Every finding on record at Professional Post Acute Center

Based on observation, interview and record review, the facility failed to ensure resident safety for two of three residents sampled for falls (Resident 75 and Resident 66) when: 1. Resident 75 was receiving incontinent care (toileting; changing a soiled adult brief) by one Certified Nursing Assistant (CNA J) when she required two caregivers to assist, and subsequently fell out of her elevated bed (a mattress raised to the caregivers preference to provide care comfortably) when she was turned on her side; and, 2. Resident 66 fell after she was left unattended at her bedside while sitting in a shower chair (a specialized, waterproof chair used for bathing residents). These failures: 1. Caused Resident 75 to sustain five bone fractures (broken bones) in her legs, strike her head and develop a hematoma (a collection of blood caused by a broken blood vessel) on the right side of her head, severe pain, fear, and trauma, and prevented her from using her wheel chair to leave her room; and, 2. Caused Resident 66 to hit her head and lose consciousness (not responding to verbal and tactile [touch] stimuli), suffer a complex laceration (a deep, jagged, or torn skin wound that requires specialized medical attention) to her left forehead, requiring hospital intervention, and sustained a T7 (thoracic vertebra located in the middle of the back; vertebra form the backbone) spinous process (bony bump on the vertebra) fracture, leading to Resident 66 being placed in a brace (an external support device designed to stabilize the spine and limit movement). Findings: 1. A review of Resident 75's facesheet (front page of the medical record that contains a summary of basic information about the resident) indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body, affecting daily activities and mobility) following a cerebral infarction (stroke; sudden interruption of blood flow to the brain) affecting the left side. Additional diagnoses, added on 6/24/26, included fracture of the lower end of the left femur (thigh bone), fracture of the upper end of the right tibia (the larger of the two bones in the lower leg), fracture of the upper end of the left tibia, displaced (fracture where the broken ends of the bone are separated and no longer aligned, often requiring medical intervention for proper healing) fracture of the lateral malleolus (bony prominence on the outer side of the ankle) of the left fibula (slender bone in the lower leg; calf bone), and fracture of the upper and lower end of the right fibula. A review of Resident 75's Minimum Data Set (MDS; a resident assessment tool), dated 4/2/26, indicated she had a BIMS (Brief Interview for Mental Status; an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15, indicating she was cognitively intact (A score of 13 to 15 indicates intact cognition, a score of 8 to 12 indicates moderate cognitive impairment, and a score of 0 to 7 indicates severe cognitive impairment). Further review of the 4/2/26 MDS, subtitled, Section GG-Functional Abilities, indicated Resident 75's upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) had, .1. Impairment on one side. Under the categories of . C. Toileting Hygiene [cleanliness]: The ability to maintain. hygiene. before and after voiding [urinating] or having a bowel movement. and . A. Roll left and right: the ability to roll from lying on back to left and right side, and return to lying on back on the bed, Resident 75 was given a score of, . 01. Dependent – Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required. Review of Resident 75's nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes), dated 3/31/26 and revised on 4/15/26, indicated, [Resident 75] has . self care/mobility performance deficit [decreased ability] r/t [related to] Hemiplegia and hemiparesis. The care plan interventions for bed mobility, initiated on 3/31/26 and revised on 6/19/26, indicated, The resident has require [sic] x2 [two] staff participation to reposition and turn in bed. Review of Resident 75's nursing care plan, dated 3/27/26 indicated, [Resident 75] likes group activities. The care plan interventions indicated, . The resident prefers to do things with groups of people. The resident prefers to go outside to get fresh air when the weather is good. Review of Resident 75's electronic medical record (EMR) revealed a nurses' note for a Change of Condition Evaluation, dated 6/19/26 at 7:26 a.m., that indicated, . 1. The Change in condition. is. Falls. Under the subtitle, 3. Review Findings. the evaluation indicated, . 4. the right leg formed a bump between the knee and the ankle where much pain was coming from on movement. Also, a little bump formed on her right temporal [side of head; between ear and cheekbone]. Recommendations: sent out [to hospital] for further evaluation. The document was electronically signed by Licensed Nurse I (LN I). Review of Resident 75's hospital physician progress note (documentation of a patient's health status, treatment progress, and condition changes over time) subtitled, Recent timeline, dated 6/23/26 at 6:37 p.m., indicated -ED [Emergency Department] visit on 6/19/26 – [Resident 75] rolled out of bed while getting changed by staff. Imaging [x-rays, etc.] showed fractures of the RIGHT proximal [upper end] fibula and tibia, possible LEFT distal [lower end] fibular fracture. Noted hematoma to right temporal/right side of the head. Review of Resident 75's hospital physician progress note subtitled, Assessment/Plan dated 6/24/26 at 11:31 a.m. indicated, Left distal femur fracture & Proximal Tib/Fib [tibial and fibula] fracture (Hemiparesis side) Right proximal tib/fib fracture. Review of Resident 75's Post-Fall Review., electronically signed on 7/10/26, indicated the IDT team (interdisciplinary team of healthcare professionals including nursing, social service, and rehabilitation staff) documented Resident 75 had a witnessed fall on 6/19/26 at 6 a.m. The Review indicated, . 3.patient care was being provided by the staff, pt [patient, Resident 75] was turned to her left side and according to [Resident 75] she grabbed the side rail [also known as bed rail], but the force she exacted during the turnover was greater than her grip, so she rolled over to the floor witnessed by the staff who was helping her. Patient stated she hit the nightstand with her head on her right temporal before she landed on the floor. 4. resident reported head impact and pain to lower extremities [legs]. transferred to the ER [emergency room] . Further review of Resident 75's Post-Fall Review., signed on 7/10/26 indicated, . 4. 1. IDT Review Summary and Recommendations. Root cause analysis (RCA; determination of incident causation) indicates impaired mobility, dependence for bed mobility. need for staff assistance during personal care, and loss of positioning during the turning process. recommendations include adherence to the resident's assessed assistance requirements during positioning. and personal care activities to promote safety and prevent further injury. During a concurrent observation and interview with Resident 75 on 7/14/2026 at 8:25 a.m., Resident 75 was lying in bed eating breakfast. Her left hand was contracted (condition where fingers bend toward the palm due to thickened connective tissue, limiting function). She stated she was unable to move her left hand and left leg due to a stroke she had in the past. Resident 75 stated she recently went to the hospital due to a fall. She stated her CNA rolled her onto her left side (to provide care) but she, rolled me too far. She stated she fell off her bed, hit her head on her roommate's table and broke both her legs. She stated it took three men using a sheet to get her back to bed and it was a very painful process. Resident 75 stated that since her fall, she has had pain that got up to a seven or eight on the pain scale (Pain assessment tool; pain intensity is described as 1-10 out of a possible ten. Pain categories are: Mild [1-3], Moderate [4-6] and Severe [7-10]). She stated she had no pain prior to the fall. Resident 75 stated she could no longer use her wheelchair after her fall because bending her legs was too painful. She stated she used to get into her wheelchair and stay out of her room for about four hours each day but now she needed to stay in bed, which she did not like. Resident 75 stated she felt traumatized and afraid after the incident. She stated CNA J had come into her room to care for her roommate and she felt scared (when she saw her). She stated seeing CNA J reminded her of the fall and she did not like to think about it. During an interview on 7/16/26 at 9:50 a.m., Licensed Nurse D (LN D) stated Resident 75 used to get up in her wheelchair, but she did not currently do so because she was in pain and did not feel up to it. During an interview on 7/16/26 at 10:12 a.m., CNA E stated prior to her fall, Resident 75 was a two-person assist (manual handling technique requiring two trained caregivers to move a person with limited mobility; utilized when a single caregiver cannot safely manage repositioning). He stated two people assisting her protected his back (from injury) and protected the resident. CNA E stated since her fall, Resident 75 was afraid and no longer got into her wheelchair because she was in pain. During an interview on 7/16/26 at 10:42 a.m., CNA F stated it took two staff to change (brief change; incontinent care) Resident 75. During an interview on 7/16/26 at 3:47 p.m., the Director of Nursing (DON) stated Nurse Practitioner G (NP G) had ordered Norco (narcotic pain reliever) for Resident 75 as she was having severe pain after the fall. During an interview on 7/16/26 at 4:08 p.m., NP G stated Resident 75 had fallen off the bed and sustained multiple leg fractures on the left and right legs. She stated Resident 75 had no pain prior to the fall, but her pain was a seven or eight [out of 10] post-fall. NP G stated Resident 75 could not use her wheelchair and was now stuck in bed. NP G stated she texted the facility Administrator about getting a special wheelchair (with a sling to accommodate her) but it had not yet arrived. During a telephone interview on 7/17/26 at 7:59 a.m., Confidential Family Member (CFM) stated he had been Resident 75's caregiver for multiple years prior to her admission to the facility. CFM stated Resident 75 could not roll (side to side) independently during toileting. CFM stated she could not grab the bed rail and pull herself onto her side. CFM stated Resident 75 could only assist and help a little. CFM stated once she was moved onto her side, she could hold the bedrail for balance, but she was vulnerable to rolling. In the past, she had unintentionally rolled from her side to her back and from her side onto her stomach. CFM stated since the incident, Resident 75 was experiencing fear from the fall. During an interview on 7/17/26 at 10:30 a.m., Physician H stated Resident 75 sustained multiple fractures and was traumatized as a result of her fall. Physician H stated Resident 75 exhibited signs of PTSD (Post-Traumatic Stress Disorder; a mental health condition triggered by experiencing or witnessing a traumatic event, leading to severe anxiety, flashbacks, and emotional distress) and she had offered her psychological support to help her cope. Physician H stated CNA J had entered Resident 75's room and smiled at her but Resident 75 verbalized she was not ready (to see her). During a concurrent interview and record review on 7/17/26 at 11:58 a.m., the Director of Nursing (DON) reviewed Resident 75's EMR. The DON confirmed CNA J had positioned Resident 75 on her left side to clean her and she went over the left side of the bed. The DON confirmed the bed was elevated at the time of the fall. The DON stated prior to the fall of 6/19/26, Resident 75 was a fall risk and was assessed to be maximum dependence; she stated everything needed to be done by the CNA. When asked if Resident 75 should have had two staff assisting her at the time of the fall, the DON stated, yes. During a telephone interview on 7/17/26 at 1:28 p.m. LN I stated she was on duty when Resident 75 fell from her bed. She stated she heard CNA J yelling for help. She stated she entered the room and Resident 75 was on the floor, located on the left side of the bed; Resident 75 was positioned on her right side. LN I stated she hit her head during the fall. She stated CNA J had turned Resident 75 on her side to clean her up when she fell from the bed to the floor. LN I stated Resident 75 told her she had tried to catch the bed rail but could not hold it well because she was not strong enough. She confirmed the bed was in an elevated position. LN I stated Resident 75 developed a left leg bump that kept increasing, she called the physician, and transferred Resident 75 to the hospital. LN I stated prior to the fall, the CNAs (on night shift) usually changed Resident 75 by themselves (one person); she stated, we thought she could hold on [to the bed rail]. She stated currently, staff utilized two people when providing incontinent care for Resident 75. Review of facility policy titled, Repositioning, subtitled, Steps in the Procedure. Repositioning the Resident in Bed, revised 2/2026, indicated, 1. Check the care plan. to determine resident's specific positioning needs including. the number of staff required to complete the procedure. 4. Raise the bed to waist level. Review of Nurse job description titled, Certified Nurse Assistant, undated, indicated, The purpose of your job position is to provide each resident with routine daily nursing care in accordance with the resident's assessment plan. 2. A review of Resident 66's admission record indicated she was admitted in March 2026 with diagnoses including nontraumatic intracerebral hemorrhage (sudden bleeding within the brain tissue not caused by physical trauma or surgery. A life-threatening medical emergency and a type of hemorrhagic stroke (when a blood vessel in the brain leaks or ruptures, causing bleeding inside or around the brain)), dementia (decline in memory, thinking, and reasoning skills severe enough to impair daily life), and Alzheimer's (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks). A review of Resident 66's Order Summary Report, dated 6/3/26, indicated Resident 66 was placed on hospice services (special kind of care that focuses on a person's quality of life, comfort, and dignity as they near the end of life) and she did not have the capacity to make healthcare decisions. A review of Resident 66's MDS, dated [DATE], indicated Resident 66 had severe cognitive impairment (a serious decline in mental function—such as memory, reasoning, and orientation—that compromises a person's safety and independence). The MDS also indicated Resident 66 needed substantial/maximal assistance (helper does more than half the effort) with sit to stand positioning and the ability to transfer to and from a bed to a chair had not been attempted. A review of Resident 66's Risk for Falls with Injury Care Plan, initiated 3/13/26, indicated Resident 66 was at risk for falls with injury related to limited mobility and a history of stroke and major neurocognitive disorder (dementia) due to Alzheimer's disease. A review of Resident 66's Limited Physical Mobility Care Plan related to Alzheimer's and weakness, initiated 6/4/26, indicated Resident 66 was bedbound and interventions included providing total assistance with transfers. A review of Resident 66's Change in Condition (COC) nursing evaluation, dated 7/13/26, and completed by Licensed Nurse L (LN L), indicated at 3:55 p.m. LN L was at the nurse's station when she heard a loud thud. LN L went into Resident 66's room whereby she observed an empty shower chair at the foot of Resident 66's bed. Resident 66 had been left unattended by her CNA. Resident 66 was observed on the floor, right side of her bed. Resident 66 had fallen onto her stomach, hitting the left side of her face/temple (between the forehead and left ear), her right arm was pinned under her body, left arm was by her side, legs were in an extended lying position (straight outward), and she was unconscious. A review of Resident 66's Progress Note titled, Alert Note, dated 7/13/26, indicated at 3:55 p.m. LN L was at the nurse's station when she heard a loud thud. LN L found Resident 66 unattended on the floor on the right side of her shower chair. Resident 66 was unconscious when found and in a prone position (a body posture where a person lies flat on their stomach, facing downward). Resident 66 was not responding to verbal or tactile stimuli for 2-3 minutes. Resident 66 opened her eyes by the 4th minute after being assessed on the floor. Resident 66 was manually positioned on her back by physical therapy staff and three CNAs after regaining consciousness. After Resident 66 was manually positioned on her back, a laceration was noted at Resident 66's top left eyebrow and left temple region. Blood was noted on the floor and Resident 66's laceration had stopped bleeding. The EMS (Emergency Medical Services, the system that provides urgent pre-hospital medical treatment, stabilization, and transport for acute illnesses and injuries) arrived at 4:10 p.m. Resident 66 was transported to an acute care facility that specialized in head injuries per the paramedics' (an advanced emergency medical professional trained to provide critical pre-hospital care and transport for sick or injured patients) suggestion. A review of the ED (emergency Department) Physician Notes and History and Physical, dated 7/13/26, indicated Resident 66 was assessed because of a ground level fall and found to have a blood pressure of 174/108 mm HG (millimeters of mercury, a unit of measure; A reading of 130/80 or higher is considered high. The upper number is the systolic [when the heart beats] and the lower is called the diastolic [when the heart rests]) that was being monitored, a left supraorbital (located immediately above the eye socket) complex laceration approximately four centimeters (cm equals 1.58 inches) in length that required six sutures (stitches are medical devices used by clinicians to hold body tissues together and close wound edges after an injury or surgery), and a T7 fracture, which was going to be treated by placing Resident 66 in a brace and working with physical therapy. During an interview 0n 7/17/2026 at 12:50 p.m. with CNA A, CNA A stated he did not take care of Resident 66, but a resident who needed total/extensive care should not be left unattended in a shower chair because it was not safe. CNA A stated if a resident was cognitively impaired with the diagnosis of Alzheimer's it was not safe to leave the resident unattended in a shower chair in the resident's room. CNA A stated if the CNA had to leave the room for some reason, the CNA should get another person to assist so that the resident was not left unattended. During an interview on 7/17/2026 at 1:28 p.m. with CNA B, CNA B stated he had transferred Resident 66 to a shower chair on 7/13/26 to give Resident 66 her scheduled shower. CNA B stated LN L came to Resident 66's room to let CNA B know the wife of the resident in room [ROOM NUMBER] C (next door to Resident 66) needed help with her husband. CNA B stated he told LN L he was busy with Resident 66. CNA B stated you never leave a resident unattended in a shower chair. CNA B stated the wife of the resident in room [ROOM NUMBER]C was pressuring LN L for the CNA to help her. CNA B stated LN L could have helped the resident in 29C or watched Resident 66, who was in the shower chair when CNA B was pulled to assist the resident in room [ROOM NUMBER]C. CNA B stated LN L did not stay with Resident 66, who was sitting in a shower chair when CNA B was pulled away. CNA B stated LN L heard the fall and ran into Resident 66's room. CNA B stated when he went back to assist Resident 66 a bunch of people were already tending to Resident 66 who had an unwitnessed fall. A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised 7/23, stipulated, Policy Statement: . Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. System Approach to Safety: . 2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment . A review of the facility's job description titled, Charge Nurse, undated, the job description stipulated, . Nursing Care Function: . Ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan. A review of the facility's job description titled, Floor Nurse, undated, the job description stipulated, . Essential Duties and Responsibilities: . Assisting and Supervising CNAs. Monitoring resident that are at risk for falls.

Based on observation, interview and record review, the Restorative Nursing Assistants (RNA) failed to carry out an ordered treatment to maintain or improve mobility and prevent decline in range of motion (ROM) for one resident (Resident 23) of two sampled residents when Resident 23's left-hand wrist brace was not applied on a daily basis.This failure had the potential for Resident 23's left hand paralysis to become contracted (a permanent or severe tightening of muscles, tendons, skin, and other soft tissues that leads to joint stiffness and limits normal movement).Findings:A review of Resident 23's admission record indicated Resident 23 was admitted in January 2019 with diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side.A review of Resident 23's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/6/26, indicated Resident 23 was cognitively intact (clear thinking and judgement/intact memory), had impaired limitation of range of motion on the left upper and lower extremities, was in the Restorative Nursing Program, and had a brace applied on four of the seven calendar days.A review of Resident 23's order summary report indicated a physician's order for RNA [Restorative Nursing Assistant- person-centered nursing care designed to improve or maintain the functional ability of residents] Program [NAME] [put on] L [left] hand wrist orthotic [brace] 1x [one time] a day for contracture prevention starting on 6/2/26.A review of Resident 23's joint mobility care plan regarding his risk for further decline of his left hand/wrist, initiated on 6/2/26, indicated the RNAs were expected to put on Resident 23's left-hand wrist brace daily for contracture prevention.A review of Resident 23's RNA task document/instructions dated 6/17/26 through 7/15/26 indicated Resident 23's left-hand wrist brace had not been applied for 10 out of 29 days (on 6/22/26, 6/25/26, 6/28/26, 7/3/26, 7/6/26-7/8/26, and 7/12/26- 7/14/26).During an interview with Resident 23 on 7/14/26 at 10:25 a.m., Resident 23 stated he was concerned because his left-hand wrist brace had been missing since 7/6/26. Resident 23 stated he needed to wear his brace every day because he was not able to move his left arm on his own and did not want to develop contractures.During a concurrent observation and interview with Resident 23 on 7/14/26 at 12:34 p.m., Resident 23 did not have his left-hand wrist brace on. Resident 23 stated his brace went down to the laundry room on 7/6/26 to be washed but was never returned to him. Resident 23 stated the left-hand wrist brace was supposed to be applied in the morning and removed before he went to bed; 12 hours on and 12 hours off. Resident 23 stated the Rehabilitation Department was supposed to order him a new brace, but he still had not received it. During a concurrent dining observation and interview with Resident 23 on 7/15/26 at 12:19 p.m., Resident 23 was not wearing his left-hand wrist brace. Resident 23 asked this surveyor if she had found out anything about his brace. Resident stated he had not been routinely wearing his left-hand wrist brace since 7/5/26. During an interview with Physical Therapist M (PT M) on 7/15/26 at 4:05 p.m., PT M stated Resident 23 was in the RNA program under the supervision of the Director of Staff Development (DSD). PT M stated there were three RNAs under the DSD. PT M stated the RNA was responsible for making sure Resident 23's left-hand wrist brace was applied every day. PT M stated if Resident 23's brace went missing; the Administrator (ADM) should have been notified so she could order a new brace.A review of Resident 23's Medication Administration Record (MAR) dated July 2026 indicated licensed nurses had marked the order for Resident 23's left-hand brace to be applied daily as completed on 7/1/26-7/15/26.During an observation in Resident 23's room on 7/16/26 at 8:15 a.m., Resident 23 was observed without a left-hand wrist brace on.During a concurrent interview and record review with the DSD on 7/16/26 at 8:30 a.m., the DSD stated Resident 23's left-hand wrist brace was to prevent contractures. The also DSD reviewed Resident 23's RNA task document/instructions dated 6/17/26 through7/15/26 and Resident 23's MAR dated July 2026. The DSD said, You are right. It is an order that should be followed. The DSD stated she thought there was a new hand wrist brace ordered and did not know why the RNA and nurse would document that Resident 23 was wearing his left-hand wrist brace if the brace was not being applied. The DSD stated she was going to follow-up with the RNA to find out why the documentation reflected the brace was being applied if the wrist brace was missing. The DSD stated there was an RNA seven days a week who should apply the left-hand wrist brace in the morning and a Certified Nursing Assistant (CNA) to remove the brace before Resident 23's bedtime.During a concurrent observation and interview with Resident 23 in the lobby on 7/16/26 at 9:41 a.m., Resident 23 approached this surveyor to inform the surveyor his brace was found in the laundry room.During a concurrent interview and record review with RNA K on 7/16/26 at 10:25 a.m., RNA K stated Resident 23's left-hand wrist brace had been sent to the laundry because it was dirty. RNA K stated he could not find Resident 23's left-hand wrist brace in the laundry room yesterday on 7/15/26. RNA K reviewed Resident 23's RNA task document/instructions and confirmed he had documented he spent 15 minutes with Resident 23 on 7/15/26, but not for applying Resident 23's brace but for providing passive range of motion exercise. RNA K stated it was very important for Resident 23 to wear his left-hand wrist brace to prevent contractures. RNA K stated if a resident's brace could not be found he would let the ADM know so she could order a new brace. During a concurrent interview and record review with Licensed Nurse D (LN D) on 7/16/2026 at 12:10 p.m., LN D reviewed Resident 23's July 2026 MAR. LN D confirmed she marked Resident 23's left-hand wrist orthotic one time a day order on 7/15/26 at 9 a.m. to indicate Resident 23's left-hand brace had been applied. LN D stated she could have sworn Resident 23 was wearing his left-hand wrist brace yesterday. LN D acknowledged she was not aware Resident 23's left-hand wrist brace had been missing on 7/15/26.A review of the facility's policy and procedure (P & P) titled, Assistive Devices and Equipment, revised January 2020 stipulated, Our facility maintains and supervises the use of assistive devices and equipment for residents.A review of the facility's P & P titled, Chart and Documentation, revised July 2025 stipulated, Documentation in the medical record will be objective. and accurate.A review of the facility's undated job description titled, Restorative Nurse Assistant, stipulated, The purpose of your job position is to provide each resident with routine daily nursing care in accordance with the resident's assessment plan along with current federal, state, and local standards that govern the facility, and as directed by your supervisors. They will relate all pertinent information concerning a resident's condition to a charge nurse when required.

Based on observations, interviews, and record review, the dietary staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for a census of 82 residents when a plastic scoop was left in the powdered sugar bin.This failure had the potential to contribute to the spread of foodborne illnesses for a vulnerable population.Findings:During a concurrent observation and interview on 7/14/26 at 6:22 a.m. with the Dietary Manager (DM), a clear plastic food scoop was observed inside a large white plastic bin labeled to contain powdered sugar. The DM stated the scoop should not have been left in the bin because doing so can pose an infection control concern and cause residents to get sick.During an interview on 7/17/26 at 1:01 p.m. with the Registered Dietitian (RD), the RD stated she expected scoops and other utensils to be kept out of any food bins. The RD explained that leaving utensils inside food containers presented a contamination risk and was not consistent with the facility's expectations for safe food storage. The RD further stated contamination of the sugar and potential exposure to unclean utensils could create illness risks for residents.A review of the U.S. Food and Drug Administration (FDA) Food Code 2022, section 3-304.12(E), indicated whenever food preparation or serving was temporarily stopped, utensils like scoops that are used with foods not requiring time or temperature controls for safety must be kept in a clean and secure place to prevent contamination.

Based on interview and record review, the facility nurses failed to ensure one resident (Resident 75) of twenty-two sampled residents was provided her orthopedic devices (leg splint and leg cast; braces) used to immobilize her recently fractured (broken bone) leg bones, when staff discarded them.This failure prevented Resident 75's fractured legs from being immobilized and stabilized, per physician orders, for over eight hours, placing her at risk of fracture displacement (broken ends of the bone are separated and no longer aligned, often requiring medical intervention for proper healing) and nerve damage, and caused her to experience pain, and feel fatigued and distressed. Findings:A review of Resident 75's admission record indicated she was a seventy-one-year-old female who was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body, affecting daily activities and mobility) following a cerebral infarction (stroke; sudden interruption of blood flow to the brain) affecting the left side. Additional diagnoses, added on 6/24/26, included fracture of the lower end of the left femur (thigh bone), fracture of the upper end of the right tibia (the larger of the two bones in the lower leg), fracture of the upper end of the left tibia, displaced (fracture where the broken ends of the bone are separated and no longer aligned, often requiring medical intervention for proper healing) fracture of the lateral malleolus (bony prominence on the outer side of the ankle) of the left fibula (slender bone in the lower leg; calf bone), and fracture of the upper and lower end of the right fibula.A review of Resident 75's Minimum Data Set (MDS; a resident assessment tool), dated 4/2/26, indicated she had a Brief Interview for Mental Status (BIMS; an assessment tool) used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15, indicating she was cognitively intact.Review of a hospital physician progress note (documentation of a patient's health status, treatment progress, and condition changes over time) subtitled, Recent timeline, dated 6/23/26 at 6:37 p.m., indicated -ED [Emergency Department] visit on 6/19/26 - the patient rolled out of bed while getting changed by staff. Imaging [x-rays, etc.] showed fractures of the RIGHT proximal [upper end] fibula and tibia, possible LEFT distal [lower end] fibular fracture. Noted hematoma to right temporal/right side of the head.Review of Resident 75's Order Summary Report, dated 6/19/26, indicated, . Patient to keep R [right] leg cast and L [left] leg splint ON AND DRY AT ALL TIMES. NO SHOWER ONLY BED BATH every shift. The order was dated 6/19/26.Review of Resident 75's nursing care plan, initiated 6/19/26 indicated, .Resident requires bilateral [both sides] lower extremity [legs] splints following fractures. The care plan interventions indicated, Maintain ACE(tm) wrap [elastic bandage or compression bandage] and air cast [removable medical device used to support, protect, and stabilize an injured limb] to left ankle as ordered. Maintain posterior [toward the back] splint to right lower extremity at all times as ordered.Review of a provider note written by Nurse Practitioner G (NP G), dated 6/25/26 at 2:07 p.m., indicated, .I went to check in on her [Resident 75] this morning. she didn't have any splints on her legs. She reports that 'the CNA [certified nurse assistant] cut them off me last night. I had a BM [bowel movement] and maybe they were dirty'. She is in pain RLE>LLE [right leg greater than left leg] possibly because she has no support stabilizing her fx [fractures]. NP G documented Resident 75 had swelling and bruising on her right leg and minimal swelling on her left ankle, and she was, . fatigued [tired] and distressed over her situation.Further review of NP G's provider note indicated Resident 75, . needs to go to the clinic or cast room [at the hospital] to fit her in new splints, especially since the left leg seems to have been custom made with plaster to accommodate her left knee. contracture [a result of her stroke; a fixed or stiff joint condition where the knee cannot fully straighten or bend, limiting function). Ortho [orthopedist; provider specializing in the musculoskeletal system] concerned that transport [driving to the hospital] could displace the fx [fracture] but SNF [the facility] is without any splints . [Resident 75] definitely has pain with any bed mobility movement.Review of a nurse progress note, dated 6/25/26 3:55 p.m. indicated, . Patient being transported to ED. to be refitted for splints by ortho [orthopedics department] . BLS [ambulance] transporting now [4 p.m.].Review of nurse progress note, dated 6/25/26, indicated Resident 75 was transported to the hospital for cast change on both lower extremities. at 1428 [2:28 p.m.] accompanied by 3 EMT's [emergency medical technicians] and she was transported back to the facility by ambulance at 9:27 p.m. The note indicted Resident 75 had new casts on both legs and she felt better.Review of Resident 75's nursing care plan, dated 6/25/26 indicated, Resident was at risk for interruption of prescribed orthopedic treatment related to need for bilateral lower extremity splints for fracture immobilization. The care plan goals indicated, Resident will receive prescribed orthopedic treatment without interruption, and splints will remain available and in place as ordered. The care plan interventions indicated, Educate nursing staff regarding orthopedic orders. If splints become. soiled. do not discard the splints until the MD [medical doctor] has been notified and a replacement plan has been established. Maintain bilateral lower extremity splints as ordered. Notify the MD immediately if prescribed splints are unavailable or immobilization cannot be maintained. Remove splints only for hygiene, skin assessment, or treatments. and reapply immediately after care.Review of Resident 75's Post-Fall Review., electronically signed on 7/10/26, indicated the IDT team (interdisciplinary team of healthcare professionals including nursing, social service, and rehabilitation staff) documented Resident 75 had a witnessed fall on 6/19/26 at 6 a.m. The IDT summary and recommendations indicated, . ER [emergency room] recommendations and new orders were. implemented, including ACE(tm) wrap and air cast to the left ankle, posterior splint to the right lower extremity [leg], pain management.During an interview on 7/16/2026 at 4:50 p.m., Resident 75 stated her leg braces had been missing. She stated she thought they were soiled and someone threw them out. Resident 75 stated she had to return to the hospital to get new braces refitted. She stated they had to move her legs to refit the braces, and the process was extremely painful.During an interview on 7/16/26 at 4:08 p.m., NP G stated Resident 75 had fallen off the bed and sustained multiple leg fractures on her left and right legs. She stated she went to see Resident 75 after the fall, and she had no braces and no wraps stabilizing her leg bones. She stated a CNA had thrown away her braces because they were dirty. NP G stated they wrapped Resident 75's legs in ACE(tm) bandages and sent her back to the that day so she could get new braces. NP G stated not wearing the leg braces and immobilizing her legs placed Resident 75 in danger of displacing her fractures and causing nerve damage. She stated she was sent to the ED, and the transportation had been painful for Resident 75.During a concurrent interview and record review on 7/17/26 at 11:58 a.m., the Director of Nursing (DON) reviewed Resident 75's Electronic Medical Record (EMR). The DON confirmed Resident 75's leg braces had become dirty with stool and they were discarded around 5 a.m. or 6 a.m. because staff thought they had an alternate pair. The DON confirmed Resident 75 had to be transported to the hospital in order to be refitted for new braces/immobilizers.A review of the facility's job description titled, Charge Nurse, subtitled, Nursing Care Functions undated, indicated, . Make periodic checks to ensure the prescribed treatments are being properly administered. and to evaluate the resident's physical. status. Ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan.Review care plans daily to ensure the appropriate care is being rendered. Review resident care plans for appropriate. approaches. Ensure that your . CNAs are aware of the resident care plan.Review of the facility's job description titled, Registered Nurse Supervisor, subtitled Essential Duties and Responsibilities, undated, indicated, . Monitoring nursing staff to ensure they are complying with the resident's care plan.

Based on observations, interviews, and record review, the Certified Nursing Assistants (CNAs) failed to ensure infection prevention measures were implemented for one resident (Resident 8) of three sampled residents, when an unlabeled, uncovered, used urinal (a portable plastic bottle with a handle and a special opening used to collect urine) was found at Resident 8's bedside table next to a water pitcher and a nebulizer mask (a plastic cup that fits over your nose and mouth which connects to a machine that turns liquid medicine into a cool, breathable mist).This failure increased the risk of cross contamination and potential transmission of infectious diseases.Findings:A review of Resident 8's admission record indicated admission to the facility on 6/11/26 with diagnoses that included Generalized Muscle Weakness and Difficulty in Walking.During an observation in Resident 8's room on 7/14/26 at 7:05 a.m., an uncovered, unlabeled urinal containing yellow liquid was stored on Resident 8's bedside table. An uncovered clear nebulizer mask and attached tubing were lying directly on the tabletop beside the urinal.During a concurrent observation and interview on 7/14/26 at 7:13 a.m. with Certified Nurse Assistant C (CNA C) in Resident 8's room, CNA C confirmed the urinal should not be on the bedside table. CNA C further stated the urinal needed to be cleaned and placed back in the urinal holder which hung from Resident 8's bed.During an interview on 7/17/26 at 1:52 p.m. with the Director of Staff Development (DSD), the DSD stated all urinals should be labeled, typically on the handle or another visible area, and kept in a designated, sanitary location. The DSD further stated it was her expectation for staff to maintain urinals in a clean and labeled condition and stored separately to prevent cross-contamination.A review of the facility's policy and procedure (P&P) titled, Bedpan/Urinal and Usage and Cleaning, revised December 2025 stipulated urinals should be covered with a lid and after use, staff must take the urinal to the bathroom, dispose of body fluids, clean, rinse, and dry the urinal, and place it in the appropriate storage.

Based on interview and record review, the facility nurses failed to notify the physician when one resident (Resident 1), out of five sampled residents, did not consume the minimum amounts of fluid and nutrition the Registered Dietitian's (RD) calculated for Resident 1 in April 2026.This failure contributed to Resident 1's hospitalization with a diagnosis of hypovolemia (a critical condition in which there is a low volume of fluid in the body, often caused by dehydration) on 4/30/26.Findings:A review of Resident 1's admission record indicated admission to the facility on [DATE] with diagnoses of Schizoaffective Disorder (a chronic mental health disorder characterized by combinations of hallucinations, delusions, a mood disorder (mania or depression), hypothyroidism (a condition where the thyroid gland does not produce enough hormones to regulate your body's metabolism), and generalized weakness.A review of all of Resident 1's care plans indicated the following goals and interventions: A care plan dated 11/15/21 indicated Resident 1 had an actual or potential nutritional problem related to her disease processes. Interventions required nursing staff to supervise and assist with meals as needed and monitor intake and record q [every] meal. A care plan initiated on 11/15/21 and revised on 2/25/26 indicated Resident 1 had a history of weight refusal. At that time, Resident 1's meal intake was assessed as good (76-100%). Interventions required nursing staff to monitor, document, and report signs of malnutrition and significant weight loss to the physician, and to weigh Resident 1 according to facility protocol. A care plan initiated on 11/27/21 and revised on 6/27/25 indicated Resident 1 was receiving a psychotropic medication (a medication affecting mood, thoughts, emotions, and behavior, used primarily to treat mental health disorders). Resident 1's goal was to remain free of drug related complications and not experience adverse side effects. Nursing staff were expected to monitor, document, and report to the physician as needed for any side effects or adverse reactions, including refusal to eat, loss of appetite, or weight loss. A review of Resident 1's nutrition assessment completed by the RD, dated 2/25/26, indicated Resident 1 had an estimated daily caloric need of 1888-2265 calories and an estimated fluid need of 1,888-2,265 ml/kcal (milliliter per calorie a unit of measure). This document also indicated Resident 1's nutritional goals were established to have .adequate PO [by mouth] intake to meet >75% of nutrition needs [and] No s/s [signs/symptoms] of dehydration. The RD's instructions for the nursing staff included monthly weights, monitor PO intake, weight changes.A review of Resident 1's weight summary indicated Resident 1's weight on 4/7/26 was 184.2 pounds. There were no other weights obtained for Resident 1 between 7/1/25 and 4/7/26 nor were there any documented refusals from Resident 1 to determine Resident 1's weight was being monitored.A review of Resident 1's nutrition and fluid intake for April 2026 indicated out of 89 meals served to Resident 1, Resident 1:Refused 58 timesConsumed 0-25% of meals: 6 timesConsumed 26-50% of meals: 7 timesConsumed 51-75% of meals: 4 timesConsumed 76-100% of meals: 14 timesThis document further indicated Resident 1 did not meet the daily caloric requirements established in the care plan or her daily goal of consuming 1888-2265 ml of fluid.A review of Resident 1's side effect monitoring for the month of April 2026, indicated nursing staff were expected to monitor Resident 1's side effects of refusal to eat.loss of appetite.weight loss every shift. Further review of this document indicated each shift documented No, which signified nursing staff had not observed any meal refusals, loss of appetite, or weight loss in Resident 1.A review of Resident 1's progress note written by the RD and dated 4/27/26 at 3:52 p.m., indicated Resident 1 had poor PO intake (<50% of meals) and 24 documented meal refusals x 2 weeks.MD [physician], SSD (Social Services Director), nurses aware.A review of Resident 1's psychiatric visit note, dated 4/28/26, indicated the Psychiatric Mental Health Nurse Practitioner (PNP) obtained report from nursing staff who reported that Resident 1 had not been eating and experienced a loss of appetite since she moved to a room at the end of a hallway on 3/5/25. The PNP indicated Resident 1 had refused 25 meals with associated weight loss. The PNP recommended Resident 1 start on an appetite stimulant medication and would defer appetite and weight management to the primary physician.A review of Resident 1's progress note dated 4/30/26 at 3:50 p.m. indicated, Resident noted with altered mental status during routine rounds. Eyes open but unresponsive to name, minimal movement. VS [vital signs] obtained 79/50 [a normal blood pressure is 120/80], P [pulse, normal 60-100] 43 R [respirations, normal 12-20] 10 O2 [oxygen saturation indicated how much oxygen is in the blood, normal 95-100%] fluctuated between 76%-89% RA [room air]. 6L [liters per minute-a unit of air flow measure] oxygen provided via NC [nasal cannula] and fluctuated between 93%-95%. Skin noted cold with temp 96.1 [normal 98.6], warm blanket provided. NP [Nurse Practitioner] notified and ordered to transfer resident to [hospital] for further evacuation (sic). Family notified. 4:10 p.m., [Resident 1] picked up by [ambulance service].A review of Resident 1's emergency room notes, dated 4/30/26, indicated Resident 1 was treated for diagnoses of hypotension (low blood pressure), shock (a life threatening, critical condition characterized by decreased blood flow to tissues, resulting in cellular deprivation of oxygen and potential organ failure), sepsis secondary to UTI (life threatening emergency where a kidney or bladder infection spreads, causing the immune system to damage its own tissue) and hypovolemia (a dangerous reduction of fluids in the body).A review of Resident 1's hospital progress notes, dated 4/30/26, at 6:11 p.m., the Critical Care MD indicated Resident 1, amongst her other diagnoses, had experienced .severe AKI [Acute Kidney Injury-causing waste to build up in the blood] with oliguria [abnormally low urine output], combined septic shock and hypovolemia with poor oral intake for many days prior, likely profoundly dehydrated which is c/w [consistent with] her very dry mucous membranes.During an interview in the hallway on 5/8/26, at 9:45 a.m., Certified Nursing Assistant 1 (CNA 1) stated night shift nursing staff were responsible for filling water pitchers, but it was everyone's responsibility to ensure the water in each resident's pitcher was fresh.During an observation in the hallway of six residents on 5/8/26 at 9:57 a.m., five residents' water pitcher was approximately half full and were at room temperature to touch. One resident had no water pitcher.During an interview on 5/8/26 at 12:38 p.m., the Director of Nursing (DON) stated nursing staff were expected to document physician notification in the progress notes. The DON reviewed Resident 1's progress notes for evidence the physician had been notified of Resident 1's repeated meal refusals and poor fluid intake. The DON confirmed she was unable to locate any documentation or physician orders indicating the physician had been informed. During an interview on 5/8/26 at 12:54 p.m., the RD stated Resident 1's weight loss was discussed after Resident 1's weight loss became apparent to her on 4/27/26. The RD acknowledged she did not call the MD or the family despite her progress note indicating otherwise. The RD explained items raised about Resident 1's weight loss during the morning leadership meeting were assigned to specific leaders for follow up, and she was unsure who had been responsible for notifying the physician, though she assumed it would be nurses. During an interview on 5/8/26at 1:18 p.m., Licensed Nurse 1 (LN 1) stated she found Resident 1 unresponsive during her first resident rounding. LN 1 stated she received no outstanding or concerning matters during change of shift report. LN 1 stated she had noticed Resident 1 was exhibiting minor changes days prior to her change of condition, such as talking less. LN 1 further stated she found out Resident 1 hadn't eaten for a few days after sending Resident 1 to the hospital. LN 1 stated licensed nurses were responsible for calling the MD for anything concerning, including refusing to eat and significant weight loss. LN 1 added nurses should then document the MD notification in the progress notes of the resident's chart.During an interview in the hallway on 5/8/26 at 1:30 p.m., the DON stated she would be concerned for a resident if she had not eaten or had poor intake for two to three days and expected nurses to have notified the MD. The DON explained early notification would allow her to ensure the resident received appropriate care and monitoring.During a phone interview on 5/8/26 at 1:48 p.m., the Social Service Director (SSD) stated she had been assigned to contact the PNP on 4/27/26 to request an evaluation of Resident 1 during the next visit regarding Resident 1's meal refusals. The SSD stated the PNP saw Resident 1 the following day. The SSD stated she was aware the PNP made recommendations but was unsure whether the PNP planned to notify Resident 1's MD.A phone call was placed on 5/8/26 at 1:57 p.m. to the MD and a message was left requesting for a return call. The MD never returned the call.During a concurrent interview and record review on 5/8/26 at 2:41 p.m., the RD stated nutrition assessments were completed quarterly, with Resident 1's most recent completed on 2/25/26. The RD had calculated that Resident 1 required 1,888-2,265 calories per day and 1888-2265 ml of fluid intake per day. Upon reviewing Resident 1's April 2026 meal and fluid intake documentation, the RD confirmed Resident 1 was not meeting the estimated daily nutritional or fluid needs required to maintain physical well-being.During a phone interview on 5/8/26 at 2:59 p.m., the Nurse Practitioner (NP) called in lieu of the MD and stated he saw Resident 1 often during his rounds at the facility. The NP stated he ordered laboratory tests after learning of Resident 1 had weight loss; however, the labs were not obtained before Resident 1 was transferred to the hospital. The NP stated he was unaware Resident 1 had refused numerous meals throughout most of April or that Resident 1 had demonstrated a poor appetite during other meals. The NP stated he would like to be notified immediately after two days of poor intake so next steps can be taken. The NP further stated the nursing department would have to investigate this breakdown in communication.A review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, revised February 2023, indicated, Our facility notifies the .attending physician.of changes in the resident's medical/mental condition. The nurse will notify the resident's attending physician when there has been a.refusal of treatment two (2) or more consecutive times. A significant change of condition is a major decline.in the resident's status that.will not normally resolve itself without intervention by staff.A review of facility's P&P titled Calorie Counts, revised April 2007, indicated, This facility will provide accurate daily caloric intake assessments as necessary for nutritional evaluation.Direct care staff will notify nursing staff of any 'poor intake', defined as consumption of 25 percent or less of a meal or snack.nursing staff will document poor intake in progress notes. Three or more episodes of poor meal intake in a two day period will be reported to the Dietitian.A review of facility's P&P titled Resident Hydration and Prevention of Dehydration, revised October 2017, indicated, This facility will strive to provide adequate hydration and to prevent and treat hydration . Minimum fluid needs will be calculated and documented using current standards of practice. Nurses will assess for signs and symptoms of dehydration during daily care . Nurses' aides will provide and encourage intake of bedside snack and meal fluids on a daily and routine basis as part of daily care.Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/ day to nursing staff . If potential inadequate intake and or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. The physician will be notified.

Based on interview and record review, the facility failed to notify a resident representative of a decline in condition for one of three sampled residents, Resident 1, when Resident 1 was transferred to the hospital and Resident 1's family member (FM) was not informed. This failure caused FM to feel angry and confused when she learned Resident 1 was hospitalized from hospital staff who had called from the intensive care unit (ICU) to inform her Resident 1 was in critical condition and being intubated (a procedure where a breathing tube is inserted into the airway to bring oxygen to the lungs).During a phone interview on 5/4/26 at 8:58 a.m., FM stated she was the primary contact for the facility staff to call whenever there was a change in Resident 1's condition. FM stated on the night of 4/30/26, around 9 p.m. she received a phone call from staff at the local acute care hospital. FM stated the hospital staff told her Resident 1 was in the ICU in critical condition, they needed to intubate her and they needed information from FM about Resident 1 fast. FM stated the hospital staff told her, Just so you know, we could lose her [Resident 1] when we intubate. FM stated to get a call like that when she did not even know Resident 1 was in the hospital made her feel angry, confused, and she wondered how long Resident 1 had been in the hospital. FM stated facility staff should have definitely called her to tell her Resident 1 was sent to the hospital. FM stated the hospital ICU doctor told her Resident 1 was dehydrated, septic (occurs when infections trigger extreme inflammation, leading to low blood pressure, organ failure, and high mortality (25-60%) if not treated immediately), and had a urinary tract infection.Review of Resident 1's face sheet indicated Resident 1 was admitted on [DATE] with medical diagnoses that included abnormality of gait and mobility, muscle weakness, and need for assistance with personal care, among others. Resident 1's face sheet indicated FM was Responsible Party and Emergency Contact #1, and Resident 1's code status (a patient's preferences for life-saving interventions if their heart or breathing stops) indicated she was to receive full treatment. Resident 1's nurse progress note written by Licensed Nurse A, dated 4/30/26 at 10:34 p.m., indicated that at 3:40 p.m., Resident 1's mental status became altered, she was not responding to her name, and her vital signs (blood pressure, pulse, breathing rate, temperature, and the percentage of oxygen in the blood) had become unstable. Further review of Resident 1's nurse progress note indicated Resident 1's nurse practitioner ordered Resident 1 to be transferred to the local acute care hospital and family was notified.During an interview on 5/4/26 at 1:46 p.m., Director of Nursing (DON) stated she recalled speaking with Licensed Nurse (LN) A on 4/30/26 about Resident 1. DON stated LN A informed her Resident 1's vital signs were unstable and she needed to go to the hospital. DON stated she called the nurse practitioner for LN A while LN A attended to Resident 1. DON stated the next day (5/1/26) she spoke with FM who was upset that she had not been informed of Resident 1's transfer to the hospital. DON stated she did not ask LN A about her progress note that indicated she had informed Resident 1's family of the transfer to the hospital.During a phone interview on 5/4/26 at 1:59 p.m., LN A stated that on 4/30/26 when Resident 1 was sent to the hospital, she did not notify Resident 1's family. LN A stated LN B notified Resident 1's family of her transfer to the hospital.During an interview on 5/4/26 at 2:19 p.m., LN B stated that on 4/30/26 when Resident 1 was sent to the hospital, she did not notify Resident 1's family. LN B stated she was on overtime, so she stayed long enough to complete some paperwork, but then told LN A that she did not call Resident 1's family. LN B stated, When I said I didn't call, maybe she (LN A) thought I said I did call. During an interview on 5/4/26 at 2:22 p.m., DON stated it was her expectation that when a resident was sent to the hospital, the nurse should call the resident's family and tell them. DON stated it was the responsibility of the floor nurse to notify the family of the transfer. DON stated it was important to notify the family so that the family is updated on the resident's care and the resident's situation.Review of facility policy and procedure Change in a Resident's Condition or Status, last revised 2/2023, indicated, Unless otherwise instructed by the resident, a nurse will notify the resident's representative if the resident is not self RP [responsible party] when: . it is necessary to transfer the resident to a hospital/treatment center.

Based on observation, interviews and record reviews, the facility failed to ensure professional standards of quality were delivered for one out of four sampled residents (Resident 1) when Resident 1 was left to self-administer his medications despite not having a medication self-administration assessment completed.This failure creates risks of medication errors such as overdose or missed doses, adverse drug interactions, and potential resident injury.Findings:A review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date to the facility in 1/2019 with diagnoses of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), Hemiparesis (a neurological condition characterized by partial weakness, reduced strength, or impaired motor function on one side of the body) and Dysphagia (difficulty swallowing).A review of Resident 1's admission/readmission data tool, dated 8/14/24, indicated Resident 1 did not want to self-administer medications.A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 2/6/26, Resident 1's score was 14 indicating intact cognition (mental action of acquiring knowledge and understanding through thought, experience, and the senses).During a concurrent observation and interview on 3/4/26 at 8:53 a.m., Resident 1 was noted to have a medicine cup labeled 18B containing three pills on top of his overbed table. Resident 1 verified he was occupying 18C bed while the medicine cup was labeled for 18B. Resident stated he was not even sure if these medications were for him. Resident 1 verified no nursing staff had assessed whether it was safe for him to take the medications without staff supervision. When asked if Resident could identify the three pills, Resident stated he believed he could identify two white pills and added, I am not sure . I don't know what the orange pill is. Resident 1 stated he had not requested to self-administer medications and had not requested staff to leave medications at his overbed table. Resident 1 stated he did not take the medications because he had a hard time taking the medications without assistance.During an interview on 3/4/26 at 9:00 a.m., Licensed Nurse (LN) A verified there was a medicine cup labeled 18B with three pills on top of Resident 1's overbed table. LN A verified 18B was occupied by another resident while Resident 1 occupies the 18C bed. LN B stated she was not sure what the medications were inside the medication cup. LN B stated she was not even sure if Resident 1 was safe to self-administer medications. LN B stated the facility policy indicated LNs were not allowed to leave medications at bedside and allow residents to self-administer medications unless there was an assessment that indicated a resident was safe to self-administer medications. LN B stated allowing residents to self-administer medications without proper assessment was a safety risk for the residents and could be a risk for choking episodes.During an interview on 3/4/26 at 9:06 a.m., LN B stated staff were supposed to watch the residents take their medications. LN B stated the Interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) had to assess residents for safe medication self-administration before a resident was allowed to take medications without supervision. LN B stated allowing residents to self-administer medications without assessment was a safety risk.During a concurrent interview and record review on 3/4/26 at 10:00 a.m. with the interim Director of Nursing (IDON), Resident 1's Physician Order Summary (POS, a healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive), for 2/2026, and Resident 1's admission/readmission data tool, dated 8/14/24, were reviewed. The IDON verified the admission/readmission data tool dated 8/14/24 indicated Resident 1 did not want to self-administer medications. The IDON verified there was no assessment completed for Resident 1 that would indicate he was safe to self-administer medications. The IDON stated since there was no assessment to check whether Resident 1 was safe to self-administer medications, staff should not allow Resident 1 to self-administer medications. The IDON stated since Resident 1 had not been assessed to safely to self-administer medications, allowing Resident 1 to self-administer medications could result in accidents such as choking. The IDON stated this was a safety issue which could hurt Resident 1.A review of the facility's Policy and Procedure (P&P) titled Administering Medications, revised 4/2019, the P&P indicated .medications are administered in a safe and timely manner and as prescribed.resident may self-administer their own medication only if the attending physician in conjunction with the interdisciplinary care planning team has determined they have the decision making capacity to do so safely.A review of the facility's P&P titled Self-Administration of Medication revised 12/2016, the P&P indicated .residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on observation, interviews and record reviews, the facility failed to ensure medications were in locked compartments and only accessible for authorized persons for one out of three sampled residents (Resident 1) when medications were left on Resident 1's bedside table.This failure put the residents at high risks for unauthorized access to the medications, ingestion by the wrong resident with possible adverse reactions.Findings:A review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date to the facility in 1/2019 with diagnoses of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), Hemiparesis (a neurological condition characterized by partial weakness, reduced strength, or impaired motor function on one side of the body and Dysphagia (difficulty swallowing).During a concurrent observation and interview on 3/4/26 at 8:53 a.m., Resident 1 was noted to have a medicine cup labeled 18B containing three pills on top of his overbed table. Resident 1 stated he was not sure if these medications were for him and added he was not sure of when these medications were left on his overbed table. Resident 1 stated staff left medications at his overbed table all the time. Resident 1 stated he did not request staff to leave medications at his table.During a concurrent observation and interview on 3/4/26 at 9:00 a.m., Licensed Nurse (LN) A verified there was a medicine cup labeled 18B with three pills on top of Resident 1's overbed table. LN A stated staff should not be leaving medications at residents' bedside because anyone could grab the medication leading to accidental ingestion of medications not meant for them, causing allergic reaction, choking incidents or hospitalization.During an interview on 3/4/26 at 9:06 a.m., LN B stated staff should not leave medications at bedside because they were supposed to watch the resident take the medications. LN B stated leaving medications at a resident bedside was a safety risk.During an interview on 3/4/26 at 10:00 a.m., the Interim Director of Nursing (IDON) stated staff should not leave medications at Resident 1's bedside. as it was not allowed per facility policy. The IDON added, other residents that wander could grab the medications left at bedside and ingest them even though they were not prescribed to them. The IDON stated this was a safety issue and could hurt the residents.A review of the facility's Policy and Procedure (P&P) title Administering Medications, revised 4/2019, the P&P indicated .medications are administered in a safe and timely manner and as prescribed.A review of the facility's P&P titled Self-Administration of Medication revised 12/2016, the P&P indicated .self-administered medications must be stored in a safe and secured place which is not accessible by other residents.staff shall identify and give to the charge nurse any medications found at bedside that are not authorized for self-administration.

Based on interview and record review, the facility failed to ensure an environment free of falls for one resident (Resident 1) of three sampled residents when the facility:1. Did not initiate a person-centered care plan for Resident 1's fall risk prior to [DATE]; and,2. Did not analyze Resident 1's risk for a fall after worsening edema (swelling from an accumulation of fluid in the body's tissues) and possible deep vein thrombosis (DVT, a blood clot in a deep vein which can cause pain and swelling) in her lower legs.These failures contributed to Resident 1 sustaining a left fibula (one of the two bones in the calf) [NAME] fracture (a break of the upper fibula usually caused by twisting or forceful rotation of the ankle) from a fall. Cross reference F557.Findings:1. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of venous insufficiency (a condition where the veins in the legs have difficulty in returning blood to the heart, often causing swelling and pain), morbid obesity (a disorder that involves having too much body fat, which increases the risk of serious health problems such as joint pain from excess weight), and personality disorder (a mental health condition characterized where people have a pattern of seeing themselves and reacting to other others in ways that cause problems). A review of Resident 1's care plans on [DATE] indicated the following:-On [DATE] a care plan was initiated for Resident 1's limited ability to perform Activities of Daily Living (ADL, basic tasks performed by individuals to maintain their daily life) related to her limited mobility and morbid obesity. Resident 1's goal was to demonstrate the appropriate use of adaptive devices (equipment used to help people perform daily activities, such as a cane or walker) to increase her ability with transfers or toilet use; however, no specific adaptive device was indicated. The interventions listed to assist Resident 1 to meet this goal included, TRANSFER: The resident has requires [sic] 1 staff assistance with transfers.[Revised] on [DATE].[and] TOILET USE: The resident has requires [sic] 1 staff participation to use toilet.[Revised] on [DATE].-On [DATE] a care plan was initiated for Resident 1's moderate risk for falls related to gait and balance problems. Resident 1's goal was to be free of serious injury through the review date of [DATE]. The last time this care plan was updated was on [DATE].-On [DATE] a care plan was initiated for Resident 1's risk for breakdown immobility related to an alteration in peripheral tissue perfusion (a reduction or impairment in blood flow to the tissues of the arms and legs, preventing them from receiving enough oxygen) due to chronic venous insufficiency. Staff were expected to implement interventions which included checking the lower extremities for pain, cramping, and weakness in one or both legs. This care plan was revised on [DATE].- On [DATE] a care plan was initiated for Resident 1's potential to demonstrate.behaviors r/t [related to] poor impulse control which indicated staff was expected to Assess and anticipate resident's needs.toileting needs, comfort level, body positioning, pain etc.-There was no documented evidence that a care plan for Resident 1's risk of falls was updated between [DATE] and [DATE].A review of Resident 1's quarterly risk data collection tool dated [DATE] at 6:37 p.m., [DATE] at 11:51 a.m., [DATE] at 11:23 a.m., and [DATE] at 5:33 p.m. indicated, .is resident at risk for falls? Yes.A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated [DATE] indicated:-Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment used to measure cognition (a person's ability to process information and understanding)) score of 15 which indicated Resident 1's cognition was intact;-Resident 1 normally used a walker as a mobility device; and,-Resident 1 required setup or clean-up assistance (meaning the helper assisted only prior to or following the activity) when transferring from a sitting to standing position and during toilet transfers.During an interview on [DATE] at 12:43 p.m., the Director of Nursing (DON) stated nursing staff did not consider Resident 1 at risk of falls prior to [DATE] and acknowledged Resident 1's care plan regarding her fall risk was initiated on the same day Resident 1 fell on [DATE].2. A review of Resident 1's order summary report dated [DATE] to [DATE] indicated the following physician's orders:-On [DATE] an order was placed for staff to encourage Resident 1 to elevate her legs using the recliner every shift for swelling; and,-On [DATE] an order was placed for a Left Duplex Scan (a non-invasive ultrasound test that uses sound waves to create images of blood vessels and assess blood flow) for veins in extremity unilateral (one side) one time only related to morbid obesity;A review of Resident 1's physician progress note dated [DATE] indicated, Assessment & Plan.Venous Stasis Edema W [with] Inflammation [the reddening and swelling of a body part as a reaction to injury or infection] of Bilat [both] Legs (primary encounter diagnosis) Note: Severe edematous leg edema with chronic inflammation changes. Left more than right leg, Patient is not compliant with leg elevation, which can be uncomfortable for patient.Patient does not walk tends to be sitting most of the day. She is at risk of DVT [deep vein thrombosis, a blood clot in a deep vein, usually in the leg or pelvis, which can cause pain, swelling, and skin changes] given that his [sic] unilateral more affected on the left leg.Hold off on antibiotics until ultrasound is done and or see any improvement with above intervention, patient is afebrile [without fever].A review of Resident 1's care plan initiated on [DATE] indicated a focus on Resident 1's left lower leg edema related to venous insufficiency; however, it did not indicate interventions staff were expected to implement regarding how the left lower leg edema could change Resident 1's mobility or what specific safety measures to implement.A review of all of Resident 1's care plans initiated between [DATE] and [DATE] showed no documented evidence of any use of furosemide, its side effects, and how it related to Resident 1's risk of falls.A review of Resident 1's care plan regarding her left lower leg edema related to venous insufficiency was revised on [DATE] to include .has increased swelling and erythema to LLE [left lower extremity]; pain, ‘achy,' and ‘hot'. but was not revised to include interventions staff were expected to implement regarding how the change in condition could change her mobility or what specific safety measures to implement.A review of Resident 1's Change in Condition Evaluation dated [DATE] at 7:36 p.m., indicated, [Resident 1] had several staff assisting her, 2 on her right side and one on her left side supporting her and attempting to pivot her to the bedside commode when she had an assisted fall to the floor.Most recent weight.307.4 [no unit of measure indicated] Date [weight was obtained] [DATE] at 4:44 p.m. [using a] Scale: Wheelchair.Is a behavioral assessment relevant to the change in condition been reported? Not clinically applicable to the change in condition being reported.List any medication changes made in the past week.Furosemide 20 mg.A review of a hospital Emergency Department (ED) admission information form, dated [DATE], indicated Resident 1 arrived to the ED on via ambulance at 7:45 p.m. with a primary diagnosis of left leg cellulitis (skin infection causing redness, swelling and pain to affected area) and a secondary diagnosis of left fibula [NAME] nondisplaced fracture. Resident 1's chief complaint indicated, Accident from [Facility], staff was attempting to help patient to commode and she slid to the floor.A review of the facility's post-fall review of Resident 1's fall dated [DATE] at 7:49 p.m. indicated, Date and Time of Fall.XXX[DATE] at [7:10 p.m.].[Resident 1] fell on both knees, both legs folded underneath her.[Resident 1 was] Receiving staff assistance with transfer to bedside commode.Was resident using assistive device for ambulation or transfer? No.Resident's footwear at time of fall.Slippers.Resident's behavior last observed prior to fall (Check all that apply).Excited, Agitated, Anxious/Nervous Appearance.Medications given in last 4 hours prior to fall .Diuretic.Has the resident received new medications in the past 7 days that may add to fall risk? Yes.Lasix(R) [furosemide].IDT Review Summary and Recommendations.Resident stated she fell because she wanted her old chair back. Resident with Hx [history] of personality disorder Root cause: Resident without apparent injuries, does have left lower leg redness to which the resident was refusing care/treatment to her leg and refused pillows or elevation. Resident requests to be in a chair/recliner.Resident has requested her old recliner [the one her son purchased for her] chair back multiple times- it is in extreme disrepair as evidence by a deep smell that affects other residents and staff.Resident stands and pivots to her bedside commode and fell.[document was signed on] [DATE].A review of Resident 1's care plans initiated on [DATE] indicated the following:-A focus on Impaired Physical Mobility General indicated, Goal[s].Resident will be able to perform activity within physical limits.Resident will be free of complications of immobility.Resident will maintain normal muscle tone.Resident will maintain safe balance and coordination.Resident will participate in prescribed rehabilitation program.Resident will perform physical activity within prescribed mobility restrictions.Resident will use adaptive techniques to safely transfer and ambulate .[Interventions to assist Resident 1 to meet these goals included] Patient will be monitored for complication such as depression, suicidal thought due to immobility.Patient will be sent out to [hospital] for checking the muscle, bones.Patient will be provided with call light and help instead of walking herself.-A focus on a risk for falls r/t Gait/balance problems indicated, Goal.The resident will not sustain serious injury.[Interventions to assist Resident 1 to meet these goals included] Ensure that [Resident 1] is wearing appropriate footwear (slippers) when ambulating or mobilizing in w/c [wheelchair].A review of Resident 1's care plan with a focus on resident is/has potential to demonstrate.behaviors r/t [related to] poor impulse control was revised on [DATE] to include, [Resident 1] has a preference to use old reclining chair (with foul odor and is dirty) oppose to a new one. She verbalizes being upset with staff due to replacement indicated the following intervention for staff to implement Assess and anticipate resident's needs.toileting needs, comfort level, body positioning, pain etc.A review of a hospital's discharge summary note dated [DATE] at 9:07 p.m. indicated, .[Resident 1] had suffered a fall at skilled nursing facility. [Resident 1] was brought here for work-up and noted to have a left fibula fracture as well as a right lower extremity deep venous thrombosis. [Resident 1] was started on anticoagulation [medical treatment that prevents blood clots] but then developed severe soft tissue hemorrhage [heavy, uncontrolled bleeding] into the left lower extremity.[Resident 1] developed progressive septic shock [a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to a drop in blood pressure and organ failure] with acute renal [kidney] failure despite antibiotics for cellulitis.[Resident 1] on [DATE].died peacefully.During an interview on [DATE] at 12:43 p.m., the DON stated the reason there were so many staff in Resident 1's room was to place her on the commode because Resident 1 stated she had been having pain in her legs. The DON further stated, Knowing what [Resident 1's] pain level was that day, I would have used a [resident lift (a mechanical device used to safely transfer residents with limited mobility)].During an interview on [DATE], at 9:29 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 had attempted to stand up from the new recliner (the one the facility gave her) chair to use the commode for 5-10 minutes. CNA 1 stated Resident 1 said she was unable to get off the new recliner chair and stand up. CNA 1 stated he went to seek assistance from his co-workers. The Nursing Supervisor (NS) and CNA 2 were available to assist. CNA 1 stated, Each of us put an arm under [Resident 1's] armpit and helped her to stand. It took a couple of times, but when [Resident 1] finally stood she went down.It happened so suddenly, and she was heavy. She fell and landed on her knees hard. CNA 1 stated Resident 1 did not use a walker or wheelchair and did not have one at the time of the fall.During an interview on [DATE] at 10:05 a.m., CNA 2 stated, When I walked in the room on [DATE], [Resident 1] had a look on her face like she was in pain. We each took an arm, and [Resident 1] was finally able to stand. When she started to turn toward the commode, [Resident 1's] knees buckled. We tried to stop the fall, but she was too heavy. She landed on her knees.During an interview on [DATE] at 10:29 a.m., the Nurse Supervisor (NS) stated Resident 1 normally was able to get up on her own. LN 1 stated CNA 1 and CNA 2 needed more help to get Resident 1 off the new recliner, so LN 1 got behind Resident 1 and helped push her up from the recliner. LN 1 stated Resident 1 finally got up but quickly became weak. LN 1 stated, The CNAs tried to catch her, but she was too heavy, so she landed on her knees and cried out in pain.During an interview on [DATE] at 10:45 a.m., the Director of Staff Development (DSD) stated an order was not necessary to use the lift equipment on a resident; however, Physical Therapy normally evaluated each resident prior to use. The DSD also stated a Registered Nurse would also be able to evaluate whether a resident was able to transfer safely. The DSD further stated if three people were attempting to transfer a resident, a total lift (a mechanical device used to safely transfer residents who cannot support their own weight) should be used.During an interview on [DATE] at 12:54 p.m., CNA 1 stated Resident 1 was uncomfortable in the new recliner (the one the facility gave her) and needed help getting up to use the commode even before she fell on [DATE].During an interview on [DATE] at 8:33 a.m., the DON stated the administration of furosemide medication would place a resident at risk for falls due to its side effects of lowering blood pressure, possible dizziness and confusion combined with an urgency and frequency to void. The DON confirmed Resident 1 did not have a care plan for the use of furosemide and one should have been created with the implementation of furosemide on [DATE].During an interview on [DATE] at 8:51 a.m., Family Member 1 (FM 1) stated Resident 1's old recliner was purchased several years ago, and Resident 1 depended heavily on this chair to maintain her independence and to be free of pain. The features of Resident 1's old recliner included: lifted Resident 1 to a standing position, oversized for a bariatric (obese) user, elevated Resident 1's legs, fully reclined Resident 1 to a lying position, and was heated. FM 1 stated these features assisted Resident 1 to feel independent and live pain free. During an interview on [DATE] at 12:24 p.m., the DON stated the care plan created for Resident 1's left lower leg edema should have triggered a care plan to be created for fall risk. The DON further stated though [Resident 1] was independent in transferring to the commode, the pain she had in her leg was enough to make her fall.During a telephone interview and concurrent record review on [DATE] at 2 p.m., Physical Therapist 1 (PT 1) stated he was unable to find any documented evidence that Resident 1 had ever been evaluated by a PT for the safe use of either a walker or a wheelchair.A review of facility policy titled Falls and Fall Risk, Managing, dated 2001, indicated, Based on previous evaluations and current data, the nursing staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.Resident conditions that may contribute to the risk of falls include.lower extremity weakness.medication side effects.functional impairments.Medical factors that contribute to the risk of falls include.heart failure.balance and gait disorders.Resident-Centered Approaches to Managing Falls and Fall Risk.Examples of initial approaches might include.a rearrangement of room furniture.improving footwear.etc.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised [DATE] indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.reflects currently recognized standards of practice for problem areas and conditions.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The interdisciplinary team reviews and updates the care plan.when there has been a significant change in the resident's condition.A review of the facility's policy titled Safe Lifting and Movement of Residents revised [DATE] indicated, .Manual lifting ((the activity involving the use of the human body to lift or support a load) of residents shall be eliminated when feasible. Nursing staff, in conjunction with rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following.Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability.Whether the resident is usually cooperative with staff.Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.

Based on interview and record review, the facility failed to allow one resident (Resident 1) to retain her personal recliner chair which assisted in supporting Resident 1's lower back and venous insufficiency (a condition where the veins in the legs have difficulty in returning blood to the heart, often causing swelling and pain).This failure resulted in Resident 1 enduring back and leg pain. Cross reference F689.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of venous insufficiency (a condition where the veins in the legs have difficulty in returning blood to the heart, often causing swelling and pain), morbid obesity (a disorder that involves having too much body fat, which increases the risk of serious health problems such as joint pain from excess weight), and personality disorder (a mental health condition characterized where people have a pattern of seeing themselves and reacting to other others in ways that cause problems). This document also indicated Resident 1 was her own responsible party.A review of Resident 1's multidisciplinary care conference notes indicated the following:-On 4/18/24 at 1:49 p.m. indicated, Resident is able to verbalize her needs and is a strong advocate for herself.-On 7/15/24 at 5:04 p.m. indicated, .her recliner chair needs to be replaced due to her incontinence as the order [sic] is very unpleasant.SSD [Social Service Director]: we have requested that she replace her electric recliner with a new one, but she has not been too receptive to this. She says she will think about it but is not sure she wants to as this chair is comfortable. Per family they will be bringing her a new recliner chair.A review of Resident 1's care plans indicated the following:-On 4/22/25 a care plan was initiated regarding Resident 1's preference for self-directed room activities indicated it was Very important [for staff] to take care of [Resident 1's] personal belongings/ things.-On 7/1/25 a care plan regarding Resident 1's potential to demonstrate verbally abusive behaviors related to poor impulse control was revised to include [Resident 1's] preference to use old personal reclining chair (with foul odor and is dirty) oppose to a new one. She verbalizes being upset with staff due to [the] replacement.A review of a Resident Council Meeting dated 4/23/25 indicated, Has [sic] issues been resolved to Resident/ Family Councils reasonable satisfaction? Yes [check marked].Spoke to [Family Member 1 (FM 1)] as well [as] patient.[FM 1] said he would look into hiring professionals to clean chair and follow back up w/ [with] facility. Facility will keep chair stored until we hear back from [FM 1]. A review of the Resident Council Meetings dated May 2025 documented no continuing complaints regarding odor from Resident 1's chair.A review of Resident 1's progress note dated 6/5/25 at 11:11 a.m. indicated, The resident's son informed the facility that he approves replacing the resident's current reclining chair with a new one, as the existing chair is very old and emits a strong, unpleasant odor. The facility has received multiple complaints regarding offensive odors originating from the chairs.A review of Resident 1's progress note dated 6/5/25 at 4:35 p.m., documented by the SSD indicated, The facility had to replace residents [sic] chair with another reclining chair due to infection control issues. Her chair was cloth and over time had become soiled. We replaced it with a faux leather recliner. Her previous chair is being stored in the garage for now. She [Resident 1] is unhappy with the current chair.A review of Resident 1's progress note dated 6/18/25 at 12:39 p.m., the SSD indicated, Resident believes that by professionally cleaning her old chair it will be sufficient but due to how far the smell is deep in the cushions we believe it will not work.Facility replaced her old one with one that was donated to the facility, but she [Resident 1] does not like the footrest as it does not elevate high enough.A review of the facility's post-fall review of Resident 1's fall dated 6/28/25 at 7:49 p.m. indicated, Date and Time of Fall.6/28/25 at [7:10 p.m.].[Resident 1] fell on both knees, both legs folded underneath her.[Resident 1 was] Receiving staff assistance with transfer to bedside commode.Was resident using assistive device for ambulation or transfer? No.Resident's footwear at time of fall.Slippers.Resident's behavior last observed prior to fall (Check all that apply).Excited, Agitated, Anxious/Nervous Appearance.Medications given in last 4 hours prior to fall.Diuretic.Has the resident received new medications in the past 7 days that may add to fall risk? Yes.Lasix(R) [furosemide].IDT Review Summary and Recommendations.Resident stated she fell because she wanted her old chair back. Resident with Hx [history] of personality disorder Root cause: Resident without apparent injuries, does have left lower leg redness to which the resident was refusing care/treatment to her leg and refused pillows or elevation. Resident requests to be in a chair/recliner.Resident has requested her old recliner [the one her son purchased for her] chair back multiple times- it is in extreme disrepair as evidence by a deep smell that affects other residents and staff.Resident stands and pivots to her bedside commode and fell.[document was signed on] 6/30/2025.During an interview on 8/13/25 at 8:33 a.m., FM 1 stated, This whole mess started when [the facility] took away [Resident 1's personal] recliner that I had purchased because it smelled. This chair was a medical necessity [for Resident 1] as much as a wheelchair would be to a quad [referring to paralysis in all 4 limbs] or a para [referring to paralysis in lower limbs]. FM 1 stated Resident 1 had a fused lower vertebra (a series of small bones that make up the spine) causing Resident 1 chronic back pain. Because of Resident 1's venous insufficiency, Resident 1 needed to elevate her feet as often as possible. FM 1 stated Resident 1 had the. recliner for many years, and it did not cause Resident 1 any problems. FM 1 stated he offered to have the chair deep cleaned by a professional company. An appointment was scheduled but was shut down by the Administrator [ADM]. FM 1 stated the replacement chair was causing Resident 1 significant pain in her lower back. FM 1 also reported the footrest on the chair dug into the back of her legs, causing further pain and it did not elevate high enough to drain her legs for her venous insufficiency. FM 1 stated since the facility took Resident 1's personal recliner chair on 6/5/25, Resident 1 suffered and diligently tried to get it back.During an interview on 8/15/25at 11:22 a.m., the SSD stated Resident 1 did not like the replacement chair because it did not recline back far enough and nor raise her legs high enough. The older chair needed to be replaced because it had years of urine soaked into the cushions. The SSD further stated, I know the family offered to have it deep cleaned but we didn't think it would get rid of the smell or get clean enough. The SSD stated this was the decision of the ADM.During an interview on 8/19/25 at 8:33 a.m., the DON stated she understood Resident 1 was uncomfortable in the replacement chair and further stated, If I were [Resident 1], I would want my chair back too. During an interview on 8/19/25 at 8:48 a.m., the ADM stated the odor from Resident 1's chair was frequently a topic of discussion at Resident Council.During an interview on 8/19/25 at 9:24 a.m., the Resident Council President (RCP) stated there was never a mention of Resident 1's chair or any odor emitted from it during the meetings.During an interview on 8/19/25 at 9:41 a.m., the Activities Director (AD) stated he was present at all the Resident Council meetings and did not recall any discussion about Resident 1's chair or any odor emitted from it.During an interview on 8/19/25at 10:02 a.m., FM 2 stated she made an appointment with a professional cleaning company to deep clean Resident 1's chair on 6/20/25 between 11 a.m. and 2 p.m.; however, FM 2 stated the Housekeeping Services Supervisor (HSS) informed her that the ADM would not approve of the Resident 1's recliner to be cleaned and any new chair purchased for Resident 1's use needed to be approved by the ADM first.During an interview on 8/19/25 at 10:32 a.m., the HSS stated the ADM instructed him to remove Resident 1's recliner chair from Resident 1's room on 6/5/25.During an interview on 8/20/25at 9:15 a.m., the Operations Manager of the cleaning company FM 2 hired confirmed an appointment had been made to deep clean an upholstered recliner chair at the facility on 6/20/25. The Operations Manager stated the appointment was cancelled on 6/19/25.During an interview on 8/20/25 at 12:37 p.m., the ADM stated the family of Resident 1 never followed up with deep cleaning Resident 1's chair. The ADM stated she spoke with Resident 1 all the time and [Resident 1] didn't like the replacement chair because [Resident 1] hated change.During an interview on 8/21/25at 11:45 a.m., the HSS confirmed he spoke with FM 2 to cancel the appointment for Resident 1's reclining chair because the ADM would not approve of having Resident 1's chair deep cleaned. The HSS stated the ADM wanted to approve of any chairs purchased by the family for Resident 1.A review of the facility's policy titled Personal Property, revised August 2022 indicated, Residents are encouraged to use personal belongings to maintain a homelike environment and foster independence. Residents are permitted to bring room furnishings if.the room is large enough to accommodate the furniture.the furniture does not infringe upon the rights of others.and the furniture does not violate current life safety code requirements.A review of the facility's policy titled Resident Rights, revised February 2021 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.self-determination.be supported by the facility in exercising .her rights.retain and use personal possessions to the maximum extent that space and safety permit.

Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment for one out of four sampled residents (Resident 3) when Resident 3's commode (a portable toilet, often resembling a chair, designed for individuals with mobility limitations who may have difficulty accessing a traditional toilet) bucket (removable container of the commode that collects wastes) was covered with a blanket.This failure has the potential to spread germs and cause infections. Findings:A review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 7/2025 with a diagnosis of Pain in right knee and difficulty in walking.During a concurrent observation and interview on 7/8/25 at 12:17 p.m., Resident 3's commode bucket was covered with blanket. Resident 3 stated he had not been given a commode with a lid for the bucket. Resident 3 confirmed staff covered the commode bucket with a blanket.During an interview on 7/8/25 at 12:25 p.m., Unlicensed Staff B verified Resident 3's commode bucket was covered with blanket. Unlicensed Staff B stated staff should not use a blanket to cover the commode bucket for infection controlas it was unsanitary.During an interview on 7/8/25 at 12:10 p.m., the Infection Preventionist (IP) stated it was not acceptable to cover the commode bucket with a blanket because it could lead to cross contamination (happens when bacteria or other microorganisms are unintentionally transferred from one object to another) which could result in infection.During an interview on 7/8/25 at 2:15 p.m., the Minimum Data Set coordinator (MDSC) stated it was not appropriate to cover the commode bucket with blanket. The MDSC stated the blanket used to cover the commode was now contaminated and could have bacteria (germs) which was a risk for cross contamination and infection.A review of the facility's policy and procedure (P&P) titled Policies and Practices-Infection Control, revised 10/2028, indicated, . this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received care consistent with nursing professional standards of quality and the resident's individualized nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when Resident 1 had symptoms consistent with a urinary tract infection (UTI- infection in any part of the urinary system, including the bladder and kidneys)over the period of approximately one month (approximately 3/5/2025 to 4/7/2025), including bladder pain and blood in her urine (hematuria), but nursing staff did not ensure her provider (physician or nurse practitioner) was notified, a urinalysis (test of urine; used to detect infection) was obtained, and the hematuria was monitored. This failure contributed to Resident 1 experiencing bladder pain for approximately four weeks, potentially delayed treatment of her UTI, and placed her at risk for kidney infection, kidney damage and sepsis (life-threatening blood infection). Findings: A review of Resident 1's facesheet (front page of the chart/medical record that contains a summary of basic information about the resident) indicated she had a history of urinary tract infection. Review of Resident 1's nursing care plan, dated 9/14/2024, indicated Resident had a history of urinary incontinence (involuntary leakage of urine from the bladder) as well as, risk of . septicemia [a serious infection where bacteria enter the bloodstream and spreads] will be minimized/prevented via prompt recognition and treatment of symptoms of UTI . Care plan interventions included, . Monitor/document for s/sx [signs and symptoms] UTI: pain . blood tinged urine . Review of Resident 1's nurse progress note, dated 2/27/2025 at 4:09 p.m., indicated nursing staff performed a Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) evaluation; Resident 1's BIMS summary score was 14 (cognitively intact). A review of Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/1/2025, indicated she had a history of urinary hesitancy (difficulty initiating or maintaining a steady urine flow). Review of Resident 1's change of condition (CIC) nurse progress note, dated 3/5/25 at 9:00 p.m. (approximately one month prior to Resident 1's admission to Hospital D), indicated, . Resident noted to have blood-tinged urine . Blood in urine . blood is noted in vaginal area . Per NP [nurse practitioner on call that evening] . continue to monitor, and refer resident to OBGYN[obstetrics/gynecology specialist; area of medicine that involves the treatment of conditions affecting the female reproductive system] consult . Review of Resident 1's CIC nurse progress note, dated 4/7/25 at 9:31 a.m., indicated, .Patient [Resident 1] reported to LN [licensed nurse] this morning that she has increasing pain radiating from her spine to feet. She also reports nausea/vomiting along with dizziness that has worsened this morning . [Resident 1] requested to be sent out to ED [hospital emergency department] . Review of Resident 1's physician History and Physical note (physician's documentation of a patient's medical history) from Hospital D, dated 4/7/25 at 3:35 p.m., indicated Resident 1 was, . being evaluated in ER [emergency room /department] for generalized weakness and noted to have hematuria in setting of UTI. Being admitted [to the hospital] for observation . UTI with hematuria . Chronic Urinary incontinence . recently noted blood-tinged urine in diaper . Review of Resident 1's physician progress note from Hospital D, dated 4/10/2025 at 9:30 a.m., indicated, E coli [bacteria/germ that can causes infection] UTI . Her incontinence puts her at risk for UTIs. Her generalized weakness is likely due to her UTI. Continue [phenazopyridine hydrochloride-pain relieving medication used to treat urinary/bladder pain]. Unfortunately the E coli is resistant to ceftriaxone [antibiotic]. Today I will start levofloxacin [antibiotic to treat infection] . During a telephone interview on 4/16/2025 at 11:30 a.m., Staff B (who worked at Hospital D) stated Resident 1 had been admitted to Hospital D (from the facility) on 4/7/25 and stayed until 4/11/25 (four-day hospital stay). Staff B stated Resident 1 was diagnosed with a urinary tract infection while at Hospital D. Resident 1 had told Staff B (via an interpreter) she had been asking for medical care at the facility, but Staff B stated it sounded to her like the facility waited over one month to provide it. During an interview on 4/21/25 at 1:50 p.m., Resident 1 stated (through an interpreter) that the night before she was sent to Hospital D (4/6/25), she did not feel good, her blood pressure was elevated, and she had pain. Resident 1 stated staff sent her to the hospital the next morning; she stated they checked her bladder at the hospital and hospital staff told her she had a urinary tract infection. Resident 1 stated she had on and off pain in her bladder for one month prior to being sent to Hospital D but she did not know if she had an infection during that time. During an interview 4/21/25 at 1:40 p.m., Licensed Nurse A (LN A) stated Resident 1 had a history of urinary tract infections and urinary retention (condition where the bladder does not empty completely or at all during urination); the urinary retention was being treated with medication. During an interview on 4/21/25 at 2:35 p.m., the Infection Preventionist (IP) stated she tracked UTI's in the facility and Resident 1 was not diagnosed with a UTI in March or April of 2025 (prior to transport to the hospital). IP stated Resident 1 was diagnosed in Hospital D with a UTI, the infection was caused by ESBL (E coli that was resistant to some antibiotics), and she was subsequently started on antibiotics. During a telephone interview and concurrent medical record review on 4/22/25 at 2:30 p.m., the Director of Nursing (DON) reviewed Resident 1's CIC dated 3/5/25 at 9 p.m. and confirmed nursing staff documented she had blood-tinged urine. When asked if her hematuria on 3/5/25 had been worked up (thorough diagnostic exam that includes history taking, laboratory tests, and x-rays [imaging to see inside the body]), the DON confirmed a urinalysis had not been obtained; the DON stated he did not know the NP's rationale for not obtaining a UA. The DON confirmed the nurse progress notes for Resident 1 did not contain documentation that her hematuria was monitored by nursing staff after it was documented on 3/5/25. During a telephone interview on 4/24/2025 at 3:50 p.m., Nurse Practitioner C (NP C) stated he cared for Resident 1. NP C stated on 3/5/25, nursing staff reported Resident 1 had vaginal bleeding with clots and he ordered a gynecology consult and a stat (to be drawn immediately) CBC (laboratory test of the patient's blood; CBC can detect anemia caused by bleeding). NP C stated no one mentioned Resident 1 also had blood in her urine and he was not aware she had been experiencing bladder pain. NP C stated if staff had told him about the hematuria, he would have ordered a UA and evaluated her for a UTI. When queried, NP C stated it could be possible that Resident 1's documented hematuria on 3/5/25 and her report that she had bladder pain off and on for a month may have indicated she had a UTI at that time (3/5/25). Review of facility policy titled, Urinary Tract Infections/Bacteriuria - Clinical Protocol subtitled Assessment and Recognition, dated 2001, indicated, .The staff and practitioner will identify individuals with possible signs and symptoms of a UTI.The presentation of symptomatic UTIs varies. Nurses should . document, and report signs and symptoms (for example, . hematuria) . Review of facility policy titled, Acute Condition Changes - Clinical Protocol, subtitled Cause Identification , revised March 2023, indicated, .The staff and physician will discuss possible causes . Under subtitle Monitoring and Follow-Up, the policy indicated, . The physician will help the staff monitor a resident . with a recent acute change of condition until the problem or condition has resolved or stabilized . Review of the Mayo Clinic's online website indicated symptoms of a UTI can include urine that appears red, bright pink, or cola-colored - signs of blood in the urine, pelvic pressure and lower belly discomfort. Nausea and vomiting can be symptoms when the infection is in the kidneys. If left untreated, UTIs can cause serious health problems including permanent kidney damage from a kidney infection and sepsis, a potentially life-threatening complication of an infection. (https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447)

Based on observation, interview and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was free from physical abuse when Resident 2 squeezed Resident 1 ' s left arm causing bruising and pain to Resident 1. This failure resulted in a physical injury and emotional distress to Resident 1. Findings: Resident 1 was admitted on [DATE] with Radiculopathy (injury or damage to nerve roots in the area where they leave the spine) and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). A review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/14/24, indicated her Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 4, which indicated severe cognitive (relating to processes of thinking and reasoning) impairment. Resident 2 was admitted on [DATE] with unspecified Dementia (a progressive state of decline in mental abilities). A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had a BIMS score of 1 which indicated severe cognitive impairment. A review of Resident 1 ' s progress note dated 2/1/25 at 1:56 p.m., indicated, At 9:40 a.m. CNA [Certified Nursing Assistant] brought [Resident 1] to the LN [Licensed Nurse] attention, [Resident 1] was crying and noted a bruise and scratch with scanty bleed to her left forearm, per CNA, she was passing by activity room and saw [Resident 2] squeeze [Resident 1's] arm and makde [Resident 1] upset and yell .left forearm cleansed with NS [normal saline, a solution used to clean wounds], pat dry, applied bacitracin [a topical antibiotic] ointment and leave open to air . During an interview on 2/6/25 at 12:45 p.m., CNA B stated she was walking another resident past the activity room/dining room on 2/1/25 when she heard Resident 1 yelling as Resident 2 was squeezing Resident 1 ' s left arm. Resident 2 had to be physically separated from Resident 1. CNA B then brought Resident 1 to her nurse for evaluation. During an interview on 2/6/25 at 12:48 p.m., CNA C stated she was walking behind CNA B when she heard yelling coming from the activity room/dining room. CNA C saw Resident 2 squeezing Resident 1 ' s left arm. Resident 1 was yelling and crying. Resident 3 was screaming, No, no! She stated she helped separate them and removed Resident 2 from the area. During an interview on 2/6/25 at 1 p.m., Resident 3 stated he was watching TV in the activity room/dining room with Resident 1 a few days ago when Resident 2 came in the room and started bothering Resident 1. Resident 3 stated, [Resident 2] grabbed her and hurt her [Resident 1] bad .She [Resident 1] started crying. During a concurrent observation and interview on 2/6/25 at 12:53 p.m., Resident 1 was seated in the activity room/dining room at a table with other residents, finishing her lunch. Resident 1 had visible bruising and scratches to her left forearm. She was unable to explain how the injury occurred to her arm. She stated her left arm hurts. During an interview on 2/6/25 at 1:12 p.m., LN stated she usually was assigned to care for both Resident 1 and Resident 2. During the incident, she stated Resident 1 had immediate bruising to her left forearm and was upset. During an interview on 2/6/25 at 1:24 p.m., CNA D stated Resident 2 can be aggressive. If Resident 2 was told to do something she did not like, she could become angry. During an interview on 2/6/25 at 2:05 p.m., the Administrator (AD)/Abuse Coordinator stated the abuse allegation was investigated and the abuse allegation was substantiated. A record review of policy titled Abuse Prevention Program dated 8/2021, indicated Our residents have the right to be free from abuse .This includes but is not limited to .physical abuse .

Based on interview, record review, and facility policy review, the facility failed to act upon pharmacy recommendation for 1 (Resident #73) of 6 sampled residents reviewed for unnecessary medications, psychotropic medication, and medication regimen review. Findings included: A facility policy titled, Medication Regimen Review (Monthly Report), with an effective date of 06/2021, indicated, The consultant pharmacist performs a comprehensive medication regiment review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to the medication therapy. The policy directed, E. Recommendations are acted upon and documented by the facility staff and or the prescriber. 1) Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit. An Admission Record revealed the facility admitted Resident #73 on 09/07/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction due to thrombosis of right middle cerebral artery, muscle weakness, and reduced mobility. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2024, revealed Resident #73 had a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident had intact cognition. Resident #73's care plan, included a focus area revised 05/20/2024, that indicated the resident had hemiplegia/ hemiparesis related to right middle artery infarct. Interventions directed staff to obtain and monitor laboratory/diagnostic work as ordered (initiated 09/08/2023). Resident #73's Order Summary Report, revealed an order dated 09/07/2023, for atorvastatin calcium oral tablet 80 milligrams, give one tablet by mouth at bedtime for high cholesterol and an order dated 09/07/2023, for clopidogrel bisulfate oral tablet 75 mg, give one tablet by mouth one time a day for blood thinner. The Consultant Pharmacist (CP) recommendation for Resident #73 dated 07/24/2024 and signed by the physician on 08/21/2024, revealed the resident took atorvastatin and clopidogrel, and did not have a recent lipid panel, comprehensive metabolic panel (CMP), complete blood count (CBC) documented in their chart. Per the recommendation, Please consider monitoring on the next convenient lab [laboratory] day and every 6 months thereafter. During an interview on 09/19/2024 at 8:49 AM, the Registered Nurse (RN) Supervisor stated she did not see any orders for the laboratory work for Resident #73. The RN Supervisor confirmed the CP's recommendations for Resident #73 dated 07/24/2024 had not been implemented. During an interview on 09/19/2024 at 9:11 AM, the Senior Director of Clinical Operations (SDCO) stated the facility acted upon the pharmacy recommendations by placement of the recommendation in the physician's binders for the physician to sign. Per the SDCO, once the physician signed the recommendation, the nurses were to ensure the recommendations were implemented. The SDCO stated she expected the staff to follow through with the pharmacy recommendations. During an interview on 09/19/2024 at 9:27 AM, the Administrator stated she expected staff to follow-up on what the pharmacist recommended or requested.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5% or less. There were two medication errors out of 27 opportunities, which yielded a medication error rate of 7.41% for 1 resident (Resident #10) of 4 residents observed for medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2023, indicated, Medication are administered in a safe and timely manner, and as prescribed. Per the policy, 9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. An Admission Record revealed the facility admitted Resident #10 on 11/05/2015. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified iron deficiency anemia, presence of a right artificial knee joint, contracture of the left knee, and generalized muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #10's care plan included a focus area revised 04/29/2024 that indicated the resident had a history of skin breakdown related, in part, to anemia and osteoarthritis of the knee. Interventions directed the staff to administer medications as ordered. Monitor/document for side effects and effectiveness (initiated 11/06/2015). Resident #10's Order Summary Report that included active orders as of 09/17/2024, revealed an order dated 09/26/2018, for oyster shell calcium D tablet 500-200 milligram (mg) unit, give one tablet by mouth one time a day for supplement and an order dated 02/23/2024, for ferrous fumarate oral tablet, give 325 mg by mouth one time a day for microlytic anemia. During medication administration observation on 09/17/2024 at 8:32 AM, Licensed Vocational Nurse (LVN) # 1 prepared medications for Resident #10. LVN #1 placed a ferrous sulfate tablet and an oyster shell calcium tablet into the medication cup, along with Resident #10's other scheduled medications, and gave those medications to Resident #10. In an interview on 09/18/2024 at 11:13 AM, the Consultant Pharmacist (CP) stated the ferrous sulfate the LVN had given to Resident #10 and the physician-ordered ferrous fumarate both contained iron but included a different salt compound. The CP stated it would have been better had LVN #1 given Resident #10 what was ordered. The CP stated if he had been observing medication pass he would have counted the exchange of ferrous sulfate for ferrous fumarate as a medication error. The CP stated any medication, not given as ordered by the physician, was considered a medication error. During a concurrent observation and interview on 09/18/2024 at 11:38 AM, LVN #1 removed the ferrous sulfate bottle used to dispense Resident #10's morning medication and compared the bottle with the physician's order. LVN #1 confirmed the physician ordered ferrous fumarate for the resident and stated she had given the resident the ferrous sulfate instead of the ferrous fumarate. LVN #1 stated she had not noticed the medications were not the same and therefore, had not reported the discrepancy to the physician or the medication error to anyone. LVN #1 then removed the calcium from the medication cart that had been given to Resident #10, reviewed the physician's order, and confirmed the order for calcium with Vitamin D. LVN #1 declined to answer why she had not given the correct medication to Resident #10, but acknowledged not giving the right medication was a medication error. In an interview on 09/18/2024 at 1:26 PM, the Senior Director of Clinical Operations (SDCO) stated she expected nurses to follow the rights of medication administration, which included the administration of the right medication to the resident. The SDCO stated if the medication in the medication cart did not match the medication ordered by the physician, she expected the nurse to call the physician for clarification. The SDCO stated since LVN #1 had not followed the physician's orders, LVN #1 had made a medication error. In an interview on 09/18/2024 at 3:11 PM, the Administrator stated that when nurses gave medications she expected the physician's orders to be followed. The Administrator stated LVN #1 made a medication error because the LVN had not followed the physician's order and had not given Resident #10 the correct medication.

Based on observations, interviews, and record reviews, the facility failed to ensure the right one of seven sampled residents, Resident 1, to be free from physical abuse when, Resident 1, who had a history of yelling and screaming due to hallucinations, was slapped on the left side of her face by another resident, Resident 2, who had a care planned intervention to modify her environment by reducing the noise level due to a potential to demonstrate aggressive behavior. Resident 1 and Resident 2 were in rooms close to each other. This failure had the potential to result in physical injuries to Resident 1. Findings: A review of Resident 1's Progress Notes, dated 8/25/24, at 5:44 p.m., authored by Licensed Nurse A, indicated, .Resident 1 was yelling in her room when Resident 2 went into the room and slapped Resident 1 on the left cheek. Resident 1 was visibly red on the left cheek following the incident . A review of Resident 1's Progress Notes, dated 8/25/24, at 11:35 p.m., authored by Licensed Nurse B indicated, Resident 1 being monitored for emotional distress related to being slapped on the left cheek by another Resident 2 .Left cheek with scattered petechiae (Petechiae are pinpoint, round spots that form on the skin. They're caused by bleeding, which makes the spots look red, brown, or purple. The spots often form in groups and may look like a rash) . A review of Resident 2's Care Plan, initiated on 5/8/23, indicated, Resident 2 has a potential to demonstrate physical behaviors (kicking staff) related to Dementia. The goal for this care plan indicated, The resident (Resident 2) will not harm self or others . One of the interventions for this focused problem indicated, Modify environment: (Specify: .Reduce noise . etc.). A review of Resident 1's Care Plan, initiated on 6/10/24, indicated, The resident (Resident 1) has a behavior problem related to Hallucinations causing her to yell and scream due to fear. During an observation on 9/3/24, at 1:10 p.m., Resident 1 was asleep in bed, and seemed comfortable. It was observed that Resident 1's room was very close to Resident 2's room. Resident 2 was observed eating her lunch in her room. During a concurrent interview and observation on 9/3/24, at 1:40 p.m., with Resident 2, she ambulated independently to the interview room without the use of any assistive device. Resident 2 stated there was a lady close to her room that yells and screams. Resident 2 stated sometimes she would go to that room and just ask the lady (Resident 2) to be quiet because there are people who want to rest. A review of Resident 2's MDS (Minimum Data Set-is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 6/25/24, Section C (Cognitive Patterns), indicated her BIMS (Brief Interview for Mental Status) score of 3, (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). Resident 2's BIMS score indicated she had a severe cognitive (relating to or involving the processes of thinking and reasoning) impairment. During an interview on 9/6/24, at 11:15 a.m., with Licensed Nurse A, she stated she was made aware of the incident by Certified Nursing Assistant C. Licensed Nurse A stated Certified Nursing Assistant C informed her that he witnessed Resident 1 was slapped on the left side of her face by Resident 2. Licensed Nurse A stated she checked Resident 1, and she had a fresh red spot on the left side of her face which was not evident during her first assessment at around 4:30 p.m. Licensed Nurse A stated that 5 p.m., the redness appeared which was approximately the size of a quarter. Licensed Nurse A stated that she called it in to CDPH (California Department of Public Health) and also faxed the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse). Licensed Nurse A stated that Resident 1 was non-interviewable. During an interview on 9/6/24, at 4 p.m., with Certified Nursing Assistant C, he stated at around 3:30 p.m., he was walking in the hallway when he saw the call light in a resident's room was on. He stated he entered the room to check the call light and Resident 1 was yelling at that time. Certified Nursing Assistant C stated he saw Resident 2 standing at the side of Resident 1's bed and slapped Resident 1 on the left side of her face. Certified Nursing Assistant C stated he did not have time to prevent the incident from happening and was shocked at what he witnessed. Certified Nursing Assistant C stated Resident 1 also looked shocked and stopped yelling after Resident 2 slapped her. Certified Nursing Assistant C stated he intervened and asked Resident 2 to go out of the room. He stated Resident 2 walked independently back to her room without the use of any assistive device. Certified Nursing Assistant C stated he reported the incident to Licensed Nurse B and Licensed Nurse D, who were doing the change of shift report at that time. When Certified Nursing Staff C was asked if Resident 2's action that he witnessed was intentional or accidental, he stated it was intentional. During an interview on 9/9/24, at 10:26 a.m., with Licensed Nurse B, she stated it was during the change of shift on 8/25/24, when Certified Nursing Assistant C reported the incident between Resident 1 and Resident 2. Licensed Nurse B stated that she reported the incident to Licensed Nurse A. Licensed Nurse B stated that she knew that allegations of abuse should be reported immediately or within 2 hours. During a follow-up interview on 9/9/24, at 10:55 a.m., with Licensed Nurse A, she stated she was aware of the reporting requirements that if it involved abuse, it had to be reported to CDPH immediately or within 2 hours. Licensed Nurse A stated that she was verifying that she called the incident to CDPH on Sunday 8/25/24, at around 9 p.m. and faxed the SOC 341 at around the same time. Licensed Nurse A stated she did not want to make excuses about the delay in reporting the alleged abuse incident. A review of Resident 2's other Care Plans, indicated, 1. Risk for fall care plan, dated, 6/27/24, indicated she was at risk for fall due to self-ambulatory (walk independently), poor safety awareness, and medication side effects. One of the interventions indicated, Provide assistance in transfer and mobility. 2. Risk for elopement/wandering care plan, dated 6/27/24, related to cognitive loss, impaired decision making, and wandering outside the facility. One of the interventions indicated, Frequent visual checks of resident's (Resident 2's) whereabouts. During an interview on 9/9/24, at 2:45 p.m., with the facility Administrator/Abuse Coordinator, she stated the abuse allegation was fully investigated. The Administrator stated she interviewed Certified Nursing Assistant C via phone. The Administrator stated the abuse allegation was substantiated (to establish by proof or competent evidence; verify). The Administrator stated new interventions are in place and was included in the 5-day report submitted to CDPH. The Administrator stated Resident 2 declined to be transferred to another room. The Administrator stated that it was her expectation that allegations of abuse are reported to CDPH immediately or within 2 hours. The Administrator stated she had evidence that the SOC 341 was faxed within 2 hours. The Administrator was informed that the phone call to report the incident was made by a facility staff on 8/25/24, at 9:02 p.m., and the faxed SOC 341 was received by CDPH on 8/25/24, at 9:13 p.m. On 9/12/24, at 10:04 a.m., an email was sent to the facility Administrator to follow-up if she had secured the faxed confirmation she stated that she had, as evidence that the facility faxed the SOC 341 immediately or within 2 hours to CDPH. The Administrator was not able to provide the fax confirmation that the SOC 341 was sent immediately or within 2 hours to CDPH to report the allegation of physical abuse between Resident 1 and Resident 2. A review of a facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation prevention Program, dated, April 2023, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical chemical restraint not required to treat a resident's symptoms.

Based on observations, interviews, and record reviews, the facility failed to ensure that an alleged violation of physical abuse to one of seven sample residents, Resident 1, was reported to the State Survey Agency immediately, but not later than 2 hours after the allegation of physical abuse was made, when Certified Nursing Assistant C witnessed Resident 2 slapped Resident 1 on the left side of her face on 8/25/24, at 3:30 p.m., and Licensed Nurse A reported the incident to the State Survey Agency via voicemail on 8/25/24, at 9:02 p.m., followed by a fax transmitted to the State Survey Agency on 8/25/24, at 9:13 p.m. The physical abuse allegation was reported by Licensed Nurse A to the State Survey Agency more than 5 hours after Certified Nursing Assistant C's allegation was made. This failure had the potential to result in further escalation and recurrence of physical abuse of Resident 1 by Resident 2 pending an investigation and identification of new measures to protect Resident 1 from Resident 2. Findings: A review of Resident 1's Progress Notes, dated 8/25/24, at 5:44 p.m., authored by Licensed Nurse A, indicated, .Resident 1 was yelling in her room when Resident 2 went into the room and slapped Resident 1 on the left cheek. Resident 1 was visibly red on the left cheek following the incident . A review of Resident 1's Progress Notes, dated 8/25/24, at 11:35 p.m., authored by Licensed Nurse B indicated, Resident 1 being monitored for emotional distress related to being slapped on the left cheek by another Resident 2 .Left cheek with scattered petechiae (Petechiae are pinpoint, round spots that form on the skin. They're caused by bleeding, which makes the spots look red, brown, or purple. The spots often form in groups and may look like a rash) . A review of Resident 2's Care Plan, initiated on 5/8/23, indicated, Resident 2 has a potential to demonstrate physical behaviors (kicking staff) related to Dementia. The goal for this care plan indicated, The resident (Resident 2) will not harm self or others . One of the interventions for this focused problem indicated, Modify environment: (Specify: .Reduce noise . etc.) A review of Resident 1's Care Plan, initiated on 6/10/24, indicated, The resident (Resident 1) has a behavior problem related to Hallucinations causing her to yell and scream due to fear. During an observation on 9/3/24, at 1:10 p.m., Resident 1 was asleep in bed, seemed comfortable. It was observed that Resident 1's room was very close to Resident 2's room. Resident 2 was observed eating her lunch in her room. During a concurrent interview and observation on 9/3/24, at 1:40 p.m., with Resident 2, she ambulated independently to the interview room without the use of any assistive device. Resident 2 stated there was a lady close to her room that yells and screams. Resident 2 stated sometimes she would go to that room and just ask the lady (Resident 2) to be quiet because there are people who want to rest. A review of Resident 2's MDS (Minimum Data Set-is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 6/25/24, Section C (Cognitive Patterns), indicated her BIMS (Brief Interview for Mental Status) score of 3, (The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points suggests severe cognitive impairment. 8 to 12 points suggests moderate cognitive impairment. 13 to 15 points suggests that cognition is intact). Resident 2's BIMS score indicated she had a severe cognitive (relating to or involving the processes of thinking and reasoning) impairment. During an interview on 9/6/24, at 11:15 a.m., with Licensed Nurse A, she stated she was made aware of the incident by Certified Nursing Assistant C. Licensed Nurse A stated Certified Nursing Assistant C informed her that he witnessed Resident 1 was slapped on the left side of her face by Resident 2. Licensed Nurse A stated she checked Resident 1, and she had a fresh red spot on the left side of her face which was not evident during her first assessment at around 4:30 p.m. Licensed Nurse A stated that 5 p.m., the redness appeared which was approximately the size of a quarter. Licensed Nurse A stated that she called it in to CDPH (California Department of Public Health) and also faxed the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse). Licensed Nurse A stated that Resident 1 was non-interviewable. During an interview on 9/6/24, at 4 p.m., with Certified Nursing Assistant C, he stated at around 3:30 p.m., he was walking in the hallway when he saw the call light in a residnet's room was on. He stated he entered the room to check the call light and Resident 1 was yelling at that time. Certified Nursing Assistant C stated he saw Resident 2 standing at the side of Resident 1's bed and slapped Resident 1 on the left side of her face. Certified Nursing Assistant C stated he did not have time to prevent the incident from happening and was shocked at what he witnessed. Certified Nursing Assistant C stated Resident 1 also looked shocked and stopped yelling after Resident 2 slapped her. Certified Nursing Assistant C stated he intervened and asked Resident 2 to go out of the room. He stated Resident 2 walked independently back to her room without the use of any assistive device. Certified Nursing Assistant C stated he reported the incident to Licensed Nurse B and Licensed Nurse D, who were doing the change of shift report at that time. When Certified Nursing Staff C was asked if Resident 2's action that he witnessed was intentional or accidental, he stated it was intentional. During an interview on 9/9/24, at 10:26 a.m., with Licensed Nurse B, she stated it was during the change of shift on 8/25/24, when Certified Nursing Assistant C reported the incident between Resident 1 and Resident 2. Licensed Nurse B stated that she reported the incident to Licensed Nurse A. Licensed Nurse B stated that she knew that allegations of abuse should be reported immediately or within 2 hours. During a follow-up interview on 9/9/24, at 10:55 a.m., with Licensed Nurse A, she stated she was aware of the reporting requirements that if it involved abuse, it had to be reported to CDPH immediately or within 2 hours. Licensed Nurse A stated that she was verifying that she called the incident to CDPH on Sunday 8/25/24, at around 9 p.m. and faxed the SOC 341 at around the same time. Licensed Nurse A stated she did not want to make excuses about the delay in reporting the alleged abuse incident. During an interview on 9/9/24, at 2:45 p.m., with the facility Administrator/Abuse Coordinator, she stated the abuse allegation was fully investigated. The Administrator stated she interviewed Certified Nursing Assistant C via phone. The Administrator stated the abuse allegation was substantiated (to establish by proof or competent evidence; verify). The Administrator stated new interventions are in place and was included in the 5-day report submitted to CDPH. The Administrator stated Resident 2 declined to be transferred to another room. The Administrator stated that it was her expectation that allegations of abuse are reported to CDPH immediately or within 2 hours. The Administrator stated she had evidence that the SOC 341 was faxed within 2 hours. The Administrator was informed that the phone call to report the incident was made by a facility staff on 8/25/24, at 9:02 p.m., and the SOC 341 was received by CDPH on 8/25/24, at 9:13 p.m. On 9/12/24, at 10:04 a.m., an email was sent to the facility Administrator to follow-up if she had secured the faxed confirmation she stated that she had, as evidence that the facility faxed the SOC 341 immediately or within 2 hours to CDPH. The Administrator was not able to provide the fax confirmation that the SOC 341 was sent immediately or within 2 hours to CDPH to report the allegation of physical abuse between Resident 1 and Resident 2. A review of a facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation prevention Program, dated, April 2023, the P&P Policy Statement indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical chemical restraint not required to treat a resident's symptoms. The P&P Policy Interpretation and Implementation indicated, 6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive behavior. 8. Investigate and report any allegations within timeframes required by federal requirements. * The State Operations Manual (SOM) Appendix PP, Guidance to Surveyors for Long Term Care Facility, dated 2/3/23, indicated the federal reporting requirements: S483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials(including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on observations and interviews, the facility failed to ensure a safe and functional environment to three of seven sampled residents (Resident 3, 4, and 5) in room [ROOM NUMBER], when the sliding door and screen door locking mechanisms were broken. This failure had the potential to result in harm to these residents in case of a violent break-in situation or when accidentally left open during extreme weather patterns, jeopardizing their health and safety. Findings: On 7/17/24, at 8:38 a.m., the California Department of Public Health (CDPH) received a complaint that included an allegation that door locks inside one of the resident rooms were broken and not able to be locked. During a concurrent observation and interview on 9/3/24, at 2 p.m., with the facility's Maintenance Supervisor in room [ROOM NUMBER], 2, and 3, it was observed that the original sliding door locking mechanisms were broken and not able to lock. It was also observed that the screen door in room [ROOM NUMBER] was not locking because it was bent and not able be locked, (A picture of the bent locking system was taken). When the Maintenance Supervisor was asked if he knew about room [ROOM NUMBER]'s sliding door and screen door was not able to be locked, he stated that this was the first time that he knew about it. The Maintenance Director was asked to try and lock both the sliding door and screen door inside room [ROOM NUMBER], and he was not able to lock it and he stated that it was broken. The Maintenance Supervisor and this surveyor also checked the original sliding door locking mechanism in room [ROOM NUMBER] and 2, and these were not able to lock. During an observation on 9/3/24, at 2:35 p.m., with the facility Administrator, she was able to show that room [ROOM NUMBER] and 2 had makeshift locking systems that locked the sliding doors inside the rooms. The makeshift lock in room [ROOM NUMBER] was missing a part and the sliding door was not able to be locked. The Administrator was observed trying to locate the missing part under the bed of the resident in 3C and was not able to find the missing piece. A review of a facility policy and procedure (P&P) titled, Quality of Life- Homelike Environment, undated, the P&P indicated on the policy statement, Residents are provided with a safe, clean, comfortable, and homelike environment and encourage to use their personal belongings to the extent possible.

Based on observation, interviews and record review, the facility did not ensure the safety of 1 out of 5 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5), when Resident 4 eloped from the facility and was found .4 miles away by the Police Department. This failure had the potential for all residents at risk of elopement, to be at risk of falls, injury and possible death. Findings: During an observation on 6/11/24, at 8:25 a.m., the front of the facility located at 81 Professional Center Parkway sat on the side of a hill, with a steep inclined driveway up to the front entrance. The facility was located on a street with moderate traffic in the middle of a hill that contained high-density housing, offices and a convenience store. The street began on a frontage road at the base of a steep incline up to where the facility was located. During an observation 6/11/24, at 10:29 a.m. the hallway corridor that ended at the north side of facility, led to the outside courtyard. The metal door that led outside was not locked or alarmed and allowed unsupervised passage for residents and staff from inside to the outside facility courtyard area. To the right of the door, resident rooms had sliding glass doors that appeared closed. A gazebo / shaded area was towards the east side of the courtyard. Behind the gazebo, there was a painted wooden shed with a door and behind the shed was a wooden painted gate (See Photo) that separated the right / east side of the courtyard from a walkway that led along the facility ' s east side out to the front of the facility and to the street (Professional Center Drive). To the left of the unsupervised door, observations indicated a steep walkway with a small chain suspended at waist level (See photo). The walkway went down a steep incline past the first floor of the facility and ended in the parking level of the front of the facility and opened to Professional Center Parkway. During an observation 6/11/24 at 10:30 a.m., Resident 4 sat in the outside courtyard, under the gazebo, playing guitar. The Maintenance Director was conducting repairs on a resident's room screen door at the corner of facility facing the courtyard. Resident 4 was dressed in pants and a shirt and wore a baseball cap. Resident 4 wore walking shoes and socks and had a monitoring device on his right ankle. During an interview and observation, on 6/11/24, at 11:20 a.m., with the Maintenance Director, he stated he checked the doors with alarms every morning. He stated the only doors without an alarm on them was the door leading from the facility out to the back courtyard and the resident rooms with patio doors that led out to the back courtyard. He stated he did not know if Resident 4 had a security device on the day he eloped. He stated he did not check the security devices on the residents and stated he did not know how the nurses checked for functionality. He stated he did not know what the manufacturer ' s instructions for use was for the security alarms and devices that alerted when a resident attempted to exit the facility. The Maintenance Director stated he conducted safety rounds once a month with other administrators and team members, that included a walk around the facility to identify what physical features might be an accident or safety hazard for residents. The Maintenance Director stated he did not recall if the outside courtyard had been identified as a resident risk. He stated, from the back outside courtyard, the residents and staff had access to the front of the facility through a gate on the east side of the courtyard (See Photo). He stated the gate was used by kitchen staff to get dietary items out of a shed (See Photo). He stated the other way was a walkway down the side of the facility but it was steep and he put a chain there to keep residents from walking out that way (See Photo). The Maintenance Director walked outside, through a door at the end of the hall by the kitchen, on the east side of the facility. The door was alarmed when he opened it. It opened onto a walkway on the east side of the facility that led to the front of the facility on the right side, and to the left side, the walkway led to the courtyard at the back of the facility on the north side against a steep hill (See photo of gate leading to outside courtyard). He stated kitchen staff used the gate all the time to get to the shed (See Photo). He stated it had a latch and they were supposed to close it. The gate was opened by the use of a simple metal latch, and the Maintenance Director opened and walked through the gate. The gate was not alarmed and did not have an auto-closure mechanism with a spring. The gate was as tall as the Maintenance Director ' s shoulders (See Photo). When he closed the gate, he stated there was the shed the kitchen staff stored stuff in (See Photo). He stated the staff used the gate to get dietary stuff out of the shed and take it back to the kitchen. The Maintenance Director reached over the top of the gate and unlocked the metal latch to open the gate and exit through the gate to leave the courtyard and go back to the walkway that led to the driveway at the front of the facility. He stated a resident as tall as Resident 4 would be able to reach over and unlatch it himself and walk away from the facility. The Maintenance Director stated he was out in the courtyard this morning to repair some patio doors. He stated he did not remember if Resident 4 had any visitors in the smoking gazebo while he was working in the courtyard. The Maintenance Director stated residents walked out to the courtyard through the one door that did not have an alarm security system, all the time. He stated they walked in and out whenever they wanted. He stated, if a resident did walk out to the front of the facility they had the potential to fall. During an interview and record review, on 6/11/24 at 10:20 a.m., Licensed Nurse B stated she did not know where Resident 4 was. She stated he was always walking around. She stated she was assigned to him. She stated she was unaware of any safety concerns for Resident 4. She stated he had a personal security alarm device, and did not check it. She stated the battery was good until 2025. During a review of a binder titled, Elopement Binder, she stated if a resident was an elopement risk the resident information and photographs were in the binder. Review of the binder indicated Resident 1, Resident 2, Resident 3, Resident 4 and Resident 5, were listed as facility resident elopement risks. She stated, if someone thought a resident was missing, they were supposed to call a Code Green. Review of the Elopement Binder indicated it was supposed to be Code Yellow. During an interview on 6/11/24, at 10:24 a.m., Licensed Nurse A stated Resident 4 was a very easy resident and did not have safety issues. She stated she did not know where Resident 4 was, and he usually walked around independently and liked to go outside to the courtyard and sit. She stated he went out there by himself. She stated no one was assigned to watch him like a 1:1 resident. She stated everyone knew he went out there. She stated she thought Resident 4 eloped out of the building through his bedroom patio, and that is why they moved him to another room that had a patio door that opened to the inner courtyard that did not have an exit to the courtyard. During an interview on 6/11/24, at 10:31 a.m., Resident 4 stated he remembered he took a walk a few days ago because he needed to go to the bank. He stated, I just had to go because I have some issues. He stated he walked out his room ' s patio door into the courtyard and walked out the gate. He stated the gate was open. The interview concluded after 20 minutes, at 10:51 a.m. During an interview on 6/11/24, at 11 a.m., the Social Services Director stated Resident 4 could ambulate without issue, had lowered cognition, participated in activities, but mostly liked to walk around the building and play his guitar. She stated she interviewed him after he eloped, and he stated, I just wanted to go out for a walk. She stated she did not think he had a security device alarm at that time. She stated he just walked away from the facility, maybe through his patio door at the time. She stated he walked into the courtyard and then outside the facility. She stated, after the elopement he was moved to room that had access to a secure inner courtyard without access to the outside of the facility. She stated she did not know if the other residents at risk for elopement were roomed on the interior secure courtyard. During an interview on 6/11/24, at 12:10 p.m., the Director of Nursing stated Resident 4 had been out on the patio this morning. She stated maintenance had watched him while he was out there. She stated all the department heads conducted safety rounds in the facility and outside the facility, everyday. She stated it had not been done for last two weeks. She stated the nursing staff were supposed to check the functionality of the resident ' s security alarm they wear, every shift, by using the testing device from the manufacturer. During an interview and record review on 6/11/24, at 1:30 p.m., with the Director of Nursing, she stated the facility did not conduct a Root Cause Analysis for Resident 4's elopement. He stated the post-event review documentation did not indicate a trigger for review of the environment. She stated Resident 4 ' s elopement was not caused by a security alarm bracelet. She stated Resident 4 was not wearing a security device at the time. She stated all the nurses knew how to check the devices for functionality. She state they should check the devices every shift, by using the manufacturer ' s testing device. During an interview on 6/11/24, at 1:32, p.m. Licensed Nurse C stated she did not know if any of her assigned residents were elopement risks. She stated she did not know of an Elopement Binder that had residents at risk of elopement listed in it at the nursing station. She stated she did not know how to check if a resident ' s personal security alarm device was working. She stated she did not know what the facility P&P was for resident security alarm device testing. During an interview on 6/11/24, at 1:35 p.m., with the Licensed Nurse B, she stated she checked the resident security alarm device by walking them past an alarm door, and if it alarmed, she knew it was working. She stated she did not know how the nurses on the midnight-to-morning shift checked the residents devices. She stated she did know about a manufacturer ' s testing device that could be used to test a resident ' s device. During an interview on 6/11/24, at 1:40 p.m., Licensed Nurse A stated resident security alarm devices were checked by using a special device that should have been in the medicine cart, every shift. She attempted to locate one in the medication carts and was unable to find a device. She stated she would walk a resident by a door with a, alarm and if the door alarmed she knew the device was working. She stated she did not know how the night nurses would check if a resident's device was working. During a phone interview and record review on 6/12/24, at 3:45 p.m., the Administrator stated, when Resident 4 eloped on 5/27/24, at dinnertime, the staff followed facility P&P. She stated they called the police, who found the resident and returned him to the facility. She stated there was no police report yet. She stated when the resident returned he was on a 1:1 observation for 72 hours, the staff checked the functionality of all the alarmed security doors, and moved him to a room without access to an outside courtyard. She stated Resident 4 was ambulatory and had never eloped since she had been at the facility, since January. She stated the facility suspected he eloped through the patio door in his bedroom that led out to the courtyard. She stated a post-event huddle was conducted and all those in attendance discussed any areas that could have been improved to prevent elopement. She stated there was no facility P&P for resident safety. She stated environmental safety rounds were conducted daily, assigned to all managers and then discussed at the stand-up meetings. She there were no cameras or video of the outside of the facility. She stated the conclusion of the stand-up meeting was the gate used by kitchen staff on the side of the building was where he probably exited the courtyard. She stated Resident 4 may have seen staff, who used the gate to come in and leave the courtyard, and gotten out of the facility through that gate. She stated she did not know if Resident 4 went out the other side of the courtyard with the chain because it was more dangerous and unleveled. A review of a facility document titled, Post event review V-2, dated 5/30/24, indicated, No in the section: 1. Was environment and assistive equipment checked for potential issues that could have contributed to event? She stated it should have been marked, Yes. She stated the environment was checked. She stated all the patio doors were closed and locked from the inside, the gate was checked, and it was closed. She stated, due to emergency egress issues, the facility could not lock the gate or outside access. She stated the gate did not close automatically, and they were in process of putting an automatic spring door closure on the gate. A copy of the receipt of purchase of the spring closure device was requested and not received by the end of the survey. She stated the gate was not secured by a closure device 12 days after Resident 4 eloped, and the facility suspected he exited through that gate. She stated the chain at the other exit was a huge trip hazard. She stated there was no timeline in place to address the two elopement / safety risks identified in the outside courtyard. She stated residents were allowed to be outside, unattended, in the patio courtyard area and monitoring them for safety was a collective team effort. She stated nurses were supposed to check residents' personal security alarm devices by walking them past a door with an alarm. She stated they did not do it on night shift. She stated there was no manufacturer ' s testing device, because they got lost and were expensive. She stated, We know the risk of elopement if that residents would wander off the premises, and hurt themselves. During a record review, a document titled, Face Sheet, indicated Resident 4 was admitted to the facility 9/16/21, with diagnoses that included Frontal Lobe and Executive Function deficit following cerebral infarction (After a stroke, it appears as a breakdown of skills needed to perform simple functional tasks like going somewhere without getting lost, following a sleep schedule, managing social situations), Encephalopathy (Damage to the brain that includes loss of memory, confusion, poor balance, difficulty coordinating muscle movements.), muscle weakness, and aphasia (A language disorder that affects how you communicate). Review of a document titled, Brief Interview for Mental Status, (BIMS) Evaluation (A screening tool used to evaluate the mental status of residents, with a rating from 0 - 15. A score of 13- 15 indicated no cognitive impairment. A score 0-12 indicated moderate to severe impairment), indicated Resident 4 had a BIMS score of 11 on his 5/16/24, Quarterly MDS (Minimum Data Sheet) (Tool used to determine well being and functionality of patients in a Skilled Nursing Facility). Review of a Facility document titled, ' FACILITY REPORTED EVENT, indicated for Resident 4, BIM Score 6. Review of a facility document titled, MORNING DAILY QA MEETING, dated 5/28/24, indicated, Elopement all doors tested for (Individual Security Alarm Device) working. Review of a facility document titled, Progress Notes, dated 5/28/24, at 5:42 a.m., The patient was last seen by this writer roughly between 16:00 (4 p.m.) - 16:30 (4:30 p.m.) as he was given his afternoon medications during that time. Once dinner trays were passed out, staff members noted that the patient was unable to be found. Following the announcement of the elopement code, all staff members at (Facility) proceeded to search for the individual at roughly 17:30 (5:30 p.m.) . Once the facility was searched, staff members also searched outside around the facility for the resident. Once the facility and nearby areas were searched, laws enforcement was then notified when the individual was still not found. When the patient was unable to be located at the facility this writer notified the administration and the DON (Director of Nursing) at 17:41 (5:41 p.m.), MD (Physician) at roughly 18:05 (6:05 p.m.), RP (Responsible Party) at 18:10 (6:10 p.m.) and law enforcement at 17:57 (5:57 p.m.) in regards to the patient ' s elopement. Law enforcement was able to locate the individual at 24-40 Redwood Highway and informed (Facility) staff at 19:35 (7:35 p.m.). Patient re-entered the facility at 19:45 (7:45 p.m.) Once the patient was asked about why or how he exited the facility, the patient was unable to provide a concise, consistent statement. Review of a facility document titled, Post - Event Review - V2, dated 5/30/24, indicated, Date and Time of event 5/27/24 8 p.m., Elopement .1. Was environment and assistive equipment checked for potential issues that could have contributed to event c. No-not applicable .Room move for better observation. Review of a facility document titled, Progress Notes IDT Review, dated 5/31/24, indicated, Root Cause: Wandering .IDT Recommendations based on root cause: Q 15 mins monitoring x 72 hours Continue to monitor the exit seeking / attempt to leave facility IDT will review after 72 hours (Personal security alarm device) replaced. Review of a facility Policy and Procedure (P&P) titled, Safety and Supervision of Residents, Revised July 2023, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .When accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible .Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. Review of a facility care plan for Resident 4, dated 9/30/21, revision on 5/28/24, indicated, At risk for elopement/wandering r/t (Related to): -cognitive loss - impaired decision making - DX(Diagnosis) history of CVA (Cerebral vascular accident)(Stroke) - wanders outside of facility property - wanders into other resident ' s rooms.

Based on interview and record review, the facility failed to ensure 1 resident (Resident 1) in a census of 86 residents received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan, the resident's preferences, and facility policy. Resident 1 described his pain as severe and stated it was #5-9 (moderate to severe) on the pain scale (Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable) and his physician ordered him to receive Hydromorphone (also know as Dilaudid; a narcotic pain medication) 4 mg (milligrams) every 4 hours on a scheduled basis. Licensed nurses did not administer Hydromorphone as ordered by the physician because the facility ran out of the medication; nurses did not consistently access and administer Hydromorphone from the emergency medication supply (known as an e-kit); nursing staff did not notify Resident 1's physician (Physician J) when they were unable to administer his pain medication for a period of 24 hours and intermittently thereafter; the pharmacy did not deliver the medication timely; and nursing staff did not develop, and revise when needed, a person-centered care plan addressing pain for Resident 1. These failures: 1) Caused Resident 1 to experience increased pain, 2) Caused Resident 1 to feel suicidal, hopeless, out of control, angry and depressed, 3) Caused Resident 1 to experience symptoms of narcotic withdrawal, and 4) Prevented Physician J from being aware of the ongoing issues related to Resident 1's Hydromorphone delivery and administration and therefore, potentially prevented him from evaluating and addressing the issue. (Online review of the Mayo Clinic website revealed a pain scale provides a standardized means of measuring pain intensity and severity. Their pain scale follows: .Pain Free = 0; Mild Pain = 1-3 (nagging or annoying but doesn't interfere with daily activities) .Moderate Pain = 4-6 (interferes with daily activities) . Sever Pain = 7-10 (disabling or unable to carry out normal daily activities) Ranges from impacts your social relationships, or sleep to being bedridden or even delirious.) [https://connect.mayoclinic.org/blog/adult-pain-medicine/newsfeed-post/what-to-expect-at-my-pain-medicine-appointment] Findings: During a confidential telephone interview on 1/5/24 at 1:54 p.m., Confidential Family Member (CF) stated the facility did not give Resident 1 his pain medication as ordered. CF stated Resident 1's physician ordered he receive Dilaudid for his pain but staff withheld it and the pharmacy sometimes did not deliver it to the facility. Review of Resident 1's medical record revealed his physician diagnosed him with Diabetes Mellitus (commonly known as diabetes; disease characterized by sustained high blood sugar levels), paraplegia (paralysis that mainly affects the legs- though it can sometimes affect the lower body), amputation (surgical removal) of his left leg below the knee, phantom limb syndrome with pain (syndrome where an individual continues to feel sensations like pain, itching, or movement, in a limb that has been amputated) and chronic pain syndrome. A physician order, dated 9/20/2023, indicated Resident 1 was to receive Hydromorphone (Dilaudid) 4 mg (milligrams), .give 1 tablet by mouth every 4 hours for chronic pain. An additional physician order, dated 10/31/2023, indicated Resident 1 was to receive Hydromorphone 2 mg, .give 2 tablet (sic) [for a total of 4 mg] by mouth every 4 hours for chronic pain. Review of Resident 1's electronic medical record revealed nursing staff documented his pain in the MAR (medication administration report). In October 2023, nursing staff documented Resident 1's pain ranged from approximately zero (no pain) to 7 (severe pain). In November 2023, nursing staff documented on his MAR that his pain ranged from approximately zero to 8 (severe). In December 2023, nursing staff documented on his MAR that Resident 1's pain ranged from approximately 2 (mild pain) to 8 (severe). Review of Resident 1's electronic medical record revealed a nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) for pain was not located in his medical record. Review of facility policy titled, Pain Assessment and Management, subtitled, General Guidelines (revised October 2022) indicated, 1. the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, (and) the comprehensive care plan . Review of Resident 1's medical record revealed the October 2023 MAR that indicated from 10/28/23 through 10/29/23, nursing staff did not give Resident 1 approximately six doses of his scheduled Hydromorphone (representing a time period of approximately twenty-four hours). The following doses were documented as not given: 4 a.m.; the nurse documented, .waiting for supplies ., 8 a.m. the nurse documented, .await for delivery ., 12 noon the nurse documented, .on order ., 4 p.m. the nurse documented, .waiting for supplies ., 8 p.m. the nurse documented, .waiting for supplies ., at midnight the nurse documented the medication was not given and at 3 a.m documented, .waiting for supplies. Review of Resident 1's medical record revealed the November MAR indicated on 11/8/2023, the midnight dose was not given and the nurse documented #9 (no side effects) and #2 (Resident not available). Review of Resident 1's medical record revealed the December MAR that indicated multiple doses of Hydromorphone were not given between 12/11/2023 to 12/14/2023. On 12/11/2023 at 4 p.m., the nurse documented Resident 1's pain scale was #7 (severe) and the rationale for not administering the medication was other. On 12/12/23 at 4 a.m., the nurse documented Resident 1's pain as #7 (severe), Hydromorphone was not given, and the nurse documented at 6:21 a.m. that they were, .waiting for supplies . On 12/13/23, the nurse documented the midnight and 4 a.m. doses were not given due to, Hold med, see progress notes. At 05:55 a.m., the nurse documented that they were, .waiting for supplies . On 12/14/23, the nurse documented the midnight dose was not given; at 00:40 a.m. (forty minutes past midnight), the nurse documented, .Previous LN (licensed nurse) shared . that resident was out of Dilaudid, refill will be process (sic), and supply will be deliver(ed) by midnight. However, no delivery has been made. Contacted pharmacy and spoke with (name), stated that refill has not been processed yet but she will process and will be delivered to the facility by 445am (sic). Per pharmacist, she was unable to give me authorization from the e-kit (emergency medication supply) since the prescription is different . At 1:23 a.m., the nurse documented, .Contacted pharmacy .Refill is (sic) yet to be processed . At 4:20 a.m., the nurse documented, Unable to get any (Hydromorphone) from the e-kit per pharmacy since prescription is different. waiting for delivery . , During an interview on 1/30/2024 at 2 p.m., Licensed Nurse C (LN C) stated the pharmacy delivered medication to the facility daily at approximately 6 a.m., 4:30 p.m., and 10 p.m. but it was sometimes hard getting medications from the pharmacy. She stated if a resident's medication was missing, nursing staff had to call the pharmacy. She stated she had had to make multiple calls (to request the medication) in the past and it occurred on all three shifts (day, evening, and night shifts). When asked why staff needed to make multiple calls, LN C stated she did not know. LN C stated she remembered Resident 1, he had an amputation of he left leg below his knee, he had a heel wound, and he would describe his pain as being, everywhere. She stated Resident 1 was receiving his Dilaudid every four hours but the pharmacy had not delivered it, she had called pharmacy (to request the medication), but it was not delivered. She stated she had to call pharmacy to get a one-time code for access to the e-kit and she was then able to administer the medication. (The e-kit required a pharmacy-provided code in order to access narcotics like Hydromorphone/Dilaudid). During the same interview on 1/30/2024 at 2 p.m., LN C stated other resident's medication were similarly impacted. She stated she had had to call pharmacy for other residents whose medications were missing but the pharmacy failed to deliver them. LN C stated when she called the pharmacy, she spoke directly with a pharmacist (versus general pharmacy staff) because she was more likely to get the medication delivered if she did so. During a telephone interview and concurrent review of email correspondence (from Pharmacist F) on 2/12/24 at 11:20 a.m., Pharmacist F (Pharm F) stated the facility requested Resident 1's Hydromorphone be refilled on 10/27/23 (the day prior to his not receiving Hydromorphone for twenty-four hours), the medication was not delivered until 10/29/23 at 2:30 a.m., and the pharmacy was only able to provide a small supply of ten tablets (the Hydromorphone was on backorder). When asked why the medication was not delivered on 10/28/23, Pharmacist F stated they attempted to fill the full order (versus the ten tablets) and the pharmacy sent out the medication on 10/28/23 at approximately midnight. When asked why nursing staff did not get the Hydromorphone from the e-kit (on 10/28/23), Pharmacist F stated Resident 1's order was for 4 m.g dose tablets and the ekit had only 2 m.g tablets. He stated the nurse could have called the physician for a one-time order (physician order for one dose of medication, versus a scheduled dose) of Hydromorphone (in order to access the e-kit medication) and stated this was common (practice). When asked why nursing staff did not get a new one-time order, Pharmacist F stated he did not know and stated that should have happened. During the same telephone interview and concurrent review of email correspondence on 2/12/24 at 11:20 a.m., Pharm F was asked why the nurse did not give the Hydromorphone on 11/8/23 dose at midnight. Pharm F stated he believed the nurses did not have the medication. During the same telephone interview and concurrent review of email correspondence on 2/12/24 at 11:20 a.m., Pharmacist F was asked about nurses intermittent failures to administer Hydromorphone to Resident 1 from 12/11/2023 to 12/13/2023. Pharm F stated he did not know why nurses did not administer Hydromorphone during this time. He stated the Hydromorphone order was changed to 2 m.g tablets (nurses would give two, 2 mg tablets) in November and was filled and delivered on 11/20/23 and 11/29/23. When asked how many tablets were delivered on 11/29/23, Pharm F stated 118 pills were delivered. When asked how many doses that represented, Pharm F stated about ten days worth and the medication would have run out on 12/11/20 (when nursing staff began documenting that the medication was missing). He stated the facility requested a refill on 12/9/23 and 12/13/23 but the pharmacy had to send a notice to the facility and provider (doctor) on both occasions; the notice indicated no refills remained and another physician order was needed. Pharm F stated the next order the pharmacy saw requested was on 12/14/23 around 12:53 a.m.; the Hydromorphone went out (with a quantity of fifty tablets) and was delivered at 6:30 a.m. on the same day. During a telephone interview on 2/12/2024 at 3:30 p.m., Resident 1 and CF were asked what it was like not receiving his Dilaudid, especially during the 24-hour period on 10/28/23. Resident 1 stated he had lots of pain, had the sweats, felt itchy, and felt like he had hives. He stated he had withdrawal (from his Dilaudid) on top of his pain. Resident 1 stated his pain was always above a 7 (severe), occasionally at a 9, but not below a 5 (moderate). Resident 1 stated missing his Dilaudid doses caused his pain to increase and made him feel like it was a hopeless situation. Resident 1 stated not receiving his pain medication made him feel angry and depressed. He stated he felt out of control and stated, I was at their whim and at their mercy. CF stated Resident 1 talked about suicide due to not getting his pain medication and the resulting increased pain. During the same telephone interview on 2/12/2024 at 3:30 p.m., CF stated she had told the prior DON and Administrator (both no longer at the facility) about Resident 1's suicidal thoughts. She stated she was not sure who they were (their names) as the facility had had multiple DON's over the past month and a temporary Administrator. Online review of the Mayo Clinic website indicated, .Do not .suddenly stop taking opioids (Hydromorphone) .Opioids withdrawal can be dangerous, and symptoms can be severe stop opioids slowly, called a taper. Tapering means slowly lowering over time the amount of opioid medicine you take until you stop completely .Symptoms of opioid withdrawal may include .mood changes such as sadness and depression . Increased pain .Goose bumps on the skin . sweating .Thoughts of suicide . (https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/tapering-off-opioids-when-and-how/art-20386036). During an interview on 2/13/24 at 11:55 a.m., Licensed Nurse H (LN H) stated she remembered Resident 1 well. She stated he used to take his Dilaudid for pain prn (as needed, not scheduled). He took it so frequently that staff called his physician and got the order changed to scheduled Dilaudid (nursing brought him his Dilaudid every four hours versus waiting for him to request it). LN H stated Resident 1's family member (CF) would sometimes call her to tell her Resident 1 was in pain. When asked if she was aware Resident 1 had felt suicidal when his medication was withheld, she stated she was not aware. During the same interview on 2/13/24 at 11:55 a.m., LN H stated pharmacy medication delivery was an ongoing issue at the facility. She stated nursing staff had to call the pharmacy multiple times for missing medications or refills, especially for narcotics (like Hydromorphone). She stated she would keep calling, they would say they would deliver the medication, but the medication would not come. LN H stated she did not know why they didn't process and send the medication. She stated sometimes the did does not message the pharmacy back (after pharmacy reached out to them). LN H stated she worked at another facility and they had a process where nurses could request a rush med, where a driver would pick up the medication and deliver it within two hours. She stated it would be nice if this facility had such a backup system. During the same interview on 2/13/24 at 11:55 a.m., LN H stated if a resident was out of a medication, nursing could call the pharmacy and access the e-kit (pharmacy would provide a code to access the e-kit). When asked why a nurse might not get a code from the pharmacy, she stated the prescription for the medication may be old and/or the resident needed a new prescription. LN H stated on day shift, a nurse could call the physician and ask for a new order. LN H stated the facility had a lot of registry nurses (provided by a contract service) and they did not always ask for help (if they had an issue) and they did not go the extra length (for their residents). During a telephone interview and concurrent medical record review on 2/14/2024 at 9 a.m., the Director of Nursing (DON) was asked about Resident 1 not being administered his Hydromorphone on 10/28/23. The DON stated Resident 1 missed a total of seven doses of Hydromorphone on 10/28/23 and nursing staff documented he had no pain (on the MAR during that time). She confirmed Resident 1's medical record contained no documentation that he was suicidal, no social service note addressing his being suicidal, and no nursing care plan to address his chronic pain. When asked what should have happened, the DON stated staff should have faxed pharmacy a request a refill, called the pharmacy and documented an estimated time of medication arrival. If the medication was not delivered, staff should have called pharmacy a second time and bumped it up, (notified) the DON or the Administrator, and documented in the record that the physician was notified. The DON stated nursing should have gotten a code to access the e-kit (and get the medication) and she stated there was no reason to go seven dosed without pain medication. During the same telephone interview and concurrent medical record review on 2/14/2024 at 9 a.m., the DON stated there was no progress note (nursing note) from nursing staff documenting why his midnight dose of Hydromorphone was not given on 11/8/23. She stated nursing should have documented the reason. During the same telephone interview and concurrent medical record review on 2/14/2024 at 9 a.m., the DON confirmed Resident 1 did not receive his 12/11/23 Hydromorphone scheduled for 6 p.m. and that nursing documented his pain was #7/10 (severe) at the time. She confirmed he did not receive his Hydromorphone on 12/12/23 at 4 a.m., nursing documented they were waiting for supplies, and his pain was #7 (severe). The DON confirmed Resident 1's Hydromorphone was not given on 12/13/23 at 4 a.m. The DON confirmed on 12/14/23, Resident 1 did not receive his Hydromorphone at midnight and 4 a.m The DON stated her expectation was that nurses needed to do what they needed to do to get the medication and they should bump it up (to leadership for assistance). During the same telephone interview and concurrent medical record review on 2/14/2024 at 9 a.m., the DON was asked if she was aware nursing staff had reported pharmacy deliveries were an ongoing problem at the facility and she stated she did not know (this). When asked if the issue with pharmacy was not resolved in October and continued into December 2023 for Resident 1, the DON stated it was a safe assumption and it appeared the issue had not been resolved. During a telephone interview on 2/21/24 4:30 p.m. and 6:00 p.m., Pharmacist G (Pharm G) stated he was the consulting pharmacist at the facility, dealt primarily with clinical issues, and delivery issues were dealt with on the dispensing side (at the dispensing pharmacy, where Pharm F was located). Pharm G confirmed Resident 1 was not given Hydromorphone for twenty-four hours on 10/28/23 and stated it was an, unfortunate situation that he missed his scheduled medication. When asked what nursing should have done in this situation, he stated that they should have notified the physician, who could have then contacted the pharmacy. During the same telephone interview on 2/21/24 4:30 p.m. and 6:00 p.m., Pharmacist G was asked about nursing staff not accessing the e-kit for Resident 1's Hydromorphone. He stated nursing can access the e-kit twenty-four hours a day and it requires a one-time code. He stated this necessitated a physician prescription which could be a verbal order, followed by a written copy (of the order) within seven days. The pharmacy could call the physician for emergency pharmacy needs. Pharm G confirmed Resident 1's issues with Hydromorphone (delivery) in October were still present in December (approximately two months later). When asked if he was aware of issues with accessing the e-kit, Pharm G stated, no. When asked if he was aware of ongoing delivery issues at the facility, Pharm D stated he was aware, but not of any specific issues. He stated there was turnover at the top (leadership at the facility) and that can happen with leadership issues. During a telephone interview on 2/27/2024 at 9:43 a.m., Physician J was asked if he was aware Resident 1 experienced pharmacy delivery issues with his Dilaudid (Hydromorphone). He stated he was aware it happened one time but did not know it was a routine issue. When asked if he was aware nursing staff had not administered Resident 1 his scheduled Dilaudid for approximately twenty-four hours on 10/28/23, Physician J stated the patient (Resident 1) shared the information with him, but nursing staff had not. When asked if nursing staff should have informed him of this, he stated, of course. Physician J stated nurses lost track of narcotic counts and they called when they ran out (of medication). Physician J was asked if Resident 1's symptoms of sweating, itching, and feeling like he had hives were consistent with narcotic withdrawal symptoms and he confirmed that they were, and stated Resident 1 was dependent on Dilaudid. Physician J was informed nursing staff did not document that they were monitoring for signs of withdrawal during that time and he stated nursing staff should have documented the issue and, escalated it up. Physician J stated if he was not available, they (his group) had an on-call (physician available to take a call) physician and staff could have escalated it up to them (for assistance). When asked if he was aware Resident 1 had felt suicidal at the time, Physician J stated, no. He stated Resident 1 had expressed to him that he was upset and uncomfortable (due to pain). Physician J was informed that Resident 1 and CF stated they had informed the previous DON and Administrator about Resident 1's suicidal ideation's and he stated, I believe them. When asked what his expectation was regarding leadership's knowledge of Resident 1's suicidal ideation, he stated the DON should call pharmacy to uncover the problem. He stated the DON should have called pharmacy when Resident 1 ran out of medications on other occasions as well. Physician J was informed Resident 1 missed multiple dosed of Dilaudid from 12/11/23 through 12/14/23. Physician J stated nursing staff should have used the Dilaudid located in the E-kit. Review of facility policy titled, Pain Assessment and Management, subtitled, Implementing Pain Management Strategies (revised October 2022) indicated, . 4. When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects . 5. The following are considered when establishing the medication regimen: .b. Administering medications around the clock . 6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider (doctor) when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications . Under subtitle, Monitoring and Modifying Approaches, the policy indicated, . 4. If the resident is prescribed opioid analgesics (pain medication), monitor for the following side effects: . b. Physical dependence which causes symptoms of withdrawal when opioid medication is stopped, or a dose is held or missed . Review of facility policy titled, Administering Medication, subtitled, Policy Statement (Revised April 2019) indicated, Medications are administered in a . timely manner, and as prescribed. Under subtitle, Policy Interpretation and Implementation, the policy indicated, .4. Medications are administered in accordance with prescribe orders, including and required time frame . Review of facility policy titled, Provider Pharmacy Requirements, subtitled Policy (dated April 2008) indicated, Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies . Under subtitle, Procedures, the policy indicated, .D. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: .2) Accurately dispensing prescriptions based on authorized prescribe orders 6) Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week .b. Medications which should be promptly available such as . drugs used to treat problems including severe pain . or other severe discomfort are available within 4 hours. Based on interview and record review, the facility failed to ensure 1 resident (Resident 1) in a census of 86 residents received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan, the resident's preferences, and facility policy. Resident 1 described his pain as severe and stated it was #5-9 (moderate to severe) on the pain scale (Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable) and his physician ordered him to receive Hydromorphone (also know as Dilaudid; a narcotic pain medication) 4 mg (milligrams) every 4 hours on a scheduled basis. Licensed nurses did not administer Hydromorphone as ordered by the physician because the facility ran out of the medication; nurses did not consistently access and administer Hydromorphone from the emergency medication supply (known as an e-kit); nursing staff did not notify Resident 1's physician (Physician J) when they were unable to administer his pain medication for a period of 24 hours and intermittently thereafter; the pharmacy did not deliver the medication timely; and nursing staff did not develop, and revise when needed, a person-centered care plan addressing pain for Resident 1. These failures: 1) Caused Resident 1 to experience increased pain, 2) Caused Resident 1 to feel suicidal, hopeless, out of control, angry and depressed, 3) Caused Resident 1 to experience symptoms of narcotic withdrawal, and 4) Prevented Physician J from being aware of the ongoing issues related to Resident 1's Hydromorphone delivery and administration and therefore, potentially prevented him from evaluating and addressing the issue. (Online review of the Mayo Clinic website revealed a pain scale provides a standardized means of measuring pain intensity and severity. Their pain scale follows: .Pain Free = 0; Mild Pain = 1-3 (nagging or annoying but doesn't interfere with daily activities) .Moderate Pain = 4-6 (interferes with daily activities) . Sever Pain = 7-10 (disabling or unable to carry out normal daily activities) Ranges from impacts your social relationships, or sleep to being bedridden or even delirious.) [https://connect.mayoclinic.org/blog/adult-pain-medicine/newsfeed-post/what-to-expect-at-my-pain-medicine-appointment] Findings: During a confidential telephone interview on 1/5/24 at 1:54 p.m., Confidential Family Member (CF) stated the facility did not give Resident 1 his pain medication as ordered. CF stated Resident 1's physician ordered he receive Dilaudid for his pain but staff withheld it and the pharmacy sometimes did not deliver it to the facility. Review of Resident 1's medical record revealed his physician diagnosed him with Diabetes Mellitus (commonly known as diabetes; disease characterized by sustained high blood sugar levels), paraplegia (paralysis that mainly affects the legs- though it can sometimes affect the lower body), amputation (surgical removal) of his left leg below the knee, phantom limb syndrome with pain (syndrome where an individual continues to feel sensations like pain, itching, or movement, in a limb that has been amputated) and chronic pain syndrome. A physician order, dated 9/20/2023, indicated Resident 1 was to receive Hydromorphone (Dilaudid) 4 mg (milligrams), .give 1 tablet by mouth every 4 hours for chronic pain. An additional physician order, dated 10/31/2023, indicated Resident 1 was to receive Hydromorphone 2 mg, .give 2 tablet (sic) [for a total of 4 mg] by mouth every 4 hours for chronic pain. Review of Resident 1's electronic medical record revealed nursing staff documented his pain in the MAR (medication administration report). In October 2023, nursing staff documented Resident 1's pain ranged from approximately zero (no pain) to 7 (severe pain). In November 2023, nursing staff documented on his MAR that his pain ranged from approximately zero to 8 (severe). In December 2023, nursing staff documented on his MAR that Resident 1's pain ranged from approximately 2 (mild pain) to 8 (severe). Review of Resident 1's electronic medical record revealed a nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) for pain was not located in his medical record. Review of facility policy titled, Pain Assessment and Management, subtitled, General Guidelines (revised October 2022) indicated, 1. the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, (and) the comprehensive care plan . Review of Resident 1's medical record revealed the October 2023 MAR that indicated from 10/28/23 through 10/29/23, nursing staff did not give Resident 1 approximately six doses of his scheduled Hydromorphone (representing a time period of approximately twenty-four hours). The following doses were documented as not given: 4 a.m.; the nurse documented, .waiting for supplies ., 8 a.m. the nurse documented, .await for delivery ., 12 noon the nurse documented, .on order ., 4 p.m. the nurse documented, .waiting for supplies ., 8 p.m. the nurse documented, .waiting for supplies ., at midnight the nurse documented the medication was not given and at 3 a.m documented, .waiting for supplies. Review of Resident 1's medical record revealed the November MAR indicated on 11/8/2023, the midnight dose was not given and the nurse documented #9 (no side effects) and #2 (Resident not available). Review of Resident 1's medical record revealed the December MAR that indicated multiple doses of Hydromorphone were not given between 12/11/2023 to 12/14/2023. On 12/11/2023 at 4 p.m., the nurse documented Resident 1's pain scale was #7 (severe) and the rationale for not administering the medication was other. On 12/12/23 at 4 a.m., the nurse documented Resident 1's pain as #7 (severe), Hydromorphone was not given, and the nurse documented at 6:21 a.m. that they were, .waiting for supplies . On 12/13/23, the nurse documented the midnight and 4 a.m. doses were not given due to, Hold med, see progress notes. At 05:55 a.m., the nurse documented that they were, .waiting for supplies . On 12/14/23, the nurse documented the midnight dose was not given; at 00:40 a.m. (forty minutes past midnight), the nurse documented, .Previous LN (licensed nurse) shared . that resident was out of Dilaudid, refill will be process (sic), and supply will be deliver(ed) by midnight. However, no delivery has been made. Contacted pharmacy and spoke with (name), stated that refill has not been processed yet but she will process and will be delivered to the facility by 445am (sic). Per pharmacist, she was unable to give me authorization from the e-kit (emergency medication supply) since the prescription is different . At 1:23 a.m., the nurse documented, .Contacted pharmacy .Refill is (sic) yet to be processed . At 4:20 a.m., the nurse documented, Unable to get any (Hydromorphone) from the e-kit per pharmacy since prescription is different. waiting for delivery . , During an interview on 1/30/2024 at 2 p.m., Licensed Nurse C (LN C) stated the pharmacy delivered medication to the facility daily at approximately 6 a.m., 4:30 p.m., and 10 p.m. but it was sometimes hard getting medications from [TRUNCATED]

Based on observation, interviews, and records review, the facility failed to provide staff supervision for transfer and ambulation to one of two sampled residents (Resident 1) when Resident 1 required extensive (resident involved in activity; staff provide weightbearing support [staff supports some of the weight of the resident]) one-person physical assist with transfers and ambulation and was found lying at the hallway. This failure resulted in Resident 1 sustaining a right femoral fracture (a break in the thigh bone) and subsequently had a significant physical functional (the ability to perform basic and instrumental activities of daily living) decline. Findings: During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to: Diabetes Mellitus (disease that result in too much sugar in the blood); Hypertension (High Blood Pressure); and Neurocognitive Disorder (decreased mental function due to a medical disease other than a psychiatric [relating to mental] illness). During a review of the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) dated 9/29/23 indicated Resident 1 had a short and long term memory problem. Her cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive one person physical assistance with transfers to and from a bed to a chair (or wheelchair); and ambulation. During a review of the document titled Post-Fall Review dated 10/21/23 indicated Resident 1 was found lying at the hallway on 10/21/23 at 7:00 p.m. The document indicated Resident 1 was last observed lying in bed/sleeping prior to the fall. During an observation of Resident 1 ' s room location on 12/26/24 at 11:02 a.m., Resident 1 ' s room was located at the middle of the hallway away from the nurses ' station. During a review of the Progress Note dated 11/03/23 at 3:09 p.m. indicated Resident 1 complained of right hip pain and a request for a STAT (translates to immediately) X-ray (a type of medical imaging that creates pictures of the bones and soft tissues) was sent to Resident 1 ' s Primary Care Physician (PCP). During a review of the document titled Radiology Interpretation dated 11/11/23 indicated Resident 1 had a right femoral fracture. During a review of the document titled Physical Therapy (PT) Evaluation and Plan of Treatment dated 11/21/23 and concurrent interview with Physical Therapist (PT) on 2/08/24 at 10:31 a.m., the document indicated Resident 1 exhibited a significant functional decline due to a right hip fracture as a result from a fall. The PT stated Resident 1 required maximum assistance with transfers and did not ambulate (walk) during her therapy sessions due to Resident 1 was put on non-weight bearing (NWB -resident must not put any weight through the affected leg or foot) to her right leg and was not able to follow weight bearing precautions due to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During an interview with Unlicensed Staff A on 12/26/23 at 1:11 p.m., when Unlicensed Staff A was asked how much staff assistance Resident 1 needed to walk and transfer from bed to wheelchair and back to her bed prior to her fall on 10/21/23, Unlicensed Staff A stated Resident 1 required extensive assist with both transfers and ambulation. Unlicensed Staff A stated Resident 1 subsequently became dependent from staff with transfer following her fall and did not ambulate. Unlicensed Staff A also stated Resident 1 spent most of the time in bed after falling. During an interview with Licensed Staff B on 2/08/24 at 11:14 a.m. when Licensed Staff B was asked if Resident 1 could transfer and walk without staff assistance, Licensed Staff B stated no; however, when asked how Resident 1 managed to transfer and walk from her room to the hallway and subsequently was found lying on the hallway on 10/21/23, she stated she did not know what happened. During an interview and concurrent record review with the MDS Coordinator (a nursing professional who helps manage a nursing team in a medical facility) on 2/08/24 at 11:48 a.m., the MDS Coordinator stated Resident 1 required extensive one person physical assistance with transfers and ambulation prior to her fall on 10/21/23. After review of the MDS dated [DATE] with the MDS Coordinator, the MDS Coordinator stated Resident 1 had a decline with her ability to transfer from extensive one person assist to being dependent with staff. The MDS Coordinator also stated Resident 1 did not walk during the seven day observation period (11/19/23 to 11/25/23). Review of the Facility policy and procedure titled Activities of Daily Living (ADL), Supporting revised on March 2018 indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking)

Based on interviews and records review, the facility failed to assess and provide necessary services to prevent the worsening of facility-acquired pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of two sampled residents (Resident 1) when Resident 1 was found to have an open wound on her sacrum (the triangular bone just below the backbone) and coccyx (the tailbone) and the facility failed to: 1. Obtain a doctor ' s order for a routine wound treatment when a sacral wound was identified; 2. Assess and document the status of wound perimeter (refers to the surrounding area of the wound edge), wound bed (the base or open area of a wound) and healing progress as part of the pressure ulcer care plan; and 3. Conduct a comprehensive nutritional assessment for Resident 1 according to facility policy on Prevention of Pressure Injuries (localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices). These failures resulted to the worsening of Resident 1 ' s sacral wound as evidenced by the development of thick adherent (a close and persistent attachment) devitalized (also called slough [a yellow, tan, green or brown in color and may be moist, loose, and stringy) necrotic (dead) tissue and an increased in wound size from 0.5 cm. (centimeter- a metric unit of length) x (by) 0.7 cm to 3.3 cm in length, 1.5 cm in width and 0.1 cm in depth. Findings: During a review of the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) dated 9/29/23, indicated Resident 1 had a short and long term memory problem. Her cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive (resident involved in activity; staff provide weightbearing support [staff supports some of the weight of the resident])) one person physical assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). During a review of the Pressure Ulcer Care Plan initiated on 11/22/23 indicated care plan interventions to include but not limited to: Administer treatments as ordered and monitor for effectiveness; Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD (Medical Doctor); Encourage to reposition self as tolerated; and Nutritional supplement as ordered for wound healing. 1. During a review of the Progress Note dated 11/22/23 at 7:49 p.m. and concurrent interview with Licensed Staff B on 2/08/24 at 11:14 a.m., the progress note indicated Resident 1 was noted with 4.5 cm x 4.5 cm of non-blanchable redness (skin redness that do not fade when a person presses on them) to sacrococcyx area (pertaining to both the sacrum and coccyx) with an open wound measuring 0.5 cm x 0.7 cm., and was treated with Medihoney (a brand name wound and burn gel). When Licensed Staff B was asked if Resident 1 ' s physician gave the order to treat the wound with medihoney, Licensed Staff B stated yes; however, after review of the Physician ' s Order for November 2023 with Licensed Staff B, she stated there was no order written for medihoney on 11/22/23. She stated she got the order herself from the physician and could have forgotten to enter a physician ' s order. Licensed Staff B stated there was a doctor ' s order written on 11/24/23 to cleanse the sacral wound and apply Medi honey every day. During a review of the Treatment Administration Record (TAR) for November 2023 and concurrent interview with Licensed Staff B on 2/08/24 at 11:21 a.m., the TAR indicated an order written on 11/24/24 to cleanse the sacral wound and apply Medihoney every day. Licensed Staff B verified that the initial wound treatment was done on 11/25/23. When Licensed Staff B was asked if she would know if wound treatment was provided to Resident 1 on 11/23/23 and 11/24/23, she stated no. She stated there was no other wound treatment order written on the TAR except for the 11/24/23. During a review and concurrent interview with the Director of Nursing (DON) on 2/08/24 at 1:35 p.m., the Progress Note dated 11/22/23 at 10:00 p.m. indicated Resident 1 ' s sacral wound was treated with Medihoney, however; after review of the Physician ' s order with the DON, the DON verified there was no written treatment order for Resident 1 ' s sacral wound on 11/22/23. When the DON was asked about her expectations form nurses when providing wound treatment to the residents, she stated, nurses cannot dispense any medication without a doctor ' s order. She stated she expected the nurses to obtain a doctor ' s order for any medication prior to medication or treatment administration following the five rights (right patient, right drug, right time, right dose, right route) of medication administration. 2. During a review of the Progress Note dated 11/23/23 at 2:42 p.m., the Progress Note indicated Resident 1 was monitored for pressure ulcer to her sacrococcyx. The Progress Note indicated, No active bleeding and no signs and symptoms of infection noted. During a review of the Progress Note dated 11/24/23 at 3:31 p.m., the Progress Note indicated, Resident 1 was monitored for pressure ulcer. The Progress Note indicated, No signs and symptoms of infection. During a review of the Progress Note dated 11/25/23 at 4:31 p.m., the Progress Note indicated Resident 1 was monitored for pressure ulcer to coccyx. The Progress Note indicated, No active bleeding and no symptoms of infection. During a review of the Progress Note dated 11/26/23 at 3:11 p.m., the Progress Note indicated Resident 1 was monitored for pressure ulcer to sacrococcyx and was repositioned every 2 hours as needed. During a review of the document titled Initial Wound Evaluation & Management Summary dated 11/28/23 indicated Resident 1 had an Unstageable DTI (Deep Tissue Injury - a form of pressure ulcer or pressure sore. A full thickness skin loss in which the base of the ulcer is covered by slough and /or eschar [a necrotic tissue characterized as dry, thick, leathery tissue that is often tan, brown or black]) to her sacrum with the wound measuring 3.3 cm in length, 1.5 cm in width and 0.1 cm in depth. The document indicated the wound had 60% (percent) of thick adherent devitalized necrotic tissue and 40% granulation tissue (reddish connective tissue [made up of cells, fibers, and a gel-like substance that forms on the surface of a wound when the wound is healing]). During a review of the Treatment Administration Record (TAR) for November 2023 and concurrent interview with the Treatment Nurse on 2/08/24 at 12:20 p.m., the TAR for Resident 1 indicated the Treatment Nurse ' s initial on 11/27/28. The Treatment Nurse verified she provided the wound treatment to Resident 1 ' s sacral pressure ulcer on 11/27/23; however, when the Treatment Nurse was asked if she noted any changes to Resident 1 ' s sacral wound during treatment, she stated no. She stated she would document in Resident1 ' s record if she observed any change. During an interview and concurrent record review with the Treatment Nurse on 2/08/24 at 12:37 p.m., the Treatment nurse stated she had a Progress Note dated 11/28/23 at 2:41 p.m. that Resident 1 was noted with unstageable DTI to her sacrum; however, the Treatment Nurse concurred that her note was based from the wound doctor ' s assessment. When the Treatment Nurse was asked if there were any notes from the nurses indicating Resident 1 ' s sacral wound had worsened prior to the wound doctor ' s visit and that the doctor was notified, she stated no. During an interview with the DON on 2/08/24 at 1:35 p.m., when the DON was asked about her expectations on what the nurses would document when assessing a pressure ulcer, the DON stated she expected for the nurses to document how the wound bed looked like, any necrotic tissue, slough observed, if it is improving or worsening, any signs of infection, if the wound treatment was effective. The DON stated she expected the nurses to notify the physician for any changes and obtain new treatment order if appropriate. During an interview with Licensed Staff D on 2/15/24 at 11:05 a.m., when Licensed Staff D was asked about the facility ' s practice for skin assessment, Licensed Staff D stated licensed nurses were to conduct a skin assessment on admission then weekly. He stated nurses were to document on the weekly nursing progress note for any new and active skin issues to keep track of any skin improvement or worsening. He stated the Progress Note should describe the condition of the wound including wound measurement, drainage, or bleeding if any, presence of odor, and signs of infection. After review of the Weekly Nursing Progress Note dated 11/26/23 for Resident 1 with Licensed Staff D, Licensed Staff D verified the Progress Note indicated, No new skin issue noted. Licensed Staff D verified the Progress Note did not indicate that Resident 1 had an open wound to her sacrum. During an interview and concurrent record review with Unlicensed Staff E on 2/15/24 at 11:10 a.m., when Unlicensed Staff E was asked how often did the direct care staff check the residents for any skin changes, Unlicensed Staff E stated resident ' s skin was constantly checked when providing incontinence (involuntary or accidental leakage of urine [wee] or feces [poo]) care (assisting a resident to apply or change incontinence products like absorbent pads) and every time shower or bed bath was provided. She stated CNAs (Certified Nursing Assistant) would report to the nurse using the facility ' s Stop and Watch tool (an early warning communication tool that CNAs can use to alert a nurse if they notice something different in a resident ' s daily care routine) if a new or worsening skin issue was observed. After review of the document titled Documentation Survey Report for Resident 1 from 11/23/23 to 11/28/23 with the Unlicensed Staff E, Unlicensed Staff E verified that on 11/25/23, A Stop and Watch alert was created indicating a new skin observation and was reported to the nurse. 3. During an interview and concurrent record review with the Registered Dietician (RD) on 2/08/24 at 1:04 p.m., when the RD was asked about her process when a resident was found to have pressure ulcer, the RD stated she would do a full nutritional assessment and will provide recommendations as needed to assist with wound healing. When the RD was asked if Resident 1 was assessed after she was noted to have sacral pressure ulcer, she stated she was on training with the facility RD prior to Resident 1 ' s hospital transfer. She stated the outgoing RD gave her a list of residents who were being monitored for pressure ulcer which did not include Resident 1. The RD also verified there was no comprehensive nutritional assessment for November 2023 from the previous RD for Resident 1 after the identification of the sacral pressure ulcer on 11/22/23. Review of the Facility policy and procedure titled Prevention of Pressure Injuries revised on April 2020 indicated under Nutrition of the Prevention list to, Conduct a comprehensive nutritional assessment for any resident at risk of pressure injury who is screened to be at risk for malnutrition; and for all adult residents with a pressure injury. Review of the Facility policy and procedure titled Nutritional Assessment revised on December 2011 indicated, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current initial assessment timeframes) and as indicated by a change of condition that places the resident at risk for impaired nutrition.

Based on interview and record review, the facility's (Facility 1) Governing Body did not ensure Administrator A followed facility policies for safe discharge when one resident (Resident 1), out of a census of 85 residents, was discharged to Facility 2 (an Independent Living home) that did not provide the care he needed. Resident 1 was assessed by the DOR (Director of Rehabilitation) at Facility 1 prior to discharge, and she determined Resident 1 required assistance with medication administration, stand-by assistance (presence of a person within arm's reach to prevent injury) when ambulating with his FWW (front-wheel walker), and Home Health services (physical therapy and occupational therapy for strength training, balance, etc.). Facility 2 provided the following: two meals a day (lunch and dinner) and housecleaning. Facility 1 did not follow the DOR's recommendations, discharging Resident 1 to a facility that did not meet his needs and did so: 1) Without physician's orders (including orders for medications); 2) Without input from the DON (Director of Nursing) and without notifying the DON; 3) Without the assistance of a qualified Social Worker; 4) Without notifying the Ombudsman (resident advocate; representative serving as a liaison between resident and facility; assists with complaint/concern resolution; investigates elder abuse), ; 5) Without consultation of the IDT (Interdisciplinary Team of healthcare professionals including nursing, social workers, pharmacy, and dietary staff); 6) Without ensuring all of his belongings were sent with him; 7) Without following up with him at Facility 2, to ensure he was safe and well; and, 8) Without accurately and completely documenting the discharge process. These failures caused Resident 1 to: 1) Be admitted to a hospital on two occasions; 2) Suffer a seizure in the Emergency Department (ED) on his first hospital visit; 3) Fall and experience knee pain; 4) Feel scared; and 5) Lose some of his belongings. These failures also impaired the review of his discharge process by facility staff and the Department. (Facility 1 is the skilled nursing facility (SNF) from which Resident 1 was discharged . Facility 2 is the Independent Living (IL) facility to which Resident 1 was sent. Hospital 3 is where Resident 1 was sent when he asked for help from a neighbor. Facility 4 is the SNF where Resident 1 currently lives, located down the street from Facility 1). Findings: Review of Resident 1's medical record (Diagnosis Information portion of the Admission Record) from Facility 1 revealed he was admitted to Facility 1 on 8/30/21. His diagnoses included epilepsy (disorder of the brain characterized by repeated seizures), intracranial injury (brain injury), osteoarthritis of the right knee (degenerative [wear and tear] joint condition), intermittent explosive disorder (explosive outbursts of anger and violence in which one reacts out of proportion to the situation), cognitive communication deficit (communication difficulty due to cognitive deficit [acquiring knowledge and understanding through thought, experience, and the senses] more than language/speech deficit), unsteadiness on his feet, and repeated falls. During a telephone interview on 4/4/23 at 11:50 a.m., the Ombudsman (resident advocate; representative serving as a liaison between resident and facility; assists with complaint/concern resolution; investigates elder abuse) stated Resident 1 was a Spanish-speaking man who was concerned he would be evicted from Facility 1 in 2021 after he was involved in an, incident. She stated she spoke to Administrator A at that time, and he moved Resident 1 to a room in another hallway (in response to the incident). The Ombudsman stated she received several incident reports involving Resident 1 (since 2021), where Resident 1 inappropriately touched other residents and one staff member. During the same interview on 4/4/23 at 11:50 a.m., the Ombudsman was asked about Resident 1's discharge from Facility 1 on 1/16/23 (almost two years after he was admitted ). The Ombudsman stated Administrator A did not notify her of Resident 1's discharge until after he was already out of the facility. The Ombudsman stated the normal process was for a facility to notify the Ombudsman thirty days prior to a Resident discharge and stated it was, not okay for Administrator A to have notified her after Resident 1 was gone. She stated she did not know where Resident 1 was sent. She stated Resident 1 did not have any family for support. She could not advocate for Resident 1 (since she was not aware of the discharge) and she, would have intervened (had she known Facility 1 was discharging him). During the same interview on 4/4/23 at 11:50 a.m., the Ombudsman stated she spoke to Administrator A after the fact (after discharge on 1/6/23) and he stated Resident 1, was agreeable (to the discharge) and with the facility where he was sent (Facility 2). She stated Administrator A told her Facility 2 was a licensed (by the State of California) Board and Care (facility providing room, board, 24-hour staffing and assistance with bathing, dressing, and medication management). During an onsite visit to Facility 4 (Resident 1's current home, at a SNF) on 4/20/23 at 4:05 p.m., Resident 1 was asked about his discharge from the Facility 1 (on 1/16/23). Resident 1 stated Administrator A wanted to discharge him, but he (Resident 1) did not want to go. On the day of discharge, Resident 1 stated he was not told he was being discharged to another facility; he stated he was told he was going on an outing. Resident 1 stated he did not take any of his personal belongings with him because he thought he was going to be returning to Facility 1. He stated he left his legal documents at Facility 1, including his identification and ATM cards. Resident 1 stated these items were never returned to him. He stated the Ombudsman went to Facility 1 to retrieve these items. During the same interview on 4/20/23 at 4:05 p.m., Resident 1 stated he was dropped off in Oakland (approximately thirty-four miles away) at a residence that housed other people in wheelchairs (Facility 2). Resident 1 stated no one prepared meals for them or gave them their medication. Resident 1 stated when he was dropped off, he had no medication at all, and he was unable to take his medication. Resident 1 stated he was scared. During the same interview on 4/20/23 at 4:05 p.m., Resident 1 stated, after a few days at Facility 2, he asked a neighbor for help. He stated the neighbor called 911 for him, and he was picked up and taken to a hospital. Resident 1 stated he spent days at the hospital before being released to his current SNF (Facility 4), where he felt more comfortable. Review of Resident 1's medical record from Hospital 3 (dated 1/31/23 at 8:39 a.m.) revealed an Emergency Department (ED) physician note indicating, History of Present Illness . (Resident 1) with past medical history of prior CVA (stroke) . with dysarthria (difficult to understand his speech) and right sided hemiparesis (weakness or partial paralysis on one side of the body), TBI (traumatic brain injury), and epilepsy (disorder of the brain characterized by repeated seizures), chronic right knee pain, presented to the ED for evaluation of reported chronic right knee pain after recurrent falls according to both EMS (emergency medical services) and patient. Reports he is unable to receive adequate care at his current living facility (Facility 2) .; has phone numbers provided to him from contacts at APS (Adult Protective Services) and CDPH (California Department of Public Health) who he says are attempting to advocate for him. Reports he is not receiving his medication regularly including his seizure meds. Is having difficulty moving around due to right sided motor deficits from last CVA but does not have new weakness . Is able to report he does not have family nearby who can help provided (sic) care for him . Continued review of Resident 1's medical record from Hospital 3 (dated 1/31/23 at 8:39 a.m.) revealed an Emergency Department (ED) physician note titled, Medical Decision Making that indicated, Differential Diagnosis (process where a doctor differentiates between two or more conditions causing a person's symptoms) Breakthrough seizure (sudden, uncontrolled electrical activity burst in the brain causing; causes changes in behavior, movements, feelings and levels of consciousness) .patellar (knee) fracture .epilepsy (neurological [brain and nervous system] disorder causing seizures), seizure disorder, subtherapeutic med levels (medication level too low to produce the intended medical effect), CVA . Patient (Resident 1) reported reaching out to a neighbor for help this morning to call for (sic) ambulance transport, unable to take maintenance meds x 2-3 (for two to three) days and no pain meds for knee pain provided .patient experienced single episode witnessed tonic-clonic (generalized seizure involving unconsciousness and violent muscle contractions; can be life threatening if untreated) seizure in ED .suspect likely breakthrough seizure (due to) . lack of access to AEDs (Anti-epileptic drugs; AEDs are the most commonly used treatment for epilepsy), provided 1g (gram) of Keppra (anti-seizure medication) in the ED . unable to confirm living facility condition for patient . patient having difficulty meeting ADLs (activities of daily living; eating, bathing, taking medications, etc.) for med admin (administration) and mobility, patient admitted to (Hospital 3) for evaluation and placement (living arrangement). During an onsite visit to Facility 1, interview, and concurrent review of Resident 1's medical record on 6/15/23 at 1:15 p.m., the current DON and current Administrator (Administrator JJ) were asked about Resident 1's discharge on 1/16/23. The DON stated 1/16/23, was her first day as the Interim DON at Facility 1, and she did not assist with Resident 1's discharge. A physician discharge order was not located in Resident 1's electronic medical record (EMR). When asked if a physician should have written a discharge order prior to Resident 1 leaving, Administrator JJ stated, they should have an order. No communication with the receiving facility (Facility 2) was located in Resident 1's EMR. The DON stated the prior Administrator (Administrator A) may have communicated via email with Facility 2 (no email communication was located or provided). A resident assessment for the appropriateness of moving Resident 1 to a lower level of care (Facility 2) was not located in the EMR. When asked who assessed residents for a lower level of care, the DON stated a physician did the discharge assessment and documented on a provider note (physician note). Review of facility policy titled, Discharging the Resident, subtitled, Preparation (revised 12/2016) indicated, .6.ensure that a transfer summary is completed and telephone report is called to the receiving facility. Under subtitle, Documentation, the policy indicated The following information should be recorded in the resident's medical record: .3. All assessment data obtained during the procedure . Review of policy titled, Discharging a Resident without Physician's Approval (revised 10/2022) indicated, A physician's order is obtained for discharges . During an interview and concurrent document review on 6/15/23 at 3:10 p.m., Licensed Nurse (LN) E stated she was a wound nurse, and she had performed a skin assessment on Resident 1 prior to discharge. LN E confirmed she documented the skin assessment, dated 1/16/23, located in Resident 1's medical record. LN E stated Resident 1 had asked about his medications and belongings, and she told him he needed to ask his nurse about that. During an interview and concurrent document review on 6/15/2023 at 3:45 p.m., LN F was asked if she was Resident 1's nurse on the day he was discharged (1/16/23). LN F stated she was not sure. When asked if she helped him get ready to leave, LN F stated she did not remember. LN F reviewed Resident 1's, Interdisciplinary Discharge Summary (IDT team's documentation of discharge), dated 1/16/23. She confirmed she signed the section titled, Nursing Services and stated she had signed the document, so I was there in the a.m. (day shift). LN F stated the social worker (Assistant D) said Resident 1 was leaving but did not specify a time. LN F stated her day shift ended at 3:30 p.m. Review of Resident 1's medical record titled, Interdisciplinary Discharge Summary, subtitled, Nursing Services (dated 1/16/23) indicated areas on the form were left blank. The line containing, Clinical lab values or diagnostic tests was not completed (it was blank). The line containing, Behavior issues was not completed and was blank (Resident 1's history of intermittent explosive disorder and inappropriately touching female residents/staff was not documented), and the line containing, Medication allergies was not completed. During an interview and concurrent document review on 6/15/23 at 4 p.m., LN L stated she was Resident 1's nurse on the evening shift (from approximately 3:30 p.m. to 11 p.m.). She stated LN F gave her report (shift summary given to the on-coming nurse) and told her Resident 1 was leaving. LN L stated Assistant D spoke some Spanish (Resident 1's primary language), and she took him Assistant D's office to review his medication. She stated Resident 1 expressed understanding of his medication and then waited for his ride. LN L stated Resident 1 was picked up after 4 p.m., and she and Assistant D took him downstairs to meet his ride. LN L stated Resident 1 had his belongings and medications at discharge. When informed there was no documentation by her in the EMR about medication teaching, medication dispensing, or belongings being sent with Resident 1, LN L stated, I should have done that. She stated Assistant D had told her she would do the documentation and told her, not to worry about it. Review of facility polity titled, Discharge Medications (revised 3/2022) indicated, 1. A physician must be contacted for an order to discharge a resident with medications before they will be dispensed . 5. The nurse shall review medication instructions with the resident . 6. The nurse shall complete the medication disposition record, including: a. the resident's name; .d. the name and prescription (Rx) number of each medication, e. the quantity .of each medication; f. the strength of each medication; g. any special instructions; h. telephone numbers for the physician, pharmacy and facility; and i. the signatures of the person receiving the medications and the nurse releasing them . Review of Resident 1's medical record, revealed a document titled, Post-Discharge Plan of Care (dated 1/16/23). Under subtitle, Medications, the document indicated, See attached. No document was attached. Under subtitle, Medication at Discharge (Prescribed and OTC [over-the-counter]), the document indicated, see attached. No document was attached. During a telephone interview on 6/20/23 at 10:44 a.m., Social Worker C (SW C) stated he was Facility 1's Social Worker from 1/16/23 (the day Resident 1 was discharged ) through May 2023. He stated his first two days of employment were spent in orientation, so he did not work with Resident 1. SW C stated Assistant D was an Assistant Social Worker and worked with Resident 1. SW C stated Administrator A asked him to follow-up with Resident 1 after discharge, but he was unsuccessful doing so. SW C stated none of the information located in Resident 1's medical record about the IL (Independent Living) home (Facility 2), where Resident 1 was sent, was correct. SW C stated the business name of Facility 2 was incorrect, the address was incorrect, and the phone number was incorrect. SW C stated he was unable to locate Facility 2 with an internet map search and stated it was, kind of bizarre. SW C stated he called the two contacts (his brother and former caretaker) listed on Resident 1's medical record and neither knew where Resident 1 was located. SW C stated something seemed wrong. SW C stated it was, weird and stated, How do you discharge someone to a place that doesn't exist? SW C stated he reported his inability to follow-up with Resident 1's discharge due to lack of accurate contact information for Facility 2. When asked what Administrator A did about this, SW C stated he did not know. During the same interview on 6/20/23 at 10:44 a.m., SW C stated he received a call from a Social Worker at Facility 4. The Social Worker called to ask how Facility 1 obtained Social Security payments from Resident 1. She stated Facility 4 currently had Resident 1, but they were having issues assisting him with Social Security payments. SW C stated he asked Administrator A about this and was informed by him that Facility 1 was never able to access Resident 1's Social Security payments, and they were never paid by Social Security. SW C stated his facility (Facility 1) paid Resident 1's first month's rent at Facility 2, where Resident 1 was discharged . During the same interview on 6/20/23 at 10:44 a.m., SW C stated he received a call from the Ombudsman who asked about Resident 1's belongings. SW C stated he dug through the office and found a stack of letters belonging to Resident 1 including some items from the Department of Motor Vehicles. SW C stated he found a temporary identification card, his identification and, quite a bit of other letters. SW C stated Resident 1 did not get everything belonging to him at discharge, I gave a lot to the Ombudsman. Review of facility policy titled, Discharging the Resident subtitled, Discharging the resident to home or another long-term care facility (revised 12/2016), indicated, .2. Be careful in packing the resident's personal effects .Review the personal effects inventory with the resident . and have them sign off that they have received all personal effects. During the same interview on 6/20/23 at 10:44 a.m., SW C was asked about Social Services at Facility 1 prior to his arrival on 1/16/23 (staff who would have assisted with Resident 1's discharge). SW C stated that Assistant D was an Assistant Social Worker. When he finished orientation, SW C stated he worked with Assistant D a half day and she left after that. When she returned, SW C stated she resigned. SW C stated Assistant D did not have training (in social work) and he was technically her boss. SW C stated Assistant D was not reliable and did not provide any notes or hand-off information about Resident 1 prior to her resignation. Review of Resident 1's medical record revealed a discharge document titled, Interdisciplinary Discharge Summary, subtitled, Rehab (rehabilitation) Services (dated 1/16/23) that indicated Patient 1, .requires Home Health to improve function, mobility, & strength. Requires w/c (wheelchair) for mobility & FWW (front-wheel walker)/ with SBA (standby assistance) for ambulation. The summary was signed by the Director of Rehabilitation. During a telephone interview on 6/23/23 at 11:15 a.m., the Director of Rehabilitation (DOR) stated she remembered Resident 1, and he had been her patient. The DOR stated she worked with Resident 1 approximately three times per week. She stated they worked on gait (manner of walking), as he had a tendency to go toward the left side, safety awareness, strength, and standby (staff within arms reach) balance. When asked how Resident 1 was doing with his therapy, the DOR stated, at the time of his discharge, he used a FWW (walker with wheels on the front to provide smoother walking pattern) for ambulation assistance, was able to walk 150 to 200 feet with standby assistance and required one to two breaks during ambulation. The DOR stated Resident 1 required verbal queuing (verbal reminders) when walking; for example, he needed reminders to take smaller steps. During the same interview on 6/23/23 at 11:15 a.m., the DOR was asked about Resident 1's Interdisciplinary Discharge Summary and confirmed she had documented the section titled, Rehab Services, dated 1/16/23. The DOR stated, at the time of discharge, I did request Resident 1 receive Home Health (Physical Therapy and Occupational Therapy) services at his new facility to assist him with navigation of his new environment and space. She stated she recommended he continue with Physical Therapy to improve and be more aware of, and acclimated to, his new surroundings. When asked if Resident 1 received those services at Facility 2, the DOR stated she was, not aware. She stated Resident 1's discharge was, abrupt and she was, not in the loop regarding discharge planning. She stated she was not aware when he was discharged and did not know where he was sent. During the same interview on 6/23/23 at 11:15 a.m., the DOR was asked if she evaluated Resident 1 for a lower level of Care (living at a facility providing fewer services because the resident was more independent). The DOR stated she evaluated Resident 1 for his physical therapy needs, including gait and transferring (example, bed to wheelchair); the DOR stated he needed supervision with these activities. The DOR stated Resident 1 required Physical Therapy and Occupational Therapy for gait, strength training, and balance and stated she communicated these needs to Administrator A and the IDT team. During the same interview on 6/23/23 at 11:15 a.m., when the DOR was informed Resident 1 was discharged to a building without supervision for ambulation or medication administration assistance, she stated, Wow. The DOR stated Resident 1 needed assistance with medication, and he could not make executive decisions, such as higher ADL activities (like medication administration). The DOR stated Resident 1 needed supervision with ambulation and needed Home Health services for PT and OT and he needed supervision with medication administration and could not take his medicine independently. During an email communication on 6/23/2023 at 10:49 a.m., the Community Care Licensing Department was contacted to verify if Facility 2 was a licensed Board and Care or Assisted Living facility. At 3:34 p.m., Technician Q responded via email and indicated, There is no license at that address (Facility 2 ' s address; Facility 2 was not a licensed Board and Care or Assisted Living facility). During a telephone interview on 6/30/2023 at 9:25 a.m., Hospital 3's Social Worker (SW H, who assisted finding Resident 1 a place to live after discharge from the hospital) was asked about Resident 1. SW H stated she assumed Facility 2 was not a licensed AL building as that type of facility was beyond Resident 1's income. SW H stated she consulted with an associate who informed her Facility 2 did not provide meals, medication administration assistance, or supervision. SW H stated she spoke to the owner of Facility 2, and he confirmed Facility 2 was an IL building that did not provide meals, medication assistance, or supervision. SW H stated Facility 2 was, like renting a room. SW H stated she placed Resident 1 into a Board and Care (after his first hospital admission), that provided more services for him. SW H stated Resident 1 lasted one day at that facility because that facility's administrator, couldn't manage Resident 1. Review of Resident 1's medical record from Hospital 3 indicated he was admitted again from 2/14/23 through 2/21/23. The physician ED note titled, HPI (history of present illness), dated 2/14/23, indicated Resident 1 had a history of, .epilepsy, CVA with severe dysarthria (difficulty in speech due to weakness of speech muscles) Present by EMS (via ambulance) with knee pain . Pt (patient) has hx (history of) multi (multiple) falls d/t (due to) chronic right knee pain with difficulty bearing weight on right knee. States he fell today . pt also requesting refill on chronic meds, also wants home health options to help with his meds, meals, states he cannot read. Also requesting a walker . Review of Hospital 3's, Hospitalists' (physicians who cares for patients inside a hospital) SNF/Rehab Discharge Summary (dated 2/21/23), indicated Resident 1 was discharged from Hospital 3 on 2/21/23, to a SNF (Facility 4). During a telephone interview on 6/23/23 at 2:11 p.m., Director of Nursing (DON) J stated she was the DON at Facility 1 from 11/14/22 through 1/13/23 (three days prior to Resident 1's discharge from the facility). When asked what Resident 1's care needs were, DON J stated Resident 1 used a wheelchair, was assisted to the bathroom by staff who waited for him at the bathroom door until he was ready, used the shower with staff help, and required 1:1 staffing (one staff assigned to one resident) due to his behavior of inappropriately touching other residents. DON J stated Resident 1 had not fallen while she was working at the facility. When asked if she thought Resident 1 could cook his own meals, DON J stated, I don't think he could cook. She stated he would only be at eye-level at the stove since he was in a wheelchair. During the same interview on 6/23/23 at 2:11 p.m., DON J stated Administrator A wanted Resident 1 out of Facility 1 because he was costing the facility money with his 1:1 staffing need. DON J stated Administrator A told her to, get rid of this guy because he was taking staff and was an inconvenience. When asked to clarify, DON J stated Administrator A verbalized to her he wished to get rid of Resident 1, and said they had to move, this guy out and find some (other) place. During the same interview on 6/23/23 at 2:11 p.m., DON J was asked about Resident 1's discharge process. DON J stated she had no idea he was being discharged on Monday (1/16/23), three days after her last day (1/13/23). DON J stated discharges went through the Social Services Department and the person acting in that capacity was Assistant D. DON J stated Assistant D was hired as an assistant, had no prior social work experience prior to working at Facility 1, and rarely made it to work. She stated Assistant D had no formal discharge planning training but did a good job. DON J stated she had informal training in the form of consultation with her (the DON) and the prior Social Worker (who was no longer at the facility). During the same interview on 6/23/23 at 2:11 p.m., DON J was asked if Resident 1's discharge was discussed at the IDT (Interdisciplinary Team) meetings. DON J stated, We weren't taking about it in IDT, and if they had been, she or the MDS (Minimum Data Set, assessment tool) nurse would have written a note (in Resident 1's medical record). When asked if nursing was cut out of Resident 1's discharge process, DON J stated nursing (staff and leadership) was not part of his discharge process. When told that Resident 1 had no physician orders in his medical record, DON J stated, Oh, my god, he had to have orders. DON J stated the facility's electronic medical record software made discharges easy. She stated there was a place to click, and the program would take you through the discharge process. She stated the software allowed staff to print the medication list, and nursing would do the medication administration education with the resident. During a telephone interview on 7/5/23 at 12:45 p.m., the owner of Facility 2 (Owner G) was asked about the services provided to residents in his building. Owner G stated his facility was an, Independent Living Group Home (care settings providing housing and limited support services) building and residents had to, help themselves. Owner G stated his facility provided complementary food, including breakfast, lunch, dinner, coffee, and pastries. When asked if he provided medication assistance for residents, he stated, No. When asked if he provided supervision, including supervision for ambulation, he stated, No. When asked if staying at his building was like renting a room, Owner G stated, Yes. Owner G stated he told Administrator A his facility was IL, and not a Board and Care or Assisted Living facility (both of which provided more care for residents). When asked to clarify whether Administrator A was aware he was sending Resident 1 to IL with no supervision and no medication assistance, Owner G stated, Yes, he knows. Owner G stated Resident 1 only stayed a few days at the building. He stated he had some sort of, attack or seizure, a resident called 911, and he was taken to the hospital. During the same interview on 7/5/23 at 12:45 p.m., Owner G stated he went to Facility 1 to assess Resident 1 prior to accepting him to his building. When asked how he had assessed him, Owner G stated he asked him if he could go to the bathroom himself and he said that he could; he asked if he could eat on his own and he said that he could. When asked if he was aware the DOR had recommended Resident 1 needed Physical Therapy and standby assistance when using the walker, as he was a high fall risk, Owner G stated No, I did not know. When asked if he was aware the DOR determined Resident 1 needed assistance with medication administration, Owner G stated, Nobody told me that. Owner G stated, if he had known about Resident 1's medication administration and standby assistance requirements, he would not have accepted him. When asked why, Owner G stated, We don't offer those services. In an email from Community Care Licensing Division (a State department regulating Independent Living facilities), dated 7/12/23, Analyst P wrote, . One of the renters, (at Facility 2) does the cooking . he does prepare lunch and dinner. For breakfast, clients make their own foods from the stocks in the kitchen. Clients interviewed confirmed a that (a resident) cooks and cleans the house. And that they don't get any assistance with ADLs. During a telephone interview on 7/12/23 at 8:45 a.m., Physician K stated he was Resident 1's physician at Facility 1 and confirmed he had medical history of epilepsy, intracranial injury, falls. When asked if his seizures were controlled while at Facility 1, Physician K stated it had been six months (since Resident 1's discharge), and stated he did not know but he was prescribed Phenytoin (antiseizure medication) to help control them. During the same interview and concurrent record review on 7/12/23 at 8:45 a.m., Physician K was asked about Resident 1's discharge paperwork titled, Physician's Discharge Summary (signed by Physician K on 1/27/23, eleven days after discharge). A box was checked on the Discharge Summary that indicated, The resident's health has improved sufficiently and no longer needs the services provided by the facility. Physician K was asked how Resident 1's health had improved sufficiently. Physician K stated Resident 1 could self-propel himself in the wheelchair and he could feed himself. He stated he thought Resident 1 could manage a lower level of care. When asked what type of facility would have been appropriate for him, Physician K stated, Assisted Living or Board and Care (not independent living). When asked if he thought Resident 1 could self-administer his own medication safely, Physician K stated he thought so. He stated Resident 1 might not know which medications were which, secondary to his brain injury, and he might have needed some clarification (by someone else). During the same interview on 7/12/23 at 8:45 a.m., Physician K was asked if he wrote discharge orders (they were not located in the medical record). Physician K stated there was, no record of me signing orders, and he stated he did not remember signing orders from six months ago. Physician K was informed Resident 1 reported he was not given his medications at discharge, but his nurse stated she had provided them. Physician K was asked how the nurse could have provided medication without orders (pharmacies can only dispense medication with a physician order) and he stated, I don't recall and stated he could not provide clarity on that. During the same interview on 7/12/23 at 8:45 a.m., Physician K was informed Facility 2 was an IL facility and did not provide supervision (for Resident 1's behaviors or for fall mitigation), did not provide assistance with showers, and did not provide assistance with medication administration. When asked if Facility 2 sounded like an appropriate[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure effective administration of its operations when the facility: 1.a) Did not ensure sufficient dietary staff (cooks and dietary aides) were employed and working in the dietary services, 1.b.) Did not ensure Registered Dietitian (RD) oversight in the kitchen and the Administrator did not provide the RD consult reports (documenting issues in the kitchen), dating back to [DATE], and 2) Did not ensure dietary services had adequate supervision when the facility did not employ a fulltime dietary manager, dating back to [DATE]. These deficiencies caused potential for staff burn out (related to over-work/staff inability to take a day off) and for food production and meal distribution errors, that could compromise the medical and nutritional status of 80 residents in a census of 80; contributed to Resident 1 receiving foods she did not like; contributed to late meal deliveries and menu substitutions; contributed to rusty equipment being utilized in food production (rather than being replaced); contributed to Manager G ' s inability to attend resident-centered meetings like Care Conferences (meeting where staff, residents and families come together to discuss care issues and goals); contributed to improper food storage and labeling; and contributed to dirty and unsanitary conditions in the kitchen, which could lead to food borne illness and potential for harm in a vulnerable population of residents, potentially impairing 80 of 80 residents' ability to attain/maintain their highest practicable physical, mental, and psychosocial well-being. An IMMEDIATE JEOPARDY (situation in which facility noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) was identified on [DATE] at 4:10 p.m. under S483.70 Administration, F835. The IMMEDIATE JEOPARDY was abated on [DATE], during an onsite visit on [DATE] at 1:45 p.m. Findings: 1) During an interview on [DATE] at 11:45 a.m., the Administrator stated the facility had a census of eighty residents with two bed holds (two residents were out of the facility and their beds were being held open for them). During a tour of the facility ' s kitchen and concurrent interviews on [DATE] at 12:15 p.m., Cook C, Cook D, and Dietary Aide E (Aide E) were plating resident ' s meals (for approximately eighty residents) and placing them in carts (to be delivered for lunch). Cook C stated no residents were receiving tube feeding (liquid nutrition through a tube into the stomach) so they were making food for all the residents. Cook C stated her work shift that day was from 4:30 a.m. to 1 p.m., Cook D stated he was working from 8:30 a.m. to 7:30 p.m. (eleven hours). Aide E stated he was working from 8:30 a.m. to 5 p.m. During the same kitchen tour and concurrent interviews on [DATE] at 12:15 p.m., Cook D stated he normally worked 11 a.m. to 7:30 p.m. (eight hours), but he was working longer because they were short staffed; he stated the Dietary Manager (Manager G) was not there that day. Aide E stated Manager G was off sick that day. Aide E stated he worked parttime at the facility, During the same tour on [DATE] at 12:15 p.m., the kitchen had multiple food containers strewn over the countertops. Cook C removed the food-holding pans from the steam table (table with slots to hold food containers which are kept hot by steam circulating beneath them) which revealed thick, rusty build-up below. Photos were taken of the kitchen and steam table. During an observation and concurrent interview on [DATE] at 12:41 p.m., the refrigerator was full of food and appeared to be overcrowded. A box of chicken was marked raw and individually frozen and was stored over a box of raw brussels sprouts and a plastic container of butter. When asked if this was how these items should be stored, Cook C stated they should not be stored that way. An undated silver container was located at the back of the refrigerator and contained a tuna sandwich, which appeared old (not fresh-looking). When asked when the sandwich had been made, Aide E stated he had no idea. A box of lettuce contained lettuce with some brown areas and was dated [DATE] (six days earlier). Cook D stated the facility got lettuce on a weekly schedule. During an observation on [DATE] at 1 p.m., a staff schedule was hanging in Manager G ' s office (inside the kitchen). The schedule indicated Cook C and Cook D had no days off from [DATE] through [DATE] (approximately two weeks); the schedule indicated Cook C and D were scheduled to have no days off from [DATE] through [DATE] (approximately two additional weeks). The schedule indicated Aide F had only one day off ([DATE]) scheduled in the month of February 2023. During an observation with Aide E and concurrent interview on [DATE] at 1:10 p.m., a thermometer was lying on a shelf in the downstairs dry food storage area; the red hand indicating the temperature was broken off the dial and was at the bottom of the device. (A thermometer is used to monitor the room ' s temperature to ensure safe food storage). Aide E could not locate a temperature log (documentation of the room ' s temperature) in the room and could not find a functioning thermometer. Bins containing sugar, powered milk, flour, food thickener, and oatmeal were dated [DATE]; none of the containers were marked with use-by dates (last day the manufacturer recommends consuming the product). During the same observation and concurrent interview on [DATE] at 1:10 p.m., the facility ' s supply of emergency dry food was located outside the dry storage room, in the basement. The emergency food was stored immediately next to a dirty, dusty cart, an overflowing bucket containing resident call lights, a bedside commode (portable chair with receptacle used as a bedside toilet) and a housekeeping cart. During an observation and concurrent interview on [DATE] at 1:45 p.m., Resident 1 was in her room and was asked about the food she received at the facility. Resident 1 stated a female from the dietary department had spoken to her about her food likes and dislikes but when asked if that person was Manager G or the Registered Dietician (RD), she stated she did not know. Resident 1 stated she liked salads and received them at lunch, but rarely at dinner. She stated she had requested no sauce on her meat, but this preference was inconsistently implemented; staff sometimes put gravy on her meat, and sometimes did not. When asked what it was like to get gravy on her meat, Resident 1 stated she had to scrape it off. Resident 1 stated that the prior day, staff gave her pasta even though she did not like pasta. She stated the same happened with fish; she was sometimes given fish even thought she did not like fish. Resident 1 stated she was also given cake, and she did not like cake. During a kitchen observation and concurrent interview on [DATE] at 2:45 p.m., Cook D and Aide E were in the kitchen. Cook D and Aide E stated they were the only staff left for the day, after Cook C went home (at 1 p.m.). Aide E stated two dietary aides had been hired the previous week, but they had quit. When asked if he had been getting his days off, Cook D stated he had not. During a kitchen observation and concurrent interview on [DATE] at 2:50 p.m., the dishwashing sink was backed up and filled with dirty, yellow-tinged water. A piece of bread was floating in the water and dirty food trays and dishes were piled to the right of the sink. Aide E was asked if the sink was blocked or if the dishwasher was broken and he stated, no. During an interview in the Administrator ' s office on [DATE] at 3 p.m., the Administrator, Interim Director of Nursing (DON), Corporate Clinical Consultant (Consultant A, a registered nurse), and Licensed Nurse B (LN B) were queried about staffing in the dietary department. When asked how many staff positions were currently open in the kitchen, the Administrator stated the facility had two unfilled dietary aide positions and one unfilled cook position. The Administrator stated the facility had two cooks and stated a third cook had, left mid shift. When asked how long the facility had two cooks, the Administrator stated, one to two weeks. During the same interview on [DATE] at 3 p.m., the Administrator, DON, Consultant A and LN B were asked if the cooks had recently gotten any days off work. The Administrator stated he thought they were getting their days off and stated, I don ' t know for sure. During a telephone interview on [DATE] at 1 p.m., Manager G was asked about the facility ' s dietary department. She stated the kitchen was in, bad shape but she was doing the best she could. Manager G stated she had been working as a cook, but mainly as a dietary aide to fill in (staffing gaps) and she had recently sustained an injury. Manager G stated it was a terrible situation (in the kitchen) and stated the staff were all stressed and residents suffer. When asked how residents were affected, Manager G stated their food had been delivered late in the past and menus had to be changed. During the same telephone interview on [DATE] at 1 p.m., Manager G stated the facility cut a dietary aide position approximately one year ago and they now only had two staff in the kitchen at night (after lunch to closing, at 8 p.m.). Manager G stated staff did not want to work the night shift due to the low staffing. Manager G stated the facility had recently hired two dietary aides; they had worked one week and then quit. She stated the kitchen was not a good environment. Manager G stated the facility needed staff and especially needed a relief cook; she stated the cooks had no days off. During the same telephone interview on [DATE] at 1 p.m., Manager G was asked how her filling in to help as an aide impacted her managerial duties. Manager G stated she had not been able to go to Care Conferences and stated she used to attend IDT (interdisciplinary team - nursing, infection control, dietary, activity, etc.) meetings, but no longer did. When asked if she was able to participate in the weight committees (meeting where staff discuss resident weight issues), she stated, no. When asked if she had attended the QAPI meeting (Quality Assurance and Performance Improvement - department leaders meeting with the goal of attaining quality standards and assuring care reaches an acceptable level), Manager G stated she had not attended QAPI meetings. Review of the facility job description titled, Dietary Manager (undated) indicated essential duties included, .Attending meetings and serving on committee ' s as needed . During a telephone interview on [DATE] at 3:11 p.m., the Registered Dietitian (RD) was asked about dietary services at the facility. The RD stated she began work at the facility in [DATE] through [DATE]. She stated she returned to the facility in [DATE] and has been the RD since that time. The RD stated she was onsite one to two day a week, performed various clinical tasks, and performed monthly kitchen inspections (including sanitation assessment). The RD stated the facility struggled with staffing (inadequate) and staff had trouble keeping up with sanitation (required cleaning) and labeling (dating food). The RD stated dietary staff were hard working people, but the issues seemed to, go back to staffing. When asked about the products that had no UB (use by) dates, the RD stated she had known about labeling issues but felt staff were improving. When asked about the overcrowded refrigerator, the RD stated she was aware of the issue and stated the freezer had been packed in the past. When asked about storing raw chicken over raw vegetables, the RD stated, most definitely chicken should not be above raw vegetables. Review of facility policy titled, Food Receiving and Storage (Revised ,d+[DATE]) indicated, Foods shall be .stored in a manner that complies with safe food handling practices. Under subtitle, Dry Food Storage, the policy indicated 1. Non-refrigerated foods .are stored in dry storage unit which is temperature and humidity controlled . 4. Dry foods that are stored in bins are . labeled and dated (use by date) . 7. Food may not be stored: i. under other sources of contamination . Under subtitle, Refrigerated/Frozen Storage, the policy indicated. 1. All foods stored in the refrigerator . are labeled and dated . 3. Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers .4. Refrigerators .are not overcrowded .9. Uncooked and raw animal products .are stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods to prevent meat juices from dripping onto these foods . During the same telephone interview on [DATE] at 3:11 p.m., the (RD) was asked about staffing in the kitchen. The RD stated staffing was the worst since she had started working at the facility. The RD stated they currently had two cooks, but they used to have three. When asked how many cooks they needed, the RD stated, I don ' t know but they had three for a long time. When asked why dietary aides had quit after working one week, the RD stated she did not know. When asked why Manager G was working as an aide, the RD stated it was because they did not have enough aides. During the same telephone interview on [DATE] at 3:11 p.m., the RD was asked if she was aware that the cooks were not getting their days off. The RD stated she did not know but it, seemed unlikely. When queried if she thought not having days off was problematic, the RD stated staff, can tire out, leading to errors and mistakes. When informed Aide F had had no day off for at least fourteen days, the RD stated she had not been aware. She stated (Aide F) could tire out and mistakes were possible. When asked if the situation in the kitchen was sustainable, the RD stated she did not think it was going to last. When asked if they had enough staff to cover for illnesses (and subsequent sick calls), she stated, definitely not. During the same telephone interview on [DATE] at 3:11 p.m., the RD was asked if she was aware Manager G had recently been injured. The RD stated she was not aware; she stated the Administrator had not informed her. When asked if she would have wanted to know this information, she stated, yes. When asked who was currently supervising the kitchen, the RD stated, I don ' t know and stated, we need a supervisor. The RD stated Cook C, Cook D and Aide F had been working at the facility a long time, but they would be under extra pressure without a manager. During the same telephone interview on [DATE] at 3:11 p.m., the RD was asked for her professional opinion on Cook D and Aide E being the sole staff in the kitchen (on [DATE]) after Cook C left at 1 p.m. The RD stated she thought one more person was needed and two people was, pushing it. During the same telephone interview on [DATE] at 3:11 p.m., the RD was asked to comment on the managerial duties Manager G was not able to perform due to her work as an aide. The RD stated she was not sure if Manager G attended resident care conferences; the RD stated she (the RD) did not attend them. Regarding QAPI, the RD stated, I ' m never there and stated if Manager G did not attend, dietary was not represented. Review of the facility job description titled, Registered Dietitian (undated) indicated, The purpose of your job position is to organize, plan and supervise the overall operation of dietary department . Under subtitle, Essential duties and Responsibilities, the document indicated, Monitoring staff to confirm they adhere to all sanitation .guidelines . Ensuring food service equipment is clean and operable .Checking food storage rooms, utility/janitorial closets for regulatory compliance .Serving and participating on various committee ' s ( .Quality Assessment and Assurance .) . During an observation and concurrent interview on [DATE] at 1 p.m., four staff were in the kitchen. Aide F stated she came to the facility at 4:30 a.m., cooked breakfast, and was leaving at 2 p.m. Certified Nursing Assistant I (CNA I) was washing dishes and stated he came in early to help out and was leaving at 2 p.m. When asked if he had been trained to wash the dishes, CNA I stated, no and stated he had worked in a facility kitchen in the past. Cook D was cooking dinner that day. Aide E stated he was working until 5 p.m. (potentially leaving Cook D alone until 8 p.m.). During an interview in the Administrator ' s office on [DATE] at 1:40 p.m., the Administrator stated after the Department (surveyor) notified him (on [DATE]) some staff were not getting their scheduled days off, the facility had changed the dietary schedule. He stated Manager G was not feeling well and she had hurt herself (and was not working). He stated he had reached out to a contracting company for dietary aides and a dietary manager. The Administrator stated he would be helping clean the kitchen that evening. Review of facility job description titled, Administrator, subtitled, Personnel Functions (undated) indicated, Assist in the recruitment and selection of .auxiliary personnel (personnel providing support services, like a cook) . Consult with department directors concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of services . Ensure that an adequate number of appropriately trained professional and auxiliary personnel are on duty at all times . An Immediate Jeopardy (IJ) was identified on [DATE] at 4:10 p.m. under S483.70 Administration. The Administrator, Interim DON (Director of Nursing), and DSD (Director of Staff Development) were notified of the IJ in the Administrator ' s office. An IJ (Immediate Jeopardy) Removal Plan (dated [DATE]) to abate the IJ was emailed to the department on [DATE] at 12:08 p.m. The IJ Removal Plan was determined to be unacceptable, and the facility was notified via email on [DATE] at 4:23 p.m. A revised IJ Removal Plan (dated [DATE]) was emailed to the department on [DATE] at 5:16 p.m. During an observation and concurrent interview on [DATE] at 11:40 a.m., Aide F (not the Certified Dietary Manager; CDM) was training two staff. Aide F stated they were newly hired dietary aides (Aide J and Aide K). Cook C was plating lunch for the residents in disposable containers. Dirty dishes were piled high next to the dishwasher. The three-compartment emergency dishwashing area was filled with water and sanitizer (three-compartment dishwashing is utilized to wash and sanitize dishes; dishes are washed in detergent, then rinsed in water, and finally placed in sanitizer). Aide F stated they were unable to get the dishwasher water to the proper temperature of 120 degrees Fahrenheit. She stated they were using the three-compartment dishwashing process for the pots and pans and utilizing disposable dishes to serve resident food. When asked about the dishes piled up next to the dishwashing sink, Aide F stated they were from yesterday and they did not have time to wash them by hand. During an interview on [DATE] at 12:15 p.m., the DON and Administrator were asked about the issue with the dishwasher. The Administrator stated part of the water heater went out the day before ([DATE]) and they were unable to get the dishwasher to the required temperature (120 degrees Fahrenheit). The Administrator stated they had Company L repair the hot water heater the day prior, but it was not functioning again that day. The Administrator stated Company L was coming that afternoon to again repair the hot water. The revised IJ Removal Plan (dated [DATE]) was determined to be unacceptable, and the facility was notified via email on [DATE] at 3:51 p.m. A second revised IJ Removal plan (dated [DATE]) was emailed to the department on [DATE] at 7:30 p.m. Additional information to evaluate the revised Removal Plan was requested via email on [DATE] at 11:47 a.m. During an observation on [DATE] at 2 p.m., CDM T was present and supervising in the kitchen. Aide E (who was cross trained to cook) was cooking dinner that night. Dietary Aide F, CNA I, and CNA AA were working as dietary aides. On [DATE] at 8:34 p.m., the Administrator emailed the additional IJ Removal Plan information (requested [DATE] at 11:47 a.m.). The revised IJ Removal Plan (dated [DATE]) was accepted on [DATE] at 1:50 p.m. The Administrator was notified by telephone at that time. The accepted plan indicated: 1) A full time (40 hours/week) Temporary dietary Manager from Company M started on [DATE] to fill the need left by the CDM ' s absence and will carry out the functions of a Dietary Services Manager as described in a job description until the permanent Manager returned. The facility met the current needs of the dietary department with two cooks and three dietary aides per day. The facility had two fulltime cooks, four fulltime dietary aides and four parttime dietary aides. Two of the aides were cross trained as cooks and could act as relief cooks. All dietary staff had competencies and had their skills checked by the RD on [DATE]. The facility will continue to meet the 2.4 required per patient day hours for CNA ' s. The scheduler is working one day a week in the dietary department. Staff that work extra shifts are doing so by their own choice, 2) One newly hired dietary aide started training and orientation on [DATE], 3) The temporary dietary Manager is conducting skills checks beginning [DATE] to all current and newly hired dietary staff, 4) The RD will conduct dietary services reviews weekly for four weeks, and thereafter monthly utilizing the RD Consultant Report, 5) The facility assessment (annual facility evaluation of its resident population to identify resources needed to provide necessary person-centered care and services) has been updated to address the dietary staffing needs, 6) Facility will continue with active recruitment and hiring efforts in place and ongoing, 7) Facility contracted with Company N as the registry provider (agency that provides contracted staff) for dietary services, 8) Facility will conduct a review of all diet cards (individual resident cards identifying specific diets, likes and dislikes, allergies, etc.) to ensure diets match current orders, 9) Facility will conduct review of all current resident ' s weights and provide appropriate nutrition interventions. RD will increase consultant report frequency to weekly until deemed unnecessary, 10) Department Managers will continue daily room rounds and conduct resident interviews regarding food and dietary services, 11) QA (Quality Assurance) committee will hold an emergency meeting on [DATE] do discuss the Plan of Action (to abate the IJ) for further action and implementation needed to sustain immediate compliance, 12) Dietary schedule updated; Administrator will review schedule twice a week until lesser frequency deemed necessary, and 13) The Regional Director of Operations and a Senior Administrator will provide weekly oversight and support to the Administrator on establishing and implementation of the Plan of Action (IJ Removal Plan). Review of an email sent by the Administrator on [DATE] at 9:15 a.m. indicated Company M is, .providing CDM coverage for the rest of this week . (not .until the permanent Manager returned ., as indicated in the IJ Removal Plan) and Company P (not included in the IJ Removal Plan) would be, .providing a full-time CDM for the facility as long as need (sic) . During a telephone interview on [DATE] at 9:35 a.m., Director O (the Senior Director of Company M) was asked what services Company M was providing the facility. Director O stated they were providing a Certified Dietary Manager (CDM) for one week and were working on a formal contract for dietary services. Director O stated the provision of the CDM was by means of a verbal understanding, not a written contract. Director O stated the CDM would help cover staffing needs, provide guidance and support to staff, and assist in staff training. During an onsite visit to verify the IJ Removal plan on [DATE] at 11:15 a.m., the Administrator stated Company P was independently owned by Consultant Q, who had assisted in training Manager G the previous year. He stated Company P would provide a CDM beginning that weekend. During an observation and concurrent interview on [DATE] at 11:30 a.m., the temporary CDM (CDM T) was in the kitchen. CDM T stated he was working at the facility from Monday through Friday of that week on a consulting basis. He stated Aide F had trained the new staff. He stated he signed off on staff skills by verbally asking them if they were able to perform the skill; he stated he did not observe the skill performance himself. When asked who had assessed the skills of Aide J (newly hired aide) and CNA U and CNA V (nursing assistants temporarily working in the kitchen), CDM T stated he did not know (#3 of the IJ Removal Plan indicated the temporary CDM would conduct skills checks, beginning [DATE], to all current and newly hired dietary staff). During an interview on [DATE] at 12:34 p.m., Cook C stated in the past, the facility had four dietary aide positions (four dietary aides per day) with varying start times: D1 start time was 4:30 a.m., D3 was 6 a.m., D3 was 11:30 a.m. and D4 was 11:45 a.m. Cook C stated the facility eliminated the D4 position (leaving three dietary aids per day) and changed the start time for D3. She stated only the cook, and one aide were in the kitchen from 5 p.m.-7:30 p.m. and the dishwasher was alone from 7:30 p.m.-8 p.m. Cook C stated the pm (approximately 11 a.m. to 7 p.m.) cook now helped wash dishes. She stated the facility needed more dietary aides. Cook C stated the CNAs were (currently) helping but they would be leaving (returning to resident care). During an interview on [DATE] at 4:10 p.m., the Administer was notified the IJ Removal Plan had been changed by the facility without department approval and could not be verified. The Administrator was instructed to submit an Addendum to the IJ Removal Plan to the department. An undated Addendum (dated [DATE]) to the IJ Removal plan was submitted to the department via email on [DATE] at 7:41 p.m. A dated Addendum, dated [DATE], was sent to the department [DATE] 8:58 a.m. The Addendum was accepted/approved [NAME] email on [DATE] at 5:07 p.m. The addendum indicated, 1) Starting [DATE], Company P will provide a CDM until the fulltime, permanent Manager returns, 2) As of [DATE], the dietary department has three permanent fulltime cooks, three permanent fulltime dietary aides and two permanent parttime dietary aides, 3) As of [DATE], the dietary department has three temporary dietary aides. The dietary aides will continue to work until the facility is able to hire two fulltime dietary aides, and 4) The RD and/or temporary CDM are conducting skills checks that began [DATE] to all current and newly hired staff to ensure appropriate competencies and skills sets are met to carry out functions of the food and nutrition services and meet the nutritional needs of all residents. During an interview and record review on [DATE] at 10:57 a.m., the Administrator reviewed the contract with Company P for CDM services titled, Dietitian consultant Contract Agreement (dated [DATE]). Under subtitle, Scope of Services, the contract indicated, 6.Dietary Manager Consultant shall keep in close communication with the Administrator, Dietary Supervisor, and Director of Nursing . When asked to clarify the role of the Supervisor (as the facility did not employ a dietary supervisor), the Administrator stated he did not want to explain. Under the subtitle, Term of contract, the contract indicated, The term of this agreement shall be a period of one year, commencing on, [DATE] . and indicated, .At the expiration date of, [DATE] . Under the same subtitle, 80 hours was handwritten in. When asked to clarify the eighty hours of time, the Administrator stated he did not recall and stated it may have been over the period of one month. When asked to clarify the dates of the contract, the Administrator stated the contract was initiated (in 2022) to hire a CDM to train Manager G and the facility was extending the contract (for current CDM services). During an interview on [DATE] at 12:10 p.m., the Administrator and DON reviewed the newest dietary schedule ([DATE] through [DATE]). The Administrator stated dietary Aide J was a no-show (did not come to work) on Friday, [DATE] (her hire date was approximately six days earlier, on [DATE]). Aide J was not on the current dietary schedule. CNA I and CNA V were off the schedule after [DATE] and Unlicensed staff W was off the schedule. Positions, A1, A2, CB1 and CB2 were on the schedule and the Administrator stated they were staff from the registry (temporary, contracted on-call staff; A1 and A2 were from Company P, CB1 and CB2 were from Company N). During an interview on [DATE] at 12:30 p.m., the DON stated Aide J had called off work on Friday, did not come to work on Saturday or Sunday, and did not respond to telephone calls from the Administrator. The DON addressed changes made to the approved Addendum (dated [DATE]): The DON stated the three fulltime aides indicated on the IJ Removal Plan Addendum were decreased to two (due to Aide J no longer on the schedule) and the three temporary aides on the Addendum (CNA I, CNA V and Unlicensed Staff W) were being replaced by the registry and agency (Company P). During an observation and concurrent interview on [DATE] at 12:40 p.m., temporary CDM R was supervising in the kitchen. A new cook (who started [DATE]) was observing Cook D. CDM R stated the cook, and two aides were in training. CDM R stated dietary Aide X and dietary Aide Y were from Company P and would work at the facility until new (permanent) dietary aides were hired. CDM R stated Aide Z started at 12:15 p.m. that day and was from Company N (a registry). During the same interview on [DATE] at 12:40 p.m., CDM R stated, this place needs to be cleaned and stated the kitchen was not clean. Review of an RD Consultant Report (completed by RD BB), dated February ,d+[DATE] (2023), indicated, .expired items discarded . Under subtitle, 7. General Sanitation . the report indicated, . walls need cleaning .drawers need cleaning .scoop drawer (holds food ladles/scoops) needs cleaning .grease build up .discarded rusted pan replacement pans ordered .2 pilot lights (gas burner kept continuously burning to light a larger burner) out on stove .microwave - rust inside - replace . During an interview on [DATE] at 2:15 p.m., the Administrator, DON, Consultant A, Licensed Nurse B, and the DSD were notified that the Addendum approved on [DATE] had been changed, the changes were not approved by the department, and the Addendum and IJ removal plan could not be verified. The Administrator was instructed to submit a second Addendum to the IJ Removal Plan to the department. A second Addendum to the IJ Removal Plan (dated [DATE]) was submitted to the department via email on [DATE] at 4:03 p.m. The second Addendum was accepted via email on [DATE] at 3:56 p.m. The addendum indicated, 1) As of February 27, 2023, the dietary department has three permanent fulltime cooks, two permanent fulltime dietary aides and two permanent parttime dietary aides, 2) As of February 27, 2023, there will be two interim dietary aides that will take the place of the temporary cross trained dietary aides. The document indicated the facility no longer needed the help of the two cross-trained CNAs or Unlicensed Staff W, 3) As of February 27, 2023, the facility will be able to get one to two dietary aides from a registry company as needed, and 4) The dietary staffing schedule had been completed and attached through [DATE]. During an interview on [DATE] at 11:45 p.m., the Administrator was asked about RD kitchen inspections (that include sanitary [TRUNCATED]

Based on interviews and records review, the facility failed to monitor, assess, and provide respiratory care to one of three sampled residents (Resident 1), when Resident 1 had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 1 suffering from breathing difficulties that required two transfers for emergency care and hospital admission, and Resident 1 subsequently passed away from [CONDITION(S)]. Findings: During record review for Resident 1, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview with Family Member K on [DATE] at 9:46 a.m., Family Member K stated Resident 1 had been coughing for two weeks before Resident 1 was sent to the hospital on or around [DATE]. Family Member K stated he had heard Resident 1 yelling I can't breathe and observed him breathing heavily and struggling to get some air. Family Member K stated he asked the nurse what was wrong with Resident 1, however the nurse did not know and told him she would inquire further. Family Member K stated no assessment was done for Resident 1. Family Member K stated Resident 1 was started on oxygen inhalation (life-supporting component of the air) because he insisted for the nurse to start the oxygen as Resident 1 was screaming I can't breathe. Family Member K stated Resident 1 died a couple of days after being sent to the hospital on [DATE]. Family Member K stated the hospital staff informed him Resident 1 arrived to the hospital with dried blood in his mouth and his lungs filled with fluid. During an interview with CNA (Certified Nurse Assistant) A on [DATE] at 12:19 p.m., CNA A stated on the week of Resident 1's [DATE] hospitalization , there were times when Resident 1 would verbalize he could not breathe. During an interview with CNA C on [DATE] at 1:07 p.m., CNA C stated prior to Resident 1's hospitalization , Resident 1 had a recent behavior of screaming he could not breathe. During an interview with Licensed Nurse D on [DATE] 1:14 p.m. Licensed Nurse D stated she once heard Resident 1 verbalized he could not breathe. Licensed Nurse D stated she did not perform respiratory assessment and did not notify Resident 1's physician due to Resident 1's vital signs (measurement of body temperature; pulse rate, respiration rate and blood pressure) were all normal. During an interview with Licensed Nurse E on [DATE] at 1:50 p.m., Licensed Nurse E stated Resident 1 had a chest x-ray (imaging test that look at the structures and organs of the chest, such a the lungs) in [DATE] due to complaint of difficulty breathing. Licensed Nurse E stated the chest x-ray result indicated Resident 1 had CHF. When Licensed Nurse E was asked what are the expectations from the nurses when a resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed Nurse E stated nurses were to listen to resident's lungs for abnormal sounds, check resident's vital signs (V/S, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) including oxygen saturation (refers to how much oxygen (air) is carried from the lungs to tissues and organs in the body) and to start oxygen as needed. During a record review for Resident 1, the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review for Resident 1, the document titled Radiology Results Report with examination date [DATE] indicated a chest x-ray result showing Resident 1 had mild [CONDITION(S)]. During a record review for Resident 1, the document titled TridentCare with test report dated [DATE] indicated Resident 1's B-Type Natriuretic Peptide (hormone produced by the heart) level was 484 pg/ml (picogram is one-trillionth of a gram/milliliter. A result greater than 100 pg/ml is abnormal. The higher the number, the more likely heart failure is present and the more severe it is). During a record review and concurrent interview with Licensed Nurse B on [DATE] at 11:59 a.m. the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed Nurse B verified there was no further order to continue [MEDICATION(S)] therapy after [DATE]. During a record review and concurrent interview with Clinical Resource Nurse F on [DATE], at 12:28 p.m., Clinical Resource Nurse F reviewed Resident 1's care plans (contains relevant information about a resident's diagnosis, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and an evaluation plan) and verified Resident 1's medical record contained no care plan for managing Resident 1's CHF. When Clinical Resource Nurse F was asked what her expectations from the nurses providing care for Resident 1 with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical Resource Nurse F stated nurses were to document their observation/ assessment in resident's record, notify the doctor for any abnormal findings and develop a care plan. During a record review for Resident 1 and concurrent interview with Licensed Nurse B on [DATE] at 1:02 p.m., Licensed Nurse B reviewed the Physician's Progress Notes and verified this portion of the resident's medical record contained no progress note from Resident 1's primary care physician to indicate Resident 1 was monitored or evaluated for CHF. During a record review and concurrent interview with Licensed Nurse B on [DATE], at 1:42 p.m., Licensed Nurse B verified Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Also on review, Licensed Nurse B verified the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed Nurse B verified there was no licensed nurse documentation from either shift on [DATE] indicating whether Resident 1's breathing was assessed, or additional care or services were provided. Licensed Nurse B verified there was no licensed nurse documentation indicating Resident 1's physician was notified of Resident 1's drop in oxygen saturation. During a record review for Resident 1, the Progress Note, dated [DATE], at 4:41 a.m., indicated Resident 1 was yelling. The Progress Note further indicated Resident 1's oxygen saturation was 85%. The Progress note did not indicate Resident 1 received oxygen inhalation. During a record review for Resident 1, the hospital document titled SNF (Skilled Nursing Facility) Admission History and Physical dated [DATE] indicated Resident 1 was admitted to the hospital on [DATE] for [CONDITION(S)] (low levels of oxygen in the body). During a record review and concurrent interview with CNA H on [DATE] at 2:20 p.m. CNA H verified Resident 1's weight on [DATE] from his weight logbook was 160.8 lbs. (pounds) During a record review and concurrent interview with Licensed Nurse B, the Progress Note, dated [DATE], at 8:08 p.m. indicated Resident 1 was found yelling frequently and more confused during the evening shift. The Progress note indicated Resident 1 had complained of difficulty breathing and requested oxygen. Licensed Nurse B there was no documentation in Resident 1's medical record indicating Resident 1 was given oxygen therapy on the evening of [DATE]. During a record review for Resident 1, the document titled IDT Weight Management assessment dated [DATE] at 12:50 p.m. indicated Resident 1's weight for the month of May was 170.7 lbs. indicating a 9.9 lbs. (5.7 %) weight gain in a month period. During a record review for Resident 1, the Progress Note, dated [DATE], at 4:04 p.m., indicated Resident 1 was lethargic (sluggish, having little energy) with an oxygen saturation between 85% and 88%. The Progress Note indicated Resident 1 was sent to the hospital for emergency care and services. During a record review for Resident 1, the document titled Certificate of Death issued on [DATE] indicated Resident 1 expired on [DATE] at 2:40 p.m. The Death Certificate indicated Resident 1's immediate cause of death was [CONDITION(S)]. During a telephone interview with Physician G on [DATE] at 3:19 p.m. when Physician G was asked what were his expectations from the nurses caring for residents with new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When Physician G was asked his reason for not extending [MEDICATION(S)] therapy after [DATE] for Resident 1, Physician G stated Resident 1's blood pressure would run low and decided to discontinue. When Physician G was asked what were the risks for the resident when not properly assessed for signs of [CONDITION(S)], Physician G stated the resident could have shortness of breath and resident's condition could get worse. Physician G verified one of Resident 1's cause of death was due to CHF. Review of the Facility policy and procedure titled Heart Failure -Clinical Protocol, revised ,d+[DATE], indicated for the physician to assist in developing a nursing care plan for residents with CHF. The policy and procedure indicated the physician would review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, renal function, [MEDICATION(S)] (medication used to treat heart failure) level, etc.) to monitor, when to report findings to the physician, etc. Also, the policy and procedure directed the physician to help monitor the progress of individuals with HF (Heart Failure), including ongoing evaluation . Review of the Facility policy and procedure titled Change in a Resident's Condition or Status, revised ,d+[DATE], indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The policy and procedure also directed the nurse to notify the resident's attending physician or physician on-call when there has been a specific instruction to notify the physician of changes in the resident's condition. The policy and procedure directed the nurse to record . information relative to change in the resident's medical/mental condition or status in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure 3 of 4 sampled residents (Residents 1, 2, and 3) received necessary care and treatment in accordance with professional standards of practice, when facility staff: 1. Delayed scheduling Resident 1's appointment for a routine suprapubic catheter (A hollow flexible tube used to drain urine from the bladder, inserted into the bladder through the abdomen) change months longer than indicated by physician order. The order indicated to have the catheter changed every 6 to 8 weeks, but it took more than four months (From 10/13/21 to 2/16/22) to have it changed. 2. Did not arrange Resident 1's orthopedic consultation (A consultation with a doctor that specializes in bone, joint and muscle injuries) secondary to a leg fracture (broken bone) or effectively manage Resident 1's leg brace (a device used to stabilize an injured leg) that was applied in an Emergency Department (ED) after diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Did not arrange Resident 2's cataract surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Did not carry-out Resident 3's physician order as written for a neurologist (a specialist in the anatomy, functions, and organic disorders of nerves and the nervous system) consultation and an MRI (Magnetic resonance imaging, an imaging technique that produce detailed images of the organs and tissues in the body). The failures associated with Resident 1's suprapubic catheter had the potential to result in avoidable infections or malfunction of the appliance. The failures associated with Resident 1's fracture had the potential to cause unnecessary discomfort and improper healing, and actually caused a device-related pressure injury (A skin injury caused by pressure from the metal brace applied to Resident 1's left leg in the ED) from prolonged use of the leg brace. The failures associated with Resident 2's cataract surgery allowed the resident's vision to continue to deteriorate, and resulted in negative psychosocial outcomes such as feelings of loss and neglect. As a result of the facility's failure to follow-up with Resident 3's neurologist consult and MRI, Resident 3 voiced psychosocial harm including profound depression, suicide thoughts and feelings of neglect. Findings: 1. Resident 1, Suprapubic Catheter Change. Record review revealed Resident 1 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident 1's MDS (Minimum Data Set-An Assessment Tool) dated 11/15/21 indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) was 15, which indicated his cognition was intact. During an interview with Resident 1 on 2/17/22 at 11:30 a.m., he stated he just had his suprapubic catheter changed on 2/16/22, and the last time it had been changed prior to 2/16/22 was 10/13/21, a difference of four months. Record review indicated Physician orders initiated on 7/31/17 and active until 2/28/22, indicated, Continue Suprapubic catheter Exchange at [General Acute Care Hospital (GACH)] every 6 to 8 weeks. Schedule with [MEDICATION(S)] Radiology (A medical subspecialty that performs various minimally-invasive procedures using medical imaging guidance [Different technologies that are used to view the human body in order to diagnose, monitor, or treat medical conditions]). Record review of a GACH report titled, IMAGING & RADIOLOGY, dated 10/13/21 indicated Resident 1 had a suprapubic catheter replacement conducted on 10/13/21 at 1:00 p.m. Record review revealed a Health Status Note dated 12/17/21 at 1:08 p.m., indicated, Received T. O. (Telephone order) Follow up Urologic (Associated with diseases of the urinary tract [The organs that make urine and remove it from the body]) Consult for Suprapubic Catheter. Notified Social Service. Record review of a Medical Provider Note dated 1/08/22 at 9:33 a.m., indicated, [Resident 1] has [CONDITION(S)] (A condition in which the flow of urine is blocked) and he is routinely scheduled for a change out of his suprapubic catheter, which is currently scheduled for about one month from now, but the patient states it has been about two months since the last change out and that it is starting to clog already. Record review of an e-mail the Surveyor sent the Administrator on 2/03/22 at 12:51 p.m., indicated a request was made to the Administrator to provide evidence of all Resident 1's catheter changes from 8/01/21 to 12/23/21. Record review indicated Medical Records Director C replied to the request and provided proof (The report titled, IMAGING & RADIOLOGY, dated 10/13/21 above) of one catheter change during the four-month timeframe, on 10/13/21. Record review indicated the Administrator was also asked by the Surveyor on 2/03/22 at 12:51 p.m., to provide evidence of all attempts to schedule Resident 1's catheter change, from 10/13/21 to 12/23/21. Record review indicated Medical Records Director C replied on 2/08/22 at 3:21 p.m. with evidence of one attempt, a Health Status Note dated 12/17/21 at 1:08 p.m. that indicated, Received T.O. (Telephone order) Follow Up Urologist Consult for Suprapubic Catheter. Notified Social Service. During an interview with the Administrator on 1/21/22 at 9:35 a.m., he stated the facility currently did not have a Social Services Director at the moment, since the last one had quit the week of 1/10/22. During an interview with the Infection Preventionist on 2/17/22 at 10:00 a.m., she stated the Social Services Director was responsible for setting up appointments for Resident 1's catheter changes. During a phone interview with Physician B, on 3/02/22 at 3:23 p.m., Physician B was asked the reason Resident 1 was ordered to have his catheter changed every eight weeks. Physician B stated a sediment could form on the catheter, which could clog it. When asked what could happen if this catheter was not changed as ordered, Physician B stated the catheter could get clogged and increase the possibility of infection. 2. Resident 1, Orthopedic Consult. During a concurrent observation and interview with Resident 1 on 2/17/22 at 11:45 a.m., he stated being very concerned about a fractured left leg that he had suffered in August of 2021. A black brace was observed on Resident 1's left leg, which kept the leg in extended position. Resident 1 stated that after he fractured his leg he was transferred to a Hospital ED where he was told he needed to see an orthopedic doctor (A physician that works to diagnose and treat broken bones) to follow up on the fracture. Resident 1 stated the brace on his left leg had been applied during this initial visit to the ED in August of 2021. Resident 1 stated he still had not received this orthopedic consult. Resident 1 stated two appointments had been scheduled for the consults, on 8/30/21 and 2/07/22, but the facility had not followed-up and the resident missed both. Resident 1 presented his cell phone, in which he had received text confirmations for both appointments. Resident 1 stated he told facility staff about his appointments, but they did not do anything and no transportation was arranged. Resident 1 stated he did not know the names of the facility staff he had notified about the appointments. Resident 1 stated that as a result of not having the left foot and brace assessed by an orthopedic doctor, he had developed a wound on the left leg caused by the brace. Record review revealed an IDT (Interdisciplinary Team) review note dated 8/04/21 at 4:14 p.m., indicated resident noted with fracture of left distal femur (Part of the tight bone closest to the knee) upon x-ray of the left knee .IDT Recommendations based on root cause: Refer to therapy and [Orthopedic] consult. [Medical Doctor] aware. Refer Resident for Ortho consult. Record review of a Health Status Note dated 8/09/21 at 2:39 p.m., indicated, Receive notes from resident's trip to [hospital] last 8/3 when he was noted through an x-ray result as having a left distal femur fracture .Referred to the hospital Ortho surgeon on call who stated that given the resident is paraplegic, fitting him with a left knee immobilizer is recommended plus a consultation with an ortho for follow up. Record review of Physician Orders initiated on 10/25/21 and active through 2/28/22, indicated, Follow up Ortho consult. Record review of a Medical Provider Note dated 11/05/21 at 9:33 a.m., indicated, [Resident 1] has also been seen for aftercare for left femur fracture for which he has a leg brace that he has had for about six months. He needs ortho follow-up and possibly a different brace .He has developed a skin wound under the brace that is being followed by the wound doctor. The note did not indicate the date when this wound was discovered, or description of the wound. Record review of another Medical Provider Note dated 1/08/22 at 9:33 a.m., indicated, Most recent wound description by the wound service is 'affected area noted scabbed, dry and intact' .His pain from his chronic wounds is treated with [MEDICATION(S)] (A controlled medication used to treat moderate to severe pain) as needed. During a phone interview with Physician B, on 3/02/22 at 3:23 p.m., Physician B discussed his monthly Medical Provider Note, specifically how the note indicated for staff to follow-up on Resident 1's orthopedic consult. Physician B stated he specifically indicated a need to follow-up because the physician's order for an orthopedic consult was written in November of 2021 and facility staff had not followed-up. Physician B stated he notified Social Services Director A (Social Services Director A left the facility in November of 2022) and Social Services Director D (Social Services Director D left the facility in January of 2022), but Resident 1 still had not received an orthopedic consult. Physician B stated the wound caused by Resident 1's left brace (under the brace) could possibly have been avoided if Resident 1 had seen the orthopedist sooner. Record review of a facility document titled, WOUND EVALUATION & MANAGEMENT SUMMARY, dated 3/31/22 indicated the wound to on Resident 1's left calf was a partial thickness (Wounds that extend to the first two layers of the skin) wound, with a duration of over 45 days, with the following measurements, Wound Size (L x W x D): 3.6 x 0.9 x Not Measurable cm (Centimeters). During a phone interview on 9/01/22 at 5:03 p.m., with Physician H, who authored the note titled, WOUND EVALUATION & MANAGEMENT SUMMARY, dated 3/31/22, Physician H stated the wound to Resident 1's left calf was the result of trauma caused by the brace he was wearing. Physician H stated he was told Resident 1 needed to wear the brace for the fracture to the left leg but he had not spoken to the Orthopedist himself. During an interview with Resident 1 on 9/01/22 at 2:55 p.m., he stated when he finally saw the Orthopedist in March of 2022, the Orthopedist told him the brace that was applied in the ER in August of 2021, on his left leg, was supposed to be in place for only four weeks. Resident 1 stated he felt emotionally affected by this lack of follow-up with his Orthopedist consult, as he was very concerned about needing surgery to repair his left leg or losing the leg all together. During an interview with the Medical Director on 3/14/22 at 1:30 p.m., he stated Resident 1 needed to see the orthopedist after his fracture in August of 2021, in order to follow-up and ensure the fracture was healing appropriately. Record review of an Orthopedist consult for Resident 1 on 3/08/22, indicated the fracture to Resident 1's left leg had healed and the brace to Resident 1's left leg was discontinued. During an interview on 2/17/22 at 1:15 p.m., the Administrator was asked by the Surveyor to provide all clinical appointments (including orthopedic consults) for Resident 1's fractured left leg, and all attempts to schedule these clinical appointments, among other documents. The facility provided all the other documents requested on 2/18/22 at 5:28 p.m., except for any evidence of any attempts to schedule Resident 1's orthopedic consult appointment. During an interview on 2/17/22 at 10:00 a.m., the Administrator stated Social Services Director A, who had left the facility at the end of 2021, received disciplinary action from the facility for not following-up on medical appointments for residents, but did not specify what residents, or the circumstances for each of the residents. 3. Resident 2, Cataract Surgery. Review of Resident 2's Face Sheet (a document with demographic and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident 2's MDS, dated [DATE], indicated his BIMS score was 15, which indicated his cognition was intact. Record review of a Medical Provider note dated 7/05/21, at 10:01 p.m., written by Resident 2's primary care physician indicated, [Resident 2] also expresses concern that he will 'go blind from [CONDITION(S)].' He was educated that [CONDITION(S)] are curable with surgery. Record review of a Medical Provider Note dated 7/23/21 at 9:27 p.m., written by Resident 2's primary care physician, indicated, [Resident 2] is seen for [CONDITION(S)], which social services [Social Services Director A] is working on scheduling surgery at [a hospital]. It is possible that he has [CONDITION(S)] associated with diabetes. Record review of a Social Service Note dated 7/21/21 at 12:16 p.m., written by Social Services Director A, indicated, called [a hospital] to attempt scheduling of [CONDITION(S)] surgery. They advised they needed a [Referral Authorization Form] which the [Primary Care Physician] should be able to provide. I e-mailed [Resident 2's Primary Care Physician] asking for this. Once a [Referral Authorization Form] is secured we should fax it to [a hospital]. Record review of a Social Service Note dated 12/27/21 at 9:02 p.m., written by Social Services Director D, indicated, Spoke with resident and was informed that he has had a doctor's order to have a surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Writer was able to speak with [Resident 2's primary care physician] this evening and he confirmed that [Resident 2] was seen by the ophthalmologist [(a doctor specialized in eye and vision care)] and confirmed the need for his eye surgery. Subsequent social services notes indicated Social Services Director D did not successfully schedule the procedure. Social Services Notes dated 12/29/21 at 10:21 a.m., 1/03/22 at 3:13 p.m., and 1/06/22 at 5:05 p.m., written by Social Services Director D indicated attempts were made to schedule the cataract removal surgery without success. Record review indicated the Surveyor sent the Administrator an e-mail on 2/03/22 at 12:51 p.m., requesting evidence that Social Services Director A had followed up with Resident 2's cataract surgery after 7/21/21. Medical Records Director C replied to the Surveyor by e-mail on 2/08/22 at 3:21 p.m., indicating the facility had no evidence Social Services Director A followed up on Resident 2's cataract surgery after 7/21/21. During a phone interview with the Administrator on 8/10/22 at 1:59 a.m., he stated Resident 2 still had not had his cataract surgery. During an interview with the Administrator on 1/21/22 at 9:35 a.m., he stated the facility currently did not have a Social Services Director at the moment, since the last one (Social Services Director D) had quit the week of 1/10/22, and Social Services Director A had left the facility at the end of 2021. During an interview with the Administrator on 2/17/22 at 10:20 a.m., he stated not being aware Social Services Director A had not followed through with Resident 2's cataract removal surgery, but confirmed Social Services Director A was responsible for this. During an interview with Resident 2 on 1/21/22 at 11:35 a.m., he confirmed he had not had his cataract removal surgery in the two years that he had been living at the facility. During a second interview with Resident 2 on 2/17/22 at 12:10 p.m., he stated Social Services Director A, Did not follow through with anything, referring to his cataract removal surgery. Resident 2 stated he needed to get closer and closer to the television to be able to watch it, as his glasses did not work anymore. Resident 2 also expressed, I want to be able to see .I can't even see the hallway. Resident 2 expressed feelings of loss. Resident 2 stated he felt neglected. During a phone interview with Physician B, on 3/02/22 at 3:23 p.m., Physician B was asked what could be the consequences of somebody that needed cataract surgery, to have the surgery delayed for several months. Physician B stated this could result in loss of qualify of life, and poor vision. During a phone interview with the Medical Director on 3/14/22 at 1:30 p.m., he stated at the end of December, 2021 he first learned about issues with the Social Services Department and discussed these issues with the Administrator. The Medical Director stated the facility had been having problems following-up with medical appointments outside the facility. 4. Resident 3, Neurological Consult and MRI. Review of Resident 3's Face Sheet (a document with demographic and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident 2's MDS, dated [DATE], indicated his BIMS score was 13, which indicated his cognition was intact. During an interview on 8/29/22 at 2:30 p.m., Resident 3 stated he had severe headaches daily, which were so bad they made him dizzy and nauseous. Resident 3 stated he wanted to see a specialist and get some tests or studies, as he was very concerned since a sibling had passed away from a brain tumor. Resident 3 stated that he felt like he wanted, To shoot his head, because of the headaches. Record review of Resident 3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Medical Provider Note dated 5/28/22 at 1:10 p.m., indicated, date of exam: 5/27/22 .Today, the resident had videocall [follow-up] consult[ation] with his Neuro [Physician K] for his [CONDITION(S)] and headache .He also has planned MRI of Brain & Cervical spine as ordered by [Physician K]. Record review of a physician orders for Resident 3, active for September 2022 and initiated on 5/26/22, indicated, Follow up appointment with [Physician K-Neurologist] in 2-3 weeks. Record review of a physician orders for Resident 3, active for September 2022 and initiated on 5/26/22, indicated, MRI of Brain & Cervical spine (Bones of the neck region). During an interview with the Administrator on 9/02/22 at 12:01 p.m., the Administrator was asked to provide evidence demonstrating facility staff acted to coordinate an MRI, ordered 5/27/22, for Resident 3. In follow-up, at 12:15 p.m., the Administrator provided a response. The Administrator stated that he had just called Physician B. The Administrator stated Physician B informed the Administrator that Resident 3 no longer needed an MRI. The Administrator stated Physician B believed that a recent CT-scan (Computed Tomography scan-a medical imaging technique used to obtain detailed internal images of the body) of the resident's brain conducted on 6/03/22 during an emergency room visit satisfied the neurology specialist's order. The Administrator stated the facility only followed-up on the resident's MRI order today, after CDPH requested information about it. During another interview with the Administrator on 9/02/22, at 12:35 p.m., the Administrator stated the facility retained no evidence that an appointment for the MRI was ever scheduled for Resident 3. During an interview with Social Services Staff J on 9/08/22 at 2:25 p.m., she was asked for any evidence Resident 3 had a follow-up appointment with the neurologist after 5/26/22, as indicated in the physician order. Social Services Staff J stated there was no evidence Resident 3 saw the neurologist again after the May 2022 consultation. During a phone interview with Physician I on 9/02/22 at 2:06 p.m., Physician I confirmed Resident 3 suffered from migraine headaches. Physician I stated the MRI for Resident 3 had not been scheduled and the physician did not know the reason. Physician I stated the facility's Social Services was not following-up on referrals and he did not know what was causing the delay. During an interview with Resident 3 on 9/08/22, at 11:41 a.m., Resident 3 stated the facility did not follow-up with the MRI or neurologist consult. Resident 3 stated he was very depressed and anxious and had frequent thoughts of death, and harming himself. Resident 3 stated he wanted to end it all. He also stated he was losing his ability to feel pleasure, and interests in his hobbies. Resident 3 stated he felt neglected, because they don't do nothing. Record review of an e-mail sent by the Administrator on 9/21/22 at 10:08 a.m. indicated the facility was without Social Services staff: from 1/11/22 to 4/04/22, and from 7/02/22 to 8/01/22. Record review revealed the facility policy titled, Referrals, Social Services, revised 12/2008, indicated, Social services shall coordinate most resident referrals. Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff .Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician .Social services will help arrange transportation to outside agencies, clinic appointments, etc., as appropriate. Record review of the facility policy titled, Resident Rights, revised 12/2016, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. A dignified existence . c. be free from abuse, neglect.

Based on observation, interview, and record review, the facility failed to ensure eight residents (Residents 2, 23, 54, 56, 62, 67, 72, 235) were free from verbal abuse and neglect by staff, including Staff I (Licensed Nurse), when: 1) Staff I communicated with residents in ways that caused discomfort to both residents and staff. 2) Staff I intimidated Resident 235 and Resident 54. 3) Resident 2 was afraid to ask Staff I for his as-needed pain medication to manage moderate or severe pain. 4) Six Residents in Resident Council vocalized fear of retaliation from Staff I. 5) Resident 23, Resident 2, Resident 62, Resident 67, and Resident 72 observed nursing staff sleeping during regular work hours at night. These failures resulted in residents feeling humiliated, angry, unwanted, no dignity, ignored and in constant pain due to medication withheld and fear of retaliation from staff and unnecessary illness. Findings: 1) During an interview on [DATE] at 10:50 a.m., Resident 56 stated that Staff I (License Nurse) called him racial names such as are you Portuguese, are you Chinese, are you Cuban, are you gay? Resident 56 stated that he reported to the Ombudsman and to Staff C. Resident 56 stated this language made him feel angry and racially profiled. During an interview on [DATE] at 1:30 p.m., Staff M, a licensed nurse, stated that she heard Staff I speak very rudely to residents. Staff M stated that her stomach turns when Staff I treated residents rudely. Staff M stated that she noticed Staff I had completed her 9:00 a.m. medication pass at 8:30 a.m. on prior days, which Staff M stated was too soon to finish. Staff M stated that Staff I was constantly sitting in front of a computer in the nurses station. During an interview on [DATE] at 10:00 a.m., Staff Z5 (unlicensed staff) stated that he observed Staff I speaks very rude to residents. Staff Z5 stated that Staff I would not give resident their pain pill right away intentionally. Staff Z5 stated that Staff I would sit in front of computer and ignore the resident. Staff Z5 stated that he confronted Staff I about giving resident's pain medication late. Staff Z5 stated that when Staff I was in a bad mood, she would yell at residents. During an interview on [DATE] at 10:30 a.m., Staff O (Unlicensed staff) stated that Staff I was very mean to residents. Staff O stated that she observed Staff I left medications on top of the bedside table while resident was asleep. Staff O stated that she heard Staff I called Resident 56 you are cholo [(a derogative reference to Mexicans)]. Staff O stated that she did not report to managers because of fear of retaliation. 2) During a concurrent observation and interview on [DATE] at 11:00 a.m., Staff I was located inside Resident 235's room. Staff I stood in front of Resident 235 while he seating on a wheelchair and a bedside table between them. Staff I leaned in closely to the resident, about six-to-eight inches away from the resident's face, and looked down at the resident while holding onto the resident's bedside table. This Surveyor asked Staff I if she was busy caring for Resident 235? Staff I stated, no. When asked to leave the area for a private interview with the resident, Staff I walked away, stomped her feet and made a grunting sound. During an interview on [DATE] at 11 a.m., Resident 54 stated that when he returned from the hospital after surgery, he pressed the call light for help and Staff I entered his room and she said to him Why are you still alive? Resident 54 stated that he felt sad when he heard that. Resident 54 stated that Staff I was mean and full of attitude towards residents. Resident 54 stated that when he asked for his pain medication, Staff I would say, You have to wait. Resident 54 stated that other staff male or female were mean also. Resident 54 stated that he was afraid to report because of retaliation from Staff I. During an interview on [DATE] at 11:10 a.m., Resident 235 (Resident 54's roommate) stated that he heard Staff I say to Resident 54: Why are you still alive? Resident 235 stated that he felt sad and angry after he heard that. Resident 235 stated that he was very afraid of both Staff I and Staff C for retaliation. Resident 235 stated that he was afraid that Staff C would jeopardize his ability to transfer to another other facility. In regard to the observation of Resident 235 made on [DATE] at 11:00 a.m., Resident 235 stated Staff I had asked him what he intended to share with the state during its annual recertification survey. 3) During an interview on [DATE] at 2:30 p.m., in Resident Council meeting, Resident 2 stated that he would not trust Staff I with his medication. During an interview on [DATE] at 11:30 a.m., Resident 2 stated that whenever Staff I is on duty to work in his care, his medication cup was always ,d+[DATE] full. Resident 2 stated that his pain pill was always missing. Resident 2 stated that Staff I never give him pain medication. Resident 2 stated that he never received relief from his pain. Resident 2 stated that he just suffered from migraine headaches rather than dealing with Staff I. Resident 2 stated that Staff I argued with him about pain medication, especially when Staff I was in a bad mood. Resident 2 stated that he did not report Staff I to the management because he was afraid of retaliation. Resident 2 stated that he felt ignored and neglected. Resident 2 stated that the facility made him feel unwanted and low class citizen. Resident 2 stated that Staff I was difficult to locate when the resident needed patient care. During a review Resident 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated that Staff I did not administer any pain medication as-needed. 4) During a confidential interview on [DATE] at 2 p.m., in Resident Council meeting, 10 residents attended. Six residents out of 10 stated that they all fear of retaliation from Staff I. During an observation on [DATE] at 2 p.m., in Resident Council meeting, seven residents were angry about the treatment from all staff, but especially Staff I. Residents felt that when they complain, nothing was done, it was ignored. During an interview on [DATE] at 10:00 a.m., Staff Z5 (unlicensed staff) stated that he observed Staff I speaks very rude to residents. Staff Z5 stated that Staff I would not give resident their pain pill right away intentionally. Staff Z5 stated that Staff I would sit in front of computer and ignore the resident. Staff Z5 stated that he confronted Staff I about giving resident's pain medication late. Staff Z5 stated that when Staff I was in a bad mood, she would yell at residents. During an interview on [DATE] at 10:30 a.m., Staff O (Unlicensed staff) stated that Staff I was very mean to residents. Staff O stated that she observed Staff I left medications on top of the bedside table while resident was asleep. Staff O stated that she heard Staff I called Resident 56 you are cholo [(Mexican associated with street gangs.)]. Staff O stated that she did not report to Managers (Supervisor) & Administrator because of fear of retaliation. During an interview on [DATE] at 9:00 a.m., Staff A (Administrator) stated that he was not aware of the name calling by Staff I to residents. Staff A stated that Staff C (Social Worker) did not inform him of any residents who complained about Staff I's behavior towards them. Staff A stated that he would place Staff I on suspension until further investigation. During an interview on [DATE] at 4 p.m., Staff A stated that Staff I was taken off schedule and that she would not return to work in the facility. A review of Staff I's personnel record revealed that Staff I's LVN was current and expired on [DATE]. Staff I's criminal record was clear, no disciplinary actions. Staff I had one competency training titled Changing and Emptying Ostomy Appliance dated [DATE]. Staff I signed the acknowledgement form titled Job Description/Charge Nurse dated [DATE], which was the same as date of hire. Staff I completed a BLS (Basic Life Support) certification on [DATE]. A review of facility Policy & Procedure (P&P) titled ,d+[DATE] revealed The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. A review of facility Policy & Procedure (P&P) titled Abuse Prevention Program revised ,d+[DATE] revealed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Under #1 Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, #3 Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . C) Identification of occurrences and patterns of potential mistreatment/abuse. D) The protection of residents during abuse investigations. F) Timely and thorough investigations of all reports and allegations of abuse; G) The reporting and filing of accurate documents relative to incidents of abuse; A review of the facility P&P titled Recognizing signs and symptoms of abuse/neglect revised ,d+[DATE] revealed Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. #1 abuse is defined as willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. #2 Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. #3 other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it. 3) Fractures, dislocations or sprains of questionable origin. B) Signs of actual Physical Neglect: 5) Improper use/administration of medication. 5. Resident 23 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 23's MDS (Minimum Data Set-An assessment tool) dated [DATE] indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 13, which indicated his cognition was intact. During an interview on [DATE] at 1:26 p.m., Resident 23 stated he had observed staff sleeping at night while on duty in the hallway and the nursing station of the facility. Resident 23 stated he had observed both Licensed and Unlicensed personnel sleeping at night. Resident 67 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 67's MDS dated [DATE] indicated his BIMS score was 14, which indicated his cognition was intact. During an interview on [DATE] at 10:45 a.m., Resident 67 stated he had observed staff sleeping in the hallways at night, while on duty. Resident 67 stated he had complained about it but had continued to see staff sleeping. Resident 2 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's MDS dated [DATE] indicated his BIMS score was 15, which indicated his cognition was intact. During an interview on [DATE] at 10:53 a.m., Resident 2 stated he had observed both Licensed and Unlicensed personnel sleeping at night while on duty. Resident 2 stated he had observed one Licensed Nurse and three Certified Nursing Assistants sleeping during work hours. Resident 2 stated this affected the way staff provided care, such as not answering call lights timely. Resident 2 also stated, Why should we pay them to sleep here? During an interview on [DATE], at 11:30 a.m., Resident 2 stated that when his call light was not answered, he would walk out from his room and found staff slept in the hallway with their leg up in the chair, some staff slept in resident rooms and other staff slept on resident beds as well as in the day room. Resident 62 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 62's MDS dated [DATE] indicated his BIMS score was 15, which indicated his cognition was intact. During an interview on [DATE] at 10:54 a.m., Resident 62 stated he had observed five to seven staff sleeping in the dining room and in the couch in the lobby area during the night shift. Resident 72 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 72's MDS dated [DATE] indicated his BIMS score was 12, which indicated his cognition was moderately impaired. During an interview on [DATE] at 2:45 p.m., Resident 72 stated he had observed Unlicensed Staff sleeping in chairs, in the hallways of the facility during the night shift. Resident 72 stated he frequently needed pain medication at night, and since his call light was not answered timely, he went out of his room to try to find assistance, and would frequently see staff sleeping in the hallways or using their personal cell phones while on duty. When asked how he felt about this issue, Resident 72 stated, It feels like they (staff) are not doing their job. During an interview with STAFF A, Administrator, on [DATE] at 2:17 p.m., he stated being aware of complaints made by residents indicating staff slept during the night shift while and duty. According to STAFF A, his plan for improvement included checking with residents to see if this continued to happen. During an interview with STAFF B, Infection Preventionist, on [DATE] at 11:30 a.m., she stated staff were not allowed to sleep while on duty but were allowed to sleep during their breaks and meal times. STAFF B was asked if the facility had a designated area or space for staff to sleep during their breaks and meal times, as she had indicated. STAFF B stated there was no designated area for sleeping. The facility's Employee Handbook dated ,d+[DATE] indicated, Gross Misconduct infractions are a direct violation of the Facility's standards of conduct, including: Sleeping during work hours.

Based on interview and record review, the facility failed to report to State Agency an allegation of verbal abuse to the appropriate agencies for one resident (Resident 56), when Resident 56 complained about repeated, offensive communication from a licensed nurse and facility staff did not escalate the concern to the facility administrator or investigate the complaint. This failure resulted in delay of a State Survey Agency and facility investigation into verbal abuse affecting Resident 56, did not ensure Resident 56's safety, and caused feelings of anger, humiliation and racially profiling. Findings: Resident 56 During an interview on 5/10/2021 at 10:50 a.m., Resident 56 stated that Staff I (Licensed Nurse) called him different names. Resident 56 stated that Staff I called him Are you gay, Are you a Portuguese, Are you Chinese? Resident 56 stated that he was angry and that Staff I was racial profiling him. Resident 56 stated that he reported the incident to the Ombudsman and to Staff C (Social Worker). During an interview on 5/12/2021 at 11 a.m., Ombudsman stated that he called Staff C to discuss the alleged verbal abuse by Staff I. Ombudsman stated that Staff C stated that he would not assign Staff I to care for Resident 56. During an interview on 5/14/2021 at 11:50 a.m., Staff C stated that he did not fill out a report or did not investigate the alleged verbal abuse reported by Resident 56. Staff C stated that he did not report to the State Agency the alleged verbal abuse by Staff I. Staff C did not inform the DON (Director of Nurses) and to Staff A (Administrator). Staff C stated that he informed Staff L (staffer) to do not assign Staff I to care for Resident 56. During an interview on 5/14/2021 at 12:20 p.m., Staff L stated that Staff C never told him that Staff I should not care for Resident 56. A record review titled Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of facility Policy & Procedure (P&P) titled 12/2006 revealed The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures.

Based on interview and record review, the facility failed to implement its abuse policy and procedure for one resident (Resident 56), when Resident 56 complained to Staff C (Social Worker) of potential abuse by Staff I (Licensed Nurse) with did not utilitze this knowledge and implement the facility's abuse policies. This failure resulted in Resident 56 not being free from abuse and being subjected to verbal abuse by staff and neglect that lead to anger, humiliation, and physical pain. Findings: During an interview on 5/10/21 at 10:50 a.m., Resident 56 stated that Staff I (License Nurse) called him racial names such as are you Portuguese, are you Chinese, are you Cuban, are you gay? Resident 56 stated that he reported to the Ombudsman (A State official who investigates complaints) and to Staff C. Resident 56 stated this language made him feel angry and racially profiled. During an interview on 5/14/2021 at 10:30 a.m., Staff O (Unlicensed staff) stated that Staff I was very mean to Resident 56. Staff O stated that she heard Staff I called Resident 56 you are cholo [(Mexican associated with street gangs ) Staff O stated that she did not report to Managers (Supervisors) or Administrator because of fear of retaliation. During an interview on 5/14/2021, at 11:40 a.m., Staff C stated he was the social worker. Staff C stated Resident 56 vocalized to Staff C a complaint of abuse concerning Staff I. Staff C stated he did not escalate this complaint to facility administration. Staff C stated that he did not write an abuse report. When asked why Staff C did not report the complaint, Staff C stated he handled the issue alone. During an interview on 5/14/2021 at 4 p.m., in the Conference Room, Ombudsman stated that on 3/2/21 she had a telephone conversation with Staff C regarding Staff I calling names such as Cuban to Resident 56. Ombudsman stated that Staff C would remove Staff I from Resident 56 care. During an interview on 5/14/2021 at 4:30 p.m., in Administrator's office, Staff A stated that he was not told by Staff C regarding a complaint of verbal abuse. During a review of the facility records, the Abuse Reporting binder in Staff C's office contained reports of abuse investigations, policy and procedures for abuse, training on abuse, as well as mandated reporter training. The binder did not contain a written record of Resident 56's complaint to Staff C about Staff I's potential abuse. A review of facility Policy & Procedure (P&P) titled Staff Responsible for Coordinating/Implementing Abuse Prevention Program 12/2006 revealed The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. A review of facility Policy & Procedure (P&P) titled Abuse Prevention Program revised 8/2006 revealed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Under #1 Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, . C) Identification of occurrences and patterns of potential mistreatment/abuse. D) The protection of residents during abuse investigations. F) Timely and thorough investigations of all reports and allegations of abuse; G) The reporting and filing of accurate documents relative to incidents of abuse.

Based on observation, interview and record review, the facility failed to provide respiratory care consistent with physicians' orders and professional standards of practice and failed to have a policy and procedure for oxygen administration for five of five residents (Residents 1, 2, 3, 4 and 5) when: 1) For Resident 1, who had COVID-19 (a [MEDICAL CONDITION] respiratory illness causing severe respiratory distress) and had a physician's orders [REDACTED]. a) did not monitor Resident 1's oxygen saturation levels every shift to ensure oxygen saturation levels of at least 90%; b) did not provide Resident 1 with oxygen per physician's orders [REDACTED]. c) did not provide Resident 1 with oxygen per physician's orders [REDACTED]. d) did not ensure Resident 1 was administered oxygen according to professional standards of practice when Resident 1 was found with labored breathing and was administered oxygen at a rate of six liters per minute via a non-rebreather mask (a type of oxygen facemask attached to a reservoir oxygen bag connected to an external oxygen tank used to deliver higher concentrations of oxygen of at least 10 liters per minute) without a physician's orders [REDACTED].>e) did not provide Resident 1 with oxygen when Resident 1 was found wearing a non-rebreather oxygen mask with a deflated oxygen reservoir bag (indicating no oxygen was available) connected to an oxygen tank with the gauge indicating 0 (zero) oxygen; and f) did not have a policy and procedure for oxygen administration. These failures could have resulted in Resident 1's death. Because of the risk of death for Resident 1 from the failure to administer oxygen per physician's orders [REDACTED]. The Administrator provided an acceptable IJ removal plan on [DATE] at 6:10 p.m. The IJ was removed on [DATE] at 3:53 p.m. in the presence of the Administrator and the DON, after verification of implementation of the IJ removal plan. 2) For Residents 2, 3, 4 and 5, who also had orders for oxygen, the facility failed to monitor their oxygen saturation levels at least once every shift and failed to have a policy and procedure for oxygen administration. These failures had the potential for Residents 2, 3, 4 and 5 not to receive oxygen and maintain adequate oxygen saturation levels per physicians' orders. Findings: 1) A review of Resident 1's Admission Record, printed on [DATE] at 1:32 p.m., indicated Resident 1 was admitted to the facility on [DATE]. A review of the facility's census (a list of all residents in the facility and their room numbers), for [DATE], indicated Resident 1's room was located in the facility's red area (for residents with COVID-19). During an interview on [DATE], at 10:40 a.m., the Administrator stated the facility had been divided into three color-coded areas: the red area housed residents who had a confirmed [DIAGNOSES REDACTED]. COVID-19 is an infectious disease that affects the lungs and causes shortness of breath and difficulty breathing. Other symptoms includes cough, fever, headache, loss of taste and smell, shaking and chills, sore throat and muscle pain. These symptoms range from mild to severe and can cause death. The risk for severe symptoms and death increases with age. The greatest risk of death is for people aged 85 or older. treatment for [REDACTED]. (https://coronavirus.dc.gov/page/what-covid-19) (https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html)(https://www.covid19treatmentguidelines.nih.gov/) During an observation on [DATE], at 1:15 p.m., Resident 1 was lying in bed in her room. Resident 1 had labored breathing and was wearing a nasal cannula connected to a portable oxygen tank with the oxygen level gauge in the tank indicating 0 (zero) oxygen. The state surveyor informed Licensed Nurse A who sent Certified Nursing Assistant (CNA) B to check on Resident 1. CNA B went into Resident 1's room and stated Resident 1's oxygen tank was empty. CNA B stated Resident 1 was supposed to be on oxygen. CNA B measured Resident 1's oxygen saturation using a pulse oximeter (a small device that slides over the fingertips and measures the level of oxygen in the blood) and stated Resident 1's oxygen saturation was 83%. Normal oxygen saturation levels measured by pulse oximetry are between ,[DATE]%. Oxygen saturation levels lower than 90% indicate hypoxemia (abnormally low levels of oxygen in the blood). Oxygen saturation levels lower than 85% indicate severe hypoxemia. (www.ncbi.nlm.nih.gov/pmc/articles/PMC 15) Hypoxemia has been associated with death in patients diagnosed with [REDACTED].org/10.1016/j.mayocp.2020.04.006 / www.mayoclinicproceedings.org) Professional standards of nursing practice indicate that residents receiving oxygen therapy require regular and frequent monitoring to ensure safe administration of oxygen. (Lippincott Manual of Nursing Practice, 9th Edition, Wolters, Kluwer Health, 2010, p. 245). During an interview on [DATE], at 1:40 p.m., the Director of Nursing (DON) stated Resident 1 had COVID-19 and confirmed Resident 1 was receiving supplemental oxygen per physician's orders [REDACTED]. A review of the Order Summary Report, dated [DATE], indicated the following physician's orders [REDACTED].@ 2 liter/min (minutes) via Nasal Cannula continuous for O2 (oxygen) sat (saturation) below 90% on RA (room air). During an observation on [DATE], at 1:50 p.m., Licensed Nurse C was in Resident 1's room checking Resident 1's vital signs. Licensed Nurse C stated Resident 1's oxygen saturation was 82%. Licensed Nurse C stated Resident 1 had run out of supplemental oxygen. A review of Resident 1's care plans (documents instructing staff on how to care for the resident), undated but provided by the facility during the survey, indicated no care plan or interventions for monitoring Resident 1's oxygen saturation or the functioning of oxygen equipment for Resident 1. During an interview on [DATE], at 3:40 p.m., the DON was asked for the facility's policy for monitoring residents receiving oxygen, including oxygen saturation. The DON stated the facility's policy was for residents to have a full set of vital signs taken once every shift (8 hours), which included oxygen saturation. The DON stated the oxygen saturation values were recorded in the residents' charts. The DON was asked for a written copy of this policy and stated she would look for it. During an interview on [DATE], at 3:40 p.m., the DON was asked for a copy of Resident 1's oxygen saturation measurements. The DON provided a copy of document titled O2 Sats Summary for Resident 1. A review of the O2 Sats Summary indicated the most recent oxygen saturation level for Resident 1 was dated two days prior, on [DATE], at 2:46 p.m., and indicated 90% and Oxygen via Nasal Cannula. The second most recent documented oxygen measurement saturation for Resident 1 was dated [DATE], at 2:30 p.m., and indicated 78% and Room Air (not on oxygen). The third most recent documented oxygen measurement saturation for Resident 1 was dated more than a month before, on [DATE], at 10:18 p.m., and indicated 96% and Room Air. During an observation on [DATE], at 4:15 p.m., Resident 1 was lying in bed in her room. Resident 1 had labored breathing and was wearing a non-rebreather oxygen mask connected to a portable oxygen tank set at a rate of six liters per minute. During a concurrent interview, Licensed Nurse C was asked if Resident 1 had a physician's orders [REDACTED]. Licensed Nurse C stated no. Licensed Nurse C stated that another nurse, Licensed Nurse D, called Resident 1's physician who told Licensed Nurse D to make Resident 1 comfortable, but stated no new oxygen orders were given. A non-rebreather oxygen mask uses an oxygen reservoir bag attached to the mask and connected to an oxygen source to deliver high concentrations of oxygen. Non-rebreather oxygen masks must be used with a high oxygen flowrate of at least 10 liters per minute and must be used cautiously by experienced medical staff (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 77) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 35). According to professional standards of practice, the administration of oxygen therapy requires a physician's orders [REDACTED].>Oxygen is a life saving treatment. It should be treated like any other drug; it should be prescribed in writing, with the required flow rate and the method of delivery clearly specified. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 09/). Oxygen is . considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . This standard procedure helps prevent incidence of misuse or oxygen deprivation which could worsen the patients [MEDICAL CONDITION] and ultimate outcome. (https://pubmed.ncbi.nlm.nih.gov/ 391/). During an observation on [DATE], at 4:40 p.m., Resident 1 was lying in bed in her room. Resident 1 was wearing a non-rebreather oxygen mask with the oxygen reservoir bag deflated (indicating no oxygen was available) connected to a portable oxygen tank with the oxygen level gauge reading 0 (zero) oxygen. There were no staff in Resident 1's room. The application of an oxygen mask without proper oxygen flow can result in death: Never apply an oxygen mask on the patient without supplemental oxygen flowing; this results in the patient re-breathing their own CO2 (carbon [MEDICATION NAME] - an asphyxiating gas), acidosis (high level of acid in the body), [MEDICAL CONDITION] (lack of oxygen in cells and tissues) and possible death. (Los Angeles Medical Services Agency - Los Angeles County. Breathing Emergency - Oxygen Delivery, undated, available at www.lacounty.gov). During an interview on [DATE], at 4:50 p.m., the DON confirmed the facility did not have a policy and procedure for oxygen administration. 2) During an interview on [DATE], at 3:40 p.m., the DON stated there were four additional residents with physicians' orders for supplemental oxygen: Residents 2, 3, 4 and 5 and provided document titled Order Listing Report, dated [DATE], which contained the physicians' orders for oxygen. A review of the Order Listing Report, dated [DATE], indicated the following physicians' orders: Resident 2: active order dated [DATE] for Oxygen @ 2 liter/min (liters per minute) via Nasal Cannula continuously Dx (diagnosis). Resident 3: active order dated [DATE] for Oxygen 2L/min (liters per minute) via nc (nasal cannula) to keep saturation > (above) 92%. Resident 4: active order dated [DATE] for Oxygen @ ,[DATE] liter/min (liters per minute) via Nasal Cannula Dx. Chronic [MEDICAL CONDITION]. Resident 5: active order dated [DATE] for Start Oxygen 2L/min via nasal cannula to keep saturation > (above) 92%. During an interview on [DATE], at 3:40 p.m., the DON was asked for records of the monitoring of oxygen saturation levels of Residents 2, 3, 4 and 5 and provided document titled Weights and Vital Summary dated [DATE] for Residents 2, 3 and 4. No records were provided for Resident 5. A review of the Weights and Vital Summary dated [DATE] for Residents 2, 3 and 4, for the previous seven days, indicated the facility did not monitor oxygen saturation levels daily or every shift, as follows: Resident 2: oxygen saturation monitored on [DATE] at 3:17 p.m., [DATE] at 7:37 p.m., [DATE] at 5:41 p.m.; ,[DATE] at 10:19 a.m.: [DATE] at 2:34 a.m.; [DATE] at 9 a.m.: [DATE] at 3:19 a.m., [DATE] at 10:25 p.m. Resident 3: oxygen saturation monitored on [DATE] at 1:26 a.m., [DATE] at 2:28 p.m., [DATE] at midnight, [DATE] at 2:26 a.m., [DATE] at 4:36 a.m., 2 p.m., 2:24 p.m., 8:06 p.m. and 8:07 p.m. Resident 4: oxygen saturation monitored on [DATE] at 1:26 a.m. and at [DATE] at 2:26 a.m. Resident 5: no records provided. A review of the facility census for [DATE] indicated Resident 2 was in the red area (for residents positive with COVID-19), and Residents 3, 4 and 5 were in the yellow area (for residents who initially tested positive for COVID-19 but now had tested negative but were still showing symptoms of COVID-19). The Centers for Medicare and Medicaid standard is for the monitoring of oxygen saturation three times per day for residents of skilled nursing facility residents with COVID-19 or who are showing symptoms of the disease (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html). Professional standards of nursing practice indicate that for patients receiving supplemental oxygen via nasal cannula nurses should assess the patient's condition, ABG (arterial blood gas - a measurement of gasses in the blood) or SaO2 (oxygen saturation) and the functioning of equipment at regular intervals (Lippincott Manual of Nursing Practice, 9th Edition, Wolters, Kluwer Health, 2010, p. 245). The medical literature indicates the need for careful monitoring of patients receiving supplemental oxygen: Like any drug there are clear indications for treatment with oxygen and appropriate methods of delivery . Vigilant monitoring to detect and correct adverse effects swiftly is essential. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 09) During an interview on [DATE], at 4:50 p.m., the DON confirmed the facility did not have a policy and procedure for oxygen administration.

Based on observation, interviews, and record reviews, the facility failed to implement its policies and procedures for the prevention of pressure injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical device or other device as a result of intense and/or prolonged pressure) for one of three sampled residents, Resident 1. This failure resulted in the development of a DTPI (Deep Tissue Pressure Injury- a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may signal the subsequent development of a Stage III-IV pressure injury even with optimal treatment.) on the left heel of Resident 1. Findings: During the review of the clinical record for Resident 1, the Discharge Summary from the acute care hospital dated 4/15/19, indicated that Resident 1 had a mechanical fall and sustained a left [MEDICAL CONDITION]. He was hospitalized from [DATE]-4/15/19. Resident 1 had a surgery done on 4/13/19 to repair the fracture and he was stable upon discharge to a skilled nursing facility on 4/15/19. During a review of the admission record for Resident 1, it indicated that he was admitted to this SNF (Skilled Nursing Facility - is a special facility that provides medically necessary professional services from nurses, physical and occupational therapists, speech pathologists and audiologists) on 4/15/19, at 1:30 p.m. During a review of the clinical record for Resident 1, an entry on the care plan initiated on 4/16/19, indicated that Resident 1 had declined in bed mobility, transfer, gait, balance, safety, postural alignment, skin integrity, and range of motion of the lower extremities. During a review of the clinical record for Resident 1, the Braden Scale for Predicting Pressure Sore Risk, an admission assessment tool, dated 4/15/19, at 2:53 p.m., indicated a score of 15. A score of 15 to 18 places the resident at risk for developing a pressure injury. During a review of the clinical record for Resident 1, the Comprehensive Care Plans initiated on 4/15/19, did not indicate interventions defined to address the risk for skin impairment and did not indicate interventions defined to promote the prevention of pressure injury development. Resident 1 was assessed as an at risk (for pressure injury)resident based on the Braden Scale for Predicting Pressure Sore Risk. During an interview with the DON (Director of Nursing) on 5/29/2019, at 3:43 p.m., she stated that if a newly admitted resident was assessed to be at risk for pressure ulcer injuries, there must be interventions in place in the plan of care to address the concern such as, pressure relieving measures to the heel and elbow, and a repositioning schedule to turn the resident from side to side every two hours. After the DON provided the comprehensive care plans for Resident 1, she was asked to review this record and verify that this care plan did not include interventions to prevent the development of pressure injury for Resident 1, the DON stated, Correct. During a review of the clinical record for Resident 1, the MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.) dated 4/22/19, indicated on Section M (assessment for skin conditions), that Resident 1 was at risk for developing pressure injuries. The MDS also indicated that Resident 1 had two unhealed Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure injuries. During the review of the clinical record for Resident 1, the comprehensive care plans initiated at the time of his admission on 4/15/19, did not indicate that there were interventions to address these unhealed Stage 1 pressure injuries. During an interview with the DON on 5/29/19, at 3:43 p.m., after she provided a copy the Section M of the MDS, she was asked if the identified unhealed Stage 1 pressure injuries were healed and what were their locations, she stated that she was unsure and will have to ask the MDS coordinator about these identified pressure injuries. The DON also stated that the MDS coordinator who did the assessment was on leave. During a concurrent interview and review of the clinical record for Resident 1 with the DON on 5/29/2019, at 3:43 p.m., an entry on the care plan which was initiated on 4/15/19, indicated that Resident 1 had a mild blanchable (color of skin returns to normal immediately when pressure is released) redness on his coccyx (tailbone). The intervention for this assessed skin issue was to monitor as ordered. After the review of the intervention defined for the blanchable redness on coccyx, the DON was asked if it was acceptable to her that the only intervention on the care plan for this identified skin integrity concern was to monitor as ordered, she stated, No. She further stated and stressed the importance of pressure relieving measures and repositioning as preventive measures. During a review of the clinical record for Resident 1, the Skin/Wound Note entry dated 4/24/19, at 5:26 p.m., indicated that Resident 1 developed a blister with black fluid on the left heel. The wound was manually measured at 5 centimeters by 4.5 centimeters. During the review of the clinical record for Resident 1, the skin integrity care plan initiated on 4/24/19, indicated a DTI (Deep Tissue Injury) was discovered on Resident 1's left heel and was assessed to be an unavoidable pressure injury. During an interview with the DON on 7/19/19, at 8:10 a.m., she was asked to clarify the entry on Resident 1's care plan on 4/24/19, the day that the pressure injury was discovered and indicating that the pressure injury was unavoidable, (Unavoidable means the resident developed a pressure injury even though the facility had evaluated the resident's clinical condition and risk factors, defined and implemented interventions that are consistent with the resident's needs, goals, and professional standards of practice; monitor and evaluated the impact of the interventions; and revised the approaches as appropriate), she stated that the pressure injury of Resident 1 was avoidable, (Avoidable means that the resident developed a pressure injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, defined and implemented interventions that are consistent with the resident's needs, goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate). She further stated that a simple intervention of floating the heels by placing pillows under the lower legs to elevate the feet could have been enough to prevent pressure injuries on the heels. During a review of the clinical record for Resident 1, the acute care hospital's Discharge Summary and Last Progress Notes dated 5/25/19, at 1:27 p.m., indicated that Resident 1 was admitted to the hospital from 5/19/19-5/26/2019 with dignoses that included UTI and pressure ulcer (pressure injury) of left heel. The discharge summary also indicated that the pressure ulcer of the left heel was acquired in the skilled nursing facility. This document also indicated that during this hospital stay, Resident 1 was seen by a podiatrist (A podiatrist is a doctor who specializes in treating the foot, ankle, and lower leg.) for left heel pressure wound care. During an interview with Licensed Staff A on 5/29/19, at 12:45 p.m., she stated that the CNAs (Certified Nursing Assistants) usually had about nine to ten residents assigned to them, and as the charge nurse, she usually had about 28-30 residents assigned to her. She further stated that she had about seven residents who were being treated with pressure injury wounds. She also stated that they had a wound nurse who did the dressing changes, but if the wound nurse was unavailable, she did the dressing changes herself. When asked if the number of staff was sufficient to provide the care needed by the residents, she stated, I don't think so. She also stated that six to seven residents per CNA will be more realistic because sometimes they were assigned to give showers to two to three residents in their shift but they were unable to do it during the shift, and so they passed them on to the next shift. She further stated that the repositioning schedule of every 2 hours will be hard for the CNAs to implement if they were assigned nine to ten residents for patient care. During an interview and concurrent observation with Resident 1 on 5/29/19, at 1 p.m., in his room, he was in bed lying on his back. Resident 1 stated that he felt some pain on the left heel prior to the discovery of the pressure injury. Licensed Staff B removed the dressing and the left heel injury was visibly covered with thick brown eschar (Eschar is an area of dead tissue on the skin. Often called a black wound, the scab may appear black with a thick collection of dry tissue. This tissue is often necrotic, or created as a result of the early death of otherwise healthy skin cells). A new dressing was reapplied using a clean technique. During an interview with Licensed Staff B on 5/29/2019, at 1:45 p.m., she stated that the pressure injury on Resident 1's left heel was discovered by CNA C on 4/24/19. Licensed Staff B also stated that she reported the discovery of the pressure injury to Licensed Staff D, the nurse in charge for Resident 1. Licensed Staff B stated that she was surprised that Resident 1 developed a pressure injury because he wore heel protectors. When Licensed Nurse B was asked if there were documentations that would show that there were interventions in place prior to the development of the left heel pressure injury on Resident 1, she stated No. She further stated that not all of the nursing staff were able to consistently adhere to the turning and repositioning schedule to prevent pressure injuries. The facility policy and procedure titled, Pressure Injury Risk Assessment, last revised in (MONTH) (YEAR), indicated that the purpose of this procedure was to provide guidelines for the assessment and identification of residents at risk of developing pressure injuries. Under General Guidelines, guideline number two indicated that the most common pressure injury was where the bone was near the surface of the body including the back of the head, around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. Under Assessment, item number four indicated that because a resident at risk can develop a pressure injury within two to six hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure injuries. The admission evaluation helps define those initial care approaches. The facility policy and procedure titled, Repositioning, last revised on (MONTH) 2013, and still a current facility policy, indicated that the purpose this procedure was to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to provide comfort for all bed or chair bound residents, and to prevent skin breakdown, promote circulation, and provide pressure relief for residents. Under, Steps in the procedure, repositioning the resident in bed, step one was to Check the care plan, assignment sheet, or the communication system to determine resident's specific positioning needs, including special equipments, resident's level of participation, and the number of staff required to complete the procedure. Under Interventions, item number one indicated that a turning/repositioning program includes a continuous consistent program for changing the resident's positions and realigning the body. A program was defined as a specific approach that was organized, planned, documented, monitored, and evaluated.

The facility failed to 1. provide adequate supervision and 2. develop a resident-centered care plan to prevent falls for one of three sampled residents (Resident 1). Resident 1 had thirteen documented falls, all occurring in her room, during a seven months period from 1/23/18 through 8/11/18. These failures caused Resident 1 to sustain lacerations, bruising, swelling, and a major [MEDICAL CONDITION] after falling on 8/11/18 and required Resident 1 to undergo an emergency brain surgery. Resident 1 was placed on a ventilator (appliance for artificial respirations) and a feeding tube, hospitalized in the intensive care unit, and experienced a severely diminished quality of life due to the injuries caused by the fall. Findings: During an interview on 9/7/18 at 10:15 a.m., Complainant X stated Resident 1 had suffered multiple falls at the facility due to lack of supervision. Complainant X stated the facility was aware of her fall history yet there was no supervision when she fell on [DATE]. Complainant X stated Resident 1 had been taken to the acute care hospital following the fall on 8/11/18. Resident 1 had required immediate brain surgery. Resident 1 could no longer walk or communicate and required a feeding tube. Complainant X stated Resident 1 had been admitted to the facility to be supervised and to prevent her from falling. Complainant X stated Resident 1 had been able to walk and communicate before the fall, and had enjoyed outings with her family. Complainant X stated Resident 1's main reason for her stay at the facility was her need for supervision. A facility document titled Admission record, dated 8/15/18, revealed Resident 1 was admitted to the facility on [DATE] with an original admission date of [DATE]. Resident 1's [DIAGNOSES REDACTED]. A facility document titled Incidents by Incident Type, dated 12/5/18, revealed Resident 1 fell 13 times on 1/23/18, 3/14/18, 3/16/18, 3/25/18, 3/31/18, 4/11/18, 4/26/18, 5/5/18, 5/18/18, 5/26/18, 6/12/18, 6/22/18, and 8/11/18. A facility document titled Progress Notes, dated 8/11/18 at 16:30 (4:30 p.m.) revealed (Resident 1) was found on the floor in her room resident noted become (sic) lethargic (drowsy). 911 called and resident was sent out to the hospital . Resident is currently in the hospital for post fall evaluation. During an interview on 9/18/18 at 12:17 p.m., Unlicensed Staff A stated he remembered Resident 1. Unlicensed Staff A stated the facility moved Resident 1 a lot into different rooms within the facility because she kept falling. During an interview on 9/18/18 at 12:25 p.m., Unlicensed Staff B stated she remembered Resident 1. Unlicensed Staff B stated staff would remind Resident 1 to ask for help but Resident 1 would not remember. Unlicensed Staff B stated CNAs (Certified Nursing Assistants) did what they could to watch Resident 1 but had nine to twelve or more other residents to take care of as well. When asked, Unlicensed Staff B stated the facility never provided one-on-one supervision (one staff member stays with the resident) for residents at risk for falls. Unlicensed Staff B stated we never do that here. During an interview on 9/18/18 at 12:32 p.m. Unlicensed Staff C stated Resident 1 used to be able to walk with a walker but then started using a wheel chair. Unlicensed Staff C stated staff would remind Resident 1 to stay in the wheel chair but she would get up anyway. Unlicensed Staff C stated staff would remind Resident 1 to ask for help but Resident 1 would forget. Unlicensed Staff C stated CNAs were instructed to keep an eye on her (Resident 1). Unlicensed Staff C stated CNAs had more residents and could not watch Resident 1 when taking care of other residents. Unlicensed Staff C stated staff would take Resident 1 to the activity room so activity staff could keep an eye on her but Resident 1 was able to leave the activity room when she wanted to. A facility document titled 11. Falls History Description: Significant Change, dated 5/24/2018, revealed (Resident 1) noted significant change in status due to decline in condition, cognitive wandering and frequent falls and decline in some ADL's (activities of daily living). Her condition is complicated by Dementia . During an interview on 12/5/18 at 11:50 a.m., Licensed Staff D stated he remembered Resident 1. Licensed Staff D stated he had worked as supervisor on 8/11/18 when Resident 1 fell . Licensed Staff D stated staff would keep telling Resident 1 to ask for help and to use her wheel chair. Licensed Staff D stated Resident 1 was non-compliant because of her dementia. Licensed Staff D stated Resident 1 was moved closer to the nurse's station, and had a low bed as well as alarms. Licensed Staff D stated the facility did not use one-on-one supervision for residents at risk for falls. Licensed Staff D stated Management Staff E had stated the facility could not have one-on-one supervision. During an interview on 12/5/18 at 12:11 p.m., Unlicensed Staff B stated CNAs were told to take Resident 1 to the activity room so people could keep an eye on her. Unlicensed Staff B stated she and other CNAs had asked Management Staff E about one-on-one supervision for Resident 1 due to her falls. Unlicensed Staff B stated the one-on-one supervision never happened. Unlicensed Staff B stated the facility did not provide one-on-one supervision. During an interview on 12/5/18 at 12:25 p.m., Unlicensed Staff F stated she remembered Resident 1 had lots of falls. Unlicensed Staff F stated CNAs were instructed to take Resident 1 to the dining room for activities so the activity staff could keep an eye on Resident 1. Unlicensed Staff F stated she could not always watch Resident 1 because she had other residents to take care of. During an interview on 12/10/18 at 9:50 a.m., Unlicensed Staff G stated she remembered Resident 1. Unlicensed Staff G stated she had been taking care of Resident 1 on 8/11/18 during the shift when Resident 1 fell . Unlicensed Staff G stated Resident 1 was always falling down. Unlicensed Staff G stated Resident 1 had been on the floor and Resident 1 had a bump on the head. Unlicensed Staff G stated Resident 1 should have had one-on-one supervision because of all the falls she had already. Unlicensed Staff G stated management staff would move Resident 1 to different rooms but Resident 1 kept falling down. During an interview on 12/10/18 at 3:54 p.m., Licensed Staff H stated he remembered Resident 1. Licensed Staff H had been the charge nurse on 8/11/18 when Resident 1 fell . Licensed Staff H stated Resident 1 had been found on the floor. Resident 1's head had been against the bed frame of her roommate's bed. Resident 1 had a bump on the back of her head. Licensed Staff H stated Resident 1's head had hit the bed. Resident 1 had been monitored at first, and then had a change in her cognition and been sent to the acute care. Resident 1 had pointed to the back of her head, stopped communicating, and started to stare at the ceiling. Licensed Staff H stated Resident 1 had fallen many times. Licensed Staff H stated Resident 1 would be reminded to use her wheel chair but she would forget and push the wheel chair around instead. Licensed Staff H stated there was no staff present when Resident 1 fell . Licensed Staff H stated Resident 1 did not have one-on-one supervision. A facility document titled Post-fall review dated signed 8/14/18 by Licensed Staff G, revealed the date and time of Resident 1's fall at 8/11/18 at 16:15 (4:15 p.m.). The document revealed Resident 1 was discovered on the floor (unwitnessed). The document revealed Resident was on the floor with her head against the metal frame of the room mates bed, resident is like on a sitting position, resident wheelchair folded on the floor beside her her hand touching the back of her head saying help it hurts. (sic) A facility document titled Progress Notes, Type: IDT (Interdisciplinary Team) Review, dated effective date 8/11/18 16:30 (4:30 p.m.), written by Licensed Staff D, revealed (Resident 1) was found on the floor in her room leaning toward bed frame and back of her head against the bed frame of room mates bed . first aid provided by applying ice pack to the back of the head . [DIAGNOSES REDACTED]. Other risk factors . for safety awareness, she was trying to be independent despite re orienting (sic) and re directing (sic). Staff was frequently reminding her the importance of usage of her cane and wheelchair . A facility document titled Fall Risk Assessment, dated 4/12/18, signed by Management Staff E, revealed Resident 1 was at risk for falls. During an interview on 12/5/18 at 1:40 p.m. Management Staff J confirmed the facility had no other fall risk assessments for Resident 1. Management Staff J stated Resident 1's fall risk was addressed in the quarterly assessments. Review of facility documents titled Quarterly assessments, dated 12/12/17, 3/12/18, and 5/24/18, revealed Resident 1 was determined a fall risk in every document. A facility document titled Progress Notes, dated 6/13/18 1:49 p.m., written by Clinician K, revealed Patient (Resident 1) had another fall in her room yesterday and sustained a bruise to her L (left) shoulder. Patient has had many, many falls in (facility). A facility document, untitled, undated, provided on 9/18/18 as Resident 1's Care Plan, revealed The resident (Resident 1) is high risk for falls r/t Deconditioning, gait/balance problems, and non compliance with use of assistive device . The entry was updated 3/26/18. Interventions included Activity Director will offer more activities, anticipate and meet the residents needs, bed in low position, be sure the residents call light is within reach and encourage the resident to use it ., encourage the resident to participate in activities ., ensure the resident is wearing appropriate footwear , keep environment clear, keep things within reach, monitor for pain, non skid socks at all times while waiting for the non skid shoes, orthostatic (lying down and standing) blood pressure check, remind to use cane, room change, put belongings on top of the drawer . Resident 1's Care Plan did not specify how staff would provide supervision to prevent Resident 1 from falling. Resident 1's Care Plan revealed The resident (Resident 1) has impaired cognitive function/dementia or impaired thought processes r/t Dementia. The document revealed potential for injury r/t NON COMPLIANCE (sic) as evidenced by refusal of Other: Fall prevention like using cane, using non-skid socks . Resident 1's Care Plan revealed an entry, undated, Resident had an unwitnessed fall on 6/22/18. The intervention following the fall revealed Activity Director will offer more activities. The care plan did not specify supervision for Resident 1. Resident 1's Care Plan revealed Resident preference for walking around puts her at risk for falls. The entry was not dated. Intervention revealed Activity staff will accompany resident, encourage use of quad cane when in or en route to or leaving from activities. Review of facility documents titled Progress Notes, Type IDT Review revealed Resident 1 had thirteen falls, twelve unwitnessed, in her room or bathroom. The IDT recommendations following the falls included Resident 1 to wear non skid socks at all times (1/23/18), to move Resident 1 closer to nursing station (3/26/18), for Resident 1's (family member) to buy new non skid shoes (4/12/18), to put all belongings on top of the drawer instead on the bedside table to avoid resident from picking things that can possibly fall whenever she moves the table . (5/21/18), Remind resident to use the cane when ambulating . (5/29/18), .the resident will be in a wheel chair (6/13/18), activity director will offer more activities (6/25/18), and continue with P[NAME] (plan of care) (3/23/18, 4/4/18, 5/3/18, 6/4/18). All entries list a [DIAGNOSES REDACTED]. Management Staff E wrote ten of the entries making recommendations following Resident 1's thirteen falls. The progress note did not specify how staff would provide supervision to prevent Resident 1 from falling. Management Staff E was not available for comment. During an interview on 12/28/2018 at 1:35 p.m., the DNS (Director of Nursing Services) stated she was not familiar with Resident 1. During the interview, DNS reviewed Resident 1's care plan. DNS stated Resident 1's fall care plan did not include supervision for Resident 1. DNS stated Resident 1's care plan should have included supervision of Resident 1. DNS stated there was also no supervision indicated on Resident 1's P[NAME] (plan of care) (computerized system for CNAs about how to provide resident specific care) or Kardex (quick reference card for all staff with pertinent information about a resident). An acute care document titled Emergency Department dated 8/11/18 18:17 (6:17 p.m.) revealed .presents with head trauma around 1630 the Pt (patient, Resident 1) fell from her wheel chair, hit the back of her head, went back into her wheel chair and slowly began to loss (sic) consciousness . Pt is unresponsive to exam . The document revealed Physical Exam Head: hematoma (collection of blood outside the blood vessel) to back of head . A CT (computerized tomography) scan (uses computers and rotating X-ray machines to create cross-sectional images of the body) performed 8/11/18 revealed large right hemisphere acute on chronic subdural hematoma (collection of blood outside the brain) . An acute care document titled H and P (History and Physical) dated Service Date 8/11/18, revealed .patient (Resident 1) .presents to the hospital after a fall with a large acute on chronic right subdural hematoma causing significant mass effect (effect of a growing mass) and midline shift (shift of the brain past the center line).the patient has had a significant injury to the brain. It is possible given the significant injury that the patient may not wake up and be able to be extubated (removal of breathing tube), let alone return to her baseline exam.the patient had good baseline functioning .we will plan a right craniotomy (surgical opening into the skull) for evacuation of the subdural hematoma as well as placement of a left external ventricular drain (device used to relieve elevated intracranial pressure) . The document revealed 1. Emergent right-sided craniotomy . and placement of a left external ventricular drain 2. Admit patient to the ICU .6. monitor subdural and subgaleal JP (Jackson-Pratt) output (drains for collecting bodily fluids from surgical sites). 13. Remain on the ventilator (appliance for artificial respirations) .16 placing feeding tube tomorrow .19. Foley catheter (urinary catheter) . The facility's policy titled Falls and Fall Risk, Managing dated 2001, revised (MONTH) 2007, revealed a Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm ould result.

Based on interview and record review the facility failed to prevent the development of pressure ulcers (areas of damaged skin caused by staying in one position for too long; they commonly form where the bones are close to the skin) to the right ischium (the curved bone forming the base of each half of the pelvis), the right hip, and the left hip, in one of three sampled residents (Resident 1). This failure resulted in Resident 1 developing a Stage 4 pressure ulcer to his right ischium, a Stage 3 pressure ulcer to his right hip, and a Stage 2 pressure ulcer to his left hip Resident 1 required hospitalization for treatment of [REDACTED]. Findings: Review of the facility's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with dementia (an overall term that describes a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), an unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough-a yellow, tan, gray, green or brown covering and/or eschar-a tan, brown or black covering in the wound bed; slough and eschar are non-viable, dead tissue) on the left hip, incontinence of bladder and bowel, and adult failure to thrive (in elderly patients, failure to thrive describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity.) Resident 1's Admission Report dated 1/23/18, noted under Skin Issue was Lt (left) hip Stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis-the thick layer of living tissue below the outer layer of skin, containing blood vessels, nerve endings, sweat glands, hair follicles, and other structures. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister). Under Bowel and Bladder, Resident 1 was identified as incontinent (loss of control of bladder and bowel), and under ADL's (activities of daily living) Resident 1 required maximum assistance of two people and was a High Risk for falls. The Admission Skin Assessment, (part of the Admission Report), however, pointed out two wounds on the left hip, one of which was identified as UTD (unable to determine) 8cm (centimeters) x 2.5cm and the other, not identified with a Stage category, measured 2.7cm x 2.4cm. Concurrent review of the facility's Order Summary Report indicated on 1/23/18, an order for [REDACTED]. On 8/1/18 the facility's Change of Condition Evaluation identified Resident 1's right ischial skin breakdown as excoriation (inflamed, irritated skin). On 8/3/18 a physician's orders [REDACTED]. Resident 1 was admitted to the acute care hospital on [DATE] and the Admission Problem List noted Pressure Ulcer of Right Buttock Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) infected with proteus (a bacteria commonly found in the intestines) on admission, Pressure Ulcer of Left Hip Stage 2, and a Pressure Ulcer of Right Hip Stage 3 (full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue - new tissue in granular form on an ulcer or the healing surface of a wound - and rolled wound edges are often present; the depth of tissue damage varies by anatomical location; undermining and tunneling (channels or tunnels beneath the wound) may occur). Resident 1 was also diagnosed with [REDACTED]. MDS (minimum data set - a resident assessment tool) assessments dated 1/30/18-admission, 4/20/18-significant change, 7/21/18-quarterly, and 8/3/18-discharge, Section C for Cognitive Behavior indicated Resident 1 was unable to complete a Brief Interview for Mental Status (BIMS) due to severely impaired memory and exhibited inattention and difficulty keeping track of what was being said. Section G for Functional Status indicated Resident 1 required extensive assistance of one to two persons for bed mobility, transfers, toileting, personal hygiene, and bathing. It was also noted that Resident 1 had impairments to both lower extremities (legs). Although Resident 1 was briefly able to use a front wheel walker for short distances after admission, his primary means of mobility was a wheelchair. Section M for Skin Conditions indicated the following: - Admission MDS dated [DATE] indicated Resident 1 was at risk for developing pressure ulcers and was admitted to the facility with two unstageable pressure ulcers. - Significant Change MDS dated [DATE] indicated Resident 1's pressure ulcers had healed. - Quarterly MDS dated [DATE] indicated Resident 1 had no pressure ulcers or any other skin problems. - Discharge MDS dated [DATE] indicated Resident 1 had one Stage 3 pressure ulcer and one unstageable pressure ulcer. A quarterly Braden Scale for predicting Pressure Ulcer Risk, dated 7/20/18, indicated Resident 1 had skin that was occasionally moist . requiring an extra linen change approximately once a day and a potential problem with friction and shear of the skin (shear is the unaligned forces pushing one part of a body in one direction, and another part of the body in the opposite direction; friction is the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.) The potential problem was described as, . During a move skin probably slides to some extent against sheets, chair, . or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. The Braden Scale evaluation indicated Resident 1 was considered as At Risk for developing a skin/pressure injury. During an interview on 8/15/18 at 1:40 p.m., Resident 1's Family Nurse Practitioner (FNP) confirmed Resident 1 was heavy care (required extensive assistance with daily care) and very contracted (stiffness, [MEDICATION NAME], and/or shortening in the connective tissues of the body; this can occur in the muscles, tendons, ligaments, and skin, often due to immobility). FNP stated she was told, on 8/1/18, by the facility's nursing staff, that Resident 1 had excoriation (irritated/damaged skin) to his right buttock area. The FNP stated she ordered a barrier cream to be applied to the affected area and an up and down schedule (providing a resident a certain amount of time up in a chair and lying in bed in order to redistribute weight and pressure.) Concurrent review of the facility's Order Listing Report indicated on 8/1/18, Resident 1 received an order for [REDACTED]. The FNP stated the CNA told her, No excoriation, there's a (wound) dressing on there, and pointed to the ischial area. FNP examined Resident 1's ischial/hip area and found on the right ischium, toward the perineum (the area between the anus and the scrotum or vulva) a 5 cm (centimeter) x 6 cm unstageable sore with brown colored eschar. FNP stated the dressing was soaked and the wound had [DIAGNOSES REDACTED] (redness of the skin as a result of injury or irritation) surrounding it. FNP stated the wound elicited pain in Resident 1, He would wince on exam. FNP stated she alerted Resident 1's physician of her findings (the ischial pressure sore) and the physician indicated he was not aware and stated nobody in the facility reported any (skin) changes to him. Resident 1's Plan of Care identified a focus problem for . potential risk for skin breakdown r/t (related to) incontinence and memory deficit, m/b (manifested by) ecoriation (sic) on right ischium. There was no entry date on the printed Plan of Care, however, during a telephone interview on 11/27/18 at 2:20 p.m., the MDS nurse verified the problem was entered into Resident 1's (electronic) Plan of Care on 8/1/18. The goal was to minimize skin excoriation . The interventions noted were, Apply treatment as per order. Reposition Q (every) 2 hours or as needed. Encourage fluids. There was no intervention noted for an up and down schedule. During an interview on 8/15/18 at 3 p.m., when asked why and how Resident 1's pressure ulcers progressed to that point, the Administrator stated, I can't answer that. The Administrator stated the CNA staff used a shower sheet to document any skin changes and gave the shower sheet to their charge nurse for review. When asked if the CNA's were not providing Resident 1 with showers, the Administrator stated, I can't answer that. Review of the CNA's documentation for Bathing for the month of (MONTH) (YEAR) through 8/3/18 indicated skin checks were completed nearly every day during the day and evening shifts. On the day shifts for 7/6/18, 7/7/18, 7/13/18, 7/17/18, 7/18/18, 7/20/18, 7/21/18, 7/23/18, 7/24/18, and 7/27/18 it was documented that skin check observations were reported to the charge nurse. On the day shifts for 7/17/18 at 10:18 a.m. and 7/18/18 at 9:47 a.m., the documentation indicated skin check observations were reported to the nurse and a Stop and Watch alert was created for new skin observations. (A Stop and Watch is an early warning communication tool that CNA's or other facility personnel use to alert a nurse if they notice something different in a resident's daily care routine. It can be written on a paper sheet or entered electronically in a resident's medical record. www.med-pass.com) On 8/15/18 all progress notes for Resident 1 dated from 6/1/18 to 8/3/18 were requested. During an interview on 8/15/18 at 3:20 p.m., the DSD (Director of Staff Development) stated he had taken care of Resident 1 a few times. The DSD stated he did not witness but thought Resident 1 was admitted to the facility with a pressure ulcer. When asked how Resident 1 developed the current Stage 4 pressure ulcer, the DSD stated, I was totally surprised about the latest one, that doesn't happen overnight. The DSD was asked how he assured his CNA staff were doing their jobs, such as reporting any skin changes to their charge nurse. The DSD stated he stressed to the CNA's, Anything new, tell me, I say! The DSD stated if any skin changes were discovered, a charge nurse typically alerted the treatment nurse (for further care and doctor's orders). The DSD stated Resident 1 could move in bed and turn himself but probably spent more time in the wheelchair . he had a chair pad. The DSD also stated he saw Resident 1 push himself up with his hands on the armrests while seated in the wheelchair. During an interview on 8/15/18 at 3:55 p.m., Licensed Nurse-A (LN-A) stated she was told by the treatment nurse on 8/1/18 that Resident 1 had a 4 cm x 4 cm area of excoriation on his buttock area. When asked if she saw the wound, LN-A stated, No, however, she informed the FNP of excoriation. LN-A stated the treatment nurse also spoke to the FNP on 8/1/18. LN-A corroborated that Resident 1 could grab the armrests (on the wheelchair) and pull himself up, he did this often. Both the DSD and LN-A stated Resident 1 loved to drink, he never refused anything (food or drink). During a follow-up interview on 8/16/18 at 12:50 p.m., LN-A confirmed she did not look at Resident 1's reported excoriation on 8/1/18, although she faxed an alert to the facility's Medical Director only to find out afterwards Resident 1's physician was not the Medical Director. When asked where the treatment nurse documented her wound care notes, LN-A stated It should be in the progress notes. The treatment nurse no longer worked at the facility. During an interview on 8/16/18 at 1:10 p.m., when asked where the treatment nurse's notes could be found, the Administrator stated, It should all be in the eMAR (electronic medication administration record) and the progress notes. All of Resident 1's skin treatment notes and assessments (by the treatment nurse) were requested. The facility did not provide the requested documents. A nursing progress note dated 8/1/18 at 2:53 p.m., by LN-A noted Resident alert and responsive no c/o (complaints of) pain no SOB (shortness of breath), noted with excoriation on right ischium 4cm x 4cm, with redness around it, no s/s (signs or symptoms) of infection, MD/Family notified, request treatment of [REDACTED]. Subsequent nursing notes dated from 8/1/18 at 6:63 p.m. through 8/3/18 at 6:38 a.m. noted the following: . observed for right ischium excoriation . no s/s of infection . turn and reposition for comfort and to prevent further skin breakdown . kept clean and dry . on monitoring for excoriation on right ischium 4cm x 4cm . treatment done by treatment nurse . dressing dry and intact, no drainage noted . kept clean and dry . no s/s of pain, 0 (zero) facial grimacing or moaning noted. The final nursing note entry dated 8/3/18 at 12:18 p.m., was by LN-A and noted, Resident alert and responsive non verbal no c/o pain no SOB noted, continue on monitoring for excoriation on right buttock still noted with redness around it, treatment as per order by treatment nurse, will continue to observe. There were no notes describing the actual excoriation or a wound beneath the dressing. According to Potter and Perry's Fundamentals of Nursing, copyright (YEAR), exposure of the wound facilitates assessment of the wound and surrounding skin. Nursing Assistive Personnel (CNA's) should be instructed to: Report any changes to (the Resident's) skin such as redness, blistering, abrasion . to the nurse for further nursing assessment. Keep (the Resident's) skin dry and provide hygiene following fecal or urinary incontinence . Reposition (the Resident) according to frequency established on nursing care plan . As part of the assessment process, the nurse should Inspect skin at least every shift for at-risk individuals needing prevention and for factors placing them at risk. On 8/3/18 at 4:26 p.m., the DSD generated a Change of Condition report which noted Resident 1 had an elevated temperature of 100.4 and a right ischial UTD (unable to determine) PU (pressure ulcer). Resident 1's physician was informed and the FNP wrote an order to transfer Resident 1 to the acute care hospital. Resident 1's right ischial pressure sore required two surgical debridement (the removal of damaged and/or dead tissue from a wound) procedures at the acute care hospital, the first one on 8/4/18 and the second one on 8/7/18. The hospital discharge summary dated 8/8/18, noted under Hospital Course and Significant Findings, Resident 1 was admitted (on 8/3/18) for workup of fever, new decubitus (pressure) ulcers and painful perineal [DIAGNOSES REDACTED] (inflammation around the genital area), and was found to have, in addition to the pressure sore, a UTI and pneumonia of the left lower lobe and required antibiotic therapy. The facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 3/2014, indicated under the section Assessment and Recognition, . the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. The facility's policy and procedure titled, Diarrhea and Fecal Incontinence, revised 9/2010, indicated under the section which described cleansing the resident, When evaluating the condition of the resident's skin, note the following: a.) Maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture), softening, or breaks in the skin; b.) Irritation, chafing (to make a part of the body sore by rubbing against it), excoriation, or rash; and c.) Pressure ulcers.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. These failures contributed to Unsampled Resident 1's low oxygen saturations of 76% on room air (normal Oxygen Saturation is ,[DATE]% on room air), a respiration rate of 10 (normal rate for adult at rest is ,[DATE] breaths per minute) requiring intubation and admit to local acute care hospital for Acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. Findings: A fax received by the California Department of Public Health on [DATE] indicated a self report of an unusual occurrence. The document was written by Administrative Staff A. The document indicated on [DATE] at 9 p.m., Licensed Staff B administered medications to the wrong resident, Unsampled Resident 1. Unsampled Resident 1 was taken via 911 to a local hospital. During a phone interview on [DATE] at 11:12 a.m., Director of Nursing Services (DNS) confirmed on [DATE] around 9 p.m. Unsampled Resident 1 had received medications prescribed for another resident. Director of Nursing Services stated Unsampled Resident 1 had been taken to the local acute care hospital due to a decreased respiratory rate and decreased O2 (Oxygen) saturation following the medication administration error. The Change of Condition (SBAR) dated [DATE] at 9:30 p.m. indicated in the section asking to describe the problem/symptoms Around 9 p.m., incorrect medication administration of the following [MEDICATION NAME] 15 mg, Xarelto 20mg, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 100 mg via GT (Gastrostomy Tube) patient assessed immediately, BP ,[DATE], Pulse 69, Rr (sic) 10, O2 sat 76 % on RA. Immediately PRN 2L given via nasal canula and a call made to 911.911 came around 9:15 pm. left with patient at 9:25pm . The document indicated Worse to the question Identify whether the problem/symptom has gotten worse/better/or stayed the same. A description of the resident under the section neuro check findings reveals Unconsciousness, lethargic, and under the section Pulmonary reveals lung sounds on the right and left side as Diminished. The most recent O2 Saturation was reported as 76% (normal rate of Saturation is between ,[DATE]%). Unsampled Resident 1 skin color was described as yellow when prompted to describe skin color changes. The medication records for the month of February 2016 did not reveal that Unsampled Resident 1 had [MEDICATION NAME] or [MEDICATION NAME] ordered by the physician. During an interview on [DATE] at 1:55 p.m., Licensed Staff C stated she had been the nursing supervisor on the evening shift on [DATE]. She had been called to assist another resident when thenurse gave medications for 22B to 23B. During a phone interview on [DATE] at 3:26 p.m., Licensed Staff B stated Unsampled Resident 1 had been fine before the meds were given. Licensed Staff B stated he did not realize he had administered the medications to the wrong resident until the resident, whom the medications were prescribed for, asked for them. When asked how he had identified the patient before administering the medication, Licensed Staff B stated he had met the patient before, thought he was another patient, but I was mistaken. When asked how he identified resident before administering medications, Licensed Staff B stated that some resident had photos on the MAR (Medication Administration Record) but this resident did not. When asked if he had checked the ID bracelet, Licensed Staff B responded No. The Emergency Department Physician Note revealed Unsampled Resident 1 was seen on [DATE] at 10:04 p.m. Unsampled Resident 1 presented with [MEDICAL CONDITION]. The Emergency Department provider notes reveals Altered Mental Status as chief complaint, and Unsampled Resident 1 became bradycardic and lost a pulse in the ambulance, and CPR was initiated. The consult/H&P notes written on [DATE] at 11:19 p.m. revealed Unsampled Resident 1 was intubated (procedure by which a tube is inserted through the mouth down into the trachea) (large airway from the mouth to the lungs) in the Emergency Department due to lack of gag reflex and unresponsive status. The resident was admitted to Critical Care. The Consult/H&P revealed Altered Mental Status .most likely due to erroneous exposure to [MEDICATION NAME] 15mg and [MEDICATION NAME] ([MEDICATION NAME]) 30 mg tonight. The Consult/H&P revealed Acute [MEDICAL CONDITION] most likely due to ALOC (altered level of consciousness) and erroneous exposure to [MEDICATION NAME] (a pain medication ) and [MEDICATION NAME] ( a hypnotic medication) at the SNF(Skilled Nursing Facility) tonight. Needed intubation for airway protection. The Consult/H&P reveals [MEDICAL CONDITION], and the plan to admit Unsampled Resident 1 to the ICU (Intensive Care Unit) on Vent (Medical ventilator)( a mechanical ventilator, a machine designed to moving breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe .) support. Medication Administration, dated 2001 and revised [DATE], provided by the facility on [DATE], indicated the Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. The Policy Statement reveals 6. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. Mosby's 2011 Nursing Drug Reference, 24th Edition, reveals Respiratory Depression, Respiratory Arrest, and [MEDICAL CONDITION] as potential Side Effects of [MEDICATION NAME] (pp. 774, 775). Lexicomp online 2016, a clinical online reference used by pharmacists, physicians, and nurses, warns that [MEDICATION NAME] has the potential adverse reaction of Respiratory Depression, and Respiratory Depression occurs most frequently in geriatric and debilitated patients, and those with conditions accompanied by [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching the tissues) .when even moderate therapeutic doses may dangerously decrease [MEDICAL CONDITION] ventilation. Lexicomp online warns that Respiratory Depression may be severe, requiring maintenance of an adequate airway, use of resuscitative equipment, and administration of oxygen, and opiate antagonist, and /or other resuscitative drugs. Lexicomp online warns about the potential adverse reaction of [MEDICATION NAME] as CNS Depression (Central nervous system depression or CNS depression refers to physiological depression of the central nervous system that can result in decreased rate of breathing, decreased heart rate, and loss of consciousness possibly leading to coma or death .) : may cause CNS depression, which may inpair physical or mental abilities . According to Lippincott's Nursing, dated [DATE], medication administration included ensuring the eight rights. The eight rights included the right patient, the right medication, the right dose, the right route, the right time, the right reason, the right response, and the right documentation.

Based on observation, interview, record review, and document review, the facility failed to: 1) Assess Resident 1 for the appropriate mechanical device for transfer using two person assist on a non-ambulatory resident 2) Develop an individualized nursing care plan specifying the mechanical device to be used and the number of staff to be utilized for transferring Resident 1. These failures resulted in Resident 1 sliding off the sling onto the floor, fracturing Resident 1's right femur, and requiring a blood transfusion for blood loss for Hemoglobin (Hgb) was 7.2 (Hgb-red blood cells that carry oxygen. Normal value 12-14). The fall had affected Resident 1's psychosocial well-being when Resident 1 exhibited anxiety, tearfulness, episodes for crying, and expressed being unhappy about the fall. Findings: Resident 1's demographic record, listing 1/11/2013 as admitted , revealed [DIAGNOSES REDACTED]. Resident 1's MDS (Minimum Data Set, an assessment tool) dated 3/9/2015 revealed that Resident 1 was totally dependent on staff for transfer and required two person assist Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position . in section G (Functional Status) of the MDS. Resident 1's History and Physical Exam dated 2/7/14 revealed total assist for OOB (out of bed) activity-- mechanical lift. The document did not specify the type of mechanical lift. Physician's progress note dated 12/27/14 showed Resident 1's chief complaint as hand weakness-decreased coordination. The same progress note further indicated: 1) Hand weakness/bilateral/generalized 2) Decreased bilateral hand coordination-HX MS-associated decrease in hand strength An acute care hospital's Pain Management Clinic Progress Note dated 4/15/15 lists progressive bilateral upper extremity weakness as Resident 1's concern. During observation and concurrent interview on 6/18/15 at 11:05 a.m., Resident 1 was observed lying in bed. When queried, Resident 1 stated only one CNA (Certified Nursing Assistant) assisted her with the transfer on the day she fell (6/4/15). Resident 1 stated the CNA was new, and had never assisted or transferred her before. Resident 1 explained she had asked for 2 staff assistance but the new CNA informed her he could perform the transfer by himself. Resident 1 further stated it was not infrequent staff transferred her with only one person assistance. Resident 1 stated it was mostly the guys (male CNAs) using the smaller lift. (Vera lift)Resident 1 said on 6/4/15 at about 10:20 a.m. she slid out of the sling onto the floor, and landed on her right leg, and felt severe pain immediately. Resident 1 further explained she had asked facility staff multiple times to use the Vander-Lift (a lifting/transfer device for the totally dependent individual) Resident 1 stated staff would tell her the Vander-Lift was not available and staff would use the Vera-Lift instead. She stated with the Vera-Lift, I need to use my arms but can't anymore. (www.osha.gov) instead of the Vera-Lift (a standing and rehabilitation aid for the extensive assistance individual. The resident needs to demonstrate some weight-bearing ability or upper-body strength in order to pivot with the use of' (this lift) (www.osha.gov)) During an interview on 6/20/15 at 2:03 p.m., Unlicensed Staff A stated he had never transferred Resident 1 before the fall, and it had been his first time assisting her. He explained she had been asking to go back to bed, and since there was no lift available he first asked her to wait. Resident 1 had been waiting for about 45 minutes, when he found a lift machine. He stated no one was around to help, and since Resident 1 had been waiting and soiled herself (had a bowel movement in her clothing) while waiting, he transferred her by himself. When asked if Unlicensed Staff A had looked for help before transferring Resident 1 by himself, he stated Nobody was in the hallway. When he was asked to clarify which lift he had used, he stated the standing lift machine, the Vera-Lift. A Nursing Progress Note dated 6/5/15 at 10:52 am written by Management Staff D revealed: IDT (Interdisciplinary Team) NOTE: WITNESS FALL. Resident alert/oriented x 3, able to communicate and verbalize needs. Up on motorized wheelchair daily (sic). 6/4/15 at around 10:30 am, resident was being transferred by CNA from her wheelchair to bed with machine. During transfer, resident started to slid (sic) from the sling so CNA tried to lower the lift and put her down leaning on her side. CNA called for help immediately and charge nurse assess the resident from head to toe. Resident was complaining of pain on R side of body 8/10 . (a pain scale rating from 0-10 giving the patient a way to rate the severity of his/her pain with 0 being no pain and 10 the most excruciating pain). A Progress Note written by Licensed Staff B dated 6/4/15 at 9:12 pm: At around 19:30 (7:30 pm), resident sent to acute care ER via ambulance with daughter at her side for right distal femur fracture . The result of the Right Femur X-ray signed on 6/5/15 at 7:01 am by the Radiologist revealed: Comminuted displaced fracture of the distal right femoral diametaphysis. The American Academy of Orthopaedic Surgeons (AAOS) (http://orthoinfo.aaos.org) defines Comminuted fracture the following way: In this type of fracture, the bone has broken into three or more pieces. In most cases, the number of bone fragments corresponds with the amount of force required to break the bone. The American Academy of Orthopaedic Surgeons defines displaced as The pieces of bone .be out of alignment (displaced). The American Academy of Orthopaedic Surgeons further explains: A femoral shaft fracture usually causes immediate, severe pain. During an interview on 6/18/15 at 11:05 am, Resident 1 stated she would normally be up in her motorized wheel chair for 6-8 hours a day, but since the fall she had not been up, and stated I don't want to get up now. Resident 1 reported feeling more anxious since the fall, and document review of a note titled Long Term Care Psychiatry dated 6/16/15 indicated noted to be tearful since readmission (after the fall), as well as She is very unhappy about the fall. Some pain in her leg. Some crying. Resident 1's Care Plan indicated the Fall Risk Care Plan, initiated 3/9/2015, did not identify how staff were to transfer Resident 1 and which lift was appropriate to use for Resident 1. The Care Plan also did not specify how many staff members needed to be present during transfers. The Fall Risk Care Plan did, however, clearly instructed staff Resident 1needs prompt response to all requests for assistance. The facility's Policy and Procedure titled Safe Lifting and Movement of Residents revised October 2009, indicated: nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document residents transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preference for assistance; b. Resident's mobility (degree of dependence); .d. weight-bearing ability; . On 10/7/15 the facility was asked to provide documentation regarding assessments completed prior to the fall for the appropriate mechanical device to use for transferring Resident 1, as well as the number of staff needed during transfer. On 10/12/15 at 11:12 a.m. during a phone interview Management Staff N stated he was not sure if there was an assessment done prior to the fall, and they started training after the fall. Management Staff N agreed to check with the Therapy Department. No documentation was provided. During an interview on 6/18/15 at 1:00 p.m., Licensed Staff I stated she was familiar with Resident 1, and her understanding was that Resident 1 was to be transferred using the total dependent lift, the Vander lift. Licensed Staff I was asked who decided which lift to use, she stated it was the Physical Therapy Department. When asked if they had seen Resident 1 recently, she answered that to her knowledge, the last therapy evaluation was done almost 2 years ago. During an interview on 6/18/15 at 1:45 p.m., Unlicensed Staff J stated he had used the Vera lift last time he worked with Resident 1, about a year ago. He demonstrated how Resident 1 would sling her arms into the holders (Patient handgrips) up to her forearm , and this way there was no need to use her hands. During an interview on 6/18/15 at 1:42p.m. Unlicensed Staff K stated regarding Resident 1's transfers, that he used the Vera -Lift on and off , the last time about one month ago. He stated he left the decision which lift to use up to the Resident 1, and how she felt that day. During an interview on 8/3/2015 at 1:20 p.m., Licensed Staff L stated that regarding the use of the lift for Resident 1, it was always supposed to be with 2 people; this was the facility's policy. When asked how staff knew which lift to use for the residents, he stated he was not sure. He explained the Vera lift was used for a resident who can help , whereas the Vander lift was used for others (residents) who need complete help. When he was asked whether there was a system in place for staff to know which Lift to use, he stated he did not know. He thought there was some type of system, but could not remember. He stated that he was the nurse in charge of Resident 1 on 6/4/15 during the a.m. shift she fell . He stated that he responded when she fell on the floor, and stated Resident 1 could not grab on to the lift, and her hands were weaker. During an interview on 8/3/15 at 1:30 p.m., Unlicensed Staff M was asked how she knew which lift to use for which resident, she stated it depended on the resident. She explained further that the Vera lift was used for residents who were able to assist in transfers and the Vander lift for residents who were full care. When she was asked how she knew which lift to use for a resident, she stated it was written in the ADL (Activities of Daily Living) Binder. She was not able to demonstrate where she would find the information. During an interview on 8/3/2015 at 3:50 p.m., Management Staff C stated the CNAs watched a video, and then were paired up with another CNA for about 3 days to train on the floor. He explained during that time they learned to use both lifts. When asked directly if this meant they learned to use the lift from another CNA, he answered yes. Management Staff C was asked if he or someone else followed up and checked the CNAs skills, and he replied that he did so during rounds. When asked to provide a skills check off sheet, he stated that he did not have any skills check off sheets or other paper form demonstrating CNAs' competence. The Acute Care Hospital record titled MD Progress Note dated 6/7/15 revealed Resident 1 complaining of right leg pain, as well as her right leg being quite edematous (swollen) compared to the left (leg). The record indicated Resident 1 had blood loss into her fracture, and MD would order a transfusion of 1 unit of packed red blood cells. The record concluded with the statement: The patient (Resident 1) requires continued hospitalization to treat her acute blood loss anemia, to monitor her for any ongoing evidence of bleeding into the fracture site . The Facility Policy and Procedure titled Safe Lifting and Movement of Residents, revised October 2009, further indicated: Staff responsible for direct resident care will be trained in the use of manual ( .) and mechanical lifting devices. The Policy further read: Staff will be observed for competency in using mechanical lifts and observed periodically of adherence to policies and procedures regarding use of equipment and safe lifting techniques. VANCARE, INC Operating Manual, December 2013, under Transfer Criteria for the Vera-Lift page 9 indicates: The Patient Must .c) Be able to put both feet on the Vera-Lift foot pad and bear weight on both legs.

Based on observation, interview, and record review, the facility failed to timely and effectively prevent and protect Resident 3 from physical harm, verbal abuse and mental anguish when there was a history of conflicts between Resident 2 and Resident 3 which led to: 1. Resident 2 grabbed and punched Resident 3 on 7/8/14 at 3:15 p.m. which resulted in 4 scratches and significant bruising to Resident 3's left forearm; 2. Resident 2 swore and punched Resident 3 on the shoulder on 7/25/14 at 10:15 a.m., 17 days after the first altercation, and 3. Resident 2 verbally abused Resident 3 before, during and after the two physical altercations noted above. Resident 2 continued to swear out loud and mouth profanities and was "giving him the finger" which led to Resident 3 being anxious and unable to sleep at night. Findings: During an interview, on 8/6/14 at 4:20 p.m., Ombudsman G stated that Resident 2 and Resident 3 had a history of [REDACTED]. Ombudsman G had met with both Resident 2 and Resident 3 on several occasions and had met with the Long Term Psychiatry Nurse Practitioner (NP) F to discuss the issues with both Resident 2 and Resident 3. Additionally, Ombudsman G stated that Resident 2 could escalate to actual physical fighting (hitting, grabbing and throwing objects) as Resident 2 had a prior history of physical fighting at this facility. (Ombudsman investigate and endeavor to resolve complaints made by, or on behalf of, individual residents in long-term care facilities). A Long Term Care Psychiatry note dated 6/26/14 by Nurse Practitioner (NP) F noted that the reason for the visit to Resident 3 that day was management of irritability: "...(Resident 3) has a lot of complaints about another resident who (Resident 3) says harasses him...I am sympathetic to (Resident 3's) complaints about the other resident - I know him (Resident 2) and consider him a bully who amuses himself by picking on other people...(Resident 3) is excitable, and there is a simmering conflict with another resident (Resident 2)...According to (Resident 3's) own values (Resident 3) is showing a very high level of restraint in not attacking the other resident." Bullying is a form of aggressive behavior in which someone intentionally and repeatedly causes another person injury or discomfort. Bullying can take the form of physical contact, words or more subtle actions...The bullied individual typically has trouble defending him or herself and does nothing to "cause" the bullying. American Psychiatric Association Resident 2's demographic face sheet dated 5/27/14 indicated that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Mood disorder: a condition impacting mood and related functions. In a mood disorder, moods range from extremely low (depressed) to extremely high or irritable (manic).Gale Encyclopedia of Medicine. (2008). Resident 3's demographic face sheet dated 6/19/14 indicated that Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 7/14/14 at 4:35 p.m. Resident 3 was seated in a wheelchair in the Activity room. Resident 3's left forearm had 4 oval shaped scab's, consistent with fingernail shapes, with scratches leading from these on the underside of the forearm and a large area of bruising on the top of the left forearm. Resident 3 stated he was on blood thinners and the bruises and scratches were from Resident 2's grabbing and scratching. Resident 3 also stated that Resident 2 always used foul language and continually "gives me the finger." On 7/8/14 Resident 3 was visiting a friend, who was Resident 2's roommate, when Resident 2 grabbed his arm, smacked his chest, hit him several times in the chest and pushed the overbed table into him and staff had to break it up and then Resident 2 also hit the staff person. Resident 3 stated: "I can't stand the foul language and having (Resident 2) give me the finger all the time...(Resident 2) antagonizes me...I feel that (Resident 2) is a bully..." Resident 3 agreed to notify staff if Resident 2 antagonized him again. During an observation and interview on 7/14/14 at 4:15 p.m. Resident 2 was seated in a wheelchair and stated that he promised to meet weekly with Management Staff D and Resident 3. Resident 2 stated he did not scratch Resident 3's arm, that Resident 3 left the room and returned with the scratches and tried to blame me (Resident 2) for them. A fax dated 7/8/14 (no time noted) was sent notifying the physician of the incident and requested treatment of [REDACTED]. The Physician responded "OK" and dated 7/8/14. A Physician (MD) E progress note for Resident 2, dated 7/8/14 at 5:45 p.m., noted a chief complaint of "...physical and verbal confrontation with another resident...confrontation, onset this afternoon, intensity: severe, quality: physical punching...verbal confrontation (cursing)...[DIAGNOSES REDACTED]..1) Assault - resident (Resident 2) physically and verbally assaulted another resident...law enforcement documented incident - Patient education - psychiatric counseling offered (declined), 2) aggressive behavior - hx (history) of inappropriate coping mechanisms...patient education - psychiatric counseling offered (declined)..." Physician E wrote an order dated 7/8/14 to monitor Resident 2 for physical and verbal aggressive behavior for 72 hours. A Physical and Verbal Aggression Care Plan was initiated on 7/8/13 for Resident 2 with a goal of no physical or verbal aggression towards other residents for 30 days with interventions that included: follow MD order to monitor for aggression every shift for 72 hours, prevent (Resident 3) from entering (Resident 2's) room, do not let (Resident 2) close to (Resident 3's) room or other places of the facility. During an interview, on 7/14/14 at 3:10 p.m., Management Staff D stated that a weekly meeting was initiated with both residents to discuss that they needed to be civil to each other and get along. When asked if this had been added to the Care Plans for both residents, Management Staff D said that it had not. During an interview, on 7/23/14 at 10 a.m., Management staff D stated that Resident 2 had admitted to being the instigator on 7/8/14 and that the weekly meetings with Resident 2 and Resident 3 were going well with no further problems. During an interview on 7/23/14 at 1:30 p.m., Resident 3 stated that even though Resident 2 had promised Management Staff D to leave Resident 3 alone, Resident 2 continued "...giving me the finger and mouthing bad words all the time...I am having difficulty sleeping due to being anxious about this...I will try to keep away from him..." Second episode of abuse: During an interview on 7/25/14 at 1:35 p.m., Resident 3 stated "... he punched me today in the right upper arm." (7/25/14 at 10:15 a.m.) Resident 2 bumped wheelchairs while trying to pass Resident 3 in the Activity room. Resident 2 used foul language and insisted that Resident 3 move and then the wheels of both wheelchairs got tangled and Resident 2 punched Resident 3 in the shoulder. Staff took Resident 2 away. During a record review, on 7/25/14 at 3 p.m., the Activity Assistant witness statement, dated 7/25/14 at 10:15 a.m., noted that Resident 2 was the aggressor and while passing Resident 3 in the activity room used foul language when Resident 3 did not move his wheelchair out of Resident 2's way fast enough for him, and Resident 2 punched Resident 3's shoulder. Resident 3 remained calm during this episode. Facility Policy titled: Abuse Prevention Program, dated revised August 2006, indicated: "Our policy is committed to protecting our residents from abuse by anyone, including but not necessarily limited to: facility staff, other residents...Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish...The facility management and staff will institute measures to address the needs of the residents and minimize the possibility of abuse and neglect...the physician and staff will address causes of problematic resident behavior where possible..."

Based on observation, interview, and record review the facility failed to provide adequate supervision and develop an effective plan of care to provide adequate supervision for 2 of 7 sampled residents (Resident's 4 and 6): 1. When Resident 4, who had exhibited mental decompensation and dangerous behaviors, eloped from the facility on [DATE] at 4:45 a.m.; on [DATE] at 3:45 a.m. and on [DATE] at 7:25 p.m. 2. When Resident 4 threw a cigarette and set the hillside behind the facility on fire when not in the designated smoking area on [DATE] and Resident 4 burned both thumbs when trying to light a cigarette with a lighter which was treated on [DATE]. 3. When the facility stopped Resident 6's one to one monitoring at 3 p.m. and at 3:30 p.m., Resident 6 hit Resident 7. (One-to-One monitoring is close observation, within arms length, of patients who have been identified as an imminent danger to themselves or others). These failures may result in: 1. treatment of [REDACTED]. 2. A fire hazard to other residents in the facility when the hillside was set on fire; 3. Repeated elopements putting the resident at risk for injury; and 4. One resident (Resident 6) physically assaulted another resident that resulted in a broken finger. Findings: 1. Resident 4's demographic face sheet dated [DATE] indicated that Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Mayo Clinic) and abnormal gait (walk). The minimum data set (MDS) an evaluation tool, dated [DATE] indicated that Resident 4 could walk with supervision. A physician order, dated [DATE], indicated that Resident 4 could go out on pass with the responsible party. The Interdisciplinary Team (IDT) review, dated [DATE] indicated that Resident 4 had poor safety awareness and judgement, unsteady gait, attempted to function beyond his capabilities and was impulsive. An Elopement Risk Assessment, dated [DATE], noted Resident 4 had an elopement risk score of 4. (score of 4 or greater represents Risk). First episode of elopement: A Change of Condition note, dated [DATE] at 6:59 a.m., indicated that at 4:45 a.m. Resident 4 left the facility without signing out, the physician was notified and the police were able to locate Resident 4 at a local grocery store buying cigarettes. Resident 4 was returned to the facility by the police at 6 a.m. Mental status is noted as forgetful, mood as anxious, and behavior as: resists care, threatening, uncooperative and verbally abusive. Additionally, this form included: "Fall Risk Factors: Poor safety judgement, psychotropic medications, cardiac med's (medications), pain med's (medications)." Google Maps: To get to the local grocery store required walking 1.1 miles. This required walking down a steep hill and crossing a traffic light at an intersection, then crossing a heavily trafficked road without a traffic signal at a freeway on-ramp to a foot path leading to a steep staircase. This led to the bridge that crossed over the freeway, then crossing a traffic light at the freeway exit intersection and crossing two additional intersections (four lanes) with traffic lights to the grocery store. Local weather: 48 degrees at 4 a.m. The Care Plan, not dated, included the problem: "Leaving facility without signing out," and included a goal of no further complications for 7 days with goal date of [DATE]. There were no specific goals. There were no specific interventions indicated as to how the facility was going to keep Resident 4 safe. The Care Plan included the problem: "Potential for injury due to fall risk," not dated, and included a goal of no major injuries from fall for three months with a goal date of [DATE]. The interventions included: Keep resident in frequently monitored areas, assist with transfers and mobility and provide reminders to use ambulation and transfer assist devices when needed. Nurses notes dated [DATE] at 7:02 a.m. noted that Resident 4 was being monitored for 72 hours because Resident 4 left the facility without signing out. The Long Term Care Psychiatry note by Nurse Practitioner (NP) F, dated [DATE] indicated: "...left building without alerting anyone a few days ago - claimed to have walked to the supermarket to buy cigarettes, which seems to be far beyond what he is actually capable of. Dramatic decompensation recently - paranoid delusions, stuck a pen in his anus ([DATE]), acutely anxious. Complains of insomnia (difficulty sleeping)... Same complaint about a patient with long red beard ("Alex") who has allegedly been openly freebasing in the courtyard. Also says he has been having sexual relationships with two female residents (one of whom died ) and wants Viagra...constant anxiety...staff confirm that there is no such person as "Alex" and that there is no way this patient is having a relationship with any woman in this facility..." During an interview on [DATE] at 10:10 a.m., NP F stated that Resident 4 confabulates (confabulation is a memory disturbance, defined as the production of fabricated, distorted or misinterpreted memories about oneself or the world, without the conscious intention to deceive). NP F stated that Resident 4 had been decompensating recently and had relayed stories that could not possibly be true. (decompensating - the appearance or exacerbation of a mental disorder due to failure of coping mechanisms in response to stress, resulting in personality disturbance or psychological imbalance). Additionaly, NP F stated he had followed Resident 4 until one month ago, when the facility stated that the family wanted their family psychiatrist to care for Resident 4. During an interview on [DATE] at 3 p.m., Management Staff D stated that the family psychiatrist had stated that the visit was a courtesy visit for the family, and no note or recommendations would be submitted. Second Incident of Elopement: A fax, dated [DATE] with no time noted, was sent to the physician which indicated: "Resident (Resident 4) was found by staff (name of staff) by the bridge and brought back to the facility around 3:45 a.m. Resident (Resident 4) left without signing out or notifying the nurse." During an interview on [DATE] at 11 a.m., when asked about finding Resident 4 on the bridge overpass of the freeway, Management Staff D stated the following: 1) Even though Resident 4 was in the wheelchair when in the facility Resident 4 could walk and had reported going to the store to buy cigarettes, 2) The Director Of Nurses (DON) had tried a Wanderguard (an electronic device attached to a resident that alarms when passed through an alarmed door) but Resident 4 had cut it off, and 3) Resident 4 was told not to walk to the store and Resident 4 seemed to understand. Additionally, Management Staff D stated that the doors to the facility were locked at night and would not allow entrance into the facility, but did not prevent opening the door from the inside and leaving the facility. Third Incident of Elopement: Nurses notes, dated [DATE] at 11:43 p.m., noted that Resident 4 was found near the stairs leading to the basement garage and was reminded not to leave without signing out. During an observation on [DATE] at 8:55 a.m., the back patio contained the designated smoking area. On the side of the back patio there was a gate which led to stairs going down to the parking garage under the building. Fourth Incident of Elopement: Nurses notes, dated [DATE] at 7:24 p.m., noted that Resident 4 left the facility without signing out or notifying nursing staff. During an observation and interview on [DATE] at 8:35 a.m., Resident 4 was seated in a wheelchair in the main lobby by the exit door with no staff visible at the nursing station, the reception desk or hallway. When asked why he left the facility Resident 4 stated he needed to get cigarettes at the grocery store. When asked how Resident 4 got to the store, Resident 4 replied "I just walked out through the front door." Fifth Incident of Elopement During an observation and interview on [DATE] at 10:40 a.m., Resident 4 was seated in a wheelchair and stated that on Sunday [DATE] staff caught him walking down the hill and made him return. During an interview on [DATE] at 11:05 a.m., LN I relayed the facility process for locating a missing resident and stated that Resident 4 had not ever signed out when leaving the facility. The book to sign out is located at each nursing station and should be completed by the responsible party. Review revealed that there were no entries by Resident 4 or Resident 4's responsible party (mother) for the dates of elopements. During an interview, on [DATE] at 1:20 p.m., Management Staff D stated that Resident 4 had agreed to wear the Wanderguard at all times and it was now on Resident 4. During an observation, on [DATE] at 1:25 p.m., Resident 4 was observed in the wheelchair going down the hallway, with no Wanderguard visible on the person. When the Director of Nurses (DON) asked Resident 4 about the Wanderguard, Resident 4 stated he left it in his room. During an interview on [DATE] at 2:40 p.m., LN J stated that whenever Resident 4 left without signing out the facility would place Resident 4 on every one hour monitoring for 72 hours, which meant that a CNA would document on a log the location of Resident 4 each hour, i.e., in room, in dining room etc. During an interview on [DATE] at 3:20 p.m. the facility Medical Director stated that walking to the supermarket and leaving the facility in the middle of the night represented very dangerous behaviors and Resident 4 had been escalating and increasing these dangerous behaviors recently. Additionally, the Medical Director stated that the facility would need to immediately "beef up" an Unsafe Behaviors Care Plan and they needed to make sure that the Wanderguard was not taken off. 2. Resident 4's Smoking Assessment, dated [DATE] at 11:57 a.m., indicated that Resident 4 could light a cigarette and did not need adaptive equipment (smoking apron, cigarette holder, supervision or one-on-one assistance) and noted that the facility would hold Resident 4's lighter and cigarettes, and that a plan of care was implemented to ensure that Resident 4 was safe with smoking. Resident 4's Smoking Care Plan, not dated, indicated a goal of smoking in designated areas and included the following interventions: explain facility smoking policy; monitor and report smoking non compliance to supervisor. Monitor need for smoking materials and remove materials as needed for safe keeping at nursing station. The nursing care plan did not specify what specific behaviors were non compliant and what non compliant behaviors should the staff monitor. First incident of unsafe smoking behaviors: Nurses notes, dated [DATE] at 2:37 a.m., indicated that Resident 4 was seen outside of the smoking area by the biohazard waste area at 1:30 a.m. and was reminded to stay in the designated smoking area. During an observation on [DATE] at 8:55 a.m., the back patio contained the designated smoking area. At the end of the smoking area there was a large red gate, which was open, and led to the facility main electrical panel and the biohazard waste storage area. Second incident of unsafe smoking behaviors: Social Service notes, dated [DATE] at 2 p.m. indicated: "(Resident 4) was involved in an incident while smoking outside the smoking area. (Resident 4) admitted he threw a cigarette into the grass area behind the building which caused a fire...(Resident 4) was again educated about smoking only in the smoking area. (Resident 4) acknowledged understanding the risks and agreed not to smoke outside the smoking area." The Smoking Care Plan was updated on [DATE] with : "...resident was re-educated to the smoking policies and procedures and acknowledged understanding." Third incident of unsafe smoking behaviors: A fax dated [DATE], with no time noted, was sent to the physician requesting an order for [REDACTED]. This fax did not include the date, time or a description of the burns. A Physician order [REDACTED]." (Silvadine cream: Silver sulfadiazine, a sulfa drug, is used to prevent and treat infections of second and third-degree burns. Second degree burn: causes blistering on the skin but does not damage the deeper layers. Third degree burn: A severe burn in which the skin and underlying tissues are destroyed and nerve endings are exposed. MedLine Plus) During an interview on [DATE] at 1:35 p.m. LN J, the wound care nurse, stated that Resident 4 had broken blisters on the tips of both thumbs that had healed well after two weeks of treatment. LN J was unable to indicate the date of the burns, just when Resident 4 had requested treatment for [REDACTED]. During observation and interviews on [DATE] at 4 p.m. and [DATE] at 10:40 a.m. Resident 4 was seated in a wheelchair on the back patio smoking with staff present. When asked how the thumbs were injured Resident 4 reported that both thumbs were burned while lighting a cigarette and demonstrated by holding both thumbs up to a lighter at the same time. Both thumbs had dry peeling skin from tip of thumb down to the first joint, with visible red/pink new skin underneath. Resident 4 stated both thumbs had blisters from the burn and staff used creams and bandages to cure them. 3. Resident 6's demographic face sheet dated [DATE] indicated that Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's Care Plan initiated on [DATE] for a behavior problem with interventions that included: intervene as necessary to protect the rights and safety of others, divert attention, take to alternate location and develop more appropriate methods of coping and interacting (with a Spanish speaker). Another Care Plan was initiated on [DATE] for impaired cognitive function/dementia with psychotropic medications ordered due to the potential to injure self or others. The intervention's included a resident behavior management program that included one on one monitoring in AM (day shift 7 a.m. to 3 p.m.) The goals were that Resident 6 would maintain current level of functioning. A change of condition note dated [DATE] at 3:30 p.m. indicated that the Activity Director saw Resident 6 hit Resident 7 on the left upper chest without any provocation and this was witnessed by other residents and activity staff. A change of condition note dated [DATE] at 8:15 a.m. indicated that Resident 6 complained of pain and swelling of the left hand with a 2 by 2 inch bruise and swollen area with tenderness and limitation of motion. Pertinent history included a previous physical aggression to another resident. Pain is described as a 5 of 10 (1 to 10 pain scale with 1 as minimal pain and 10 extreme pain). X-ray of the left hand on [DATE] showed a fracture involving the fifth finger with soft tissue swelling. During an interview on [DATE] at 9:25 and 9:55 a.m., the Long Term Care Psychiatry Nurse Practitioner (NP) F, stated that Resident 6 had been placed on one to one observation for the last 2 weeks due to an increase in combative behaviors and felt that Resident 6 could injure other residents. During an interview on [DATE] at 11:45 a.m. Management Staff C and Management Staff D stated Resident 6 had a history of [REDACTED]. Resident 6 had decreasing combative behaviors so had been put on one to one monitoring for the day shift only (7 a.m. to 3 p.m.). Management Staff D stated that there was no specific policy in the facility for one to one monitoring and determinations were made based on the behavior's. Management Staff C and D concurred that the altercation occurred at 3:30 p.m. on [DATE], after the one to one monitoring had ended for that day, at 3 p.m.

Based on observation, staff and resident interview, and record review; the facility failed to ensure one of 15 sampled resident's (Resident 11) ability to toilet, transfer between bed and wheelchair, and walk did not diminish when Resident 11 did not receive specialized therapy due to facility acquired pressure ulcers on his left buttock and both heels of his feet. These failures resulted in a functional decline related todecreased ability to toilet and walk and the potential for worsening pain and further functional decline (Cross reference Tag 314). Findings: Review of the clinical record on 3/10/11 at 3 p.m., revealed a "history and physical examination acute rehabilitation." The physician documented Resident 11's skin was clean, dry, and intact, his muscle strength was 4+/5 (A score of four indicates movement against gravity and moderate resistance at least 10 times without fatigue, 5 indicates full range of motion against gravity and full resistance for the patient's size, age, and sex. Merck 2010) in both his upper and lower limbs, and Resident 11's rehabilitation potential was "good." The physician wrote occupational therapy orders: dated 2/28/11, occupational therapy, three times per week for four weeks, including therapeutic exercises, neuromuscular reeducation, group treatment, therapeutic activities, and self-care. The physician wrote physical therapy orders: dated 3/2/11, physical therapy, three times per week for four weeks, including therapeutic exercise, neuromuscular re-education, therapeutic activities, gait training (relearning to walk safely and efficiently with or without an assistive device), and manual diathermy (heat therapy for pain). Occupational and physical, "Plan of Treatment," documents, dated 2/28/11 and 3/2/11 respectively, revealed the following descriptors: 1. Therapeutic exercises; exercises that develop strength, endurance, range of motion, and flexibility. 2. Neuromuscular reeducation; re-education of movement, balance, coordination, kinesthetic sense (sense of one's own body movement, position, and weight), posture for sitting and/or standing activities. 3. Group treatment; two or more people. 4. Therapeutic activities; dynamic activities to improve functional performance. 5. Self-care; safety, instruction of using assistive device, and activities of daily living training, i.e. toileting, bathing. 6. Gait training; includes stair climbing and transfers related to gait. A, "Nursing Admission Assessment," dated 2/25/11, indicated Resident 11 required limited assistance with toileting, transferring, and walking. The document also indicated Resident 11's skin was dry/flaking, pink, warm, had normal elasticity. The assessment lacked documented evidence of skin breakdown on Resident 11's heels or left buttock. During an observation and concurrent interview on 3/7/11 at 10 a.m., Resident 11 was in his room, seated in his wheelchair. Resident 11's feet were positioned parallel with his knees, resting on the metal foot rests of the wheelchair. Both feet were wrapped in gauze bandages. Resident 11 did not wear heel protectors. Resident 11 stated his feet had gotten, "quite chafed." During an observation and concurrent interview on 3/10/11 at 4 p.m., Resident 11 was seated in his bed, evenly on his buttocks, in an upright position, a bar that lifted the blankets, kept the blankets from touching Resident 11's feet. Resident 11's friend was at his bedside. Resident 11 stated since he came back from the acute care hospital, he had not been in, "top shape." Resident 11's friend stated Resident 11 had been complaining about the pain in his feet when trying to go to physical therapy (prior to discovery of the pressure ulcers), but facility staff did not look at his feet. Interview and concurrent record review on 3/10/11 at 2:30 p.m., revealed an occupational therapy progress report, dated, 2/28/2011 - 3/06/2011, which indicated Resident 11 was previously able to transfer to the toilet with assistance, but Resident 11 was not able to transfer to the toilet on 3/8/11. The Occupational Therapist (OT) stated when she tried to work with Resident 11 on transferring to the toilet, he required the assistance of three staff members due to the ulcers on his heels. The OT stated nursing staff informed her Resident 11 could spend very brief periods time on his feet. The OT documented Resident 11, "...has ulcers on plantar surface (bottom) of B (both) heels which impacts ability to practice standing., ...is allowed to stand briefly only to transfer to wheelchair." The OT documented Resident 11 had continued deficits in activity tolerance and functional transfers and required the continuation of occupational therapy services. Continued record review on 3/10/11 at 3 p.m., revealed a Minimum Data Set (MDS) assessment tool, dated 1/28/11, which indicated Resident 11 had occasional pain which did not limit his day-to-day activities, and was managed with as needed pain medication. However, an "Interdisciplinary Team Conference," note, dated 3/9/11, indicated Resident 11's ability to participate in physical therapy was limited by pain, Resident 11 could, "...stand 30 seconds," and he was started on a pain management program that included regularly scheduled doses of narcotics in addition to doses as needed for dressing changes. During an interview on 3/11/11 at 10:30 a.m., the Physical Therapist (PT) stated she could no longer work with Resident 11's feet because he complained the pain from the pressure ulcers on his heels was too severe. Record review on 3/11/11 at 10:30 a.m., revealed a physical therapy, "Plan of Treatment," dated 3/2/11, which indicated Resident 11's previously needed assistance with transfers and walked with a Front Wheeled Walker (FWW). The plan indicated Resident 11, "would benefit from skilled physical therapy." A "Physical Therapy Progress Note, "dated 3/11/11, indicated the Physical Therapist (PT) documented Resident 11; was able to transfer between bed and wheelchair with minimal assist (1-25%) but, was limited by pain secondary to both heel blisters and his weight bearing status was unknown. When queried, the PT stated Resident 11 was not receiving services for transferring between bed and wheelchair due to a newly discovered pressure ulcer on his sacrum. The PT stated the therapeutic activity she provided for Resident 11 (during March 2011) related to transferring between bed and wheelchair was education about the possible use of a slideboard for transfer due to the pressure ulcer on his sacrum. The same physical therapy progress note also indicated Resident 11 was, "...unable to participate in ambulation training." The note revealed Resident 11's response to treatment was, "...Currently limited by pain secondary to B (both) heel blisters." The PT documented Resident 11 had continued deficits in activity tolerance and required skilled therapy for pain management and continued to require physical therapy services.

Based on observation, staff and resident interview, and record review; the facility failed to prevent facility acquired pressure sores for one of 15 sampled residents (Resident 11) who was at risk for a developing pressure sores when: a pressure relieving device for the bed and a turning/repositioning program were not implemented as assessed, and a nursing plan of care was not developed, which resulted in multiple pressure sores; one unstageable (the depth of the wound can not be determined) pressure sore on the left heel, a stage II (blister or open wound) pressure ulcer on his right heel, a stage II pressure ulcer on his left buttocks, and a stage I (redness that does not fade when touched) on his left buttocks (Cross Reference F310). Findings: Review of the clinical record on 3/10/11 at 3 p.m., revealed a "history and physical examination [REDACTED]. The physician documented Resident 11's skin was clean, dry, and intact. A, "Nursing Admission Assessment," dated 2/25/11, indicated Resident 11's skin was dry/flaking, pink, warm, and had normal turgor (elasticity). The assessment lacked documented evidence of skin breakdown on Resident 11's heels or left buttocks. A Minimum Data Set (MDS) assessment tool, dated 1/28/11, indicated Resident 11 did not have any pressure sores, but was at risk for developing pressure sores. The MDS indicated Resident 11 was had a pressure relieving device for his bed and was on a turning and repositioning program. A Care Area Assessment (CAA) tool, dated 1/31/11, entitled "Pressure Ulcer(s)," indicated Resident 1 was at risk for skin breakdown and that a care plan for pressure ulcers would be developed. During an observation and concurrent interview on 3/7/11 at 10 a.m., Resident 11 was seated in his wheelchair, in his room. Resident 11's feet were positioned parallel with his knees, resting on the metal foot rests of the wheelchair. Both feet were wrapped in gauze bandages. Resident 11 did not wear heel protectors. Resident 11 stated his feet had gotten, "quite chafed." During an observation and concurrent interview on 3/10/11 4 p.m., Resident 11 was seated in his bed, in an upright position, a foot cradle (a bar that supports linen) kept the blankets from touching Resident 11's feet. Resident 11's friend was at his bedside. Resident 11 stated since he returned from the acute care hospital, he had not been in, "top shape." Resident 11's friend stated Resident 11 had been complaining about the pain in his feet prior to discovery of the pressure ulcers on his heels, but facility staff did not look at his feet. Resident 11's friend stated Resident 11 provided his own gel cushion for his feet to relieve the pain when facility staff did not respond to his complaints. During an interview and concurrent record review on 3/10/11 at 3:35 p.m., Licensed Staff (LS) F stated he discovered pressure ulcers on both of Resident 11's heels on 3/3/11. A, "Change in Condition Assessment," dated 3/3/11, indicated LS F documented Resident 11 had a 7.5 centimeter (cm) x 6 cm, fluid filled "blister" on his right heel and a 4 cm x 2.5 cm "blister" on the left heel. LS F stated a, "Nursing Admission Assessment," dated 2/25/11 and a re-entry MDS, dated [DATE], indicated Resident 11 did not have pressure sores. LS F stated the MDS indicated Resident 11 was at risk for developing pressure sores. LS F stated the active clinical record lacked documented evidence of a care plan related to the prevention of skin breakdown or pressure ulcers dated prior to LS F's discovery of the pressure ulcers on 3/3/11. LS F stated Resident 11 did not have pressure sores when he was re-admitted to the facility on [DATE]. During an observation and concurrent interview 3/11/11 at 7:22 a.m., LS C performed a dressing changes on Resident 11's heel and left buttocks. Observation of the left heel revealed a large (4.5 cm x 5 cm) fluid filled blister, with a yellow margin and an area of purple/black tissue measuring 2.5 cm x 4.5 cm, covered the bulk of Resident 11's left heel. LS C stated when he initially assessed Resident 11's left heel, the pressure ulcer was black and he was not able to stage the pressure ulcer. Observation of Resident 11's right heel revealed a pressure ulcer measuring 7 cm x 6.5 cm. The pressure ulcer was boggy, covered with pale, white skin, and covered the majority of Resident 11's heel surface. LS C stated he staged the right heel pressure ulcer as stage II. LS C stated the blister recently ruptured and was draining fluid. LS C notified the physician and obtained an order to start Resident 11 on antibiotics. LS C stated Resident 11 was not on a low air loss (LAL) mattress when he initially assessed the pressure ulcers on Resident 11's heels, on 3/3/11, and that he requested a LAL mattress for Resident 11 after his assessment. Continued review of physician orders [REDACTED]. During an interview on 3/11/11 at 7:45 a.m., Unlicensed Staff (US) J stated Resident 11 was not on a turning and repositioning program until after the pressure ulcers on his heels were discovered on 3/3/11. US J pointed to the wheelchair Resident 11 was observed sitting in at 10 a.m. on 3/11/11, and stated Resident 11 was "always" sitting in his wheelchair. During continued observation of the dressing change procedure on 3/11/11 at 7:55 a.m., LS C performed two measurements of pressure ulcers on Resident 11's left buttocks. One pressure ulcer measured 2 cm x 1 cm, was bright red and the skin was visibly broken. LS C stated the ulcer was stage II. The second left buttock pressure ulcer measured 4 cm x 4 cm and was bright red. LS C stated the ulcer was stage I. Review of "Change in Condition Assessment," dated 3/8/11, on 3/10/11 at 3:35 p.m., indicated LS C documented Resident 11 had a 1 cm x 2.5 cm Stage I pressure ulcer on his left buttocks. A nurse's note, dated 3/3/11, indicated Resident 11 did not receive the low air loss mattress until 3/3/11, six days after Resident 11 was readmitted and pressure ulcers were discovered. Review of a facility policy entitled, "Pressure Ulcer and Wound Management," dated 9/20/10, revealed the facility ensured, "appropriate" interventions including: assistance with turning and repositioning, application of pressure relieving device to the bed, apply pillow/heel protector/foot cradle or other lower extremity device as indicated, and encourage maximum mobility unless contraindicated (i.e. ambulation, range of motion), were implemented to maintain skin integrity, assist in wound healing, and prevent avoidable skin breakdown. The policy further indicated maintenance of skin integrity, assistance with wound healing, and prevention of skin breakdown were necessary for Residents to attain or maintain highest level of physical, mental, or psychosocial well-being.