monitored. An interview on 8/28/25 at 10:46 A.M. was conducted with licensed nurse (LN) 2. LN 2 stated she was aware of the allegation that Resident 1's wife smacked Resident 1. LN 2 stated the plan of care was to ensure Resident 1's safety and visitations should be in the common area only. LN 2 stated staff assigned to Resident 1 should be monitoring and should be aware of the incident. During an interview on 8/28/25 at 10:54 A.M. with CNA 2, CNA 2 stated Resident 1's wife used the microwave the day before on 8/27/25 then proceeded to go into Resident 1's room without being monitored. CNA 2 stated she was not aware that Resident 1's wife was not supposed to be in Resident 1's room alone. During an interview on 8/28/25 at 11:04 A.M. with LN 4 (Resident 1's assigned LN), LN 4 stated she did not receive report regarding Resident 1's abuse allegation and was not aware of the plan of care that Resident 1's visits with his wife should be monitored/ or that the visits should only be in the common area. An interview on 8/29/25 at 10:59 A.M. was conducted with the Director of Nursing (DON). The DON stated Resident 1's wife was allowed to visit Resident 1 in public areas such as the TV room or activity room, where the visits may be monitored, and not in Resident 1's room. The DON acknowledged that staff should monitor Resident 1 whenever his wife visits, to protect the resident from abuse. A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022 was conducted. The P&P did not provide guidance for corrective actions when a family member was the alleged perpetrator. A review of the facility's policy and procedure (P&P) titled. Visitation, dated September 2022 was conducted. The P&P indicated, Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as.denying access or providing limited and supervised access to an individual if that individual is suspected of abusing.a resident.

Based on interview and record review, the facility failed to provide copies of medical records within two business days of the request for one of two sampled residents (1). As a result, Resident 1's family member was not aware of her medical status.Findings: Per the facility's admission record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include a history of falls. On 8/21/25 at 12:20 P.M., an interview was conducted with the Medical Records Director (MRD). The MRD stated, Resident 1's family member submitted a request for copies of medical records from the facility on 8/15/25 (four business days prior to the interview) and the facility was still working on completing the record request. The MRD stated that she planned on completing the record request within five business days of the request. Per the facility's Authorization Form For the Release of Health Information, dated 8/15/25, the family member of Resident 1 requested copies of Resident 1's medical records. Per the facility's policy, titled Release of Information, revised November 2009, 10. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such a request.

Based on observation, interview, and record review, the facility failed to ensure prescribed medications (meds) were administered as ordered by the physician for two of two sampled residents (Resident 1, Resident 2) As a result, Resident 1 was found unresponsive and life sustaining measures were performed including cardiopulmonary resuscitation (CPR). A. Resident 1 was admitted to the facility on [DATE] at 1:37 P.M., with a diagnosis of atherosclerotic heart disease of native coronary artery and atrial fibrillation (irregular heartbeat that affects blood flow) per the facilities admission record and admission note. A review of Resident 1's physicians orders (PO), dated [DATE], Indicated Resident 1 was a full code The PO's indicated Resident 1 was prescribed the following meds to be administered on [DATE] at 9 P.M. Risperidone (mood disorder med) 2 mg (milligram), one tablet (tab) by mouth (PO) in the evening. Trazodone HCl (an antidepressant) 50 mg, one tab PO at bedtime. Budesonide-Formoterol Fumarate (inhaler for chronic obstructive pulmonary disorder, COPD) 80-4.5 MCG (microgram)/ACT (actuation), 2 puffs twice a day. Carvedilol (cardiac med for high blood pressure) 25 mg, one tablet PO two times a day. Dronedarone HCL (med that helps maintain normal heart rhythm) 400 mg, one tablet PO, two times a day. Eliquis (blood thinner for clot prevention) 5 mg, one tablet PO, two times a day. A review of Resident 1's nursing note, dated [DATE] at 4:35 A.M., indicated, .New Admit, monitoring resident alert able to make simple needs known appears somewhat confused at times. A review of Resident 1's progress note, dated [DATE] at 7:58 A.M., indicated, . resident found not breathing, non-responsive by CNA, code blue immediately initiated. During an interview on [DATE] at 1:43 P.M, licensed nurse (LN) 1 stated, the LN should notify the pharmacy a new admission's medication orders, and the pharmacy will deliver the medications. LN 1 stated, if a new admission's evening medications are not delivered by administration time, the LN should pull the scheduled medications from the e-kit pyxis (emergency medication storage machine) if they are available. LN 1 stated nurses are instructed to call the pharmacy if the medication is an important medication and not available for administration. LN 1 stated if the medication is important enough to be in the e-kit, it is important to remove and give at the ordered time of administration. During an observation, interview and record review on [DATE] at 2:15 P.M., the assistant director of nursing (ADON) and director of nursing (DON) reviewed med inventory of the facility's e-kit pyxis. The inventory indicated the e-kit pyxis contained three of Resident 1's six prescribed evening meds including: 10 tabs of Eliquis 2.5mg 10 tabs of Carvedilol 6.25mg 18 tabs of Trazodone 50mg The e-kit pyxis did not contain any doses of Risperidone, Budesonide-Formoterol, or Dronedarone. A review of Resident 1's eMAR (electronic medication administration record) dated [DATE] indicated Resident 1 did not receive the following scheduled medications at 9 PM as ordered: RisperiDONE 2 mg PO TraZODone HCl 50 mg PO Budesonide-Formoterol Fumarate 80-4.5 MCG/ACT inhaler Carvedilol 25 mg PO Dronedarone HCl 400 mg PO Eliquis 5 mg PO A review of the e-kit transaction history dated, [DATE]-[DATE], indicated none of the three available medications in the e-kit were ever removed to be administered to Resident 1. A review of Resident 1's medication administration progress notes, dated [DATE], indicated , .New admit; meds not here yet. , as the reason all six medications, scheduled for 9:00 P.M., were not administered. During an interview on [DATE] at 3:55 P.M., LN 2 stated upon admission to the facility a resident's medication orders will be reconciled and approved and submitted to be filled and delivered by the pharmacy. LN 2 stated the nurse will access medications in the ekit pyxis if they have not been delivered to the facility by the time of medication pass. LN 2 stated the physician should be notified if the med has not been delivered and is not in the ekit by the time of scheduled administration. Once the nurse administers the medication it should be charted as given in the medication administration record (MAR). LN 2 stated a resident who has a diagnosis of heart disease or atrial fibrillation would be at risk for developing cardiac complications such as a blood clots, headache, or chest pain if they did not receive ordered cardiac medications. During an interview on [DATE] at 3:31 P.M., the Nurse Practitioner (NP), stated the licensed nurse is supposed to notify the NP or physician when a new admission arrives to the facility and obtain verbal authorization over the phone for the resident's medications. The NP stated the approved resident medication list should be sent or called into the pharmacy and the medications should be delivered by the pharmacy. The NP stated if a resident is admitted to the facility at 4 P.M. and does not receive their evening medications the NP or the physician should be notified. A review of Resident 1's progress notes did not indicate the NP or the physician were notified Resident 1 did not receive evening medications or that the medications had not been delivered from the pharmacy. During an interview and record review on [DATE] at 4:39 P.M., the DON reviewed Resident 1's MAR and progress notes, dated [DATE]. The DON acknowledged the MAR indicated Resident 1 did not receive multiple medications scheduled for the 9:00pm Med pas on [DATE], including cardiac medications, carvedilol and Eliquis, which were available to withdraw from the e-kit pyxis. The DON stated if Resident 1 was admitted to the facility at 1:37 P.M. the 9:00 P.M. medications should have been given. The DON stated if the medications had not arrived from the pharmacy by medication pass they should have been pulled out of the e-kit pyxis. The DON stated Resident 1 was admitted to the facility after a hospital stay where he had elevated troponins (blood marker for heart attack) and an abnormal EKG (electrocardiogram that reads the rhythm and rate of the heart). The DON stated, I don't know what to say. They should have checked the pyxis. The DON stated medication nurses were expected to pull needed medication from the pyxis if medication had not arrived by the time of scheduled administration. During an interview on [DATE] at 10:42 A.M., the facility pharmacist (FP), stated Resident 1's orders were received by the pharmacy on [DATE] at 8:33 P.M., and delivered to the facility on [DATE] at 2:42 A.M. The FP stated once orders are sent to the pharmacy, they will be filled and sent to the facility on the next shipment. The FP stated they have several deliveries a day. The FP stated the facility is able to call in a one-time dose if a prescribed medication is not in the ekit. B. Resident 2 was admitted to the facility on [DATE] with a diagnosis of COPD and pneumonia (respiratory infection) per the facility admission record. During an interview on [DATE] at 2:35 P.M., Resident 2 stated she was admitted a few days ago from a local hospital following a respiratory infection. Resident 2 stated she arrived at the facility after dinner the day she was admitted . Resident 2 stated she did not get all her evening medications or ordered respiratory treatments but was unable to recall which medications she did not get. A review of Resident 2's Physician's orders, EMAR, and progress notes, dated [DATE], indicated the following medications were scheduled for 9:00 P.M and charted as not given: Ipratropium Bromide Inhalation Solution 0.02%, via nebulizer Atrovent HFA Inhalation Aerosol Solution 17 MCG/ACT, inhaler Ipratropium-Albuterol Inhalation Solution 2.5-0.5 MG/3 ML, via nebulizer A review of the facility policy titled, Administering Medications, revised [DATE], indicated, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication. 7. Medications are administered within one (1) hour of their prescribed time

Based on observation, interview, record review, and facility policy review, the facility failed to obtain consent for the use of bed rails for 2 (Resident #9 and Resident #24) of 3 sampled residents with bed rails installed; and failed to complete assessments for the continued use of bed rails for 3 (Residents #9, #24, and #54) of 3 sampled residents reviewed for accidents. Findings included: A facility policy titled, Bed Safety and Bed Rails, revised 08/2022, revealed, 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The policy specified, 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. 1. An Admission Record revealed the facility admitted Resident #9 on 03/13/2021. According to the Admission Record, the resident had a medical history that included diagnoses of senile degeneration of the brain, dementia, history of traumatic brain injury, and a history of falling. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. According to the MDS, Resident #9 required partial/moderate assistance with rolling from lying on their back to the left and right sides, with moving from sitting on the side of the bed to lying flat on the bed, and with moving from lying on their back to sitting on the side of the bed. Resident #9's Care Plan Report, included a focus area revised 09/20/2024, that indicated the resident was at risk for altered activities of daily living (ADL) related to a decline in functional ADL activity such as bed mobility and transfers. Interventions directed staff to provide bilateral quarter bed rails to assist the resident with bed mobility, getting out of bed, turning and repositioning, supporting themselves during care, and entering/exiting the bed more safely (initiated 06/15/2022). Resident #9's Order Summary Report, revealed an order dated 10/20/2022, for Side/Bed Rail(s) Up x 2 for Bed Mobility (Turning & Positioning). Resident #9's Bed Rail Observation/Assessment forms dated 03/18/2022, 06/14/2022, 06/18/2022, 09/08/2022, 12/08/2022, 03/08/2023, and 06/08/2023, revealed recommendations for bilateral upper quarter bed rails. The section of the assessments titled, Risks, Benefits and Informed Consent was blank on all documents, and there was no evidence that Resident #9 or their representative was informed of the medical necessity to use side rails or the associated risks and benefits. The assessment forms did not include signatures for Resident #9 or their representative to validate informed consent for the use of side rails was obtained. Resident #9's Progress Notes, for the timeframe from 06/08/2023 through 05/03/2025 revealed no documentation of informed consent or additional assessments for the use of bed rails. An observation on 05/07/2025 at 1:09 PM revealed Resident #9 was in bed with bilateral side rails up. During an interview on 05/07/2025 at 1:29 PM, the Director of Nursing stated the facility was not able to locate the initial consent form for Resident #9's side rails. During an interview on 05/08/2025 at 9:28 AM, Certified Nurse Assistant #4 stated Resident #9 used their side rails for turning and positioning. 2. An Admission Record revealed the facility admitted Resident #24 on 09/27/2015. According to the Admission Record, Resident #24 had a medical history that included diagnoses of dementia, osteoarthritis of bilateral knees, and age-related physical debility. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2025, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. According to the MDS, Resident #24 required substantial/maximal assistance with rolling from lying on their back to the left and right sides, with moving from sitting on the side of the bed to lying flat on the bed, and with moving from lying on their back to sitting on the side of the bed. Resident #24's Care Plan Report, included a focus area initiated 03/15/2022, that indicated the resident was at risk for altered activities of daily living (ADL) related to a decline in functional ADL activity such as bed mobility and transfers. Interventions directed staff to provide bilateral quarter bedside rails for bed mobility and transfers (initiated 03/15/2022). Resident #24's Order Summary Report, revealed an order dated 10/20/2022, for Side/Bed Rail(s) Up x 2 for Bed Mobility (Turning & Positioning). Resident #24's Side/Bed Rail Evaluation/Consent, dated 03/03/2018, revealed an evaluation showed the resident had medical symptoms of generalized weakness and balance deficits, and they required bed rails for bed mobility and boundary identification. The Side/Bed Rail Evaluation/Consent included a recommendation for bilateral quarter side rails at the top of the resident's bed. Further review of the document revealed Resident #24 was informed of the risks and benefits of the side rails, but there was no signature to validate informed consent for the use of side rails was obtained. Resident #24's Bed Rail Observation/Assessment forms dated 03/16/2022, 06/01/2022, 09/05/2022, 12/05/2022, 03/06/2023, 09/06/2023, 12/06/2023, 03/06/2024, and 06/06/2024 revealed recommendations for bilateral upper quarter bed rails. The section of the assessments titled, Risks, Benefits and Informed Consent was blank on all documents, and there was no evidence that Resident #24 or their representative was informed of the medical necessity to use side rails or the associated risks and benefits. The assessment forms did not include signatures for Resident #24 or their representative to validate informed consent was obtained for the use of side rails. Resident #24's Progress Notes, for the timeframe from 12/11/2024 through 05/07/2025 revealed no documentation of informed consent or additional assessments for the use of bed rails. An observation on 05/07/2025 at 12:56 PM revealed Resident #24 was in bed with bilateral side rails up. During an interview and observation on 05/08/2025 at 7:44 AM, Resident #24 stated they used the side rails to reposition themselves in bed and demonstrated use of the side rail. 3. An Admission Record revealed the facility admitted Resident #54 on 01/12/2022. According to the Admission Record, Resident #54 had a medical history that included diagnoses of osteoarthritis of the right ankle and foot, generalized muscle weakness, and lack of coordination. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/14/2025, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. According to the MDS, Resident #54 required partial/moderate assistance with rolling from lying on their back to the left and right sides, with moving from sitting on the side of the bed to lying flat on the bed, and with moving from lying on their back to sitting on the side of the bed. Resident #54's Care Plan Report, included a focus area revised 04/24/2022, that indicated the resident was at risk for altered activities of daily living (ADL) related to decline in functional ADL activity such as altered bed mobility and transfers. The focus area specified Resident #54 required quarter side rails for bed mobility, turning, and repositioning. Interventions directed staff to provide bilateral quarter bedside rails to assist with bed mobility (initiated 03/16/2023). Resident #54's Order Summary Report, revealed an order dated 10/20/2022, for Side/Bed Rail(s) Up x 2 for Bed Mobility (Turning & Positioning). A Side/Bed Rail Evaluation/Consent, dated 01/12/2022, revealed Resident #54 was evaluated for the use of side rails and found to have medical symptoms of generalized weakness and balance deficits. The document contained a recommendation for bilateral quarter side rails at the top of the bed. The Side/Bed Rail Evaluation/Consent was signed by Resident #54 to validate they were informed of risks and benefits and gave consent for the use of the side rails. Resident #54's Bed Rail Observation/Assessment forms dated 03/26/2022, 06/26/2022, 07/15/2022, 10/14/2022, 01/01/2023, 04/13/2023, and 07/14/2023 revealed recommendations for bilateral upper quarter bed rails. The section of the assessments titled, Risks, Benefits and Informed Consent was blank on all documents, and there was no evidence that Resident #54 or their representative was informed of the medical necessity to use side rails or the associated risks and benefits. The assessment forms did not include signatures for Resident #54 or their representative to validate informed consent for the use of side rails was obtained. Resident #54's Progress Notes, for the timeframe from 07/12/2023 through 05/07/2025 revealed no documentation of informed consent or additional assessments for the use of bed rails. An observation on 05/05/2025 at 10:10 AM revealed Resident #54 had quarter side rails on their bed. An observation on 05/06/2025 at 1:46 PM revealed Resident #54 was in bed with bilateral side rails up. During an interview on 05/07/2025 at 1:29 PM, the Director of Nursing confirmed Resident #54's last side rail assessment was completed on 07/14/2023. During an interview on 05/07/2025 at 10:03 AM, the Assistant Director of Nursing (ADON) stated the admitting nurse would assess residents to determine if they needed side rails for mobility and obtain consents. The ADON stated residents should have a side rail assessment completed at least quarterly, according to the MDS calendar. The ADON said the MDS Coordinator was responsible for determining if there was continued need for side rails. During an interview on 05/07/2025 at 10:38 AM, the MDS Coordinator stated the admitting nurse completed residents' initial side rail assessments and obtained consent from the residents or their representatives. Per the MDS Coordinator, the facility provided quarter side rails to help with turning and repositioning. She stated nurses must complete annual and quarterly assessments for the continued use of the side rails. During an interview on 05/07/2025 at 1:29 PM, the Director of Nursing confirmed the facility had not completed side rails assessments for Residents #9, #24, and #54. She stated the facility changed electronic medical record systems and the MDS Coordinator informed her the assessments had not been triggered in the current system. During an interview on 05/08/2025 at 9:15 AM, the Medical Director (MD) stated residents used side rails for turning and positioning. The MD stated the residents should be assessed at least quarterly to ensure the continued use of the rails was necessary. During an interview on 05/08/2025 at 10:39 AM, the Administrator stated the residents could use the side rails for repositioning themselves in bed. The Administrator stated his expectations were nurses would ensure consents were completed prior to installing side rails, and staff would complete quarterly assessments related to the continued use of side rails.

Based on observation, interview, record review, and facility policy review, the facility failed to store continuous positive airway pressure (CPAP) masks in a manner that limited the spread of infection for 2 (Resident #22 and Resident #47) of 2 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, CPAP/BiPAP [bilevel positive airway pressure] Support, revised 03/2015, revealed, General Guidelines for Cleaning, that specified, 9. Storage of equipment: Head gear/mask/nasal pillows when not in use will be stored in a bag labeled with date and changed weekly. 1. An Admission Record revealed the facility admitted Resident #22 on 03/05/2025. According to the Admission Record, the resident had a medical history that included diagnoses of cancer of the left bronchus or lung, obstructive sleep apnea, and shortness of breath. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2025, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #22 received intermittent oxygen therapy and utilized a CPAP machine as a non-invasive mechanical ventilator. Resident #22's Care Plan Report, included a focus area initiated 03/06/2025, that indicated the resident was at risk of complications with the respiratory system due to lung cancer with shortness of breath and sleep apnea. Interventions directed staff to provide CPAP as ordered (initiated 03/06/2025). Resident #22's Order Summary Report, revealed an order dated 03/05/2025, for CPAP/BiPAP at bedtime for sleep apnea. An observation on 05/05/2025 at 2:07 PM revealed Resident #22's CPAP mask was on top of the dresser next to the resident's bed. The CPAP mask was not in a bag, and it was in direct contact with the surface of the dresser. An observation on 05/06/2025 at 8:49 AM revealed Resident #22's CPAP equipment, including the CPAP mask and tubing, was on top of the dresser. The CPAP mask was uncovered and was placed directly on the top of the dresser. 2. An Admission Record revealed the facility admitted Resident #47 on 03/10/2025. According to the Admission Record, the resident had a medical history that included diagnoses of asthma, obstructive sleep apnea, atelectasis (collapsed lung), and shortness of breath. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2025, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #47 utilized a CPAP machine as a non-invasive mechanical ventilator. Resident #47's Care Plan Report, included a focus area initiated 03/22/2025, that indicated the resident had CIPAP/BiPAP therapy related to obstructive sleep apnea. Interventions directed staff to provide CPAP at the setting of 7-20 (initiated 03/22/2025). Resident #47's Order Summary Report, revealed an order dated 03/10/2025, for CPAP/BiPAP at bedtime for sleep apnea. An observation on 05/05/2025 at 11:46 AM revealed Resident #47's CPAP machine was on the dresser on the right side of the bed. The mask and tubing were uncovered and rested on the top surface of the dresser. An observation on 05/06/2025 at 8:47 AM revealed the CPAP mask was uncovered, on top of Resident #47's dresser. During an interview on 05/07/2025 at 12:08 PM, Licensed Vocational Nurse (LVN) #2 stated she was currently assigned to Resident #47, and also cared for the resident on 05/06/2025. LVN #2 confirmed the resident's CPAP mask should be stored in a bag. LVN #2 said the night shift nurse was responsible for ensuring CPAP equipment was stored properly. During an interview on 05/07/2025 at 10:00 AM, Certified Nurse Assistant (CNA) #1 stated that when residents finished using their CPAP machines, the equipment should be kept in a bag. CNA #1 stated nurses were responsible for ensuring CPAP masks were placed inside bags. During an interview on 05/07/2025 at 10:11 AM, the Assistant Director of Nursing (ADON) stated nursing staff should ensure CPAP masks and tubing were stored in bags after use. She stated masks should not be left on the top of residents' dressers without being placed in bags related to infection control practice, as they could get dirty or fall to the floor. During an interview on 05/07/2025 at 11:53 AM, the Infection Preventionist (IP) confirmed that a CPAP mask should not be uncovered on a resident's dresser. The IP stated CPAP masks should be placed inside dated bags which were hung on the CPAP machines. The IP stated the date should reflect when the mask was last cleaned. The IP stated she previously had to redirect staff regarding not leaving CPAP masks on dressers to ensure masks did not fall to the floor or get dirt or debris inside them. During an interview on 05/08/2025 at 7:13 AM, LVN #3 stated that after a resident had completed using the CPAP machine, the mask should be cleaned and placed inside a bag. During an interview on 05/08/2025 at 10:07 AM, the Director of Nursing (DON) stated the expectation was nurses would place CPAP masks in bags after use. The DON stated bags should be dated and changed every week and as needed. The DON said if CNAs noticed that a mask was not in a bag, they should place it in a bag for infection control. During an interview on 05/08/2025 at 10:53 AM, the Administrator stated staff thought the respiratory therapist was responsible for placing CPAP equipment into a bag. The Administrator stated the facility staff dropped the ball and did not ensure the CPAP equipment was placed in bags and dated.

Based on interview, record review, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) was accurately coded regarding a feeding tube for 1 (Resident #2) of 2 sampled residents reviewed for tube feeding. Findings included: A facility policy titled, Resident Assessments, revised 10/2023, revealed, 10. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline. 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessment will consistently reflect information in the progress notes, plans of care, and resident observation/interviews. An Admission Record indicated the facility admitted Resident #2 on 01/06/2024. According to the Admission Record, the resident had a medical history that included diagnoses of malignant neoplasm (cancer) of the tongue, irritative hyperplasia (overgrowth of cells due to chronic irritation) of the oral mucosa, moderate protein calorie malnutrition, dysphagia (difficulty swallowing), and gastrostomy (a surgical procedure to create an opening in the stomach, through which food and medication are administered). Resident #2's Order Listing, revealed the resident's enteral feeding order was discontinued on 10/09/2024. Resident #2's medication administration record for the timeframe from 01/01/2025 through 01/31/2025, revealed no evidence to indicate the resident received nutrition by way of a feeding tube. A quarterly MDS, with an Assessment Reference Date (ARD) of 01/11/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition The MDS indicated that the resident had a feeding tube and received 50% or more of their total calories and 500 cubic centimeters per day or less of fluids through a tube feeding. During an interview on 05/06/2025 at 11:14 AM, Resident #2 stated they no longer had a feeding tube. Licensed Vocational Nurse #5 verified Resident #2's feeding tube was removed on 10/02/2024 and since then, the resident received nutrition orally. During an interview on 05/06/2025 at 11:44 AM, the MDS Coordinator reviewed Resident #2's electronic medical record and verified the resident's quarterly MDS with an ARD of 01/11/2025 should not indicate the resident received a tube feeding. During an interview on 05/06/2025 at 11:55 AM, the Registered Dietician stated Resident #2's quarterly MDS should not show the resident received a tube feeding. During an interview on 05/08/2025 at 9:50 AM, the Director of Nursing (DON) stated she expected all staff members who completed sections of the MDS to collect and include all data, to ensure the MDS was completed and accurate. The DON stated Resident #2's feeding tube was pulled out and not replaced, per the resident's request. The DON reviewed Resident #2's MDS with an ARD of 01/11/2025 and stated the MDS should not reflect that the resident received nutrition from a feeding tube. During an interview on 05/08/2025 at 10:31 AM, the Administrator stated he expected MDS to be accurate.

Based on observation, interview, and record review, the facility failed to keep room temperatures between 71 F and 81 F for four of six sampled residents (1, 2, 3, 4). As a result, residents felt uncomfortably cold. Findings: On 4/8/25 at 10:20 A.M., an interview and observation of resident room temperatures was conducted with the Maintenance Director (MD). The room temperatures read 64 F, 68 F, 69 F, 68 F, 72 F, and 72 F. The MD stated, resident rooms should have been between 71 F and 81 F. On 4/8/25 at 10:28 A.M., an interview was conducted with Resident 1 (room temperature 64). Resident 1 stated he felt that his room was too cold. On 4/8/25 at 10:33 A.M., an interview was conducted with the Responsible Party of Resident 2 (RP 2). RP 2 stated, he thought that Resident 2's room was too cold for her. RP 2 further stated, he visited Resident 2 regularly, and she often complained to him that the room was too cold. Per the facility's policy, titled Homelike Environment, revised February 2021, .The facility staff and management maximizes .the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .comfortable and safe temperatures (71 F - 81 F) .

Based on interview and record review, the facility failed to ensure resident records for a resident who left the facility against medical advice (AMA) was accurate and complete for one of two residents (Resident 5) reviewed for complete medical record when: 1. There was no documentation regarding Resident 5 ' s AMA and physician notification. 2. The hospital discharge medication list for Resident 5 was not accurately transcribed. These failures had the potential to cause miscommunication among care providers affecting residents ' treatment and safety, and use of unnecessary medication for the residents. Findings: On 10/10/24 at 9 A.M., an unannounced onsite visit at the facility was conducted related to a complaint. 1. Resident 5 was admitted to the facility on [DATE] with diagnoses including hepatic encephalopathy (brain dysfunction due to liver disease) according to the facility ' s Admission Record. During a review of progress notes (PN) for Resident 5 dated 9/28/24 at ., the PN indicated, .AMA. The PN did not have information regarding events leading to the AMA and there was no documented physician notification. An interview and concurrent record review of Resident 5 ' s progress notes was conducted with the social service director (SSD) on 10/10/24 at 11:34 A.M. The SSD stated she and the facility ' s case manager were assigned to coordinate discharge planning for resident. The SSD reviewed the PN for Resident 5 and stated the PN for Resident 5 indicated, .9/27/24 .Pt [patient] reported to this SN (skilled nurse) that she had an uncomfortable conversation with Dr. [NAME] at bedside early in the morning . The SSD stated the PN on 9/27/24 did not indicate the incident of Resident 5 leaving AMA or physician notification. The SSD stated the progress notes should have a reason why Resident 5 requested to leave AMA, what the facility can address, educate Resident 5 of risks and a physician notification. The SSD further stated it was important to have complete documentation for communication purposes and to know what transcribed on 9/27/24. On 10/10/24 at 11:57 A.M. a concurrent record review and interview was conducted with licensed nurse (LN) 3. LN 3 stated on 9/27/24 he saw Resident 5 walk out of her room carrying some of her belongings. LN 3 stated he walked with Resident 5 to the lobby and Resident 5 sat on a chair. LN 3 stated he was notified by Resident 5 that she was ready to go home, and her wife will take care of everything. LN 3 reviewed Resident 5 ' s PN and stated he did not document the conversation with Resident 5 and that Resident 5 left the facility AMA. LN 3 further stated there was no physician notification documented. During an interview and concurrent record review on 10/10/24 at 12:15 P.M. with registered nurse supervisor (RNS), the RNS stated she was at the back station when the director of staff development (DSD- a licensed nurse certified for staff training) notified her that Resident 5 wanted to leave. The RNS stated she went to the front station and saw Resident 5 at the nurse ' s station. The RNS stated Resident 5 told her she was leaving because she can walk and take care of herself. The RNS reviewed Resident 5 ' s PN. The RNS stated she did not document the conversation with Resident 5 and there was no physician notification documented. The RNS stated a complete documentation was needed for reference. The RNS further stated if documentation was not complete, there will be no clear picture of what happened to the resident. 2. During a review of Resident 5 ' s hospital record titled, Discharge Summary, date 9/25/24, the discharge summary indicated a list of medications for Resident 5 upon discharge from the hospital. On page four through six of the discharge summary titled .Discharge Medications . Discontinued Medications . indicated, .spironolactone (a medication that helps the body get rid of excess fluid and salt by having an increased release of urine) 25 mg (milligram) tablet . Page 23-24 of the discharge summary indicated, .spironolactone . 25mg . 9/19/24 0904 (9:04 A.M.) Held by provider .9/19/24 0930 (9:30 A.M.) Dose Auto Held .9/20/24 0900 (9:00 A.M.) Dose Auto Held . 9/21/24 0900 Dose Auto Held . 9/22/24 0900 Dose Auto Held . A review of the facility ' s physician ' s orders for Resident 5 was conducted. The facility ' s physician ' s orders titled, Order Summary Report, indicated, . Active Orders As Of: 09/25/24 . Spironolactone Oral Tablet 25 MG . Give 1 tablet by mouth one time a day . A telephone interview conducted on 10/11/24 at 1:07 p.m. with the RNS to verify Resident 5 ' s admission orders and hospital discharge medications. The RNS stated she did not know how to view admission orders for Resident 5 in the electronic medical record because Resident 5 was already discharged from the facility. A telephone interview was conducted on 10/11/24 at 1:30 p.m. with the DSD. The DSD stated she had the copies of the hospital discharge summary and admission orders for Resident 5.The DSD stated licensed nurses were responsible for reviewing residents ' medications from the hospital and then transcribe them as admission orders at the facility. The DSD stated she reviewed the copies of Resident 5 ' s hospital discharge summary and Resident 5 was taking spironolactone at the hospital. The DSD stated she did not see the discontinued medication list on the discharge summary. An interview with the Director of Nurses (DON) was conducted on 10/10/24 at 3:13 P.M. The DON stated it was important to provide a proper discharge for residents and document in the resident ' s record as evidence of conversation with the resident and the physician. The DON further stated DON stated medications were reconciled upon resident ' s admission to the facility to avoid errors and ensure accuracy of medications. A review of the facility ' s policy and procedure (P&P) titled, Discharging a Resident without a Physician ' s Approval, dated October 2022 was conducted. The P&P indicated, . Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident ' s attending physician is promptly notified . During a review of the facility ' s P&P titled, Charting and Documentation, dated July 2017, the P&P indicated, . The medical record should facilitate communication between interdisciplinary team [IDT: team members with various areas of expertise who work together toward the goals of their residents] regarding the resident ' s condition and response to care . The following information is to be documented in the resident medical record . Events, incidents or accidents involving the resident . A review of the facility ' s policy and procedure (P&P) titled, Reconciliation of Medications on Admission, dated July 2017 was conducted. The P&P indicated, . Purpose . to ensure medication safety by accurately accounting for the resident ' s medications, routes and dosages upon admission . Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications .

Based on interview and record review, the facility failed to ensure one resident (1) and their responsible party (RP) was informed of charges for Medicare and non-Medicare-covered services, per policy, at admission and did not provide a breakdown of charges at RP request for continued physical and occupational therapy services after benefit exhaustion. This deficient practice placed Resident 1 and the RP at risk of being uniformed of charges and obligations leading to undue hardship. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of a fracture to the right fibula (one of two bones, between the knee and the ankle, that support the body) and fracture of the right patella (a bone at the kneecap that protects the joint and aids in muscle movement) per the facility admission record. A review of the facility's document titled Eligibility Coverage Detail Report dated 3/14/24, indicated Resident 1 received Medicare benefits that were active through a Medicare Advantage plan. A review of the document dated 6/21/24 titled Notice of Denial of Medical Coverage, sent to the facility by Resident 1's insurance company, indicated Resident 1's skilled nursing facility (SNF) benefit coverage would end for Resident 1 on 6/23/24. A review of Resident 1 ' s order summary report, order date range: 03/01/2024 - 09/30/2024, indicated Resident 1 had physical therapy services ordered five to six times a week for the period of 3/15/24 - 8/26/24, and occupational therapy services ordered five times a week for the periods of 3/15/24 - 7/29/24, and 8/22/24 -9/19/24. On 9/6/24 at 1:27 PM, an interview and record review were conducted with the facility ' s business office manager (BOM). The BOM stated residents and/or their RP are provided with written financial information about Medicare-covered services on admission to the facility. The BOM stated if a resident has insurance managed by an HMO (Health Maintenance Organization, an insurance group that provides health services for a fixed annual fee) the resident will receive a breakdown of any copay obligations and non-covered services in writing as part of the written admission agreement which was reviewed and signed by with the resident and/or RP. The BOM stated a copy of the financial breakdown was given to the Admissions Director (AD) to include in the admissions packet to be reviewed and signed by the resident and/or RP. The BOM stated Resident 1 should have received a written breakdown of coverage and copay obligations with the admissions packet. On 9/18/24 at 1:47 P.M., an interview and concurrent record review of Resident 1's clinical record was conducted with the AD. The AD stated the admissions packet and accompanying financial breakdown of coverage from the business office was not provided to or signed by Resident 1 and/or RP. A review of Resident 1's clinical record indicated the facility had no evidence of a signed admissions packet for Resident 1. The AD stated he runs a monthly quality assurance performance improvement (QAPI) program report that indicates the names of residents who have not had an admissions packet reviewed and signed. The AD stated Resident 1 had been listed on the QAPI report for incomplete admissions packet review since March 2023 The AD stated the admission packet reviewed financial obligations, resident rights, and facility accommodations. The AD stated if the admissions packet was not signed and uploaded to the electronic health record, it was not completed. The AD acknowledged Resident 1, and the RP were not informed of resident rights and financial obligations at the time of admission, and they should have been. On 9/18/24 at 2:24 P.M., a subsequent interview and record review was conducted with the BOM at the facility. The BOM stated a few days before resident's skilled nursing facility (SNF) benefit became exhausted, the facility would inform the resident and/or RP that Medicare-covered services would be ending, and the resident would be charged as private pay if they did not have secondary insurance coverage. The BOM stated if the resident/RP requested to continue non-covered treatment services, they would receive a written financial statement estimating the cost of those charges on a weekly basis. The BOM stated charges for non-Medicare covered physical and occupational therapies were collected one week in advance from the resident/RP before the services were provided. The BOM stated Resident 1's RP requested physical therapy and occupational therapy services to continue following benefit exhaustion on 6/23/24. The BOM stated the facility started to charge Resident 1 for physical and occupational therapy services on 7/1/24. A review of the facility document titled Transaction Report Effective Date May 1, 2024- [DATE] printed 9/18/24, indicated one check for $2,400 on 6/28/24 and a second check for $1,100, on 8/11/24, was provided to the facility by Resident 1's RP for physical and occupational services. A review of the letter provided to the RP from the BOM, regarding physical and occupational therapy charges, dated 8/12/24, was conducted with the BOM. The BOM stated the resident and RP had not been provided with written information regarding payment and charges for skilled physical and occupational therapy services prior to this letter. On 9/27/24 at 11:54 A.M., an interview with the director of nursing (DON) was conducted. The DON stated it was the expectation that residents are given written financial information upon admission regarding covered services and share of cost by the business office. The DON stated the expectation was that the admission packet, which included the financial information provided by the BOM, was reviewed and signed by the resident or the RP. On 9/27/24 at 12:05 P.M. a concurrent interview was conducted with the DON and the administrator (ADMIN). The ADMIN stated it was facility practice to provide a pricing sheet to the resident or RP for services requested not covered by insurance before those services were provided. The ADMIN stated a written estimate for those services should be provided prior to the services starting. The ADMIN stated he could see how it would create a financially unfair situation to the resident and RP if a cost estimate of uncovered services was not provided before receiving those services. The ADMIN acknowledged Resident 1 and RP was not provided written financial information regarding the cost of covered and non-covered services at admission or before non-covered physical and occupational therapy services were requested to continue. A review of the facility policy, revised March 2019, titled Admission Criteria indicated, . Policy Interpretation and Implementation 1. The objectives of our admission criteria policy are to . d. review with the resident, and/or his/her representative, the facility's policies and procedures relating to resident rights, resident care, financial obligations .

Based on interview and record reviews, the facility failed to consistently document a change of condition assessment for two of three residents reviewed for changes in condition. (Resident 6 and Resident 7) This failure had the potential to promptly identify and delay the necessary treatments for the residents ' declining condition. Findings: 1. Resident 6 was readmitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack) and cerebrovascular disease (stroke) according to the facility ' s Admission Record. Resident 6 was discharged to the hospital on 1/10/24 according to the facility ' s Progress Notes (PN) dated 1/10/24. During an interview on 3/7/24, at 9:50 A.M. with Licensed Nurse (LN) 2, LN 2stated it was facility policy to notify the attending physician for a resident ' s change in condition. LN 2 stated an assessment of the resident will be conducted prior to calling the physician and the resident will be monitored every shift for 72 hours. During an interview on 3/7/24, at 10:02 A.M. with LN 1, LN 1 stated a resident who was not feeling well was considered a change in condition. LN1stated vital signs (the body ' s temperature, heart rate, respirations and blood pressure) will be taken, the physician will be notified and an SBAR (situation, background, assessment, recommendation- a communication tool used during crucial situations) change in condition will be created in the resident ' s EMR (electronic medical record). LN 2 further stated the resident with a change in condition should be monitored every shift for 72 hours and documented in the progress notes. A review of the facility ' s PN for Resident 6 was reviewed. The PN dated 1/2/24, 8:47 A.M., the PN indicated, .Note Text: resident with episode of vomiting . PN dated 1/2/24, 10:15 A.M. indicated, .change in condition . Resident with x 1 episode of vomiting before breakfast, unable to take all due medications and did not want to have breakfast .Blood Pressure 96/56 . PN dated 1/2/23, 11:02 P.M. indicated to continue intravenous hydration due to elevated BUN (blood urea nitrogen- blood test to check kidney function). There was no PN documented regarding Resident 6 ' s change in condition on 1/3/24 A.M. shift and on 1/4/24 A.M. shift. During a review of PN dated 1/7/24 written at 7:48 P.M., the PN indicated LN 3 documented Resident 6 had, Increased confusion and does not make eye contact. During a phone interview on 3/12/24, at 12:52 P.M. with LN 3, LN3 stated a change in Resident 6 ' s condition must have an entry for every shift charting for monitoring. LN 3 reviewed Resident 6 ' s PN and stated that every shift charting was not completed for 1/7/24 on night shift, 1/8/24 all shifts, and 1/9/24 all shifts. LN 3 further stated Resident 6 had another change in condition on 1/10/24 and was sent out to the hospital. 2. Resident 7 was readmitted to the facility on [DATE] with diagnoses including pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit according to the facility ' s Admission Record. During a review of the facility ' s PN for Resident 7, the PN indicated a change in condition documentation dated 1/10/24, 3:14 P.M. The PN indicated .Observe resident blood dripping from the nose . There was no assessment of Resident 7 ' s condition in the PN for A.M. shift on 1/11/24. On 1/11/24, 9:52 P.M. the PN indicated Resident 7 ' s lab results were sent to the nurse practitioner. The PN indicated the nurse practitioner ordered iron and intravenous (IV-into the vein) hydration and blood draw. On 1/12/24, 1:54 A.M. the PN indicated Resident 7 had abnormal lab results. There were no assessments of Resident 7 ' s change in condition that were documented on the PN for 1/12/24 for the A.M. and P.M. shift. During a review of the facility ' s PN for 1/13/24, there were no assessments of Resident 7 ' s change in condition for the A.M. and P.M. shifts. On 1/14/24 2:07 A.M. the PN indicated Resident 7 had difficulty breathing with oxygen level that dropped from 89% to 79% (how well the lungs are working with normal range of 95-100%). The PN further indicated 911 was called and Resident 7 was sent out to hospital. An interview with the Director of Nursing (DON) was conducted on 3/18/24, at 12:15 P.M. The DON stated it was his expectation for nursing staff to complete an alert charting every shift for 72 hours for residents with changes in condition. The DON stated the physician may have orders in which nursing staff would have to follow and monitor for worsening of the resident ' s condition. During a review of the facility ' s policy and procedure (P&P) titled Change in a Resident ' s Condition or Status, dated February 2021, the P&P did not provide guidance to staff regarding the expectation and frequency of assessing a resident with a change in condition.

Based on interview and record review, the facility failed to hold a blood pressure (BP) medication as prescribed by the physician for one resident (Resident 1) with a low BP. As a result, Resident 1's BP had the potential to further decrease below normal and increase the risk of harmful side effects. Findings: Resident 1 was admitted to the facility on [DATE] with heart failure (a condition where the heart dose not pump enough oxygen rich blood to the body), per the resident's admission record. A review of Resident 1's physician orders, active January 2024, indicated Resident 1 was prescribed one 25 milligram (mg) tablet of metoprolol (a medication used to decrease blood pressure and heart rate) two times a day for hypertension (high blood pressure). The physician's order indicated instructions to hold the metoprolol if Resident 1's systolic blood pressure (SBP, the number of the BP reading that indicates the pressure on the blood vessels when it contracts) number was below 110 or heart rate below 60. On 2/14/24 at 3:10 P.M., an interview and concurrent record review was conducted with the infection preventionist/Licensed Nurse (IP/LN). Resident 1's medication administration record (MAR) was reviewed with IP/LN. The IP/LN stated the physician's administration instructions on the MAR indicated Resident 1's metoprolol should held if the SBP reading was below 110. The MAR indicated the IP/LN had documented Resident 1's BP was 102/86 on 1/24/24 at 9:00 A.M., and that she had administered one 25 mg tablet of metoprolol to Resident 1. The IP/LN stated she should not have given Resident 1 the metoprolol on 1/24/24 because his BP was below 110. The IP/LN stated it was important to check physician orders before administering medication because if it is given when it should not be it could cause harm to the resident. A record review was conducted of Resident 1's January 2024 MAR. The MAR indicated Resident 1 was administered one tablet of metoprolol 25mg when his SBP was below 110 on the following dates: 1/5/24 at 9:00 A.M., BP 109/59 admin by LN 31/8/24 at 5:00 P.M., BP 94/64 admin by LN 41/14/24 at 9:00 A.M., BP 97/53 admin by LN 31/24/24 at 9:00 A.M., BP 102/86 admin by IP/LN On 2/24/24 at 3:20 P.M., an interview and concurrent record review of Resident 1's January MAR was conducted with the director of nursing (DON). The DON stated the LN's should have known to check Resident 1's BP against the physician's order instructions for metoprolol. The DON stated Resident 1 should not have received metoprolol if his SBP was under 110. A review of the facility policy titled, Medication and Treatment Orders, revised July 2016, did not address withholding resident medications under physician's ordered parameters.

Based on interview and record review, the facility failed to employ a qualified full time Infection Preventionist (IP, the person(s) designated by the facility to be responsible for the infection prevention and control program) with primary professional training, education, and experience as a Licensed Nurse. This failure had the potential to compromise the facility's ability to maintain a safe and effective infection prevention and control program (IPCP) for all residents residing in the facility. Findings: On 11/28/23 at 12:17 PM an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the facility's current infection preventionist was IP/CNA (certified nursing assistant). On 11/28/23 at 1:36 PM an interview was conducted with the IP/CNA. The IP/CNA stated she had been working in role of IP since May 2023. The IP stated she was responsible for educating staff on infection control practices and transmission-based precautions as well as the monitoring and reporting of disease outbreaks in the facility. The IP/CNA stated she had worked in the facility as a Certified Nursing Assistant (CNA) and a Unit Clerk prior to being hired in the IP role. The IP/CNA stated she was not a licensed nurse and had not completed primary professional training in nursing. The IP stated she was responsible for updating residents' vaccine status on the CAIR (California Immunization Registry) website but because she was not a licensed provider, she had to use the previous infection preventionist's login information to sign on. On 11/28/23 at 2:29 PM an interview with the director of nursing (DON) was conducted. The DON stated the IP was hired in the role of infection preventionist in May 2023. The DON stated the IP was not a licensed nurse and had not completed primary professional training or earned an advanced degree in another health-related field. The DON stated he oversaw the clinical side of the infection prevention control program and that he fulfilled any clinical duties in the role. A record review of the facility's job description, titled Infection Control Nurse was conducted. The job description was signed by the IP on 7/4/22, which indicated, .Must maintain all required continuing education for licensing. Must remain in good standing with the State Board of Nursing at all times . On 5/11/23, A review of the All Facilities letter (AFL 21-51), dated December 13, 2021, titled Assembly [NAME] (AB) 1585 - Expansion of SNF (skilled nursing facility) Infection Preventionist (IP) Minimum Qualifications, indicated, Effective January 1, 2022, AB 1585 expands existing eligibility and minimum qualifications for a SNF's IP. The IP must have primary professional training as a licensed nurse, medical technologist, microbiologist, epidemiologist .

Based on observation, interview, and record review, the facility failed to ensure the safety for one of three sampled residents (Resident 1) when: 1a. Resident 1 was left unsupervised, eating in the dining room. 1 b.Resident 1 was left unsupervised in her wheelchair in the hallway. These failures had the potential to cause harm and affect the Resident 1 ' s well-being. Findings: 1a. A review of Resident 1 ' s admission record indicated, Resident 1 was admitted to the facility on [DATE] with medical diagnoses of dysphagia (inability to swallow). Alzheimer ' s disease (altered memory). A review of Resident 1's minimum data set (MDS- an assessment tool) dated 7/4/23 indicated, Resident 1's BIM's score summary was 2 which meant, the resident was unable to complete the interview. The same MDS assessment, under Functional status indicated, Resident 1 required staff supervision with eating. An observation was conducted on 6/8/23 at 1:25 P.M. in the facility dining room. Resident 1 was observed eating her pureed (ground pressed) food unsupervised. An interview and record review was conducted on 6/8/23 at 1:29 P.M. with certified nursing assistant (CNA 2). CNA 2 stated Resident 1 should have been supervised while eating to prevent her from choking. A review of Resident 1 ' s meal ticket (meal information) indicated, Feeding supervision with assistance. An interview was conducted with licensed nurse (LN 2) on 6/8/23 at 2:17 P.M. LN 2 stated Resident 1 should have been supervised while eating to monitor for safety. During an interview on 7/20/23 at 2:34 P.M. with the Director of Nursing (DON), the DON stated residents who required attention in the dining room should be supervised for safety. A review of the facility ' s policy titled, Assistance with Meals, (revised 3/2022), indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff will serve resident trays and will help residents who require assistance with eating. 1b. A review of Resident 1 ' s minimum data set (MDS, an assessment tool) assessment dated [DATE] indicated, Resident 1's BIM's score summary was 2 which meant, the resident was unable to complete the interview. The same MDS assessment indicated, Resident 1 ' s functional status on locomotion off unit (areas set aside for dining, activities or treatments) required one-person physical assist. A phone interview conducted on 6/26/23 at 3:21 P.M., with the facility housekeeper (FHK). The FHK stated Resident 1 was wheeling herself back to her bedroom without supervision from the nursing staff on 6/6/23 between 6:00 P.M. -6:30 P.M. The FHK stated he wheeled Resident 1 inside her bedroom because there was no nursing staff available. The FHK further stated assisting residents in wheelchair was not part of his job description and he should have informed qualified staff that Resident 1 needed transfer assistance. An interview was conducted on 7/20/23 at 2:35 P.M. with the DON. The DON stated qualified facility staff may have been busy on the evening of 6/6/23 and failed to supervise the transfer needs of Resident 1. A review of facility ' s Job description: Housekeeper (undated) indicated Notify the Director of Housekeeping, Administrator, or Director of Nursing immediately regarding safety issues or concerns.

Based on interview and record review, the facility failed to monitor and provide bowel management (process an impaired person uses to control his defecation) to one of three residents (Resident 1). This failure had the potential to cause discomfort and progression of bowel complications. Findings: A review of Resident 1 ' s face sheet (document that gives patient information) indicated she was admitted to the facility on [DATE] with medical diagnoses of fracture of left ulna (one of the two bones in the left forearm), dementia (impaired memory and thinking), muscle weakness. An interview conducted with licensed nurse (LN A) on 5/10/23 at 10:13 A.M. LN A stated residents who did not have bowel movement for three days should be given the bowel protocol (routine mediations to move bowel). A record review of Resident 1 ' s activities of daily living (ADL, refers to people ' s daily self-care activities) charting with the LN A on 5/10/23 at 10:30 A.M indicated, Resident 1 did not have a bowel movement from 4/19/23 to 4/25/23. There was no evidence Resident 1 refused her medications after 4/20/23. A concurrent interview with LN A confirmed Resident 1 should have been offered and given the bowel protocol. Review of the facility ' s policy Bowel Management Protocol dated indicated The 3-11 House Supervisor will review the resident flow record and compose a list of those residents not having a bowel movement in 3 days. 6. The 3-11 nurse will provide medication as ordered by the physician or obtain a physician ' s order. The medication could consist of a. suppository b. Milk of Magnesia 30-60 cc c. Lactulose.

Based on observation, interview and record review, the facility failed to ensure personal privacy was maintained to one of three residents (Resident 1) when Resident 1 ' s incontinence (lack of control over urination and defecation) brief, foley catheter tubing, and drainage bag (tubing inserted into the bladder attached to a bag to collect urine) were exposed to the public walking in the facility hallway. This failure had the potential to affect the resident ' s wellbeing. Findings: Review of Resident 1 ' s face sheet indicated she was admitted on [DATE] with diagnoses including hemiplegia (inability to move one part of the body) cognitive communication deficit (difficulty with thinking and expressing oneself), cerebral infarction (blockage in the brain) neurogenic bladder (lack of bladder control due to brain problem. Review of Resident 1 ' s minimum data assessment (MDS, an assessment tool) indicated she was cognitively impaired. An observation was conducted on 4/17/23 at 10:15 A.M. in the facility hallway. Resident 1 was lying in bed inside her room, and bed close to the door. Her gown was observed pulled upwards exposing her bilateral legs, incontinence brief, foley catheter with a urine drainage bag hanging by the side of her bed. On 4/17/23 at 10:23 A.M., an interview with licensed nurse (LN A) was conducted. LN A stated Resident 1 was dependent to staff for care. LN A confirmed the above observation and stated the resident should have been covered to avoid exposure of her incontinence brief including the foley catheter tubing and the urinary drainage. An interview with the director of nursing (DON) was conducted on 4/17/23 at 1:45 P.M. The DON stated all residents should be treated with dignity by protecting their privacy and preserving their dignity regardless of their mental status. Review of the facility ' s policy Dignity revised February 2021 indicated Resident are always treated with dignity and respect. Staff promote, maintain and protect resident privacy including bodily privacy. Staff are expected to promote dignity and assist residents; for example: keep the urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to develop and implement a care plan for elopement (a form of unsupervised wandering that leads to a resident leaving the facility without staff being aware), for one of four residents (Resident 1) reviewed for accidents. As a result, Resident 1 was at risk, when a plan of care with interventions was not developed to prevent future elopements. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included traumatic subarachnoid hemorrhage (bleeding in the brain), cognitive communication deficit (difficulty with thinking and communicating), and abnormal gait and mobility (when a person is unable to walk the usual way), per the facility ' s Admission Record. On 3/7/23 at 4:25 P.M., an interview was conducted with the complainant. The complainant stated he left his local church on 3/6/23 around 10:30 P.M., and while driving home when he noticed an elderly man in a wheelchair, wheeling himself slowly down a sidewalk. The complainant stated the man was not dressed appropriately for the cold weather, so he stopped his vehicle to inquire. The complainant stated the elderly man seemed confused and disoriented, saying he was going to church. The complainant stated he was aware a nursing home was nearby, up a hill and adjacent to the church, so he wheeled the elderly man back to the facility. On 3/14/23 at 11:35 A.M. and observation and interview was conducted with Resident 1 as he laid in bed. Resident 1 could not recall leaving the facility or anyone bringing him back. On 3/14/23, Resident 1 ' s clinical record was reviewed: According to Minimum Data Set (a clinical assessment tool) dated 2/21/23, Resident 1 had a cognitive score of 7, indicating severe impaired cognition. The Functional Status indicated a one-person staff assist was required for transferring, dressing, and toiletry for Resident 1. There was no documented evidence of the elopement in the nursing Progress Notes after the resident was returned. There was no documented evidence an Interdisciplinary Team (IDT-team member from different disciplines working together to set goals and to make decisions involving resident care), was conducted after the elopement was reported. According to the facility ' s quarterly Wandering Risk Observation/Assessment evaluations, dated 1/8/23, Resident 1 was scored at 9, indicated At risk to Wander. There was no documented evidence a care plan or other interventions were in place to prevent an elopement. On 3/14/23 at 1:04 P.M., an interview was conducted with the ADON. The ADON stated when Resident 1 was returned to the facility on the evening of 3/6/23, he informed the Director of Nursing (DON) of the elopement via text and asked what procedures should he followed regarding Resident 1 ' s elopement. The ADON stated he was instructed to complete a Change of Condition form and notify the physician and family. The ADON stated he was unaware he should have completed a care plan for an actual elopement. The ADON was unaware if an IDT conference had been conducted to prevent Resident 1 from future elopements. On 3/14/23 at 1:18 P.M., an interview was conducted with Licensed Nurse 3 (LN 3). LN 3 stated care plans were started as a baseline (to outline a process for development of an initial person-centered care plan withing 48 hours of admission, that will provide instructions for care) and then added on later to the care plan. new problems when identified. LN 3 stated once a problem had been identified, interventions needed to be put in place, so staff were consistently providing care and treating the problem. On 3/14/23 at 1:25 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated if an elopement occurred, a care plan should be developed immediately to prevent additional elopements from occurring. The DSD stated care plans provided a history of events and listed interventions put in place for all staff to apply consistently. The DSD stated if a resident was identified as a potential wanderer or elopement risk during their quarterly assessments, a care plan should have been developed at that time to prevent any future elopements. On 3/14/23 at 1:39 P.M., an interview and record review was conducted with the DON. The DON stated Resident 1 ' s elopement should have been documented and investigated better. The DON stated interventions and a care plan should have been in place before the elopement, because the facility ' s elopement assessment score of 9, identified him as an At risk for wandering. The DON stated by not developing a care plan and having an IDT meeting, Resident 1 ' s safety was at risk. According to the facility ' s policy, titled Care Planning-Interdisciplinary Team, dated March 2022, .2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT) .) Based on observation, interview, and record review, the facility failed to develop and implement a care plan for elopement (a form of unsupervised wandering that leads to a resident leaving the facility without staff being aware), for one of four residents (Resident 1) reviewed for accidents. As a result, Resident 1 was at risk, when a plan of care with interventions was not developed to prevent future elopements. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included traumatic subarachnoid hemorrhage (bleeding in the brain), cognitive communication deficit (difficulty with thinking and communicating), and abnormal gait and mobility (when a person is unable to walk the usual way), per the facility's Admission Record. On 3/7/23 at 4:25 P.M., an interview was conducted with the complainant. The complainant stated he left his local church on 3/6/23 around 10:30 P.M., and while driving home when he noticed an elderly man in a wheelchair, wheeling himself slowly down a sidewalk. The complainant stated the man was not dressed appropriately for the cold weather, so he stopped his vehicle to inquire. The complainant stated the elderly man seemed confused and disoriented, saying he was going to church. The complainant stated he was aware a nursing home was nearby, up a hill and adjacent to the church, so he wheeled the elderly man back to the facility. On 3/14/23 at 11:35 A.M. and observation and interview was conducted with Resident 1 as he laid in bed. Resident 1 could not recall leaving the facility or anyone bringing him back. On 3/14/23, Resident 1's clinical record was reviewed: According to Minimum Data Set (a clinical assessment tool) dated 2/21/23, Resident 1 had a cognitive score of 7, indicating severe impaired cognition. The Functional Status indicated a one-person staff assist was required for transferring, dressing, and toiletry for Resident 1. There was no documented evidence of the elopement in the nursing Progress Notes after the resident was returned. There was no documented evidence an Interdisciplinary Team (IDT-team member from different disciplines working together to set goals and to make decisions involving resident care), was conducted after the elopement was reported. According to the facility's quarterly Wandering Risk Observation/Assessment evaluations, dated 1/8/23, Resident 1 was scored at 9, indicated At risk to Wander. There was no documented evidence a care plan or other interventions were in place to prevent an elopement. On 3/14/23 at 1:04 P.M., an interview was conducted with the ADON. The ADON stated when Resident 1 was returned to the facility on the evening of 3/6/23, he informed the Director of Nursing (DON) of the elopement via text and asked what procedures should he followed regarding Resident 1's elopement. The ADON stated he was instructed to complete a Change of Condition form and notify the physician and family. The ADON stated he was unaware he should have completed a care plan for an actual elopement. The ADON was unaware if an IDT conference had been conducted to prevent Resident 1 from future elopements. On 3/14/23 at 1:18 P.M., an interview was conducted with Licensed Nurse 3 (LN 3). LN 3 stated care plans were started as a baseline (to outline a process for development of an initial person-centered care plan withing 48 hours of admission, that will provide instructions for care) and then added on later to the care plan. new problems when identified. LN 3 stated once a problem had been identified, interventions needed to be put in place, so staff were consistently providing care and treating the problem. On 3/14/23 at 1:25 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated if an elopement occurred, a care plan should be developed immediately to prevent additional elopements from occurring. The DSD stated care plans provided a history of events and listed interventions put in place for all staff to apply consistently. The DSD stated if a resident was identified as a potential wanderer or elopement risk during their quarterly assessments, a care plan should have been developed at that time to prevent any future elopements. On 3/14/23 at 1:39 P.M., an interview and record review was conducted with the DON. The DON stated Resident 1's elopement should have been documented and investigated better. The DON stated interventions and a care plan should have been in place before the elopement, because the facility's elopement assessment score of 9, identified him as an At risk for wandering. The DON stated by not developing a care plan and having an IDT meeting, Resident 1's safety was at risk. According to the facility's policy, titled Care Planning-Interdisciplinary Team, dated March 2022, .2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT) .)

Based on observation, interview, and record review, the facility failed to ensure resident safety after an elopement occurred for one of four residents (Resident 1) reviewed for accidents. As a result, Resident I left the building unnoticed, and was at risk for injuries, falls, and environmental exposure to cold weather. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included traumatic subarachnoid hemorrhage (bleeding in the brain), cognitive communication deficit (difficulty with thinking and communicating), and abnormal gait and mobility (when a person is unable to walk the usual way). On 3/7/23 at 4:25 P.M., an interview was conducted with the complainant. The complainant stated he had left his local church around 10:30 P.M., and while driving he noticed an elderly man in a wheelchair, wheeling himself slowly down a sidewalk. The complainant stated the man was not dressed appropriately for the cold weather, so he stopped his vehicle to inquire. The complainant stated the elderly man seemed confused and disoriented. The complainant stated he was aware a nursing home was nearby, up a hill and adjacent to the church, so he wheeled the elderly man back to the facility. The complainant continued to state he kept ringing the [NAME] outside of the facility until someone came to the door. The complainant, spoke with the Assistant Director of Nursing (ADON) of the facility, who was unaware the resident had been missing. On 3/14/23 at 11:35 A.M. and observation and interview was conducted with Resident 1 as he laid in bed. Resident 1 could not recall leaving the facility or anyone bringing him back. On 3/14/23, Resident 1 ' s clinical record was reviewed: According to Minimum Data Set (a clinical assessment tool) dated 2/21/23, Resident 1 had a cognitive score of 7, which indicated severe impaired cognition. The Functional Status indicated a one-person staff assist was required for transferring, dressing, and toiletry for Resident 1. According to facility ' s Change of Condition note, dated 3/6/23 at 10:35 P.M., Resident found wandering outside of facility . According to the facility ' s quarterly Wandering Risk Observations/Assessments, dated 1/8/23, Resident 1 had a wandering risk score of 9, indicating, At risk to wander. There was no documented evidence a care plan or other interventions were in place to prevent an elopement. On 3/14/23 at 1:04 P.M., an interview was conducted with the ADON. The ADON stated the facility doors were all locked at 7 P.M., for the night. The ADON believed the only way Resident 1 made it outside was through an employee door, near the laundry room in the back. The back door should have alarmed when opened. The ADON stated when Resident 1 was returned by the private citizen, the facility was unaware the resident had been missing. The ADON stated he asked the Director of Nursing (DON) what he should do via text. The ADON stated he was instructed to complete a change of condition form and notify the physician and family. The ADON stated he was unaware he was required to take any other actions related to the incident. On 3/14/23 at 1:25 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the doors were all locked at 7 P.M. The only door left with access was the service entrance that alarms at nursing Station 2. The DSD stated all staff should be aware of the location of their residents. The DSD stated if a resident eloped, the facility was required to look for the resident inside and outside, notify the police, the physician, the residents ' family, the Administrator, the DON, and the California Department of Public Health. On 3/14/23 at 1:39 P.M., an interview and record review was conducted with the DON. The DON stated Resident 1 ' s elopement should have been documented and investigated better. The DON stated interventions and a care plan should have been in place before the elopement, because the facility ' s elopement assessment score of 9, identified him as an At risk for wandering. The DON stated by not developing a care plan or having an IDT meeting, Resident 1 ' s safety was at risk. According to the facility ' s policy, titled Wandering and Elopements, dated March 2019, The facility will identify residents who are at risk of unsafe wandering .1. If identified as at risk for wandering, elopement, or other safety issues, the residents ' care plan will include strategies and interventions to maintain the residents ' safety . Based on observation, interview, and record review, the facility failed to ensure resident safety after an elopement occurred for one of four residents (Resident 1) reviewed for accidents. As a result, Resident I left the building unnoticed, and was at risk for injuries, falls, and environmental exposure to cold weather. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included traumatic subarachnoid hemorrhage (bleeding in the brain), cognitive communication deficit (difficulty with thinking and communicating), and abnormal gait and mobility (when a person is unable to walk the usual way). On 3/7/23 at 4:25 P.M., an interview was conducted with the complainant. The complainant stated he had left his local church around 10:30 P.M., and while driving he noticed an elderly man in a wheelchair, wheeling himself slowly down a sidewalk. The complainant stated the man was not dressed appropriately for the cold weather, so he stopped his vehicle to inquire. The complainant stated the elderly man seemed confused and disoriented. The complainant stated he was aware a nursing home was nearby, up a hill and adjacent to the church, so he wheeled the elderly man back to the facility. The complainant continued to state he kept ringing the [NAME] outside of the facility until someone came to the door. The complainant, spoke with the Assistant Director of Nursing (ADON) of the facility, who was unaware the resident had been missing. On 3/14/23 at 11:35 A.M. and observation and interview was conducted with Resident 1 as he laid in bed. Resident 1 could not recall leaving the facility or anyone bringing him back. On 3/14/23, Resident 1's clinical record was reviewed: According to Minimum Data Set (a clinical assessment tool) dated 2/21/23, Resident 1 had a cognitive score of 7, which indicated severe impaired cognition. The Functional Status indicated a one-person staff assist was required for transferring, dressing, and toiletry for Resident 1. According to facility's Change of Condition note, dated 3/6/23 at 10:35 P.M., Resident found wandering outside of facility . According to the facility's quarterly Wandering Risk Observations/Assessments, dated 1/8/23, Resident 1 had a wandering risk score of 9, indicating, At risk to wander. There was no documented evidence a care plan or other interventions were in place to prevent an elopement. On 3/14/23 at 1:04 P.M., an interview was conducted with the ADON. The ADON stated the facility doors were all locked at 7 P.M., for the night. The ADON believed the only way Resident 1 made it outside was through an employee door, near the laundry room in the back. The back door should have alarmed when opened. The ADON stated when Resident 1 was returned by the private citizen, the facility was unaware the resident had been missing. The ADON stated he asked the Director of Nursing (DON) what he should do via text. The ADON stated he was instructed to complete a change of condition form and notify the physician and family. The ADON stated he was unaware he was required to take any other actions related to the incident. On 3/14/23 at 1:25 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the doors were all locked at 7 P.M. The only door left with access was the service entrance that alarms at nursing Station 2. The DSD stated all staff should be aware of the location of their residents. The DSD stated if a resident eloped, the facility was required to look for the resident inside and outside, notify the police, the physician, the residents' family, the Administrator, the DON, and the California Department of Public Health. On 3/14/23 at 1:39 P.M., an interview and record review was conducted with the DON. The DON stated Resident 1's elopement should have been documented and investigated better. The DON stated interventions and a care plan should have been in place before the elopement, because the facility's elopement assessment score of 9, identified him as an At risk for wandering. The DON stated by not developing a care plan or having an IDT meeting, Resident 1's safety was at risk. According to the facility's policy, titled Wandering and Elopements, dated March 2019, The facility will identify residents who are at risk of unsafe wandering .1. If identified as at risk for wandering, elopement, or other safety issues, the residents' care plan will include strategies and interventions to maintain the residents' safety .

Based on interview and record review, the facility failed to honor and promote a resident's rights for full resuscitation efforts for one of seven residents (Resident 1), reviewed for expiration. As a result, Resident 1's wishes of full resuscitation were not honored or attempted. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture of left pubic hip. On [DATE], Resident 1's clinical record was reviewed: According to the physician orders, dated [DATE], .Full Code (if a person's heart stops, full resuscitative measures are to occur) . According to the Physician Orders for Life-Sustaining Treatment (POLST) form, dated ,d+[DATE], Resident 1 indicated, Attempt resuscitation/CPR, Full Treatment , was checked off. The physician's History and Physical, dated, [DATE], indicated Resident 1, .has the capacity to understand and make decisions . On [DATE] at 9:41 A.M., an interview was conducted with LN 2. LN 2 stated she arrived for work around 7 A.M., on [DATE]. LN 2 stated the CNA's informed her Resident 1 was unresponsive. LN 2 stated she went to Resident 1's room and LN 1 was present. LN 2 stated she asked about Resident's code status and asked someone to go check it in the chart. LN 2 stated Resident 1 was pulseless and had a stiff jaw, when she tried to move it. LN 3 had arrived with the crash cart, and they made the decision to pronounce Resident 1 expired. LN 2 stated CPR was never performed or attempted. On [DATE] at 5:43 A.M., an interview was conducted with LN 1. LN 1 stated on day shift CNA 2 came in early and informed him Resident 1 was unresponsive. LN 1 stated the morning nurse supervisor had arrived and made the decision to pronounce the resident was dead without performing CPR. On [DATE] at 12:48 P.M., an interview was conducted with LN 4. LN 4 stated if a resident was found in full cardiac arrest, she would want to know what the resident's code status was. LN 4 stated if the resident was listed as full code, CPR should be started and 911 needed to be called. LN 4 stated it was the facility's obligation to honor the resident's code preference and every attempt should be made to meet the resident's wishes. On [DATE] at 1:39 A.M., the DON was interviewed. The DON stated since Resident 1 was a full code, he expected LN 1 to initiate CPR, until the physician or two registered nurses arrived to call the code. On [DATE] at 8:05 P.M., an interview was conducted with CNA 2. CNA 2 stated she arrived late on the morning of [DATE]. She was supposed to be at work at 6:30 A.M., and she actually arrived at 6:40 A.M. CNA 2 stated the previous registry (a private company who supplies temporary staff to facilities) CNA for that section was already gone, so she never received report. CNA 2 stated she started doing rounds and found Resident 1 unresponsive. CNA 2 stated she immediately informed the LN, and did not start CPR, because she was unaware of what the residents code status was. The Registry CNA 3 could not be located through the registry company and therefore was unavailable for interview. According to the facility's policy, titled Resident Rights, dated [DATE], .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .g. exercise his or her rights as a resident of the facility .h. be supported by the facility in exercising his or her rights; . 2. In order to facilitate resident choices, the administration and staff will .b. gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; . According to the facility's policy, titled Emergency Procedure-Cardiopulmonary Resuscitation, dated February 2018, .6. If an individual is found unresponsive .licensed staff members who is certified in CPR/BLS shall initiate CPR . 7. If the resident's DNR (do not resuscitate) status is unclear, CPR will be initiated until it is determined that is a DNR or physician's order not to administer CPR .

Based on interview and record review, the facility failed to ensure accurate documentation was completed by a licensed nurse (LN) regarding the events of a cardiac arrest and resuscitation efforts, for one of seven residents (Resident 1) who expired, reviewed for Resident Records. As a result, Resident 1's resuscitative efforts were inaccurate and misleading. Finding: Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture of left pubic (hip), fracture of T5-T8 vertebra (spine, upper back), and multiple fractures of ribs, right side, per the facility's Admission Record. On [DATE], Resident 1's clinical record was reviewed: According to the physician orders, dated [DATE], .Full Code (if a person's heart stops, full resuscitative measures are to occur) . According to the Physician Orders for Life-Sustaining Treatment (POLST) form, dated ,d+[DATE], Resident 1 indicated, Attempt resuscitation/CPR, Full Treatment , was checked off. The physician's History and Physical, dated, [DATE], indicated Resident 1, .has the capacity to understand and make decisions . According to the Progress Notes, dated [DATE], 6:50 A.M., Licensed nurse 1 (LN 1) CNA (certified nursing assistant), notified licensed nurse (LN) that patient was unresponsive and not breathing .0652, initiated code blue (start resuscitative efforts), started chest compressions 5 rounds of CPR was conducted and at 0700 (7 A.M.) resident was pronounced by MD (Medical Doctor) .Resident RP (responsible party) was notified .death confirmed at 0700. According to the Progress Notes, dated [DATE], 7:27 A.M., LN 1's typed nurses note weres crossed out in its entirety, and labeled, Incorrect documentation-06:50 CNA make LN that resident is expired because she is pale and unable to wake resident up. LN goes to assess resident while nurse supervisor and other RN (registered nurse) to assess resident. Both RN's come to resident room and assess resident while I check resident code status and state she is expired and decided not to initiate CPR. I let them know she is full code. Last time I had seen resident was around ,d+[DATE] (5:30 A.M.-6 A.M.) when I assisted NOC (night shift 11:,d+[DATE] A.M.), CNA change resident. Resident was fine and no COC (change of condition) was noted at that time. On [DATE] at 11:34 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated he learned of Resident 1's death on the morning of [DATE]. When he arrived at the facility he reviewed Resident 1's nurses notes. The DON stated LN 1's initial nursing notes, were not thorough and clear, so he asked LN 1 to document the event better. On [DATE] at 9:41 A.M., an interview was conducted with LN 2. LN 2 stated she arrived for work around 7 A.M., on [DATE]. LN 2 stated CNA's Informed her Resident 1 was unresponsive. LN 2 stated she went to Resident 1's room and LN 1 was present. LN 2 stated she asked about Resident's code status and asked someone to go check it in the chart. LN 2 stated Resident 1 was pulseless and had a stiff jaw, when she tried to move it. LN 3 had arrived with the crash cart, and they made the decision Resident 1 had expired. LN 2 stated CPR was never performed. LN 2 instructed LN 1 to document what happened, while LN 2 notified the physician, the DON, and the family. On [DATE] at 5:43 A.M., an interview was conducted with LN 1. LN 1 stated he last saw Resident 1 around 5:30 A.M., when he helped the CAN, change the resident. LN 1 stated the day shift CNA came in early and informed him Resident 1 was unresponsive. LN 1 stated the day LN's and supervisor arrived and made the decision to pronounce the resident without performing CPR because she was cold. LN 1 stated he crossed out his original documentation and made another entry indicating CPR was performed. LN 1 stated he crossed out and rewrote the entry because his superior told him the original documentation made it sound like he was incriminating the day nurses, for pronouncing death. LN 1 stated The DON provided a hand written note of what he wanted LN 1 to write. LN 1 stated he felt he had no choice, thinking he would be fired, so he charted what the DON wanted. LN 1 stated he charted that CPR was performed when it really was not, and his charting did not reflect the true events that had occured. On [DATE] at 1:39 A.M., a subsequent interview was conducted with the DON. The DON stated he would never ask a staff member to chart something that was not accurate, under any circumstances. The DON stated if documentation was ever changed, it should only be to be more accurate and precise. The DON stated since Resident 1 was a full code, he expected LN 1 to initiate CPR, until the physician or two registered nurses called the code. According to the facility's policy, titled Death of a Resident, Documenting, dated [DATE], Appropriate documentation shall be made in the clinical record concerning the death of a resident. 1. A resident may be declared dead by a Licensed Physician or Registered Nurse with physician authorization in accordance with State law. According to the facility's policy, titled Charting and Documentation, dated [DATE], .3. Documentation in the medical record will be objective, complete, and accurate . According to the facility's policy, titled Emergency Procedure-Cardiopulmonary Resuscitation, dated February 2018, .6. If an individual is found unresponsive .licensed staff members who is certified in CPR/BLS shall initiate CPR unless: .b. There are obvious signs of irreversible death (e.g. rigor mortis (stiffing of the muscles). 7. If the resident's DNR (do not resuscitate) status is unclear, CPR will be initiated until it is determined that is a DNR or physician's order not to administer CPR .

Based on interview and record review, the facility failed to provide oral hydration as ordered by the physician ' s plan of care for one of two residents (Resident 1), reviewed for care plan. As a result, Resident 1 was at risk for dehydration and electrolyte imbalance (not enough minerals in the body, ie, calcium, potassium, magnesium). Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/6/22, an unannounced visit was made to the facility. According to the Admission Minimum Data Set (a clinical assessment tool) dated 5/7/22, Resident 1 had a cognitive assessment score of 3, indicating severely impaired cognition. Per the physician orders, dated 5/12/22, Resident 1 was to drink 240 ml (milliliters) of water every four hours (between 7 a.m. - 7 p.m.) with Staff to assist to ensure ALL 240 ml is consumed, four times a day for hydration. Resident 1 ' s Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . From 6/1/33 through 6/14/22, 120 ml or less was provided 24 times out of 55 opportunities. The facility ' s progress notes were viewed from 6/1/22 through 6/14/22, which contained no documented evidence Resident 1 refused or declined fluids as ordered by the physician. There was no documented evidence Resident 1 was assessed for signs and symptoms of dehydration (dry [MEDICATION(S)] membranes, skin turgor [skin ' s elasticity]). According to the care plan titled Nutrition/Dehydration risk, dated 5/6/22, list interventions, .Encourage resident to drink plenty of fluids throughout the day .Monitor for signs and symptoms of dehydration as exhibited by poor skin turgor, dry [MEDICATION(S)] membranes . According to the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/11 through 6/18/22, the same antibiotic was prescribed twice a day for a second urinary tract infection. On 9/13/22, a second unannounced visit was made to the facility. On 9/13/22 at 12:13 P.M., an interview was conducted with Licensed Nurse (LN 3). LN 3 stated urinary tract infections could be caused from dehydration or improper urinary catheter care (a flexible tube inserted into the bladder to drain urine). LN 3 stated if a physician ordered fluids to be administered, there was a reason, and staff should be ensuring the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . LN 3 stated dehydration could be harmful and cause a decline in the resident ' s recovery. On 9/13/22 at 12:18 P.M., an interview was conducted with certified nurse assistant (CNA 1). CNA 1 stated it was everyone ' s responsibility to encourage residents to drink fluids, in order to prevent dehydration. CNA 1 stated if a resident required every four-hour fluid assistance, the CNA would provide the total amount at the end of their shift to the LNs for documentation. CNA 1 stated if a resident was not drinking the full amount, they should inquire why and inform the LN, so it could be documented, and interventions could be implemented. On 9/13/22 at 12:23 P.M., an interview and record review was conducted with the Director of Nursing (DON), regarding Resident 1 ' s fluid intake. The DON stated if the physician ordered 240 ml every four hours, he expected staff to follow the order. The DON stated if the order was not being carried out, he expected the staff to document in the progress notes why, so there was a record of refusal, or inability to consume the total amount. The DON stated the risk to Resident 1 was dehydration and infection. According to the facility ' s policy, titled Physician Orders, dated June 2013, .A physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the facility ' s policy, titled Hydration-Clinical Protocol, dated September 2017, .Treatment/Management: 1. The physician will manage significant fluid and electrolyte imbalance .2. The staff will provide supportive measures such as supplemental fluids .

Based on interview and record review, the facility failed to implement heel protectors for 1 of 3 sampled residents (2), from 3/16/13 until 4/2/13. As a result of the omission of planned care, Resident 2 developed a Stage III (open blood blister/s - full tissue thickness into the muscle) right heel and left heel Stage III pressure sore. In addition, Resident 2 required 30 days additional skilled facility care for treatment of [REDACTED]. Findings: On 5/8/13 Resident 2's closed clinical record was reviewed. Resident 2 was admitted on [DATE] for rehabilitation after surgical repair of a fractured right hip. According to the Resident Admission Record, Resident 2 was responsible for decision making. MD 1's physician admission order's for Resident 2, dated 3/15/13, included Occupational Therapy and Physical Therapy to regain function following hip surgery. Per the OT Progress Note on 3/19/13, Resident 2's bed mobility required maximum assistance and functional transfers (bed to wheelchair) required two caregivers. The facility Minimum Data Set assessment tool, on 3/22/13, Resident 2 scored 15 of 15 points on the Brief Interview for Mental Status meaning no short or long term memory losses. Per Resident 2's full nursing admission assessment, completed by LN 5 on 3/15/13, the right heel was reddened with blanchable skin/tissue. This meant blood circulated more slowly to this area increasing the risk for breakdown. Resident 2's surgical fracture site was on the right side. LN 5's assessment recorded deep tissue injury to the right and left buttocks (bottom). Per the Care Plan History, initiated by the night shift on 3/16/13, LN 8 listed Altered Skin Integrity related to cardiovascular disease ([MEDICAL CONDITION] and high blood pressure), "Right heel redness blanchable" in relation to the deep tissue injury to both buttocks and Nutrition/Hydration. Resident 2's heels were to have heel protectors (foam shaped cushions) per LN 8's documented intervention. On 6/4/13 at 10 A.M., Resident 2 was interviewed by telephone. The resident said, "The therapy people didn't believe me when I warned them my heels were bad from lying in bed." Resident 2 explained that bad meant sore. The resident told "a couple of people" his heels were sore at different times, but could not remember who they were. During a follow-up telephone interview on 6/11/13 at 11 A.M., Resident 2 was asked about the heel protectors for pressure relief. The resident said, "No, before my heels broke down, they used nothing. They didn't do anything until there was blood on the sheets. Then they put the pillows under my heels (legs)." Per the OT Progress Notes written on 4/2/13 at 8:50 A.M., Resident 2 was in bed and noted to have an open wound on his right heel. The Certified Occupational Therapy Assistant (COTA) wrote the nursing staff was "alerted immediately." The COTA visited Resident 2 in the morning to get him ready for therapy. This included placing shoes on his feet. On 4/2/13 at 10:15 A.M., LN 3 documented in the Progress Notes, "Noted with blood blister (2) sites to right foot, surrounding area with redness & warm to touch, kept area clean & dry, dressing applied." Per the Observation Report on 4/2/13 at 2:58 P.M., LN 3 indicated Resident 2 had two (2 by 2 cm or size of penny coin) blood blisters on the right foot. LN 3 listed the tissue surrounding the blood blisters as red but did not include a measurement. On 6/6/13 at 4:40 P.M., The acting facility wound nurse was interviewed. LN 3 said, "(On 4/2/13) the COTA was going to put his shoes on and called me in saying I needed to see. There were two small blisters on the outer right heel. The entire foot was red and warm to the touch." LN 3 acknowledged this detailed description was not documented in the medical record. LN 3 said the blisters and area of [DIAGNOSES REDACTED] (redness) were not measured. LN 3 said the DON was immediately informed after the discovery of the blood blisters. LN 3 stated the DON observed the blisters she was instructed to get a Doppler (ultrasound) study, which was negative for [MEDICAL CONDITION] (clot blocking blood vessels). During the same interview, LN 3 said the blood blisters on the right heel were broken open with blood on the resident's sock and sheet. LN 3 said she did not observe or assess Resident 2's other heel. On 6/10/13 at 2:50 P.M., the COTA, who worked with Resident 2 on the morning of 4/2/13, was interviewed. The COTA said, "There was blood on the sock from broken blood blisters. It was his right heel that had two small blood blisters. I don't remember any redness to his heel or foot. There wasn't a lot of [MEDICAL CONDITION] (swelling) in his right foot from (right hip) surgery." The COTA said the resident's shoes were examined and found to be free of any pressure points that could cause blisters. The COTA, who saw Resident 2 on 3/22/13, 3/25/13, 3/26/13, 3/27/13, 3/29/13, 4/1/13 and 4/2/13, said Resident 2's heels were not off loaded or cushioned in any manner from touching the bed. The COTA further said, "When I saw him, his heels were generally on the bed. I came in to find one pillow at the foot of the bed but not enough to keep his heels off the bed. On 6/11/13 at 2:30 P.M., CNA 4, who regularly cared for Resident 2 prior to discovery of the blood blisters, was interviewed. CNA 4 said that his heels were never floated or cushioned before he got "the heel problem (pressure sores)." CNA 4 could not remember heel protectors in use for Resident 2. On 6/20/13 at 7:30 A.M., LN 8 was interviewed. LN 8 created Resident 2's admission Care Plan for heel protectors. LN 8 could not remember ever seeing heel protectors on Resident 2. The WS consultation, dated 4/3/13 at 3:52 P.M., was reviewed. Resident 2's broken right heel blister/s was assessed as an ulcer/pressure sore that measured the size of a half dollar coin, 3.0 cm by 3.2 cm. The right heel pressure sore depth could not be determined due to "90% eschar (dead, leathery, black tissue)." This was the right blood heel blister/s identified by LVN 3 on 4/2/13 as the size of a penny. The WS assessed the lateral (side) of the right heel and foot as cold and red. According to the facility's Wound Treatment Protocols, a wound with eschar was a Stage III or IV (both full tissue thickness). The WS also identified a new left heel ulcer/pressure sore, previously unidentified by the facility. It measured 1.6 cm by 1.4 cm by 0.1 cm deep, the size of a dime coin. The WS staged the pressure sore as a Stage III. Attempts to contact the WS for interview were unsuccessful.. Per MD 1's Physician order [REDACTED].M., Resident 2's order indicated, "R (right) pressure relieving heel protector (Prevalon Boot) at all times." Prevalon was a brand name for a soft boot designed to lift the heel off of the mattress to minimize heel pressure. On 4/5/13 at 2 P.M., MD 1 wrote an order for [REDACTED]. Per the Physician's Progress Note dated 4/5/13 at 2 P.M., "Bilateral heel pressure ulcers (direct quote was underlined)" MD 1's documentation indicated Resident 2 had bilateral developing heel ulcers that were probably a Stage III without evidence for infection. The physician went on to chart that the venous Doppler was negative (for [MEDICAL CONDITION] or clot) and an arterial study showed moderate [MEDICAL CONDITION]. The physician's plan included dressing both pressure ulcers/sores, off-loading both heels (pressure relief by floating heels from the mattress). On 6/20/13 at 7:15 A.M., the MRD reviewed Resident 2's medical record and acknowledged there was no documentation of heel protectors in the staff Progress Notes or Treatment Administration Record prior to 4/2/13. The facility provided no written evidence that heel protectors were provided to Resident 2. On 7/30/13 at 10:55 A.M., a telephone interview was held with MD 1. MD 1 said, "If the nurses' identified a need for heel protectors and wrote it in the (resident's) care plan, then they should have implemented them to relieve the heel pressure." Per the medical record, Resident 2 was transferred on 4/12/13, to the local hospital. Resident 2 was discharged from the local hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to another facility (SNF 2) for continued care under the care of MD 2 on 4/17/13. SNF 2 provided Resident 2's medical record for review on 5/29/13. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2 received treatment to his heels until discharge home, on 5/18/13. Discharge orders included, "Cleanse bilat. heel wnds (wounds) with NSPR (normal saline spray), pat dry. Apply nickel thick layer of Santyl Oint (enzymatic ointment used to dissolve dead tissue), cover with Oil [MEDICATION NAME] gauge (oil impregnated) & secure with Kirlix (brand of fluffy gauge wrap) - change (dressing) every day." On 8/13/13 at 1:45 P.M., Resident 2's attending physician during the SNF 2 admission on 4/17/13 until discharge home on 5/18/13, was interviewed by telephone. MD 2 said, "(Resident 2's) admission to (SNF 2) was mainly to treat both heel pressure sores..." MD 2 explained, "(Resident 2's) discharge home included Home Health (Agency) care to perform heel pressure sore dressing changes." The facility P&P, dated October, 2010, and titled Prevention of Pressure Ulcers (sores listed, "Use foam, gel or air cushion as indicated to relieve pressure."

Based on interview and record review, the facility failed to ensure 1 of 1 sampled residents (Resident 1) was transferred appropriately with two-person assistance and the use of a mechanical lift (Hoyer). As a result, the resident sustained [REDACTED]. Twelve days after the injury Resident 1 was transferred to the acute care hospital and required surgical repair of the fractured thigh. Findings: Resident 1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was interviewed on 7/9/12 at 10 A.M. The resident stated she was showered by Certified Nursing Assistant (CNA) 1 on the morning of 5/30/12. Afterwards, she felt chilled and wanted to get back into bed to warm up. CNA 1 called for staff assistance, however, no one responded. CNA 1 said he could get her back to bed by himself. Resident 1 asked him to wait for help and to get the Hoyer lift (a mechanical device with a sling used for transferring patients in and out of bed or wheelchair). CNA 1 insisted he could put her back to bed by himself. CNA 1 held Resident 1's upper arms, put one of his knees against her "bad " knee (i.e. her paralyzed left knee) and got her up to the edge of the bed. As he turned her to move her body and legs onto the bed, she felt something "pop" in her left leg and then felt terrible pain. CNA 1 pulled her up to the head of the bed, covered her, and left the room. No one responded when she cried out. The resident said she phoned her son and told him what happened. Resident 1 stated the pain got progressively worse over the next 12 days, to the point where staff could not adjust the head of her bed upwards for her to eat, because the pain was so bad. Resident 1's clinical record was reviewed on 7/10/12. According to the Minimum Data Set ((MDS) dated [DATE], the facility assessed Resident 1 as alert, oriented, and capable of making her own decisions. In addition, Resident 1 was assessed with [REDACTED]. Resident 1's care plan, dated 9/2/11, indicated the resident should be transferred with the use of a mechanical lift (Hoyer). CNA 1 was interviewed on 7/9/12 at 12:30 P.M. He stated he showered Resident 1 on 5/30/12, shortly before lunch, and then wheeled her back to her room in a shower chair. CNA 1 said since the resident was shivering, he was anxious to get her back to bed. He called for staff assistance, but no one responded. CNA 1 confirmed that he transferred the resident without the assistance of another staff member and without the use of the Hoyer lift. He said he was able to get Resident 1 propped up on the edge of the bed, but when he turned her and brought her legs up, Resident 1 screamed and cried. CNA 1 said he immediately got the medication nurse, although he could not recall the nurse's name. He said the regular medication nurse was off that day and a different nurse was on duty. There was no documentation in Resident 1's clinical record on 5/30/12 regarding the incident or the completion of a nursing assessment after the incident. Licensed Nurse (LN) 2 was interviewed on 7/9/12 at 1:10 P.M. LN 2 said she was the treatment nurse on 5/31/12. She said she approached Resident 1 to apply the routine medication patches to the resident's knees. She said Resident 1's left knee was swollen, warm to the touch, and reddened. She reported this observation to the Director of Nursing (DON). LN 2 said she called the nurse practitioner and got a verbal order for a stat (immediate) x-ray. According to the clinical record, the resident's left knee was x-rayed on 5/31/12 at 4:05 P.M., more than 24 hours after the resident sustained [REDACTED]. The DON was interviewed on 7/20/12 at 4 P.M. She said that CNA 1 did not report the injury on 5/30/12, nor did he report the injury on 5/31/12, until she questioned him about it. She said LN 2 discovered the injury to Resident 1's knee on 5/31/12. According to the facility's policies and procedures, revised August 2006 and titled, Accident and Incidents - Investigating and Reporting, "Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned...The Nurse Supervisor/Charge Nurse must be immediately informed of accidents or incidents so that medical attention can be provided...The Nurse Supervisor and/or Charge Nurse shall: Examine all accident/incident victims; Notify the Medical Director or the victim's personal or Attending Physician, and inform the physician of the accident or incident..." According to the nurse's notes dated 5/31/12 at 3:32 P.M., LN 2 documented that Resident 1 reported severe left knee pain, 7 out of 10 on a pain scale (zero (0) being no pain and ten (10) being excruciating pain); however, LN 2 documented the resident's pain level as zero on the Medication Administration Record (MAR). The licensed nurses who worked the evening and night shifts on 5/31/12 also documented the resident's pain level as zero. Per the May 2012 MAR, Resident 1 received no medication for pain on 5/31/12. LN 2 was interviewed by phone on 9/17/12 at 2:30 P.M., and asked why she did not offer Resident 1 pain medication on 5/31/12, given that she documented the resident's level of pain as 7 out of 10. LN 2 stated, "She (Resident 1) complained all the time ...the topical (medication applied directly to the skin) patches usually took care of it." The resident's family member (FM) was interviewed on 7/2/12 at 10 A.M., and stated he visited Resident 1 on Sunday, 6/3/12. He said Resident 1 did not receive any pain medication between the time she called him on 5/30/12 and his visit on 6/3/12. The FM stated he could not adjust the head of Resident 1's bed upwards without her crying out in pain. When the nurses came in to change her brief, Resident 1 could barely shift onto her right side for a moment. The FM said he asked the medication nurse (LN 1) if she would request an order for [REDACTED]. According to the Nurse's Notes dated 6/3/12 at 1:37 P.M., the resident received Tylenol 325 milligrams (mg) for complaints of left knee pain "with little relief." Despite the resident getting little relief from the Tylenol, the attending physician was not contacted until the resident's son requested the facility to contact the physician for pain medication orders, as documented in the Nurse's Notes dated 6/3/12 at 1:57 P.M. At that time, the resident was prescribed Norco (narcotic pain medication) every 4 hours as needed for pain. The resident was to receive 1 tablet for mild and 2 tablets for moderate to severe pain. According to the Narcotic Drug Record, the resident received 1 tablet of Norco on 6/3/12 at 11 P.M. for pain rated 6/10. The resident continued to receive Norco 2 tablets every 4 to 6 hours between 6/4/12 and 6/8/12. According to documentation on the Medication Administration Record (MAR), the pain was rated as 7/10 to 9/10 (severe pain per the pain scale) prior to the medication and 2/10 to 8/10 (mild to severe pain) after the pain medication was administered. According to the Nurse's Notes, dated 6/4/12 to 6/8/12, the patient continued to complain of pain when her left leg was moved; was assessed with [REDACTED]. On 6/4/12, testing was ordered to rule out a blood clot in the leg. According to the Nurse's Notes, dated 6/7/12, the resident was seen by a pain specialist. The pain specialist (MD 1) ordered 2 new medications, Celebrex (anti-inflammatory medication) 200 milligrams (mg) once daily and a Flector patch (used to treat pain) to be applied every 12 hours. MD 1 also increased the dose of Neurontin (used for nerve pain) from 100 to 300 mg three times each day. On 6/11/12, twelve days after the incident, Resident 1 was transferred to an acute care hospital for evaluation. The resident's Attending Physician (MD 2) was interviewed by phone on 9/18/12 at 3:30 P.M. MD 2 stated she was in the facility doing her Monday rounds on 6/11/12, when LN 6 asked her to see Resident 1 for the resident's unresolved pain. MD 2 stated the resident's left knee was swollen and warm to touch. She wrote orders to send the resident to the hospital for an evaluation. According to hospital records, reviewed on 7/10/12, Resident 1 arrived at the emergency room (ER) on 6/11/12. An x-ray of her left leg showed a mid-shaft fracture of her left femur (thigh) with soft tissue swelling. Surgical repair of the resident's left femur fracture was completed on 6/12/12. Post-operative complications necessitated a stay in the intensive care unit, a blood transfusion, and hospitalization for a total of 9 days.