Every finding on record at Quartz Hill Post Acute

Based on interview, record review, and policy review, the facility did not ensure that one of four residents sampled (Resident 1) did not get unnecessary medication when Resident 1 received a nicotine patch (a medicated adhesive patch that sticks to the skin to deliver a steady, controlled dose of nicotine into the bloodstream) when she was not a smoker.This failure caused Resident 1 to have diarrhea, be very unhappy and stressed and had an unwanted adverse effect to her physical and emotional well-being.Findings:Review of a facility policy titled, Adverse Consequences and Medication Errors revised June 2025 indicated 1. Review the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. 2. When a resident receives a new medication order, review: b. written diagnosis/indication supporting the use of the medication; g. documentation of the clinical rationale for using the medication.Review of a facility policy titled, Health, Medical Condition and Treatment Options, Informing Residents of revised November 2025 indicated that Every resident is informed of.treatment and/or care.Review of a facility policy titled, Reconciliation of Medications on Admission revised July 2017 indicated to review all the medications the resident was taking at the facility before going to the hospital and compare that list to any medications ordered or changed by the hospital to .determine if there are discrepancies/conflicts.for which there is no diagnosis or condition to support the use of the medication. The policy indicated that if discrepancies or conflicts are found that the facility should discuss with the resident or family and contact the attending physicianReview of a facility policy titled, Administering Medications revised April 2019 indicated that if a medication is believed to be inappropriate for a resident that the Attending Physician will be contacted.Review of a facility policy titled, Medication Regimen Reviews revised February 2025 indicated that the Medication Regimen Review (MRR) helps to identify irregularities such as medications being ordered that are not supported by medical evidence.Review of Resident 1's medical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including long term use of antibiotics due to infection of her knees.Review of Resident 1's Minimum Data Set (MDS - a federally mandated assessment tool) section C, 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 4/24/26, completed by the MDS nurse, indicated a score of 15 indicating good decision-making ability.During a phone interview on 5/15/26 at 11:23 am, Resident 1 indicated that while she was a resident of the facility, she was given a nicotine patch but that she was not a smoker. Resident 1 indicated that after she returned to the facility on 4/27/26, from a hospital stay, she was not given any information about the nicotine patch when it was put on her body a few days later. Resident 1 indicated that the nicotine patch made her feel sick, have diarrhea, and that she was really unhappy and stressed about this happening while she was a resident of the facility. Resident 1 indicated that Charge Nurse B (CN B) told her that she was never supposed to get a nicotine patch and showed her a physician's order for her for nicotine patches from the hospital.During a concurrent interview and record review on 5/15/26 at 1:02 pm, with CN B of Resident 1's Medication Administration Record (MAR) for the months of April and May 2026, the physician's order dated 4/27/26 from the facility, and the physician's order from the hospital dated 4/27/26, CN B confirmed that Resident 1 had orders for nicotine patches for smoking cessation (quitting smoking) and that Resident 1 had refused the nicotine patches on 4/28/26, 4/29/26, and 4/30/26. CN B indicated that she had not contacted the AP regarding Resident 1 refusing the nicotine patches. CN B indicated that she had taken care of Resident 1 before Resident 1 had been sent to the hospital from the facility on 4/24/26 and that Resident 1 was not a smoker, but that she returned from the hospital on 4/27/26 with a physician's order for nicotine patches. CN B indicated that she did not investigate why a resident who had no order for nicotine patches before leaving to go to the hospital came back to the facility a few days later with a physician's order for nicotine patches. CN B indicated that when Licensed Nurse (LN D) put a nicotine patch on Resident 1 and Resident 1 felt very sick, that Resident 1 was livid and that then CN B investigated and discovered that Resident 1 should not have gotten the nicotine patches because she was not a smoker and CN B indicated that she showed the physician's order for the nicotine patches from the hospital to Resident 1.During a concurrent interview and record review on 5/27/26 at 11:23 am, of Resident 1's records titled, Social Services Bundle assessment - WH V4 Sample - V2 dated 4/22/26 and 4/29/26 the Social Services Assistant (SSA) confirmed that both records indicated that Resident 1 was not a smoker.During an interview on 5/27/26 at 11:29 am, interview the Activities Director (AD) indicated that Resident 1 was not a smoker. AD indicated that if Resident 1 were a smoker the nursing staff would have notified her, or she would have observed Resident 1 in the smoking area and either of those would have triggered her to do a smoking assessment of Resident 1 which she did not do because Resident 1 was not a smoker.During a phone interview on 5/27/26 at 11:39 am, with the pharmacist (Pharm) indicated that if a person was not a smoker and was given a nicotine patch it would make their stomach upset with nausea and/or diarrhea. The Pharm indicated that a person who is not a smoker should not be given a nicotine patch. When asked if the pharmacist who reviewed Resident 1's medication should have noted that Resident 1 was not a smoker and should not get a nicotine patch, the Pharm responded that it was a physician's order.Review of Resident 1's record titled , Pharmacist's Report to Nursing - Medication Regimen Reviews performed between 4/28/26 and 4/29/26 indicated no reference to the physician's order for nicotine patches nor that Resident 1 was not a smoker.During an interview on 5/27/26 at 2:02 pm, Charge Nurse C (CN C) indicated that she had completed the medication reconciliation for Resident 1 upon her return to the facility from the hospital on 4/27/26. CN C indicated for medication reconciliation that she would review the physician's orders and cross reference with previous physician's orders and if there were any major changes she would reach out to the physician to find out more. CN C indicated that she was not aware whether or not if Resident 1 was a smoker and that she had never seen Resident 1 smoke. During an interview on 5/27/26 at 2:36 pm, the Director of Nursing (DON) acknowledged that Resident 1 was not a smoker. DON confirmed that Resident 1 should have received patient medication education. When asked about her expectations regarding medication reconciliation, DON indicated that when a resident returns to the facility from a hospital stay, that if a physician orders a medication for a resident, then the charge nurses would put it into the resident's physician's orders. DON confirmed that if a resident refuses a medication three times, then the nurse should notify the physician.

Based on observation, interview and record review, the facility failed to update the responsible party (RP) for one of two sample residents, (Resident 2) when Resident 2 had a fall. This failure violated the rights of Resident 2 and the RP to for all changes to be reported immediately. Findings: A review of the facility ' s policy undated, titled, Acute Condition Changes-Clinical Protocol, indicated the nurse and physician will discuss and evaluate the situation. The physician should request information to clarify the situation, for an example vital signs, physical findings, a detailed sequence of events, and descriptions of symptoms. Many acute changes of condition can be managed effectively in nursing facilities with outcomes that are comparable to those of hospitalization . This discussion should consider the patient ' s overall condition, prognosis, and wishes (either direct or as conveyed by a substitute decision-maker/ RP). Resident 2 was admitted to the facility on [DATE], for diagnoses that included neoplasm of the colon (a growth or tumor in the colon), pneumonia (lung infection causing inflammation and fluid), urinary tract infection (UTI, a bacterial infection of the urinary tract), Chronic Pulmonary Obstructive Disease (COPD, a progressive lung disease), dysphagia (difficulty swallowing), anxiety (an uncomfortable feeling of uneasiness, dread, or fear), atrial fibrillation (irregular and fast heart rate), congestive heart failure (serious disease when the heart cannot keep up with the body ' s need), Peripheral Vascular Disease (PVD, a slow and progressive blockage of the blood circulation) and presence of a heart pace maker (battery-powered, surgically placed device that helps the heart speed up and beat regularly). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 1/9/25, indicated that Resident 2 had a Brief Interview for Mental Status, (BIMS) score of 8 out of 15 which indicated a severe cognitive (ability to think and reason) impairment. This MDS also indicated Resident 2 required maximum assistance with toileting, lower body dressing, all transfers, and bathing. During an interview on 2/28/25 at 1:30 pm, Resident 2 stated, I remember the fall, it was last Friday evening. They did not update my family member when I fell , I did when she came in to visit. She is very involved and worries about me. During a concurrent interview and record review on 2/28/25 at 12:45 pm. Registered Nurse (RN) A confirmed Resident 2 fell in her room on 2/21/25 and a change in condition and a physician update was documented in the medical record on 2/21/25. RN A confirmed the RP was not updated on 2/21/25 when a change in condition was identified and documented. During a phone interview with the Director of Nursing (DON) on 2/28/25 at 12:50 pm, the DON confirmed the RP should be updated with any fall or change in condition. The DON confirmed it is the facility ' s policy to update the RP even if the resident is alert and oriented unless the resident specifically requests no updates. DON added, This update to the RP was missed for Resident 2 if it is not documented in the medical record, but I would ask the nurse who was present to be sure. During an interview on 2/28/25 at 2:10 pm, RN B confirmed he did not update the RP or family member on 2/21/25 when Resident 2 had a fall. RN B stated, I updated the doctor but did not update the family, I will know moving forward, even if there is no apparent injury. During an interview on 2/28/25 at 2:30 pm, the Administrator confirmed the RP was not updated for Resident 2 after a change in condition.

Based on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of five percent or less. There were three errors out of 29 opportunities, which yielded a medication error rate of 10.34% for 2 (Resident #77 and Resident #75) of 4 residents observed for medication administration. Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame and 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. The KwikPen pre-filled insulin pen user manual revised 07/2020, specified, Prime before each injection. Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensure that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Resident #77's Order Summary Report that contained active orders as of 02/13/2025, revealed an order dated 03/22/2023, for multivitamin oral tablet, give one tablet by mouth one time a day for supplement. There was also an order dated 03/23/2023, for Humalog (insulin lispro) KwikPen subcutaneous solution pen-injector 100 units per milliliter, inject as per sliding scale with meals for diabetes mellitus. During medication administration observation on 02/12/2025 at 7:23 AM, Licensed Vocational Nurse (LVN) #1 administered medications to Resident #77, to include one multivitamin with mineral tablet. The surveyor noted LVN #1 did not prime the needle before he placed it on the insulin lispro kwikpen and turned the dose knob to two units. During an interview on 02/12/2025 at 12:45 PM, LVN #1 confirmed he administered a multivitamin with mineral tablet to the resident and stated technically he did not give the right medication, but he thought the order could be interchangeable. LVN #1 stated he did not know that the insulin pen needle needed to be primed. During an interview on 02/13/2025 at 12:53 PM, the Director of Staff Development (DSD) stated that when administering medications, the nurse should recognize the five rights, to include the right resident, route, medication, dose, and time, and should check the physician's order three times. The DSD stated the insulin pen needle should be primed with two units prior to dialing up the dose. During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated the insulin pen needle should be primed with two units prior to use. Per the DON, the nurses should have followed the physician's orders to give the correct medication to the resident. During an interview on 02/13/2025 at 1:42 PM, the Administrator stated he deferred all nursing concerns to the DON. 2. Resident #75's Order Summary Report for active orders as of 02/13/2025 included an order dated 10/14/2022, for senna-docusate sodium oral tablet 8.6-59 milligrams (mg), give two tablets by mouth one time a day for bowel care. During medication administration observation on 02/12/2024 at 7:47 AM, Licensed Vocational Nurse (LVN) #2 administered two senna 8.6 mg tablets to Resident #75. During an interview on 02/12/2025 at 12:43 PM, LVN #2 stated she gave plain senna tablets that did not contain docusate sodium to Resident #75. LVN #2 stated she should have checked the label of the medication with the order. During an interview on 02/13/2025 at 12:53 PM, the Director of Staff Development stated that when administering medications, the nurse should recognize the five rights, to include the right resident, route, medication, dose, and time, and should check the physician's order three times. During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated that when administering medications, the nurse should review the physician's order and do the five rights with each medication three times. Per the DON, the nurses should have followed the physician's orders to give the correct medication to the resident. During an interview on 02/13/2025 at 1:42 PM, the Administrator stated he deferred all nursing concerns to the DON.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and changed their gloves during the provision of incontinence care for 1 (Resident #109) of 1 sampled resident reviewed for urinary catheter. Findings included: An Admission Record indicated the facility admitted Resident #109 on 01/19/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/26/2025, revealed Resident #109 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for toileting hygiene and always incontinent of bowel. Resident #109's care plan, included a focus area revised 02/12/2025, that indicated the resident had an alteration in elimination of bowel and bladder. On 02/12/2025 at 11:20 AM, the surveyor observed Licensed Vocational Nurse (LVN) #7 and Certified Nursing Assistant (CNA) #23 perform incontinence care on Resident #109. Once CNA #23 cleaned bowel from Resident #109's buttocks, she did not wash her hands or change her gloves, before she applied a clean incontinence brief underneath the resident. CNA #23 was also noted to touch the bed control of Resident #109's bed while wearing gloves she used to clean bowel from the resident's buttocks. During an interview on 02/12/2025 at 11:35 AM, CNA #23 stated she would change her gloves during incontinence care if the gloves became soiled. CNA #23 stated hand hygiene and gloves should be changed when she went from a dirty to clean task during the provision of care. CNA #23 acknowledged she did not perform hand hygiene or change her gloves when she provided care to Resident #109. During an interview on 02/12/2025 at 12:50 PM, LVN #7 stated hand hygiene and gloves should be changed when she went from a dirty area to a clean area during incontinence care. LVN #7 stated she and CNA #23 should have changed their gloves when the resident's incontinence brief was removed and before they placed a clean incontinence brief on the resident. During an interview on 02/13/2025 at 12:47 PM, the Infection Preventionist stated during incontinence care, staff should perform hand hygiene and change their gloves with each step. During an interview on 02/13/2025 at 12:52 PM, the Director of Staff Development stated gloves should be changed and hand hygiene should occur in between the dirty and clean tasks. During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated that when staff provided incontinence care, they should perform hand hygiene, put on gloves, provide the care, and after the resident was cleaned, they should change their gloves and then replace the incontinence brief and clothing, remove their gloves, and perform hand hygiene. During an interview on 02/13/2025 at 1:42 PM, the Administrator stated he deferred any concerns related to incontinence care to the DON.

Based on interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was timely reported to the state survey that involved 2 (Resident #12 and Resident #58) of 4 sampled residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 04/2021, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy specified, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Per the policy, 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. An Admission Record indicated the facility admitted Resident #12 on 10/17/2023. According to the Admission Record, the resident had a medical history that included diagnoses of muscle weakness, cognitive communication deficit, and arthritis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/26/2025, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. An Admission Record indicated the facility admitted Resident #58 on 07/19/2023. According to the Admission Record, the resident had a medical history that included diagnoses of cognitive communication deficit, psychotic disorder, major depressive disorder, anxiety disorder, and cerebrovascular disease. A quarterly MDS, with an ARD of 01/28/2025, revealed Resident #58 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Resident #12's Progress Notes dated 02/03/2025 at 10:26 PM, indicated at approximately 10:00 PM, a certified nursing assistant informed a nurse that Resident #12 reported that their roommate (Resident #58) had attacked them. Per the Progress Note, Resident #12 reported their roommate came over to their side of the room and attempted to forcefully take their call light out of their hand. The Progress Note revealed Resident #12 reported that their roommate scratched their left hand near the base of their thumb and index finger. According to the Progress Note, the nurse noted discoloration in the area that was beginning to bruise. The Progress Note indicated the Administrator and Director of Nursing (DON) were notified and Resident #12 was moved to another room in the facility for their safety. The Report of Suspected Dependent Adult/Elder Abuse, completed 02/03/2025, indicated the state survey agency received the abuse allegation on 02/04/2025 at 1:48 PM, which was greater than the two-hour time frame for reporting an allegation of abuse. During an interview on 02/12/2025 at 1:44 PM, the Administrator and DON both stated they were notified of the allegation of abuse that involved Resident #12 and Resident #58 by way of a text message on 02/03/2025. The Administrator stated he did not report the allegation of abuse to the state survey agency within two hours because there was no injury to the resident.

Based on interview, record review, and facility policy review, the facility failed to follow the physician's order for the use of an as-needed blood pressure medication for 1 (Resident #17) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. An Admission Record indicated the facility readmitted Resident #17 on 12/11/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of essential primary hypertension (high blood pressure). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #17's care plan included a focus area initiated 06/14/2022 that indicated the resident had altered cardiovascular status related to hypertension. Interventions directed staff to give medications for hypertension, document response to medication and any side effects, and monitor blood pressure and notify the physician of any abnormal readings. Resident #17's Order Summary Report which included active orders as of 02/13/2025, revealed an order dated 12/11/2024, for clonidine hydrochloride (HCL) tablet 0.1 milligram (mg), give one table by mouth every six hours as needed for hypertension for a systolic blood pressure (SBP) greater than 150 millimeters of mercury (mmHg). Resident #17's Medication Administration Record [MAR], for 01/2025, revealed clonidine HCL 0.1 mg was not administered to the resident when their SBP was greater than 150 mmHg on 01/09/2025 at 2:00 AM, 01/12/2025, and 01/16/2025. Per the MAR, on 01/09/2025 at 2:00 AM, the resident had a blood pressure reading of 158/98 mmHg; on 01/12/2025 at 2:00 AM, the resident had a blood pressure reading of 190/87 mmHg; and on 01/16/2025 at 8:00 AM, the resident had a blood pressure reading of 158/90 mmHg. Resident #17's MAR for 02/2025, revealed clonidine HCL 0.1 mg was not administered to the resident when their SBP was greater than 150 mmHg on 02/07/2025. Per the MAR, on 02/07/2025 at 2:00 AM, the resident had a blood pressure reading of 154/77 mmHg. During an interview on 02/12/2025 at 12:16 PM, Licensed Vocational Nurse (LVN) #3 stated she did not recall administering Resident #17 clonidine, but she should have if the resident's SBP was greater than 150 mmHg. During an interview on 02/13/2025 at 11:16 AM, LVN #4 reviewed Resident #17's MAR and confirmed she should have administered clonidine to the resident on 01/16/2025 at 8:00 AM but could not remember if she did or not. During an interview on 02/13/2025 at 11:33 AM, LVN #5 stated if a medication was supposed to be given when a resident's blood pressure was high, then it should be administered and there should be documentation of the administration. During an interview on 02/13/2025 at 12:53 PM, the Director of Staff Development stated the nurses should follow the physician orders and give or hold medication according to the physician orders, and it should be documented. During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated her expectation was that the nurses follow physician orders and parameters and document. During an interview on 02/13/2025 at 1:42 PM, the Administrator stated he deferred all nursing concerns to the DON, but stated the staff should follow the physician's orders.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure there was a physician's order for the use of non-invasive mechanical ventilator for 1 (Resident #1) of 3 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, CPAP/BiPAP [continuous positive air pressure/bilevel positive air pressure] Support, revised 03/2015, specified 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP [positive end-expiratory pressure] pressure for the machine. An Admission Record indicated the facility admitted Resident #1 on 10/21/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of obstructive sleep apnea. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #1's care plan included a focus area revised 10/29/2024 that indicated the resident required respiratory therapy/pulmonary hygiene due to obstructive sleep apnea and was at risk for impairments with full lung expansion, shortness of breath, decreased oxygen saturation, and impaired functional mobility. Interventions directed staff to provide treatments per physician orders, monitor oxygen saturation before and after treatments, and notify the physician of any shortness of breath or oxygen saturation less than 90 percent. Resident #1's Respiratory Therapy Assessment, dated 10/30/2024, indicated the resident was educated on the use of the non-invasive mechanical ventilator, respiratory therapy, and treatment used for the maintenance of their respiratory status. Resident #1 Respiratory Therapy Daily Note, dated 11/13/2024, indicated the resident successfully used the non-invasive mechanical ventilator. Resident #1's Respiratory Therapy Weekly Progress Note, dated 11/15/2024, indicated the resident used a home non-invasive mechanical ventilator at night and as needed. Resident #1's Order Summary Report which contained active orders as of 02/11/2025, revealed no order for the use of a non-invasive mechanical ventilator. On 02/10/2025 at 10:03 AM, Resident #1 was observed lying in bed with a non-invasive mechanical ventilator on their nightstand. During an interview on 02/11/2025 at 1:54 PM, the Registered Nurse (RN) Respiratory Therapist (RT) stated residents should have orders for the use of a non-invasive mechanical ventilator that included the settings and when it should be applied. The RN RT stated Resident #1 was not currently on her case load, but the resident did use a non-invasive mechanical ventilator and should have an order for the use of it. During an interview on 02/12/2025 at 4:52 PM, Licensed Vocational Nurse (LVN) #3 stated residents needed to have orders to use a non-invasive mechanical ventilator that included the rate it was to be set at. LVN #3 stated Resident #1 used a non-invasive mechanical ventilator and was able to put on their own mask. During an interview on 02/13/2025 at 11:16 AM, LVN #4 stated if a resident used a non-invasive mechanical ventilator, they should have an order that included the settings, when to use it, and when to clean it. LVN #4 stated Resident #1 did use a non-invasive mechanical ventilator. During an interview on 02/13/2025 at 12:53 PM, the Director of Staff Development stated residents should have orders for the use of a non-invasive mechanical ventilator that included the settings, when to use, when to clean, and who to contact if it was not working to get it serviced. During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated residents needed to have orders for the use of a non-invasive mechanical ventilator that included the application and removal, maintenance orders, and cleaning of the system. During an interview on 02/13/2025 at 1:42 PM, the Administrator deferred all nursing concerns to the DON, but that he expected everything to be in place for the use of respiratory equipment.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety when: 1. Dietary Manager (DM) was not wearing a hair net in the kitchen. 2. Food was not properly covered, labeled and dated. These failures created a potential risk for exposure to foodborne illnesses in a medically vulnerable population of 110 residents who received food prepared in the kitchen. Findings: 1. During review of facility Policy & Procedure (P&P) titled Kitchen Cleaning Policy and Procedures, 4/20/23, the P&P indicated food employees shall wear hair restraints such has hair nets. During concurrent observation and interview with the DM on 1/16/25 at 10:20 AM, the DM was not wearing a hair net in the kitchen. The DM confirmed that she should be wearing a hair net while in the kitchen. 2. During review of facility Policy & Procedure (P&P) titled, Procedure for Refrigerated Storage, no date, the P&P indicated food items will be covered, labeled, and dated. During concurrent observation and interview with DM on 1/16/25 at 10:23 AM, in the walk-in refrigerator the DM confirmed that there were two pans containing cranberry bars which were not covered, labeled, and dated.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were adhered to when Licensed Nurse A (LN A) provided patient care in the dining room without following infection control policy and procedures. These failures had the potential to cause the spread of infection and disease to other residents in the dining room. Findings: A review of the facility's, policy titled, Infection Prevention and Control Program dated August 2016 indicated a. Important facets of infection prevention include: (2) instituting measures to avoid complications or dissemination (spread) and .adhere to proper techniques and procedures. A review of Resident 1's Admission Record , indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory and ability to make sound decisions), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness), diabetes (high sugar in the blood). During an observation on 1/17/25 at 12:08 PM, in the dining room, LN A entered the dining room and checked Resident 1 ' s blood sugar by pricking her finger with a lancet (a small, sharp needle used to prick the skin to obtain a blood sample) and using a glucometer (a devise used to measure blood sugar level) at the table. During an observation on 1/17/25 at 12:13 PM, in the dining room, LN A entered the dining room and gave Resident 1 insulin (a biological product to treat blood sugar disease) using an insulin syringe (a short thin needle used to inject insulin into the body) at the table. During an interview on 1/23/25 at 11:32 AM, with the Infection Control Nurse (IP), the IP confirmed that checking blood sugar and giving insulin in the dining room did not meet the facility ' s infection control policy or standard practices.

Based on observation, interview, and record review the facility failed to ensure the right to personal privacy for one of five sampled residents (Resident 1), when patient care was provided to Resident 1 without privacy being provided. This failure had the potential to cause distress and embarassment for Resident 1 by having other residents watching and knowing her medical problems. Findings: A review of the facility's, policy titled Restorative Nursing Services, dated July 2017 indicated, 5. Restorative goals may include, but are note limited to supporting and assisting the resident in: c. Maintaining his/her dignity . A review of Resident 1's Admission Record , indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory and ability to make sound decisions), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness), and diabetes (high sugar in the blood). During an observation on 1/17/25 at 12:08 PM in the dining room, Licensed Nurse A (LN A) entered the resident's dining room and checked Resident 1 ' s blood sugar by pricking her finger and using a glucometer (a devise used to measure blood sugar level) at the dining table, while other residents were at the table. During an observation on 1/17/25 at 12:13 PM in the dining room, LN A entered the dining room and gave Resident 1 an insulin (a biological product to treat blood sugar disease) shot at the dining table, with other residents at the table. During an interview on 1/23/25 at 11:32 AM, with the Infection Control Nurse (IP), the IP confirmed that checking blood sugar and giving insulin in the dining room did not meet the facility ' s standard practices for ensuring patient privacy and dignity.

Based on observation, and interview, the facility failed to clean the assistive devices used to transfer residents for five out of six mechanical lifts. This failed action had the potential for the spread of infection to clients, staff, and visitors. Findings: A review of the facility's policy revised 7/2017, titled, Lifting Machine, Using a Mechanical, indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. This policy also indicated to wash and sanitize lift according to manufacturer's instructions, disinfect lift surfaces, wipe with a clean towel until dry. During concurrent observations and interviews on 6/21/24 at 12:09 through 12:24 pm with Licensed Nurse (LN) 1, five out of six mechanical lifts were soiled with cumulative dust, sticky yellow and brown colored substances, dried food particles, and grime. LN 1 confirmed these lifts were not clean and could cause the spread of infection to other residents, staff, and visitors and needed to be cleaned as soon as possible. During an interview on 6/21/24 at 12:30 pm, the Administrator (Admin) confirmed that five mechanical lifts were not clean. Admin stated, We use a contract outside agency for cleaning equipment, I will call the agency and get these lifts cleaned immediately. We take pride in our facility being clean, we may need to increase the days the lifts are cleaned to keep in order for use.

Based on observation, interview, and record review, the facility failed to ensure that one of five sampled residents (Resident 2), received assistance with activities of daily living (ADLs) to attain or maintain their independence when routine and scheduled showers and bathing were not completed. This failure had the potential to result in Resident 2 feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: A review of the facility's policy revised 2/2018, titled, Bath, Shower/Tub, indicated the purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. This facility's policy also indicated to Notify the supervisor if the resident refuses the shower/tub bath. A review of the facility's policy revised 2/2021, titled, Dignity, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. This facility's policy also indicated residents are treated with respect and dignity at all times, and individual needs and preferences of the resident are identified through the assessment process. During a review of Resident 2's medical record, the Admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur (broken thigh bone), diabetes (a disease when too much sugar is in the blood), high blood pressure, heart disease, acquired absence of kidney, and dependence on renal (kidney) dialysis (removes toxins from the blood). During a review of Resident 2's care plan, a focus dated 4/2/24 indicated Resident 2 had a potential/actual impairment to skin integrity, and this care plan indicated an intervention for staff to Keep skin clean and dry, use lotion on dry skin to maintain or develop clean and intact skin by 6/14/24/24. This care plan dated 4/2/24 also indicated, Resident 2 has an ADL (activities of daily living are hygiene, toileting, grooming, bathing, and eating) deficit, and needs assistance. A Review of Resident 2's Minimum Data Set (MDS, a resident tool assessment) dated 4/8/24, indicated Resident 2 required maximal assistance assist during activities of daily living such as transfers in and out of bed and bathing. Resident 2 had a BIMS (brief interview for mental status) score of 8, indicating Resident 2 with a severe impairment and was not competent to make his own decisions. During a review of Resident 2's medical record dated 4/2024 and 5/2024, a document titled, Documentation Survey Report v2, indicated indicated Resident 2 had one shower from 4/1/24 through 5/29/24, and this shower was completed and documented on 5/9/24. This document also indicated no refusals of baths or showers were documented. During an interview on 6/21/24 at 4:10 pm, the Director of Nursing (DON) confirmed Resident 2 only had one shower for the entire months of April 2024, and May 2024. DON stated, This resident is fragile, and the showers help with skin assessments needed. I confirm the showers should have been completed, even if we had to change days to accommodate dialysis schedule.

Based on interview, record review, and the facility's policy, the facility failed to complete assessments and add pertinent interventions on the care plan developed for one of three residents, (Resident 2) requiring renal (kidney) dialysis. This failure had the potential for re-hospitalization , and a negative clinical outcome. Findings: A review of the facility's policy revised 9/2010, titled, End-Stage Renal Disease, Care of the Resident with, indicated residents with end-stage renal (ESRD, kidney disease) will be cared for according to currently recognized standards of care. This policy also indicated staff caring for residents with ESRD, including residents receiving dialysis (removing toxins from the body) care outside the facility, shall be trained in the care and special needs of these residents. Number five of this policy indicated the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. A review of Resident 2's medical record, the Admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur (broken thigh bone), diabetes (a disease when too much sugar is in the blood), high blood pressure, heart disease, acquired absence of kidney, and dependence on renal (kidney) dialysis (removes toxins from the blood). A Review of Resident 2's Minimum Data Set (MDS, a resident tool assessment) dated 4/8/24, indicated Resident 2 required maximal assistance assist during activities of daily living such as transfers in and out of bed and bathing. Resident 2 had a BIMS (brief interview for mental status) score of 8, indicated Resident 2 had a severe impairment and was not competent to make his own decisions. A review of Resident 2's care plan, a focus dated 4/2/24 indicated Resident 2 had a problem listed for dialysis, and this care plan did not include post dialysis assessments, to include assessment of Resident 2's left arm fistula (a surgical procedure that creates a connection between an artery and vein for dialysis access) for bleeding, and for all staff to not obtain a blood pressure in the Left arm. A review of Resident 2's Active Orders dated 5/28/24, indicated to remove pressure dressing to dialysis fistula site fours hours post treatment one time a day on every Monday, Wednesday, and Friday. These Active Orders, also indicated Resident 2 goes to a local dialysis center every Tuesday, Thursday, and Saturday which would indicate this dialysis order for dressing removal was prescribed for the wrong days for dressing removal. During an interview on 6/24/24 at 12:30 pm, the Director of Nursing (DON) confirmed the facility did not follow their policy and procedure for dialysis care for Resident 2 and post dialysis assessments were not completed for Resident 2.

Based on interview, and record review, the facility failed to ensure professional staff were licensed in accordance with California state laws, when registered nurse (RN) 1 was employed from 11/2/23 through 1/4/2024 without a valid registered nursing license issued by the Board of Registered Nursing This failure had the potential to result in substandard quality of care to all the residents in the facility and negatively impact their quality of life and ability to attain or maintain their highest practicable level of physical, emotional, and psychosocial well-being. Findings: A review of the Employee Information Form, dated 11/2/23, indicated that RN 1 was hired full-time on the day shift with a date of hire of 10/30/23. A review of the facility ' s job description titled RN-Charge Nurse, dated 11/2/23, indicated the position Must possess a current, unencumbered, active license to practice as an RN in this state. The primary purpose of the position was to provide direct nursing care to residents and to supervise day-to-day nursing activities, and to ensure that the highest degree of quality care is maintained at all times. A review of the Application for Employment, dated 10/30/23, indicated that RN 1 presented a valid registered nursing license number. A review of the California Board of Registered Nursing-Licensing Details indicated the license number provided by RN 1 was verified by the facility on 11/21/23. A review of RN 1 ' s Employment Eligibility Verification Form, indicated that the documents provide by RN 1, to verify her identity, did not match the information on the Registered Nursing-Licensing Details. The RN license was registered to an individual with a similar name; however, the first name was spelled differently, and the middle name was not the same. During an interview on 6/14/24 at 12:40 pm, with the Director of Nursing (DON), the DON confirmed that RN 1 was not licensed, and she had missed this verification upon hire. DON confirmed the error of the spelling of RN 1's first name, and confirmed she did not check the middle name for validity. DON stated, I will never let this happen again, I will triple check to make sure the license verification is accurate. A review of the Change in Relationship Form, dated 1/5/24, indicated that RN 1 ' s employment was terminated with the facility.

Based on observation, interview and record review, the facility failed to follow the skin assessment care plan and monitor the skin condition for one of 3 sample Residents (Resident 1). This failure resulted in Resident 1 did not have skin assessment and wound care treatment until 2 days after his re-admission and had the potential to contribute to wound infection. Findings: A review of Resident 1's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a problem in the brain. It is caused by a chemical imbalance in the blood), Alcoholic Cirrhosis (Cirrhosis is scarring of the liver caused by long-term liver damage after many years of heavy drinking. The scar tissue prevents the liver working properly) of Liver with ascites (the build-up of fluid in the space between the lining of the abdomen and abdominal organs), diabetes (elevated blood sugar), and difficulty in walking. Resident 1 was transferred to the local hospital on 7/31/2023 for vomiting blood, he was readmitted to the facility on [DATE] with diagnoses which included esophagitis (Inflammation that damages the tube running from the throat to the stomach) with bleeding, and abdominal pain. He was his own health care decision maker. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered , revised 3/2022, indicated that The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions , and Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . A review of Resident 1's care plan, initiated on 5/26/2023, revised on 8/4/2023, indicated that the skin plan was to anticipate skin breakdown secondary to: generalized weakness, liver cirrhosis, diabetes . , and the interventions/tasks included Daily skin inspection during care: Notify Licensed Nurse (LN) of skin integrity impairments . A review of Resident 1's progress note, dated 8/2/2023 at 4:20 pm, indicated that Resident 1 was readmitted to the facility at 3:30 pm from the hospital. There's no note indicated that Resident 1 had skin issue on his left big toe. A review of Resident 1's Weekly Skin Alteration Report , dated 8/4/2023 at 12:16 pm, indicated that Resident 1 had a new Non-pressure area on the left great toe with discoloration , and the Date of First Observance was on 8/4/2023. The size of wound was 1 centimeter x 1.2 centimeter . The Assessment/Care plan Summary indicated that Patient returned from hospital and was noted to have a new area of concern on the left great toe that was no noted prior. The tip of the left great toe is black in color with surrounding erythema noted. MD notified and ordered bilateral lower leg arterial dopplers (an imaging test to check the blood flow in the arteries in the legs) . A review of Resident 1's Skin/Wound progress note, dated 8/4/2023 at 12:20 pm, indicated that Resident 1 was noted to have a new area of concern on the left great toe that is black in color with surrounding area blanching erythema . there's no Skin/wound assessment on the day, 8/2/2023, Resident 1 was readmitted back to the facility. A review of Resident 1's physician order, Left great toe: Paint with betadine every day on every dayshift , dated 8/4/2023, started on 8/5/2023, 3 days after the resident was readmitted . During a concurrent observation and interview on 8/9/2023, at 3:03 pm, Resident 1's left great toe appeared to be swollen with redness, and a 1 cm x 1 cm black area presented at the tip of the toe. Resident 1 stated that he bumped himself but could not recall where and when it happened. During a concurrent interview with the Administrator (ADMIN) and Assistant of Director of Nursing (ADON) and record review on 8/9/2023 at 3:27 pm, ADMIN stated that Resident 1 was readmitted with a skin abrasion on his left big toe. ADON admitted that there's no skin assessment record could be located on the day Resident 1 was readmitted and she stated that The admitting nurse should do the entire assessment, including skin assessment . It should be done on 8/2/2023 .

Based on observation, interview, and record review the facility failed to follow the most recent care plan for one of two residents (Resident 1) to provide one on one checks per physician orders for safety after a recent suicide attempt. This failure had the potential to cause Resident 1 physical and psychosocial harm. Findings: A review of the facility's policy titled Depression-Clinical Protocol revised ,d+[DATE], indicated number 2, The nurse shall assess and document/report the following: Vital signs, description of affect, level of activity and responsiveness, whether mood decline is associated with anorexia, (not eating), crying and sleeplessness; pain assessment, suicidal ideation, (If present, follow facility policy/protocol for suicide threats). A review of the facility's policy titled Suicide Threats dated ,d+[DATE], indicated resident suicide threats shall be taken seriously and addressed appropriately. Number seven stated, If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised ,d+[DATE], indicated Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation including the right to receive the services and/or items included in the care plan. During a record review of a document titled, Care Plan revised [DATE], indicated new interventions for new problem, Resident 1 had mood problem and verbalized want to self-harm, as well as engaged in actual self-harm, cutting behavior. One on one supervision to be provided for increased visual accountability of safety and wellness of patient. Every fifteen-minute checks for safety, daily visits daily with DSS for 72 hours, and longer if indicated. A review of a document titled Individual Progress Note dated [DATE] from a local hospital for Crisis evaluation indicated Resident 1 was being evaluated for danger to self, following [Resident 1] engaging in cutting behavior, he has a superficial cut to the left wrist. Resident 1 was admitted to the facility on [DATE] for diagnoses that included repeated falls, injury of the head, and major depressive disorder (a persistently low or depressed mood that causes a sense of loss and sadness, and anxiety (feeling of uneasiness, worry and fear of everyday life). During a record review for Resident 1, a document titled Minimum Data Set (MDS, a resident assessment), dated [DATE] indicated Resident 1 had a slight cognitive impairment, (ability to think, reason, and recall) with a Brief Interview Mental Status score of 10. During a record review for Resident 1, a document titled Social Service Note dated [DATE], indicated Follow up to recent event: Resident 1 self-harming by cutting wrist causing a superficial laceration. During an interview on [DATE] at 7:30 am, Licensed Nurse (LN) A stated, Yes, Resident 1 is still on every fifteen-minute checks related to a suicide attempt. During an observation on [DATE] at 7:45 am through 8:45 am, no fifteen minutes were completed for Resident 1 from any staff members, which was in the updated care plan for safety. During an observation on [DATE] at 7:35 am, Resident 1 was eating breakfast while sitting on the side of the bed. Left wrist had a Band-Aid with dried, dark red colored substance. During an interview on [DATE] at 7:50 am, Resident 1 (tearful) stated, Yes, I am sad. My wife died a couple of months ago; she was my wife for over [AGE] years. I feel so lost without her, just lost. I miss her, I met my wife in grade school. I was supposed to go home after rehab. I tried to cut my wrist, but all I had was a butter knife. Resident 1 confirmed left wrist Band-Aid had dried blood from cutting his wrist. During an interview with the physician on [DATE] at 8:20 am, the physician confirmed every fifteen-minute checks should be completed on Resident 1 for safety related to recent self-harm attempt on [DATE], and recent hospitalization for suicide attempt. During a follow up interview on [DATE] at 8:30 am, Resident 1 stated, I am so sad, I miss my wife, tearful at intervals. No one understands, my wife was my best friend, I was supposed to go home and not live here. I don't want to hurt my son, but I am just lost. I can't stop feeling this way. A document titled Safety Check log for Resident 1, undated indicated no fifteen-minute checks were completed for 8:00 am, 8:15 am, 8:30 am and 8:45 am on [DATE]. These time periods were blank and no initials. During an interview on [DATE] at 9:10 am, Director of Nursing (DON) stated, Yes, I was called about Resident 1 and came in on a Holiday and updated the care plan to complete every fifteen-minute checks. The staff should be doing every fifteen-minute checks, the Certified Nursing Assistants, (CNA) should be getting verbal reports from the nurses. During a record review of Resident 1's medical record a document titled Physician Verbal Order , dated [DATE] at 9:21 am, indicated One on one for resident, 24 hours a day, every shift, for observation for three days, 24 hours a day for 72 hours. During an interview on [DATE] at 9:56 am, the Director of Social Services stated, I knew Resident 1 had not been paid by the Veteran's Administration (VA) for 90 days and he was upset his money was late. I did not know his wife had passed. I will call the VA back to find out if they are working on it. During an interview on [DATE] at 10:35 am, CNA B stated, From my understanding, I thought it was me and the nurse doing the checks on Resident 1, not just me. I did not get report from the nurse this morning, I was running late. During an interview on [DATE] at 11:30 am, the Administrator confirmed Resident 1 had 24-hour supervision effective 10:00 am [DATE] for three days per physician order and a new appointment was made for the VA to evaluate depression. During an interview on [DATE] at 11:35 am, the Director of Nursing (DON) confirmed Resident 1's care plan was revised, but not followed by staff. DON also confirmed the fifteen-minute checks were not completed on [DATE] from 8:00 am to 8:45 am, and the recording log was blank for those time frames. DON confirmed the nurse did not give report or communicate to the CNAs on [DATE] on the hall for safety, supervision of Resident 1.

Based on observation, interview, and record review the facility failed to ensure direct care and administrative staff reported allegations of staff to resident abuse to the mandated agencies for one of two sampled residents (Resident 1). This had the potential to put all residents at risk for abuse from staff at the facility. Findings: A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Identify and assess incidents of abuse. Investigate and report any allegations for abuse within the timeframes as required by federal requirements. Protect residents during the abuse investigations. A review of facility policy revised April 2012, titled, Recognizing Signs and Symptoms of Abuse/Neglect indicated abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical harm, pain, or mental anguish. Signs of actual physical abuse are welts and bruises, abrasions or lacerations, and black eyes. Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling. A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss. A review of Resident 1's medical record a document dated 6/3/23 titled Progress Note, indicated Certified Nursing assistant reported a bruise to coccyx for Resident 1, MD notified and monitor until resolved. A review of Resident 1's medical record a document dated 6/4/23 titled Change in Condition Progress Note, indicated Resident 1 up in wheelchair and noticed a dark bluish bruise around Resident 1's right eye, Also bluish bruise on Resident 1's left wrist, updated MD and Responsible party. A review of Resident 1's medical record, a document dated 6/8/23, titled Interdisciplinary Team (IDT) Review of Skin alteration, indicated Resident 1 was found on 6/4/23 by the am staff to have a purple discoloration to her medial eye socket of the right eye. There is also a purple discoloration on the left dorsal wrist. IDT met and determined that the cause for the bruise could be anti-coagulant therapy, (use of blood thinners for heart disease). Also, Resident 1 is noted to prefer to sleep on her right side, often holding onto the quarter rail and leaning her head on the rail. A review of Resident 1's medical chart indicated no mandatory reporting or investigation documentation of new blue discolorations for Resident 1's right eye, left wrist and coccyx area through 6/13/23. During an interview on 6/13/23 at 11:50 am, the administrator (Admin) confirmed the allegation of abuse to Resident 1 from an employee was not reported to CDPH and stated, I was here on Monday 6/5/23 and saw the bruising to Resident 1's eye but thought since we removed the bedrail I did not have to report. Admin confirmed etiology, (cause) of bruises are still unknown and the facility staff was not sent home for an investigation to be completed for allegations of abuse to Resident 1. During an interview with the Director of Nursing (DON) on 6/13/23 at 12:10 pm. DON stated, We did not send a report to California Department of Public Health (CDPH) for Resident 1's bruising of Right eye and left wrist. The staff accused of alleged abuse to Resident 1 was not in the building on 6/4/23. I think the bruising was from the bed rail. No, I cannot say for certain. During an interview on 6/13/23 at 12:50 pm, the DON and Admin confirmed they were aware of the allegations of Employee to Resident abuse because the California Board of Registered Nursing (BRN) had emailed and called the DON to obtain information and update the facility an allegation had been filed against an employee. DON stated, BRN would inform me how to proceed with options to protect the staff and residents. We were emailing back and forth and talking on the phone. During an observation on 6/13/23 at 3:10 pm, Resident 1 was lying in bed, severe bruising noted to right periorbital (around the eye) area, three small bruises on the left wrist, no bruising area noted to the coccyx. Resident 1 also had two new bruises, dark purple areas, not documented to the right top of forehand, and upper right arm. During an interview on 6/13/23 at 3:20 pm, Registered Nurse (RN) B stated, I could not determine what could have happened to Resident 1, that is why I was calling the staff, no one reported the bruising to me. I did not report or fax CDPH, when I called the DON and she said they would follow up on it. During a follow up interview on 6/13/23 at 3:25 pm, RN B also confirmed two new dark purple bruises on Resident 1, one large purple area covering the top of right hand, the other dark purple bruise on the upper right arm. RN B stated, No I did not see those new bruises, I will go tell the Admin now. During an interview on 6/13/23 at 3:45 pm, RN A stated, I thought Resident 1's bruising was going to be reported or I would have. There are fax forms at all the nurses' stations. I do not think this bruising was handled right, they should have reported it, we are all mandatory reporters. During an interview on 6/13/23 at 4:02 pm, the ADON stated, I had no idea I was being accused of abuse, I just found out today. I did bring up the bruising of Resident 1 to her right eye, left wrist, and coccyx at Interdisciplinary Team (IDT) meeting, and there was no known cause at the time it was reported by RN B. During an interview on 6/13/23 at 4:32 pm, the Director of Staff Development stated, I heard about the bruising to Resident 1 from the Admin. Should I have reported it? I teach the staff to report, without the Admin if needed. During a follow up interview on 7/12/23 at 3:40 pm, the Admin and DON confirmed the alleged abuse should have been reported to CDPH and all entities per abuse policy, and the resident should have been protected while this allegation was investigated. The DON stated, I will make sure moving forward all this is completed as well as the five day follow up report. I will work together with the Admin to meet the time frame per policy.

Based on interview and record review the facility failed to ensure allegations of staff to resident abuse were investigated and residents were protected during this process for one of two residents (Resident 1). This put all residents at risk for staff to resident abuse. Findings: A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Protect residents during the allegation of abuse investigations. A review of facility policy revised April 2012, titled, Recognizing Signs and Symptoms of Abuse/Neglect indicated abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical harm, pain, or mental anguish. Signs of actual physical abuse are welts and bruises, abrasions or lacerations, and black eyes. Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling. A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss. A review of Resident 1's medical record a document dated 6/3/23 titled Progress Note, indicated Certified Nursing assistant reported a bruise to coccyx for Resident 1, MD notified and monitor until resolved. A review of Resident 1's medical record a document dated 6/4/23 titled Change in Condition Progress Note, indicated Resident 1 up in wheelchair and noticed a dark bluish bruise around Resident 1's right eye, Also bluish bruise on Resident 1's left wrist, updated MD and Responsible party. A review of Resident 1's medical record, a document dated 6/8/23, titled Interdisciplinary Team (IDT) Review of Skin alteration, indicated Resident 1 was found on 6/4/23 by the am staff to have a purple discoloration to her medial eye socket of the right eye. There is also a purple discoloration on the left dorsal wrist. IDT met and determined that the cause for the bruise could be anti-coagulant therapy, (use of blood thinners for heart disease). Also, Resident 1 is noted to prefer to sleep on her right side, often holding onto the quarter rail and leaning her head on the rail. A review of Resident 1's medical chart indicated no mandatory reporting or investigation documentation of new blue discolorations for Resident 1's right eye, left wrist and coccyx area through 6/13/23. During an interview on 6/13/23 at 11:50 am, the administrator (Admin) confirmed the allegation of abuse to Resident 1 from facility staff was not reported to CDPH and stated, I was here on Monday 6/5/23 and saw the bruising to Resident 1's eye but thought since we removed the bedrail I did not have to report. Admin confirmed etiology of bruises are still unknown and the alleged staff member was not sent home for an investigation to be completed for allegations of abuse to Resident 1. During an interview on 6/13/23 at 12:50 pm, the DON and Admin confirmed they were aware of the allegations of facility staff member to Resident abuse because the California Board of Registered Nursing (BRN) had emailed and called the DON to obtain information and update the facility an allegation had been filed against an employee. DON stated, BRN would inform me how to proceed with options to protect the staff and residents. We were emailing back and forth and talking on the phone. During an observation on 6/13/23 at 3:10 pm, Resident 1 was lying in bed, severe bruising noted to right periorbital (around the eye) area, three small bruises on the left wrist, no bruising area noted to the coccyx. Resident 1 also had two new bruises, dark purple areas, not documented to the right top of forehand, and upper right arm. During an interview on 6/13/23 at 4:02 pm, the ADON stated, I had no idea I was being accused of abuse, I just found out today. I did bring up the bruising of Resident 1 to her right eye, left wrist, and coccyx at Interdisciplinary Team (IDT) meeting, and there was no known cause at the time it was reported by Registered Nurse (RN) B. During a follow up interview on 7/12/23 at 3:40 pm, the Admin and DON confirmed any employee will be sent home to protect all residents until a thorough investigation has been completed to rule out any type of alleged abuse per facility abuse policy.

Based on interview and record review, the facility failed to transfer one of two sampled residents, (Resident 1) safely using a Hoyer lift (a mechanical lift used to transfer residents) when one Certified Nursing Assistant left Resident 1 without a mat in place beside the bed while leaving the room. This failure resulted in an avoidable accident when Resident 1 sustained a fall hitting her head, right shoulder, and right elbow. Findings: During a review of a policy revised March 2018, titled Falls, and Fall Risk, Managing, indicated 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 try to minimize complications from falling. During a review of a policy revised July 2017, titled Safe Lifting and Movement of Residents, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. This policy also indicated resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. During a review of a policy revised July 2017, titled Accidents and Incidents, indicated incident and accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility, and to analyze any individual resident vulnerabilities. Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling. A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss. During a record review of Resident 1's medical record, a review of a care plan revised on 5/23/23 indicated Resident 1 is at risk for falls related to dementia, non-ambulatory, chronic pain and history of falls. This care plan also indicated Resident 1 is at risk for injury from falls related to anti-coagulant therapy (blood thinners) required for heart disease. During a record review of Resident 1's medical record, a document dated 7/3/23 at 3:00 pm, titled Interdisciplinary Team Fall (IDT) Review, indicated Resident 1 had an unwitnessed fall out of bed in resident's room. Root cause indicated Certified Nursing Assistant (CNA) had removed mattress on floor beside bed and went to get the Hoyer lift for a transfer, when CNA returned with the Hoyer lift, the resident was found on the floor beside the bed. During a record review of Resident 1's medical record, a document dated 7/3/23 titled Progress Notes, indicated CNA found Resident 1 at bedside on her right side, as Resident 1 was calling out. During a record review of Resident 1's medical record, a document dated 7/4/23 at 9:50 pm, titled Progress Notes, indicated Resident 1 is on alert monitoring for a recent fall. Resident had a bluish bruise to the right temple area, also bruising noted to right shoulder and right elbow areas. During a record review of Resident 1's medical record, a document dated 7/4/23 at 1:52 pm, titled Progress Notes, indicated Resident 1 had periorbital bruising and hematoma. Resident was found on night shift out of bed with bruising which later developed to hematoma above right eye. During a record review of Resident 1's medical record, a document dated 7/5/23 indicated resident has bruising to right forehead, right shoulder, and right elbow related to a recent fall. During an interview on 7/12/23 at 12:30 pm, the Director of Nursing confirmed Resident 1's fall was preventable and was due to the CNA not placing the mat beside the bed when he stepped out of Resident 1's room.

Based on interview and record review, the facility failed to ensure one resident (Resident 1) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 put her hand towards her face. This had the potential to result in a decline in her physical, emotional and psychosocial well being. Findings: On 3/10/23 at 3:40 pm, the California Department of Public Health received a report (via phone) that Resident 1 alleged CNA 1 called her disrespectful and put her hand up to her face. A follow up written report was faxed on 3/10/23 at 5:06 pm. A review of Resident 1's record indicated she was admitted on [DATE], with diagnoses that included a stroke, morbid (severe) obesity, hemiplegia (inability to move one side of the body), diabetes, and anxiety disorder. During an interview on 3/16/23 at 11:20 am, Resident 1 stated CNA 1 was across the hall helping another resident and she waved at her to get her attention because she needed to go to the bathroom. She said when CNA 1 came in the room she told me not to disrespect her that way then she waved her hand in my face. She said CNA 1 did not touch her face but her hand was right up in her face and she told CNA 1 to stop and started yelling for the nurse. Further review of the record included an Interdisciplinary Team (IDT-group of healthcare disciplines that meet to discuss resident care needs) note, dated 3/14/23, which indicated on 3/10/23, Resident 1 reported a verbal altercation with CNA 1. The night shift nurse had over heard the altercation and removed CNA 1 from the room. Per policy, CNA 1 would receive appropriate disciplinary action and re-training. During an interview on 4/27/23 at 12:45 pm, CNA 1 confirmed she wrote a statement on 3/9/23 at 11:48 pm. She said she asked Resident 1 to try not to wave and holler. CNA 1 said she stuck her hand out and said stop and did not realize her hand was in Resident 1's face who then swatted her hand away. During an interview on 3/20/23 at 1:15 pm, Licensed Nurse (LN) 1 said she heard Resident 1 yelling so she went into the resident's room. Resident 1 said CNA 1 pulled on her and put her hand toward her face. LN 1 said she asked CNA 1 to leave the room and had another CNA take over that room. The investigative report report provided by the adminstrator concluded there was not abuse but CNA 1 was unprofessional. A review of the facility's policy, Resident Rights, dated 2/2021, indicated, Employees shall treat all residents with kindness, respect and dignity.

Based on interview and record review, the facility failed to safely monitor and evaluate a newly prescribed high-risk medication (drugs with potential to cause significant harm)called [MEDICATION(S)] (medicine used to treat mood swings) in one (Resident 1) out of three sampled residents when: The Medical Doctor (MD 1) did not order the necessary laboratory (or lab- blood test) tests to evaluate the drug level, did not address the warning signs of drug toxicity (severe medical condition as result of drug effect on the body) and/or did not seek specialized expert opinion in handling the case or consult the facility's Consultant Pharmacist (CP, a pharmacist that helped facility with drug review and monitoring). As a result, Resident 1 developed [MEDICATION(S)] toxicity (severe condition of having too much [MEDICATION(S)] in the body) and was hospitalized for over two weeks. Findings: A review of Lexicomp online, a nationally recognized medication information resource, last accessed on 6/16/22, indicated the following warnings on the use of [MEDICATION(S)]: ALERT: US Boxed Warning (or Black Box Warning, BBW, the highest level of warning on a medication from FDA, or Food and Drug Administration, a federal government agency responsible for safe drug use) - Monitoring: [MEDICATION(S)] toxicity is closely related to serum (blood) [MEDICATION(S)] levels and can occur at doses close to therapeutic (means normal) levels. Facilities (means lab facility) for prompt and accurate serum [MEDICATION(S)] determinations should be available before initiating therapy. Only prescribe in settings where serum concentration (means blood level) monitoring is available. Toxic effects occur with serum concentrations =1.5 mEq/L (mEq/L is milliequivalent per Liter which was a measure of volume) and may be seen in some patients with serum concentrations as low as 1.2 mEq/L . serum electrolytes [means elements in the blood such as sodium (salt) or potassium] (baseline [means at the start], then periodically); ECG with rhythm strip [or Electrocardiogram, a test that detected heart rhythm problems] (baseline for all patients > [more than][AGE] years of age or if underlying cardiac (means heart) risk factors, repeat as clinically indicated); . serum [MEDICATION(S)] levels (twice weekly until both patient's clinical status and levels are stable, then repeat levels every 1 to 3 months or as clinically indicated; closely monitor in patients with significant renal [Kidney] or cardiovascular [heart] disease, dehydration, sodium [salt] depletion, or those taking concomitant medications that impact renal function); . signs of [MEDICATION(S)] toxicity (e.g., diarrhea, vomiting, tremor, mild ataxia [poor muscle control], drowsiness, muscular weakness). Toxic concentrations 9harmful level in body): > [more than]1.5 mEq/L: . Early signs and symptoms of intoxication (intoxication occurs long before someone passes out) may include marked tremor, nausea, diarrhea, blurred vision, [CONDITION(S)] [dizziness], confusion . > [more than] 2.5 mEq/L; Intoxication symptoms may progress to include severe neurological [nerve] complications, seizures, coma, cardiac [CONDITION(S)] [heart rhythm problem], and permanent neurological impairment. >3.5 mEq/L: Potentially lethal (deadly) toxicity. A review of Resident 1's medical records titled, Admission Record and Diagnosis Information, (a record that listed the resident's medical problems and information), dated 2/24/22, the record indicated Resident 1 was admitted on [DATE] with diagnoses that included [CONDITION(S)] (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to care out day to day tasks), [CONDITION(S)] (a mental disorder which disrupted the thought process), anxiety disorder (a mental disorder caused feeling of being unsettled), and [CONDITION(S)] disease (a disorder that affects movement). Review of Resident 1's untitled medical record for doctor's progress notes, dated 1/24/22, the handwritten note by MD-1indicated [Resident 1] has mental issues, throws hot tea to the staff . want more coffee and .coke. Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by Licensed Nurse 1(LN1), dated 1/26/22 at 2:33 PM, the note indicated the MD 1 evaluated Resident 1 for increased behavior issues, Resident 1 has had an increased uncontrollable screaming, extreme angry outbursts, and violent/physical episodes. MD 1 has ordered [MEDICATION(S)] 300 mg (or milligram was a unit of measure) po (orally) TID (three times a day) for [CONDITION(S)] and to have labs (blood test) checked (CBC/CMP/[MEDICATION(S)]) [CBC, stand for Complete Blood Count, a test of blood for anemia; CMP stands for Complete Metabolic Panel, a test that showed elements in the body such as salt or potassium; and [MEDICATION(S)] is a drug for mood swings and doctor ordered the blood level) . Review of Resident 1's medical record titled, Medication Administration Record, (or MAR- a drug chart that serves as a legal record of the drugs administered to resident), dated as January of 2022, the MAR indicated the first dose of the [MEDICATION(S)] 300 mg capsule was administered on 1/26/22, at 5:00 PM. Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by Licensed Nurse 3 (LN 3), dated 1/29/22 at 1:53 PM, the note indicated, MD 1 signed and sent back all lab work (blood test). No new orders at this time. Review of Resident 1's medical record for laboratory (lab) results, dated 1/27/22, the record indicated under CMP lab work (CMP stands for Complete Metabolic Panel, a test that showed elements in the body such as salt or potassium), Resident 1's sodium (salt) level was lower-than-normal value at 135 mmol/L (or millimole per liter was a lab unit of measure) and blood Creatinine level was 0.7 mg/dL [Creatinine was a measure of how well kidney worked; milligrams (mg) per deciliter (dL) was a measure of unit for kidney function]. Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by Licensed Nurse 1 (LN1), dated 2/2/22 at 10:16 AM, the note indicated, MD 1 was in for evaluation of Resident 1 r/t (regarding the) nursing reporting increased physical and verbal behaviors. MD 1 assessed and gave new order to increase [MEDICATION(S)] form 300mg . TID to 450mg ER (or Extended Release - or slow-release form of the medication) PO (orally) TID (three times daily) for [CONDITION(S)]. Further review of Resident 1's medical record, under doctor's progress notes, for 2/2/22 date, the medical record did not indicate an MD 1's written progress notes or resident evaluation or justification for [MEDICATION(S)] dosage increase. Review of Resident 1's medical record titled, Medication Administration Record, dated as February of 2022, the MAR indicated the first dose of the [MEDICATION(S)] 450mg ER tablet was administered on 2/3/22, at 5 PM. Review of Resident 1's untitled medical record for doctor's progress notes, handwritten by MD 1, dated 2/4/22, the note indicated, behavior problem, yelling, [CONDITION(S)] not controlled with [MEDICATION(S)]/[MEDICATION(S)] ([MEDICATION(S)] medication for mood swings; [MEDICATION(S)] was a nerve pill); [MEDICATION(S)] added on for control. Will monitor side effects . Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by Licensed Nurse 3 (LN 3), dated 2/4/22, at 10:44 AM, the note indicated, MD 1 in this AM & verbally told about Res-1's possibly having increased arm/hand shaking. He was told it could be from her increase in [MEDICATION(S)] .MD 1 wrote no new orders at this time. Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by LN 3, dated 2/5/22, at 12:50 PM, the note indicated, Monitoring resident r/t (regarding the) increase in her [MEDICATION(S)] [not [MEDICATION(S)]] . She has been noted with bi-lat (both side of body) arms and hand shaking on and off this shift. Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by Licensed Nurse 4 (LN 4), dated 2/6/22 at 2:54 AM, the note indicated, She has been noted to have increased . arm/hand shaking. Resident has . Parkinson. Will continue to monitor. Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by LN 3, dated 2/6/22 at 1:53 PM, the note indicated, Resident 1 has needed assistance with ambulation (moving or walking) today r/t ( related to) increased body tremor (shaking) for safety reasons . MD1 faxed to see if he wants to add [MEDICATION(S)] [not [MEDICATION(S)]] to her allergy list. Review of a facility's fax (short for facsimile, a telephonic transmission of printed material) communication document with the MD1, regarding Resident 1's status, dated 2/6/22, at 9:30 AM, the handwritten document by LN 3, indicated, resident has had loose stools on and off yesterday and today. Could be a S/E (Side Effect) of her [MEDICATION(S)] 450mg. She also has increased body shaking/tremors . She also has .[CONDITION(S)] (swelling) to her left foot. Please advise . MD1 response to LN 3 on the same fax document, was to discontinue [MEDICATION(S)] and start [MEDICATION(S)] (a water pill). Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by Licensed Nurse 5 (LN 5), dated 2/7/22 at 1:15 AM, the note indicated Resident 1 show episodes of tremor . not stable on her feet when walking . Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by LN 5, dated 2/7/22 at 3:27 AM, the note indicated, Resident 1 showing s/s (signs and symptoms) of lower extremity (lower part of the body) weakness during ambulation (walk) to bathroom .continue to have incontinence of urine (unable to control bladder). Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by Licensed Nurse 6 (LN 6), dated 2/7/22 at 8:04 AM, the note indicated, resident continue to be monitored for having tremors, loose stools, decrease in mental status, resident unable to get out of bed to use bathroom. She was not able to be sit on her bed without going backward .continue to have loose stool, unable to feed self. Review of Resident 1's medical record titled, Progress Notes: Health Status Note, written by LN 6, dated 2/7/22 at 9:39 AM, the note indicated, got an order to send resident to the hospital to be eval (evaluated) for .diarrhea, [CONDITION(S)], tremors, lower extremities weakness, mental change, increase assistance needed with ADL (Activities of Daily Living), crying out . they took resident to the hospital at 9:26. A review of Resident 1's hospital record titled, ED Note (Emergency Department Note), dated 2/7/22, at 9:40 AM, written by Medical Doctor 2 (MD 2), the note indicated Critical (urgent) condition addressed for impending deterioration include: Altered mental status, [MEDICATION(S)] toxicity, prolonged QTc (a dangerous heart rhythm abnormality), [CONDITION(S)] (low potassium level). A review of Resident 1's hospital record titled, Neurology Consult Note, (specialist doctor for brain and nerves), dated 2/7/22, at 9:40 AM, written by Medical Doctor 3 (MD 3), the note indicated Resident 1 was admitted for progressive symptoms of increasing lethargy, tremor, worsening gait 9balance) and diarrhea . in the emergency department the patient's [MEDICATION(S)] level was found to be about 2.7 (actual level 2.8) . although her level did normalized within 48 hours, she continue to be extremely lethargic, not speaking and only moaning. The note on the assessment/Plan section indicated, .she does have persistent symptoms, most notably obtundation (reduced level of alertness), and .this is likely secondary to SILENT syndrome (SILENT, stand for Syndrome of Irreversible [MEDICATION(S)]-Effectuated Toxicity; means a permanent type of nerve damage as result of too much [MEDICATION(S)] in the body) neurotoxicity (nerve damage) . The note further indicated, Improvement can happen from SILENT syndrome over the course of weeks to years . A review of Resident 1's hospital document for lab results, with date range of 2/7/22 to 2/17/22, the result indicated the following blood levels as follow: 2/7/22 at 10:30 AM: [MEDICATION(S)] level of 2.78 mEq/L and Creatinine (kidney function) of 1.28 mg/dL (Creatinine normal level 0.57-1.11 mg/dL). 2/7/22 at 2:05 PM: [MEDICATION(S)] level of 2.63 2/8/22: [MEDICATION(S)] level of 2.44 2/9/22: [MEDICATION(S)] level of 2.19 2/10/22: [MEDICATION(S)] level of 1.53 2/11/22: [MEDICATION(S)] level of 1.06 and Creatinine of 0.73 2/17/22: [MEDICATION(S)] level of 0.64 Further review of lab record indicated the normal range (non-harmful) for [MEDICATION(S)] was between zero and one. A review of the hospital document titled, Physician Note Final Report, dated 2/22/22, written by Medical Doctor 4 (MD 4), the note indicated Resident 1 was ready for discharge after admission to the hospital with a [MEDICATION(S)] level of 2.8. The note further indicated neurology doctor suspected diagnosis of SILENT syndrome (Syndrome of Irreversible [MEDICATION(S)] Effectuated Neurotoxicity) and recommended continued supportive care as improvement was expected over a prolonged period. The hospital final report indicated, Patient was unable to walk, clearly due to the [MEDICATION(S)] toxicity . and patient now on her prior medication regiment except [MEDICATION(S)] . During a concurrent interview and record review on 2/24/22, at 11:50 AM., the Medical Records staff (MR) provided a copy of baseline labs done on 1/27/22, which included a potassium level which was 5.0 (normal range 3.5 to 5.1). The MR confirmed there was no [MEDICATION(S)] level or ECG in the record. Upon request, MR provided a copy of the Black Box Warning that was present in Resident 1's record in the physician's order for [MEDICATION(S)]. This was the same warning as in Lexicomp: [MEDICATION(S)] toxicity is closely related to serum [MEDICATION(S)] levels and can occur at doses close to therapeutic levels. Facilities for prompt and accurate serum [MEDICATION(S)] determinations should be available before initiating therapy . serum (blood) [MEDICATION(S)] levels (twice weekly until both patient's clinical status and levels are stable . During an interview on 2/24/22 at 2:45 PM, the Director of Nursing (DON) B confirmed the pharmacist had not reviewed the [MEDICATION(S)]. The DON B stated they called the facility's Consultant Pharmacist (CP)who reported the evaluation was done on 2/7/22 and because the [MEDICATION(S)] had been discontinued on 2/6/22, this medication did not show up on their review. The DON B stated the first signs and symptoms of [MEDICATION(S)] toxicity were discussed with MD 1 who evaluated Resident 1 but did not know if the tremors were due to [CONDITION(S)] or [MEDICATION(S)] toxicity. DON B stated the symptoms continued, so the [MEDICATION(S)] was discontinued on 2/6/22 and the last dose was given on 2/6/22 at 8 AM. Resident 1 was then sent to the hospital on 2/7/22. During a concurrent interview on 2/24/22 at 3:10 PM, with the DON A, the DON B, and the Administrator, they confirmed Resident 1 was started on [MEDICATION(S)] and the pharmacist did not review the medication before it was started, no [MEDICATION(S)] level was done, and Resident 1 was hospitalized with [MEDICATION(S)] toxicity. During an interview with MD 1 on 4/28/22 at 8:55 AM, MD 1 stated Resident 1 had increased behaviors and they had exhausted other medication options, so he ordered [MEDICATION(S)]. MD 1 stated, according to the drug reference program he used, a [MEDICATION(S)] level should have been done two weeks after initiation of the drug, but by then she was in the hospital. During a telephone interview with the facility's Consultant Pharmacist (CP), on 4/28/22 at 10 AM, the CP stated a [MEDICATION(S)] level should have been drawn five days after starting the drug. CP stated, during a Drug Regimen Review (or DRR, a process of reviewing medication orders for safe use), she would have asked about the [MEDICATION(S)] level. CP stated the pharmacy was not asked to review [MEDICATION(S)] use while Resident 1 was on the [MEDICATION(S)]. CP stated when monthly DRR was conducted on 2/7/22, Resident 1's [MEDICATION(S)] had already been discontinued and she was in the hospital. During an interview with the DON B, on 4/28/22 at 10:30 AM, the DON B stated when drug orders were entered into the computer and there was a Black Box Warning (or BBW, the highest level of warning for drug safety) alert, the nurses should have paid attention to that information. During an interview on 4/28/22 at 1:45 PM, the Charge Nurse (CN) said when they first got the [MEDICATION(S)] order, MD 1 had ordered baseline labs (baseline lab is a blood tests that checked body's status prior to start of medication) but had not ordered a [MEDICATION(S)] level. The next day she did rounds with MD 1 and was asked about the [MEDICATION(S)] level. CN further stated, MD 1 told her he was going to wait two weeks and order a [MEDICATION(S)] level and labs to check kidney function. Review of the facility's policy titled, Medication Therapy, last revised in 4/2007, indicated, All medication orders will be supported by appropriate care processes and practices. The policy further indicated, all decisions related to medication shall include appropriate elements of the care process, such as: Adequately detailed assessment. The policy indicated, when circumstances are present that represent a greater risk for medication-related complication, the staff and practitioner will review the medication regimen for continued indications, proper dosage and . possible adverse consequences. The policy on section # 5 indicated, The physician will identify situations where medication . is being given in excessive doses, ., without adequate monitoring, . when the results of ongoing assessment, or the presence of clinically significant adverse consequences monitoring, suggests that a medication should be reduced or discontinued entirely. The policy on section #8 indicated, The Medical Director and Consultant Pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. Review of the facility's policy titled, Medication Utilization and Prescribing-Clinical Protocol, last revised in 4/2018, the policy indicated, The physician and staff will identify situations in which a resident is taking medications associated with potentially significant medication-related problems such as . adverse drug reactions. The policy under Cause Identification, indicated for Any new onset or clinically significant symptoms . the physician and staff will review the possible contributions . to the problem. A. Many medications . are associated with adverse consequences that resemble medical illnesses. The policy under Treatment/Management indicated, The physician will provide and/or document a rationale when the indication, dose, duration, or frequency of a prescribed medication is greater than commonly accepted practice or the manufacturer recommendations or the medication is considered high-risk compared to other available relative alternatives. The policy further indicated, The physician will document a clinically pertinent rationale for not modifying a medication in a situation where an adverse drug reaction is likely. The policy under monitoring indicated, The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medication to determine if the medication and doses are still relevant and not causing undesired complications.

Based on interview and record review, the facility failed to provide an adequate level of supervision and assistance to prevent a fall for one of one sampled residents (Resident 1) when Resident 1 was left up and unattended in a rolling shower chair (a chair on wheels used in bathing). This resulted in Resident 1 sustaining a fall which later developed into a left femur (large upper leg bone) fracture requiring surgical intervention. Findings: Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS, a standardized resident assessment tool), dated 8/21/17, indicated Resident 1 had impaired cognitive function (the ability to think and reason) and was completely dependent on staff to assist with mobility, transfers, and toileting. Resident 1 also had a history of [REDACTED]. A review of a nursing progress note, dated 9/15/17 at 9:22 pm, indicated Resident 1 was previously (at approximately 4 pm) found by staff on the floor next to her bed laying on her left side. Resident 1 had been left in a rolling shower chair briefly when the fall occurred. The fall was witnessed by Resident 1's roommate. Resident 1's left hip was x-rayed and showed no fractured bones. A review of Resident 1's progress notes, dated 9/16/17 through 9/19/17, indicated she continued to complain of pain in her left leg and started receiving her as needed pain medication more frequently. The facility ordered an x-ray of her left knee on 9/19/17, which was negative for any fractured bones. A review of Resident 1's progress notes and physician orders, dated 9/20/17 through 10/6/17, indicated that she again continued to complain of pain and a new x-ray of her left hip was obtained on 10/6/17, which showed a moderately displaced fracture of proximal shaft of femur. Resident 1 was immediately transferred to the hospital for surgical intervention to repair the fractured bone. During an interview with the Administrator and Director of Nursing (DON), on 10/17/17 at 8:40 am, they acknowledged that the Certified Nursing Assistant (CNA) 1, involved in this incident, had made an extremely poor decision when she left Resident 1 unattended in the rolling shower chair. The DON stated that it was an error to leave a resident up in a rolling shower chair alone and that this should never have happened. During an interview with Resident 1's roommate, on 10/17/17 at 10:55 am, she recalled that CNA 1 had just gotten Resident 1 up in the shower chair and that she left the room to get more shower blankets. She stated CNA 1 was only out of the room for about 30 seconds when Resident 1 started rocking back and forth and then fell out of the rolling shower chair face first onto the floor. Resident 1 was interviewed on 10/17/17 at 11:10 am, but due to her cognitive deficits was unable to answer questions appropriately. During an interview with CNA 1, on 10/17/17 at 12 pm, she reported that she left Resident 1 up in the rolling shower chair in order to grab another bath blanket from the hallway linen closet. CNA 1 stated that she was only out of the room for less than 30 seconds when she heard Resident 1's roommate calling out for assistance. CNA 1 stated that she felt absolutely horrible as this was her fault and that she should have never left Resident 1 alone. The facility's policy titled, Accidents and Supervision to Prevent Accidents, dated 8/6/07, was reviewed and included the following: The (facility) will provide an environment that is free of accident hazards over which the facility has control and provides supervision and assistive devices to each resident in order to prevent avoidable accidents . (Facility) provides training to employees for identification of potential hazards, prevention of accidents, safe transfer techniques and safe use of mobility devices.

Based on observation, interview, and record review, the facility failed to ensure physician ordered medications were available in the facility for administration and to administer medications as ordered by the physician for two of ten sampled residents (Residents 1 and 2) when: 1. Resident 1 was not administered medications, as ordered by the physician; a. Six of 92 doses of Nitroglycerin patch (topical medication used for chest pain) were not applied; b. One of 92 doses of Lorsartin Potassium (blood pressure medication) was not administered; c. Two of 92 doses of Nortriptyline (antidepressant) were not administered; d. One of 92 doses of Trazadone (antidepressant) was not administered; e. One of 92 doses of Lasix (diuretic medication used to remove excess fluid in the body) was not administered; f. Three of four routine doses and one as needed dose of Norco (narcotic medication used to treat pain) were not administered; g. One of 184 doses of Carvedilol (blood pressure medication) was not administered; h. 15 of 276 doses of Gabapentin (used to treat nerve pain) were not administered; i. Two of 92 doses of Amlodipine (used to improve blood flow and prevent chest pain) were not administered. The facility's failure to administer physician ordered medications resulted in Resident 1 suffering pain unnecessarily and had the potential for Resident 1 to develop chest pain, abnormal blood pressure levels, increased depression, and increased symptoms of congestive heart failure. 2. Resident 2 was not administered medications, as ordered by the physician; a. Levothyroxine (a thyroid medication); b. Hydralazine (for blood pressure control); c. Sinemet (for Parkinson's disease symptoms); d. Chlorthalidone (for blood pressure control); e. Plavix (a blood thinner); f. Zetia (for cholesterol control); g. Glimepiride (for blood sugar control); h. Amlodipine (for blood pressure control); The facility's failure to administer physician ordered medications resulted in Resident 2 having increased blood pressure and feelings of powerlessness and frustration. These failures had the potential for other residents who receive medications to suffer adverse clinical outcomes if not given medications, as ordered. Findings: 1. Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a colostomy (an opening through the lower abdomen to the large intestine/colon for excretion of fecal contents) and chronic pain. Resident 1's Minimum Data Set (MDS, a resident assessment), dated 4/6/17, identified that she did not have memory problems. Resident 1's Nursing Notes (NNs), and Medication Administration Records (MARs), from 3/1 to 5/31/17 (92 days), were reviewed. The MARs contained checkmarks for when a medication was administered as ordered, and codes for when a medication was not administered as ordered. The MARs defined code 9 to mean Other/See Nurses Notes. During an interview and concurrent record review of Resident 1's MARs and NNs on 6/21/17 at 2 pm, the Medical Records Director (MRD) confirmed the following: a. Resident 1 was not provided six of 92 applications for her daily Nitroglycerin Patch 0.2 milligrams (mg) per hour, order start date 12/21/16, for chest pain (to be removed at night). On 3/25/17 at 9:14 am and 3/26/17 at 8:44 am, the Nitroglycerin Patch NN read, Awaiting delivery from pharmacy. There were four more MAR code 9 entries for the Nitroglycerine patch on 3/11/17 at 7:33 am, 4/12/17 at 9:20 am, 4/26/17 at 10:26 am, and 5/9/17 at 7:29 am where the corresponding NN was blank as to why it was not applied. The blank NN associated with the code 9 MAR entry had the medication order detail automatically populated, but the NN did not contain any other information as to why the medication was not administered, or resident notification, or physician notification. These incomplete NN were all documented by Licensed Nurse (LN) C. b. Resident 1 was not provided one of 92 doses of Lorsartin Potassium 100 mg, ordered 9/15/16, daily for blood pressure control. On 3/26/17 at 8:45 am, the Lorsartin Potassium NN read, awaiting delivery. c. Resident 1 was not provided two of 92 doses of Nortriptyline 10 mg, an antidepressant ordered 4/25/16 for pain management, to be given nightly. On 5/2/17 at 7:15 pm, the Nortriptyline NN read, Awaiting delivery from pharmacy. On 5/3/17 at 8:47 pm, the Nortriptyline NN read, Waiting delivery from pharmacy. d. Resident 1 was not provided one of 92 doses of Trazadone, an antidepressant ordered 1/18/17 for insomnia, to be given every evening. On 5/8/17 at 8:20 pm, The Trazadone NN read, Awaiting delivery. e. Resident 1 was not provided one of 92 doses of Lasix 20 mg, a diuretic ordered on [DATE] for decreasing excess body fluid, to be given one time a day. On 5/17/17 at 7:48 am, The Lasix NN read, Out of Stock- reordered. f. Resident 1 was not provided three doses in a 24 hour period of Norco 5/325 mg (an Opioid), ordered on [DATE] for moderate chronic pain, to be given routinely every six hours. On 5/19/17 at 6:28 am, the Norco NN read, on order. On 5/19/17 at 11:41 pm, Norco NN read, awaiting medication from pharmacy. On 5/20/17 at 4:30 am, Norco NN read, awaiting medication from pharmacy. Resident 1 was not provided one Norco 5/325 mg PRN (as needed) for moderate oral pain (a temporary order to be given up to every six hours in addition to the routine dose) on 5/9/17. On 5/9/17 at 7:33 am, the Norco PRN NN, documented by LN C, contained no information to indicate why the medication was not given, although code 9 was documented on the MAR. g. Resident 1 was not provided one of 184 doses of Carvedilol 12.5 mg, ordered on [DATE] for blood pressure control, to be given twice daily. On 5/25/17 at 7:55 am, the Carvedilol NN read, on order. h. Resident 1 was not provided 15 of 276 doses of Gabapentin 300 mg, ordered on [DATE] for nerve pain, to be given three times a day. Review of NN indicated Gabapentin was not administered on 3/1/17 at 12:36 pm, 3/11/17 at 12:58 pm, 3/15/17 at 11:55 am, 3/18/17 at 12:04 pm, 3/22/17 at 12:25 pm, 3/24/17 at 12:16 pm, 3/30/17 at 11:19 am, 3/31/17 at 10:52 am, 4/1/17 at 10:51 am, 4/4/17 at 11 am, 4/8/17 at 11:52 am, 4/12/17 at 11:14 am, 4/18/17 at 12:20 pm, 4/19/17 at 12:23 pm, and 4/28/17 at 12:55 am. All these Gabapentin NN were documented by LN C and contained no narrative to indicate why the medication was not given. Review of a physician's orders [REDACTED]. i. Resident 1 was not provided two of 92 doses of Amlodipine 10 mg, ordered for high blood pressure, to be given daily. On 3/3/17 at 8:33 am and 5/4/17 at 8:31 am, LN C documented code 9 on the MAR but the Amlodipine NN contained no narrative for why the medication was not given. During an interview and concurrent review of Resident 1's NN on 6/21/17 at 2 pm, MRD acknowledged that the 33 NN that corresponded to the MAR code 9 entries did not contain documentation of physician notification, resident notification (except Norco), nor alternate treatments ordered. During an interview on 7/13/17 at 12:20 pm, LN C stated every entry that he coded as 9 on Resident 1's MAR, that had missing documentation in the NN, indicated that the medications were not available to be given. LN C stated he did not notify the physician of the omitted medications. During an observation and interview on 6/1/17 at 10:40 am, Resident 1 was observed lying on her bed. Resident 1 stated that she does not really know what her medications look like except her Norco. She stated that the nurses crush her medications because of her colostomy, so she is not aware if her other medications are not given. Resident 1 stated that she was unaware of other medications that were not provided to her other than her Nitro patch and Norco. Resident 1 stated that she did not get two doses of her pain medication Norco recently because the nurses had not reordered in time. Resident 1 stated that due to not receiving her pain medications she did not feel good, that she had pain, and their was nothing she could do. Resident 1 stated that she did not get two doses of her pain medication Norco recently because the nurses had not reordered in time. Resident 1 stated that due to not receiving her pain medications she did not feel good, that she had pain, and their was nothing she could do. She stated the nurses Have time to laugh and talk, they should have the time to order it. Resident 1 stated her legs and feet were in pain, that the regular Tylenol that she was given did not work. Resident 1 stated that she was awake all night in pain. Resident 1 stated I was upset, I feel that if a persons is in pain they should have the right for relief. During an interview, on 5/30/17 at 3:30 pm, LN A stated that he had made several of the notes in Resident 1's record related to medications not being available and was not able to give medications as ordered. LN A stated that he did not notify the physician when medications were unavailable. During an interview on 5/30/17 at 4:30 pm, LN B stated that she may run out of a residents medication about once a week due to pharmacy refusing to deliver when ordered too early. LN B stated that she did not notify the physician when medications were unavailable On 5/30/17 at 5 pm, during an interview and review of Resident 1's record, the Director of Nursing (DON) acknowledged that the facility has had multiple pharmacy reorder issues resulting in problems in administering medications as ordered to Resident 1. The DON stated the physician, Resident 1, and the pharmacy should have been notified about Resident 1's missing medication administrations and that was not done as required. During an interview on 7/13/17 at 2:20 pm, the DON stated that LN C, who had left the NNs blank when medications were not given, should have followed the facility's protocol and notified the pharmacy, Resident 1, and the physician, when medications were not available and/or administered as ordered. On 5/20/17 at 5:24 am, Resident 1's NNs read, At 2300 (11 pm) resident has Norco due (,) resident was given Tylenol instead of Norco's due to the fact that she doesn't have Norco's available, Resident was informed that she was out of her Norco's and was awaiting for the Dr. signature to refill order . resident was very upset about the situation . resident was up all night stating 'That she can't sleep w/o (with out) the pain medication and her legs kept her up at night and that the pain was a 9/10' . This level is considered severe pain as identified by a physician order, started on 3/29/16, that read Pain Monitoring using Verbal/Non-verbal 0-10 scale (zero being no pain and ten worst possible pain) every shift for Monitoring Level of Comfort. On 4/12/17, the order was modified to add pain descriptions and read 0 to 3 Mild, 4-7 Moderate, 8-10 Severe. During an interview, on 6/1/17 at 8 am, LN A stated that he worked on 5/19/17, pm shift, and Resident 1 was more anxious than usual. He stated she says 'I am in excruciating pain and left to suffer', when she does not get her Norco. He stated that he explained to her that the computer reorder required a new C2. LN A stated that on 5/20/17 he did not speak with Resident 1's attending physician (AP) about the medication, but had talked with the pharmacy, who said they had contacted AP. Resident 1's 5/2017 MAR read that on 5/19/17 at 11:42 pm and 5/20/17 at 4:31 am, Tylenol 650 mg was given for breakthrough pain. Follow up documentation for both of these Tylenol doses identified that they were ineffective. A NN read on 5/20/17 at 4:30 am, resident has c/o (complaint of) pain 9/10 awaiting other medication from pharmacy that is stronger. During an interview, on 6/1/17 at 11:30 am, the Director of Nursing (DON) stated that Resident 1 should have been able to have relief from her pain. 2. Resident 2's medical record was reviewed. Resident 2 was readmitted to the facility 1/19/17 with [DIAGNOSES REDACTED]. Resident 2's MDS, dated [DATE], identified that he had no memory problems and made his own decisions. During an interview, on 5/26/17 at 4 pm, Resident 2 stated that the facility had run out of medications that treat his blood pressure and his Parkinson's disease and that they were not given as prescribed. Resident 2 stated that he wondered why and how the facility could have run out of his medications. Resident 2 stated that he had complained of the problem to the DON, Administrator and physician three or four times. Resident 2 stated that not receiving his medications left him feeling a loss of control in his life. During an interview on 6/1/17 at 9:40 am, Resident 2 stated that missing the medications left him feeling frustrated and upset. Resident 2 stated that his wife had kept detailed records of the missing medications and that she was really mad about the situation. Resident 2's MARs were reviewed for entries that did not contain a check that a medication was given, but had a code 9, and the NN indicated that the following routine medications were not available to be given during the month of 5/2017: a. On 5/4/17 at 7:19 am, Levothyroxine; NN read, medication on order. b. On 5/4/17 at 7:20 am, 12:45 pm, and 4:09 pm, Hydralazine; NN read, medication on order at 7:20 am, and Awaiting pharmacy delivery at 4:09 pm. No physician notification was documented for these missed medications. c. On 5/10/17 at 4:23 pm and 7:10 pm, Sinemet; NN read, on order. d. On 5/16/17 at 8:03 am, Chlorthalidone; NN read, contacted pharmacy, (pharmacy staff) states I need to fac(x) the script they did not receive this medications over the computer, same with Plavix. e. On 5/16/17 at 8:04 am, Plavix with instructions Do not stop administration without a doctor's order; NN read, faxed script. Another NN, dated 5/16/17 at 1:04 pm, read, patient contacted pharmacy regarding missing Plavix, pharmacy stated it was delivered. Will try to locate and F/U (follow up). wife is concerned about missing medications. Reassured wife that nursing was promptly taking action about locating medications. MD notified. Resident 2's blood pressure was higher than all other levels documented in the Weights and Vitals Summary, for 5/2017, on 5/16/17 at 8:02 am, at 198/90. f. On 5/17/17 at 7:36 am, Zetia; NN read, out of stock- reordered from pharmacy. g. On 5/19/17 at 7:26 am, Glimepiride; NN read, on order h. On 5/19/17 at 11:35 am, and 4:07 pm, Hydralazine; NN read, on order at 11:35 am and Awaiting delivery from pharmacy at 4:07 pm. No physician notification for these missed medications was documented. i. On 5/23/17 at 7:04 am, Amlodipine; NN read, Medication is on order from pharmacy. j. On 5/24/17 at 8:01 am, Glimepiride; NN read, Awaiting delivery from pharmacy. On 5/30/17 at 3:55 pm, during an interview and review or Residents 1 and 2 record. The Director of Nurses (DON) acknowledged the above findings, and stated the facility has had multiple pharmacy reorder issues resulting in problems in administering medications as ordered. The DON stated the physician should have been notified about all missing medication administrations and that this was not done. The DON stated that she had not yet put in place actions that would prevent the reorder problems from reoccurring.

Based on observation, interview, and record review, the facility failed to ensure adequate care to meet the health needs for two of ten sampled residents (Residents 1 and 2) when: 1. Resident 1 did not receive two sequential doses of her routine pain medication (over a seven hour period), as ordered by her physician every six hours, due to her physician's decision not to verbally authorize an emergency release of the medication from the facility emergency medication supply when the facility ran out of the medication, and nursing's failure to provide the physician with documents needed to reorder the controlled substance timely. These failures resulted in Resident 1 having severe pain for seven hours, increased anxiety, loss of sleep, and frustration. 2. Resident 2 did not receive his routine medications on several occasions when the facility staff reported that they were not available to give. These failures resulted in Resident 2 having feelings of frustration and powerlessness, and the potential for adverse health effects such as elevated blood pressure. (Refer to F 425) Findings: 1. Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 4/6/17, identified that she did not have memory problems. During an interview and observation on 6/1/17 at 10:40 am, Resident 1 was observed lying on her bed. Resident 1 stated that she did not receive two doses of her pain medication [MEDICATION NAME] recently because the nurses had not reordered in time. Resident 1 stated that due to not receiving her pain medications she did not feel good, that she had pain, and their was nothing she could do. She stated the nurses Have time to laugh and talk, they should have the time to order it. Resident 1 stated her legs and feet were in pain, that the regular Tylenol that she was given did not work. Resident 1 stated that she was awake all night in pain. Resident 1 stated I was upset, I feel that if a person is in pain they should have the right for relief. Resident 1's 4/2017 Medication Administration Record (MAR) was reviewed and included the following physician's orders [REDACTED]. 1. An order, started 6/28/16, read, [MEDICATION NAME] 5-325 milligrams (mg) every six hours for moderate pain. This order was changed on 4/26/17 to eliminate the word Moderate and read for pain. 2. An order, started 3/29/16, read, Pain Monitoring using Verbal/Non-verbal 0-10 scale (zero being no pain and ten worst possible pain) every shift for Monitoring Level of Comfort. On 4/12/17, the order was modified to add pain descriptions and read, 0 to 3 Mild, 4-7 Moderate, 8-10 Severe. 3. An order, started 4/25/16, read, [MEDICATION NAME] 10 mg (an anti-depressant), daily for chronic pain. 4. An order, started 5/3/16, read, [MEDICATION NAME] 300 mg (an anti-convulsant) was to be given three times a day for [MEDICAL CONDITION] (nerve pain). 5. An order, started 12/21/12, read, [MEDICATION NAME] 24 hour patch 0.2 mg/hour applied daily for [MEDICAL CONDITION] (chest pain). 6. An order, started 4/29/16, read, Tylenol ([MEDICATION NAME]) 650 mg every four hours as needed for mild to moderate break through pain. This order was modified on 4/26/17 to read, for mild break through pain. 7. A muscle rub cream, started 2/24/17, was ordered every two hours as needed for knee pain. Resident 1's 5/2017 MAR contained the following changes in pain management orders: 1. On 5/5/17, Resident 1 received an additional, seven day order, for [MEDICATION NAME] 5-325 mg PRN (as needed) for pain every six hours. The order was clarified on 5/5/17 to include for moderate oral pain 4-7 out of 10. Then, was again clarified on 5/8/17, to include the precaution not to exceed three Grams (3000 mg) in 24 hours of [MEDICATION NAME] from all sources. The order was discontinued on 5/12/17 at 11:59 pm. 2. On 5/10/16, [MEDICATION NAME] was increased to 400 mg three times a day. 3. On 5/19/16, [MEDICATION NAME] 5/325 was discontinued at 2:57 pm, then rewritten to start at 5 pm with a new use that read for Chronic Moderate Pain. Resident 1 MAR's read she had taken PRN Tylenol, for break through pain four times in 4/2017. In 5/2017 she had taken it 17 times (14 of these doses were after her seven day temporary [MEDICATION NAME] order was discontinued on 5/12/17). On 5/20/17 at 5:24 am, Resident 1's Nursing Notes (NN) read At 2300 (11 pm) resident has [MEDICATION NAME] due (,) resident was given Tylenol instead of [MEDICATION NAME] due to the fact that she doesn't have [MEDICATION NAME] available, Resident was informed that she was out of her [MEDICATION NAME] and was awaiting for the Dr. signature to refill order . resident was very upset about the situation . resident was up all night stating 'That she can't sleep w/o (without) the pain medication and her legs kept her up at night and that the pain was a 9/10' . During an interview on 6/1/17 at 8 am, Licensed Nurse (LN) A stated that he worked on 5/19/17, pm shift, and Resident 1 was more anxious than usual. He stated she says 'I am in excruciating pain and left to suffer', when she does not get her [MEDICATION NAME]. He stated that he explained to her that the computer reorder required a new C2 (a controlled substance, written order signed by the physician). LN A stated that on 5/20/17 he did not speak with Resident 1's physician about the medication, but had talked with the pharmacy who said they had contacted her physician. LN A stated that the pharmacy reported back to him that Resident 1's Attending Physician (AP) had said I'm not signing it now, the nurses should have done their job, the residents are left to suffer. When LN A was asked about use of the emergency medications available on site (when authorized by the physician), he stated that the pharmacy had originally authorized the staff for removal of eight doses of [MEDICATION NAME] on the night of 5/19/17, but then rescinded the authorization. LN A stated he faxed a form to Resident 1's physician office for the C2 authorization prior to the end of his shift, as he was not sure if the facility had already done it. LN A stated he did not contact the facility medical director (who also could have authorized release of emergency medication) when Resident 1's Attending Physician (AP) refused to release the emergency pain relief medication or offer alternatives. Resident 1's MAR read that her [MEDICATION NAME] routine order times were changed on 5/19/17 at 1:45 pm, to read 5 am, 11 am, 5 pm and 11 pm. The MAR also read that on 5/19/17 at 11:42 pm, and 5/20/17 at 4:31 am, Tylenol 650 mg was given for breakthrough pain. Follow up to documentation for both of these Tylenol doses identified that they were ineffective. A NN read on 5/20/17 at 4:30 am, resident has c/o (complaint of) pain 9/10 awaiting other medication from pharmacy that is stronger. Resident 1's 5/2017 MAR and NN identified that she did not get two sequential doses of routine [MEDICATION NAME] on 5/19/17 at 11 pm, and 5/20/17 at 4 am, and that the next dose was given at 6 am when a medication authorization was received. Resident 1 went without her ordered [MEDICATION NAME] for seven hours, and did not have pain relief based on her physician decision not to allow a verbal authorization to release [MEDICATION NAME] from the emergency drug supply, and facility nurse's failure to contact the facility medical director. During an interview on 6/1/17 at 11:55 am, the facility contracted Registered Pharmacist (RPh) A stated that he recalled the problem with Resident 1 not receiving her routine [MEDICATION NAME] on 5/19/17 to 5/20/17. RPh A stated that her physician was unwilling to give a verbal authorization for the facility to obtain the medication from the emergency supply. RPh A stated that the pharmacy had made a mistake in authorizing release of emergency [MEDICATION NAME] medication for Resident 1 on 5/19/17, that the authorization was withdrawn as they did not have a current order for the missed doses. RPh A stated that the Resident 1's physician had refused to authorize emergency release of the [MEDICATION NAME] Medication. RPh A stated that Resident 1's AP told him that People need to be doing their jobs, and that it is too bad when patients have to suffer when people do not do their jobs. During an interview on 6/1/17 at 12:05 pm, Resident 1's AP stated I will not authorize Schedule 2 medications over the phone . People need to be doing their jobs . I do not recall exactly when that was (refusal to authorize release of Resident 1's [MEDICATION NAME]) but I am in the office 7 days a week and can do Schedule 2 authorizations. AP stated The patient suffers when they do not do their job, I do my job. 2. Resident 2's medical record was reviewed. Resident 2 was readmitted to the facility 1/19/17 with [DIAGNOSES REDACTED]. Resident 2's MDS, dated [DATE], identified that he had no memory problems and made his own decisions. During an interview, on 5/26/17 at 4 pm, Resident 2 stated that the facility had run out of medications that treat his blood pressure and his [MEDICAL CONDITION] and that they were not given as prescribed. Resident 2 stated that he wondered why and how the facility could have run out of his medications. Resident 2 stated that he had complained of the problem to the DON, Administrator and physician three or four times. Resident 2 stated that not receiving his medications left him feeling a loss of control in his life. During an interview on 6/1/17 at 9:40 am, Resident 2 stated that missing the medications left him feeling frustrated and upset. Resident 2 stated that his wife had kept detailed records of the missing medications and that she was really mad about the situation. Resident 2's MARs were reviewed for entries that did not contain a check that a medication was given, but had a code 9, and the NN indicated that the following routine medications were not available to be given during the month of 5/2017: 1. On 5/4/17 at 7:19 am, [MEDICATION NAME] (a [MEDICAL CONDITION] medication); NN read, medication on order. 2. On 5/4/17 at 7:20 am, 12:45 pm, and 4:09 pm, [MEDICATION NAME] (for blood pressure control); NN read, medication on order at 7:20 am, and Awaiting pharmacy delivery at 4:09 pm. No physician notification was documented for these missed medications. 3. On 5/10/17 at 4:23 pm and 7:10 pm, [MEDICATION NAME] (for [MEDICAL CONDITION] symptoms); NN read, on order. 4. On 5/16/17 at 8:03 am, [MEDICATION NAME] (for blood pressure control); NN read, contacted pharmacy, (pharmacy staff) states I need to fac(x) the script they did not receive this medications over the computer, same with [MEDICATION NAME]. 5. On 5/16/17 at 8:04 am, [MEDICATION NAME] (a blood thinner) with instructions Do not stop administration without a doctor's order; NN read, faxed script. Another NN, dated 5/16/17 at 1:04 pm, read, patient contacted pharmacy regarding missing [MEDICATION NAME], pharmacy stated it was delivered. Will try to locate and F/U (follow up). wife is concerned about missing medications. Reassured wife that nursing was promptly taking action about locating medications. MD notified. Resident 2's blood pressure was higher than all other levels documented in the Weights and Vitals Summary, for 5/2017, on 5/16/17 at 8:02 am, at 198/90. 6. On 5/17/17 at 7:36 am, [MEDICATION NAME] (for cholesterol control); NN read, out of stock- reordered from pharmacy. 7. On 5/19/17 at 7:26 am, Glimepiride (for blood sugar control); NN read, on order 8. On 5/19/17 at 11:35 am, and 4:07 pm, [MEDICATION NAME]; NN read, on order at 11:35 am and Awaiting delivery from pharmacy at 4:07 pm. No physician notification for these missed medications was documented. 9. On 5/23/17 at 7:04 am, [MEDICATION NAME] (for blood pressure control); NN read, Medication is on order from pharmacy. 10. On 5/24/17 at 8:01 am, Glimepiride; NN read, Awaiting delivery from pharmacy. On 5/30/17 at 3:55 pm, during an interview and review or Residents 1 and 2 record. The Director of Nurses (DON) acknowledged the above findings, and stated the facility has had multiple pharmacy reorder issues resulting in problems in administering medications as ordered. The DON stated the physician should have been notified about all missing medication administrations and that this was not done. The DON stated that she had not yet put in place actions that would prevent the reorder problems from reoccurring. The DON stated the facility should have had measures in place so Resident 1 would not have suffered in pain.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one of one resident (Resident 1) when a physician's orders [REDACTED]. This significant medication error caused or contributed to oversedation of Resident 1 requiring the administration of [MEDICATION NAME] (a medication used to reverse the adverse effects of narcotic (potent pain medication) overdose). Findings: A review of the record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. A review of the ,[DATE] medication administration record (MAR) indicated Resident 1 received a dose on [DATE] at 3:14 am. A review of DailyMed, a compendium of manufacturer's required (by the FDA, Food and Drug Administration) labeling information, indicated MS ER had a black box warning (the strongest warning the FDA required, and signified the drug carried a significant risk of serious or even life-threatening adverse effects, including death. The monograph further indicated the recommended starting dose was 15 mg; and that serious, life-threatening, or fatal respiratory depression (decreased breathing rate) may occur with use of MS ER, which was not indicated for PRN use. Furthermore, elderly patients were more likely to experience adverse effects than younger patients due to altered clearance from the body. Review of a physician's orders [REDACTED]. This order was entered into the MAR as MS (did not specify either ER or IR) 30 mg routinely every eight hours for pain to start on [DATE] at 9 pm. The MAR reflected Resident 1 received a MS ER 30 mg dose at 9 pm on [DATE] for a pain level of 2 (mild pain, on a scale of ,[DATE], indicating the most severe pain) and eight hours later at 5 am on [DATE] for pain of 0 (no pain at all). A review of the facility's controlled drug record for Resident 1's MS ER indicated one MS ER 30 mg tablet was signed out on [DATE] at 8 pm and one MS ER tablet was signed out on [DATE] at 4:40 am. A review of Lexi-comp ONLINE, a nationally recognized drug information source, indicated adverse effects related to [MEDICATION NAME] included central nervous system (CNS) depression (sedation, or decreased mental alertness); respiratory depression (slowed breathing);and [MEDICAL CONDITION] (low blood pressure). A review of the nurse's progress note, dated [DATE] at 9:16 am, indicated documentation the nurse held the MS for confusion and unable to do for herself (the last dose given was on [DATE] at 5 am). On [DATE] at 9:39 am, the documentation indicated Resident 1 was more confused, lethargic and unable to hold water glass and medication cup in hand. The physician was notified by licensed nursing staff and wanted [MEDICATION NAME] on hold. The progress note documentation further indicated Resident 1 was assessed at 6:30 pm and was unable to keep her eyes open and could not verbalize answers or follow commands. She appears to be overmedicated. The physician was notified and ordered [MEDICATION NAME] 0.4 mg IM (in the muscle) every one hour as needed for oversedation. This was given at 6:30 pm and at 7:15 pm. At 7:30 pm, Resident 1 was noted to be awake and verbalizing appropriately. A review of the manufacturer's product information, indicated MS ER will continue to release [MEDICATION NAME] and add to the [MEDICATION NAME] load for 24 to 48 hours or longer, necessitating prolonged monitoring and potentially additional doses of reversal agent. A review of the nurse's progress note, dated [DATE] at 11 am, indicated the night shift nurse had checked on Resident hourly throughout the night and the resident had been awake, lucid and able to carry on a conversation until around 6:30 am on [DATE], at which time Resident 1 was found to be unresponsive. The assistant DON assessed Resident 1 and was able to get a faint blood pressure. The physician was notified and although Resident 1 was a Do Not Resuscitate and was on comfort measures, ordered her to be sent to the Emergency Department (ED) where she expired. A review of the ambulance documents indicated Resident 1 was given [MEDICATION NAME] without results. During an interview and record review of the [MEDICATION NAME] controlled drug record on [DATE] at 3:30 pm, the Director of Nurses (DON) confirmed Resident 1 received MS ER 30 mg doses at 9 pm on [DATE] and at 5 am on [DATE]. The DON stated the facility used MS ER because the MS IR had not been delivered from the pharmacy, and was therefore not available, and due to a transcription error on the MAR. During an interview on [DATE] at 2 pm, Licensed Nurse (LN) A stated she worked day shift on [DATE] and was told by the night shift nurse that Resident 1 was acting a little unusual and was less talkative. LN A stated Resident 1 was talking but couldn't hold her water cup or put her pills in her mouth, so she told the physician who said to hold the [MEDICATION NAME]. LN A said she came back to work the night shift at 10 pm on [DATE] and was told by the evening nurse to keep an eye on Resident 1 and [MEDICATION NAME] could be given, if needed. LN A stated she didn't think Resident 1 needed [MEDICATION NAME] during the night because she was awake and talking. At around 6:30 am on [DATE], Resident 1 was not responsive and not talking. LN A stated she asked the Assistant DON to check on the resident and estimated 30 to 40 minutes from that time until they called the physician who called back right away and ordered an ambulance be called to transfer Resident 1 to the ED. During an interview on [DATE] at 4 pm, LN B stated she worked evening shift on [DATE]. She wasn't told in report from the day shift nurse of any medication changes and was surprised to see the MS ER had been changed from PRN (as needed) to every eight hours as a scheduled dose when she looked at Resident 1's MAR. LN B confirmed Resident 1's pain level of 2 at the time she gave the MS ER at 9 pm. She said she gave the pain medication because according to the MAR it was ordered to be given every eight hours. LN B stated Resident 1 was alert and not oversedated while under her care on [DATE]. During an interview on [DATE] at 5:50 am, LN C said she was told by LN B that Resident 1's MS ER was now a scheduled medication as opposed to an as needed medication. LN C stated she did not review the [DATE] physician's orders [REDACTED]. She gave the MS ER to Resident 1 at 5 am on [DATE] even though Resident 1 was not having pain at that time, because according to the MAR, it was supposed to be given at that time. During an interview on [DATE] at 11 am, the DON stated every morning Administrative nurses check all prior orders from the previous day, but wasn't done in this case because the new order written on [DATE] was after their morning meeting and was written on a Friday. The orders would have been reviewed on Monday [DATE], but Resident 1 had already been transferred to the ED. The facility had no policy for medication order reconciliation. During an interview on [DATE] at 11:50 am, Resident 1's physician (MD) stated he had concerns about the MS and ordered [MEDICATION NAME] which was reported to be effective. MD stated he reviewed the MAR and the dates and times the last two doses of MS ER were given ([DATE] at 9 pm and [DATE] at 5 am). The MD stated he did not feel Resident 1 expired due to the MS ER because of the length of time between the last dose and the use of the [MEDICATION NAME]. A review of the emergency response team (paramedic) report, dated [DATE], indicated at 8:35 am, Resident 1 was found to an altered level of consciousness, an abnormally low heart rate of 40 beats per minute, and third-degree atrioventricular (AV) Block (complete heart block, a disorder of the cardiac conduction system where there is no conduction through the AV node. Therefore, complete dissociation of the [MEDICAL CONDITION] and ventricular activity exists. Patients with third-degree AV block typically experience severe [MEDICAL CONDITION] (an abnormally-low measured heart rate), [MEDICAL CONDITION], and at times, hemodynamic (relating to the flow of blood within the organs and tissues of the body) instability. A review of the hospital emergency room report, dated [DATE] and timed 9:01 am, indicated Resident 1 arrived completely unresponsive with agonal respirations (an abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing). Resident 1 was diagnosed with [REDACTED]. Resident 1 expired on [DATE] at 9:08 am.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from physical restraint for one of 15 sampled residents (Resident 3) when the facility placed a wanderguard (bracelet secured to ankle that cannot be removed by resident, alarmed if the resident left the facility and would continue to alarm until a code was put into the device by staff) without justification of use or a documented incident of wandering (pointless movement with no rational sensible course) or elopement (unsupervised wandering outside the building) being reported, documented and or an assessment completed. The facility did not evaluate and assess the negative impact the wanderguard had on Resident 3 nor evaluated the plan of care when the resident and Family Member (FM) requested to ensure Resident 3's right to be free from physical restraint. This resulted in a violation of Resident 3's right to be free from physical restraint (any manual method or physical or mechanical device, material, or equipment attached to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body), a restraint for convenience (any action taken by the facility to control resident behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest), having decreased activity, strength, quality of life, and feeling uncomfortable and depressed which resulted in self isolation. Refer to F 248 and F 250. Findings: A review of the facility's Patient Elopement policy, dated 5/28/16, indicated, that if a resident is missing, complete an Unsafe Wandering Patient Profile and distribute to persons searching. If an elopement occurs but patient is not missing or is found to do the following: 1). Asses for injury. 2). Asses the patient's risk for future events of the same nature. a. Complete Unsafe Wandering Form. 3). Revise Care Plan and implement interventions. 4). Communicate revisions to nursing staff. 5). Root Cause Analysis- Investigate the cause of the event. A review of the facility's admission record indicated Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission, Resident 3 was living independently in an apartment. Resident 3 was able to make health care decisions for herself; her daughter was her emergency contact. A review of physician's orders, dated 2/10/16, included, Resident 3 may participate in activities (including out of the building activities) per care plan. There was no physician's order for the initial use of a wanderguard on Resident 3 in the record. A review of the Medication Administration Record [REDACTED]. A review of the Minimum Data Set (MDS, a resident assessment), indicated, in two quarterly MDS' on 5/19/16 and 8/19/16, Section C for Cognitive Patterns, did not identify any behaviors of inattention or disorganized thinking. A review of a MDS, dated [DATE], indicated, Resident 3 responded that it is very important to go outside and to get fresh air when the weather is good. A review of the Initial Psychosocial Profile, dated 2/17/16, indicated in section G, Mental/Sensory/Functional Loss & Decline and Psychosocial Elements, no psychosocial elements were identified that could impact Resident 3 meeting her individual goals. A review of Section G, Coping Style, indicated, Resident 3 loves to take walks. A health status note, dated 2/16/16 at 3:05 pm, indicated, Resident 3 upon leaving her room, was stable. A health status note, dated 3/7/16 at 12:54 pm, a LN documented, Resident 3 needed re-orientation constantly throughout the day for her to be aware of what she was doing, and where she was at and upon leaving her room, she was stable. A health status note, dated 3/23/16 at 1:08 am, a LN documented, Resident 4 was able to self transfer with staff supervision. A weekly progress note, dated 3/26/16 at 5:43 pm, indicated, a LN documented, patient sometimes has episodes of confusion. A health status note, dated 5/3/16 at 5:34 pm, a LN documented, patient is alert and oriented with some confusion, but able to make needs known, is active and ambulates with FFW (front wheel walker). The weekly progress note, dated 5/30/16 at 9:20 pm, a LN documented, Resident 3 had no episodes of wandering this period, impaired cognition related to dementia but was able to make needs known and followed commands, was encouraged to request assistance prior to ambulating or transferring. A health status note, dated 6/1/16 at 2:16 pm, indicated, a LN documented, Resident 3 was independently walking and discharged from restorative nursing assistant program (ambulating the resident on regular basis). A health status note, dated 7/4/16 at 10:13 am, indicated, LN F documented, Resident 3 had no attempt for elopement or wandering that week. A health status note, dated 7/8/16 at 6:30 am, indicated, a LN documented, Resident 3 has not been wandering near exits, however, enjoys the facility courtyard. A health status note, dated 7/27/16 at 2:10 pm, indicated, the Interdisciplinary Team (IDT, a team of different professional disciplines who meet to evaluate care needs and recommend plans of care) documented that Resident 3's diet, weight, and intake was discussed by the IDT. This was the first and only documentation of an IDT being conducted for Resident 3. This IDT meeting did not indicate any documentation of Resident 3 having a wanderguard attached to her ankle. A MAR indicated [REDACTED]. This was the first documented record of Resident 3 having wanderguard. A health status note, dated 8/6/16 at 6:44 pm, indicated, a LN documented, Resident 3 walks in halls, but does not wander, environment is well organized and free of obstacles. A health progress note, dated 8/13/16 at 11:24 pm, indicated, a LN documented, Resident 3 was alert, forgetful, ambulating freely and steadily, and wanderguard was in place without discomfort. A physician progress notes [REDACTED]. There was no further documentation found in the record that the wanderguard was evaluated for clinical justification for use. A health status note, dated 8/27/16 at 5:03 pm, indicated, a LN documented, able to make her needs known, is ambulatory with a steady gait, works with therapy for strengthening. A progress note, dated 8/31/16 at 11;23 pm, indicated, a LN documented, resident expressed this shift that she has been experiencing sadness over loss of lifestyle and finding herself feeling down. A review of the physician notification note, dated 9/23/16, indicated, Resident 3 has had some decrease in strength and would benefit from Physical Therapy (PT) and Occupational Therapy (OT) for evaluation and treatment. The physician signed the order, dated 9/29/16. A health status note, dated 9/26/16 at 9:58 am, indicated, a LN documented, no attempts of elopement or wandering this week, uses FWW for mobility, and wishes to discharge home to her apartment at some point. A health status note, dated 10/9/16 at 11:36 pm, a LN documented, found in her room today crying. Resident 3 stated that she wanted to go to a State that euthanized people because she was done. She just wanted to be able to go out and enjoy the sunshine and walk through the garden. She was depressed that she couldn't even open her windows and smell the fresh air. She stated that more than anything, she wanted the wanderguard off and it was all a mistake because she just wanted to be out in the fresh air, she is 90 and doesn't want to run away. She started to cry. Physician was faxed a request to evaluate getting wanderguard off resident's leg. Resident 3 smiled at the idea of open windows and going outside. A physician's notification note in Resident 3's paper chart, dated 10/9/16, indicated Resident 3 informed a LN that she wanted the wanderguard on her right ankle evaluated. The LN documented patient is very depressed and feels she cannot go outside just to sit in the middle area (courtyard) and feel the sun. The physician wrote OK will evaluate. A physician's notification note, dated 10/13/16, four days later, indicated, Resident 3 does not seem to be an elopement risk, alert and oriented times three (person, place,and time), some short-term memory loss, stays in room, calm, and easily redirected. The physician wrote an order to discontinue the wanderguard on 10/13/16, five months after it was initiated. A health status note, dated 10/14/16 at 11:36 pm, indicated, a LN documented, Resident 3 is happy to have the wanderguard off, she is pleasant and forgetful. A health status note, dated 10/17/16 at 3:55 am, indicated, a LN documented, patient on alert charting (frequent resident monitoring) for having the wanderguard removed 10/13/16, there have been no attempts to wander outside of the facility. A health status note, dated 10/19/16 at 11:46 pm, indicated, a LN documented, Resident 3 enjoyed a day outside with her FM. During observations conducted on 10/25/16 at 2:10 pm, 10/25/16 at 3:00 pm, and 10/25/16 at 3:55 pm, in the hallway outside of Resident 3's room, she was asleep in bed. During an interview on 10/25/16 at 4:45 pm, Resident 3 stated, she is more sleepy lately. Resident 3 stated, the doctor told her to get more exercise and she walked out the front door, she sat on the bench by the pillar when staff came out and put something on her ankle. Resident 3 stated, that she could not go out after wanderguard was attached because alarm would go off and staff did not take her out just her FM. During an observation on 10/26/16 at 8:05 am, in hallway outside of Resident 3's room, she was asleep in bed. During an interview on 10/26/16 at 8:09 am, Resident 3's roommate stated, Resident 3 usually eats her breakfast and it is not her pattern to sleep. During an interview and concurrent review on 10/26/16 at 9:25 am, LN C stated, that Resident 3 did not have an elopement incident, but her room was near the entrance. LN C reviewed Resident 3's electronic record and stated the wanderguard was ordered on [DATE], and was discontinued on 10/13/16. During an interview on 10/26/16 at 9:30 am, Certified Nursing Assistant (CNA) L stated, when Resident 3 was admitted to facility, she was confused, went outside and wanderguard put on, but has been fine since. The CNA L stated, it took about a one month for her to adjust and no further attempts to elope and that Resident 3 did not normally take naps throughout the day. During an interview and concurrent review on 10/26/16 at 11:10 am, the Social Services Director (SSD) stated, she was not aware resident had wanderguard during stay and was not aware of any concerns. SSD stated, the notes in electronic record dated 8/12/16, care conference at bedside no concerns, no discussion of wandering. During an interview on 10/26/16 at 12:03 pm, Activities Assistant (AA) stated, residents who have wanderguards are allowed to go out into the courtyard, as it is secure area. AA stated, that it is unfortunate that the alarm sounds (wanderguard alarm). The AA stated, that Resident 3 waits for her daughter, who usually visits daily around 4:00 pm to 5:00 pm The AA states, she knows which residents like to go outside, that it is not a planned scheduled activity and she does not have a list of residents who like to go outside. AA stated, she needs a third person if she plans on take residents outside. The AA stated, the Activities Director is on a leave of absence and there is only one other Activities Assistant besides herself at the facility. During an interview on 10/26/16 at 4:50 pm, Resident 3's FM stated, she felt it was her fault that Resident 3 had the wanderguard initiated after she took her mom for ice cream at the golf course across from the facility and told her she could stay and sit on bench outside the front door and enjoy the sunshine. FM stated, the next day, Resident 3 had wanderguard on her ankle and the nursing supervisor told her it was unsafe for her to be in the front area outside. FM stated, she told the nursing supervisor that is not the case with her mom and wanted wanderguard off her Mom, back in May of 2016. FM stated the nursing supervisor told her no and that the physician told her the wanderguard was precautionary. FM stated, a couple of weeks ago, LN G called her and said her mother was crying and depressed about having the wanderguard on and that she would ask the doctor to evaluate it and discontinue the wanderguard on Resident 3. FM stated, that the alarm on the wanderguard was jarring and her mother did not go out as much as she would have without the wanderguard. FM stated, her mother felt like a prisoner with the wanderguard on, was independent prior to admission to facility and has never had depression. During an observation on 10/27/16 at 8:10 am, in the hallway outside of Resident 3's room, she was asleep in bed. During an interview on 10/27/16 at 2:35 pm, the Director of Nursing (DON) stated, she did not know of any incident of wandering or elopement that resulted in Resident 3 having a wanderguard during her stay at facility. The DON stated, her expectation for the wanderguard use for a resident was to perform an assessment, monitor the resident and revaluate quarterly. The DON stated, the wanderguard should have been care planned as to how many times Resident 3 wandered. The DON stated, that facility does not have a wanderguard policy and stated Resident 3 did not have an initial wanderguard assessment nor an incident report documented when it was initiated.

Based on observation, interview, and record review, the facility failed to ensure one of 15 residents (Resident 14) was provided with sufficient fluid intake to meet her hydration needs. This failure contributed to Resident 14's dehydration, constipation, and urosepsis (a severe urinary tract infection) which required hospitalization and treatment with intravenous (IV, via the vein) fluids, IV antibiotics, and transfer to another acute care hospital, where there was a physician specialist (OBGYN, specializing in women's reproductive health) to determine if Resident 14's bleeding was from her reproductive organs, or from the infection in her urinary system. Findings: Lexicomp online (online medical database), updated 10/26/16, defined dehydration as the term doctors use when the body loses too much water. Losing too much water is a problem, because our bodies need a certain amount of water to work normally .Dehydration can be mild or severe. Mild dehydration doesn't usually cause problems. But if mild dehydration isn't treated, it can get worse. Severe dehydration is a medical emergency and can be life-threatening. Resident 14 was readmitted to the facility from a general acute care hospital on [DATE] with [DIAGNOSES REDACTED]. During an observation on 10/27/16 at 3:35 pm, Resident 14 was lying on her bed with the head slightly elevated (approximately a 25 degree angle). There was a bedside tray table with an empty red plastic cup on it. A sign posted on a wall in Resident 14's room read, Swallow precautions-drink slowly sit at 90 degree angle chin tuck. There was a strong urine smell detected in the room. Resident 14 was wearing an absorbent incontinence brief, and responded to her name, but was unable to answer questions. During a concurrent observation and interview with Licensed Nurse (LN) R on 10/27/16 at 3:35 pm, she stated Resident 14 would drink fluids when prompted. When asked about Resident 14's fluid status, LN R replied she did not know because, without a physician's orders [REDACTED]. During a concurrent interview and record review with the facility's Registered Dietician (RD) on 10/28/16 at 8:24 am, she reviewed the annual Medical Nutrition Therapy Assessment, dated 11/18/15, which revealed that Resident 14 had inadequate/suboptimal oral intake and recommended weekly weights, and 2133-2489 milliliters (ml) of fluid in 24 hours to remain hydrated. When asked how the facility ensured Resident 14 consumed the recommended amount of fluid, the RD replied they would watch for clinical signs and symptoms of dehydration, which included concentrated dark colored urine, UTI's, dry skin and mouth, a blood urea nitrogen (BUN, lab measurement of hydration status via kidney function) above the normal level of 20, constipation, and weight loss. The RD went on to explain that when the facility documented the percent of meals consumed, that did not include the fluids, and staff did not document that information separately unless instructed to by physician order [REDACTED]. A review of Resident 14's nursing progress note, dated 8/5/16, at 9:57 pm, revealed that she had a UTI. A review of Resident 14's nursing progress note, dated 8/25/16 at 1:46 am, revealed that her ring fell off due to weight loss. A fax, dated 9/7/16 (re-faxed and signed by the physician on 9/12/16), indicated that Resident 14 had lost five pounds in less than one week. A review of Resident 14's nursing progress note, dated 9/11/16, revealed that Resident 14 continued to have dark smelly urine. A nursing progress note, dated 9/15/16 at 4:22 am, revealed a lab order to check kidney function. The labs revealed a normal BUN, and a creatinine level of 0.66 (late indicator of dehydration and kidney damage). The nursing progress note, dated 9/15/16 at 2:05 pm, revealed Resident 14's urine continued to be yellow/orange and foul smelling. A nursing note, dated 10/3/16 at 10:29 pm, revealed Resident 14 had decreased urination. A nursing note, dated 10/9/16, at 1:45 pm, revealed that earlier in the day, Resident 14 had an elevated heart rate of 140 beats per minute (a sign of infection and dehydration), her skin was gray and her words did not make sense (indicating a change in mental state). At 6:40 am, Resident 14 was sent via ambulance to the Emergency Department (ED) of a local general acute care hospital for evaluation and treatment. During an interview with the physician on 10/27/16 at 11:45 am, he confirmed that he sent Resident 14 to the hospital. During an interview with LN Q on 10/28/16 at 10:56 am, she stated when Resident 14 developed a UTI, she should have been placed on I&O's and confirmed that she was not. LN Q reviewed the 8/2016, 9/2016, and 10/2016 nursing progress notes, and confirmed that the LN's were not monitoring and documenting Resident 14's specific fluid intake. LN Q confirmed that there was no orders or care plans in place to monitor Resident 14's UTI or dehydration risk. During an interview with the Director of Nursing (DON) on 10/28/16 at 11:45 am, she stated there was no I&O policy, but nursing judgment dictated that I&O monitoring should have been started when a resident had a UTI. The DON further clarified that nursing did not need an order to start I&Os. The DON stated that the broken process contributed to Resident 14's dehydration. A review of the acute care hospital records revealed that when Resident 14 arrived in theER on [DATE], she was diagnosed with [REDACTED]. A review of the ED physician documentation, dated 10/9/16 at 12:43 pm, revealed that upon admittance to the ER, Resident 14's signs of dehydration included a high heart rate, a blood pressure lower than her normal level, and low urine output. Resident 14 had an elevated BUN of 63, an elevated creatinine of 1.55, a potassium of 5.8 (normal is 3.5-5.0), her blood was hemoconcentrated (dehydrated). Additionally, Resident 14's CT of the abdomen showed fecal impaction (blocked up colon,which can be a result of dehydration). Resident 14 was treated with intravenous (IV, via the vein) antibiotics, 1000 milliliter (ml) of IV fluids over an hour, with an additional 2000 ml of IV fluids to follow, then transferred in critical condition to a another acute care hospital for a higher level of care. A review of the second acute care hospitals records indicated that on 10/9/16, Resident 14 was diagnosed with [REDACTED]. Resident 14 stayed in the hospital for three days for treatment and was discharged back to the facility on [DATE].

Based on observation, interview, and record review, the facility failed to provide necessary care and services for one of 20 sampled residents (Resident 13) when: 1. Resident 13 was not provided routine care before (pre) and after (post) [MEDICAL TREATMENT] (a process of filtering the body's blood), as required by the facility's policy and [MEDICAL TREATMENT] care plan, for the period of her [MEDICAL TREATMENT] while in the facility. These failure had the potential that Resident 13 may have developed life threatening complications such as hemorrhage (bleeding out), infection,[MEDICAL CONDITION] (multi-system failure), fluid imbalance, clot formation, stroke and death. 2. Resident 2 was not assessed for weight status over an extended period of 12 months. During this time Resident 2's nutritional care plan was also not reviewed and updated as required. These failures had the potential that Resident 2's nutritional needs may have gone unmet, and that she may have sustained periods of significant weight fluctuations and health risk, without the facility having the knowledge to take action. Findings: 1. A facility provided policy titled Residents Receiving [MEDICAL TREATMENT], dated 10/31/09, read Licensed nurses evaluate the resident's for signs and symptoms of infection/bacteremia, bleeding/hemorrhage, septic shock and/or excess/deficient fluids Licensed Nurses manage [MEDICAL TREATMENT] to maintain patency (unobstructed/open) and adequate blood flow for [MEDICAL TREATMENT] . The center communicates resident information on the day of [MEDICAL TREATMENT] pertinent to receiving therapy. (FRM ) [MEDICAL TREATMENT] Communication Record Plan of care includes directives for managing the resident's needs [MEDICAL CONDITION] Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A [MEDICAL TREATMENT] care plan, dated 3/1/16, read (Resident 13) has RUE (right upper arm) AV (artery to vein) fistula (connection) with shunt (a diversion) [MEDICAL TREATMENT] days Tues, Thurs, Sat Check complete [MEDICAL TREATMENT] communication log record on return from [MEDICAL TREATMENT] for any reports Communicate and send [MEDICAL TREATMENT] Communication record with (Resident 13) to every [MEDICAL TREATMENT] appointment for any reports Coordinate resident's care in collaboration with [MEDICAL TREATMENT] center Monitor access site upon return from [MEDICAL TREATMENT] for bleeding, redness, swelling, pain, and non functioning graft-notify physician as needed Monitor shunt site by palpating (feel) for thrill (vibration of blood flow) and auscultating (listening) for Bruit (sound of blood flow) Notify [MEDICAL TREATMENT] unit and physician if bruit or thrill is absent (as may be a sign of impaired or restricted blood flow or of a blood clot formation) On 8/4/16 at 4:45 pm during a concurrent interview and record review, Medical Records Director (MRD) stated that the record did not contain many of the [MEDICAL TREATMENT] communication records (FRM ) for Resident 13's [MEDICAL TREATMENT] visits. She stated that she files them after the nurses review them, but was unaware that anyone ensured ongoing completion of the [MEDICAL TREATMENT] communication records. She stated she would attempt to find where the records had gone. On 8/5/16 the [MEDICAL TREATMENT] center faxed the missing records to the facility and these were provided by the Director Of Nursing (DON) for review. Evaluation of the [MEDICAL TREATMENT] records for the period of 5/3/16 to 8/4/16, revealed that there were 39 [MEDICAL TREATMENT] records. Of these 39 records, 14 records were generated from the [MEDICAL TREATMENT] center and not the facility. These 14 records did not contain documentation, per care plan, for assessment of Resident 13's pre and post [MEDICAL TREATMENT] status, there was no evaluation of signs or symptoms of infection, dressing condition, bruit or thrill. None of the 39 [MEDICAL TREATMENT] records had any acknowledgement that the facility receiving nurse had received the written information provided by the [MEDICAL TREATMENT] center. A review of Resident 13's licensed nursing progress notes from 5/3/16 to 8/4/16 identified that the nurses had made 32 (14 on the morning shift, 8 on the afternoon shift and 10 on night shift) entries for evaluation of Resident 13's [MEDICAL TREATMENT] site for the period. Of these 32 licensed nurses notes no mention was made of issues brought about by the [MEDICAL TREATMENT] center or of medications given by the [MEDICAL TREATMENT] center. Issues occurring at [MEDICAL TREATMENT], as noted on the [MEDICAL TREATMENT] communication records, that the facility nurse records did not identify having knowledge of included the following, for 5/3/16 to 8/4/16: On 8/4/16, patient passed out; On 7/30/16, left lower leg swelling, patient complaint of infected toe on left foot; On 7/5/16, incontinent, and shortened treatment; On 7/2/16, pain in access site during treatment; On 6/29/16, early off treatment, patient complaint of arm hurting; On 6/25/16, off treatment early patient said tired and would like to go home; On 6/4/16, refused renal supplement drink (sent by facility); On 5/17/16, requested off treatment early, signed AMA (against medical advice); and On 5/11/16, Refused liquid protein supplement. Her lung sounds were diminished at the bases and she had bilateral ankle [MEDICAL CONDITION]. On 8/5/16 at 9:45 am, during a concurrent record review and interview DON stated that the facility [MEDICAL TREATMENT] policy was not followed, nurses should have communicated using the facility form with the [MEDICAL TREATMENT] center, and that the forms should have been maintained in the record. DON also stated that for Resident 13 pre and post [MEDICAL TREATMENT] evaluations were not consistently being done or documented by nursing due to the lack of physician orders [REDACTED]. DON stated that communication from the [MEDICAL TREATMENT] center was not documented as received by the facility. 2. Resident 2's record was reviewed on 8/2/16. Resident 2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident 2's,Weight and Vital Summary indicated that Resident 2 was last weighed on 8/10/15 (101.8 pounds). There were no current weights recorded in the record. A Weight Management policy reviewed on 6/28/16 indicated that residents were weighed on admission, then weekly for four weeks, and then monthly or more frequently determined by the Interdisciplinary Team (IDT, a group of professionals that provide care for the residents). Resident 2's care plan, Potential risk for nutritional decline, dated 11/27/14 was reviewed and included the risks, low [MEDICATION NAME] (protein in the blood) and a low weight below desired range. The care plan included that Resident 2 had multiple episodes of aggressive behavior and refused to be weighed. The goals listed in this care plan were; labs (laboratory blood draw results) would normalize ., will have no significant weight loss ., gain weight greater than 2 lbs in a week with a goal weight of 120 pounds (lbs) Under interventions, initiated 11/4/14, and revised 6/22/16, were pre [MEDICATION NAME] blood test levels (11/6 /15 and revised 6/22/16) There were no new interventions for Resident 2's refusal to obtain her weights and laboratory blood tests A physician's orders [REDACTED]. Complete Blood Count (CBC, a test that identifies blood volume, [MEDICAL CONDITION], infections, the types and amount of blood cells in the blood), Comprehensive Metabolic Panel (CMP, blood test that measures sugar, sodium, potassium, magnesium, calcium (electrolytes essential for muscle and body function) in the blood), Fasting Lipid Panel (evaluates good and bad cholesterol in the blood and the potential for [MEDICAL CONDITION], a build up of fat in the arteries), Hemoglobin A1c (tests sugar levels in the blood over a three month period) The ordered laboratory blood tests were obtained on 5/11/16, which included a low calcium level of 8.5 (normal range 8.6 to 10.4 mg/d; and a low [MEDICATION NAME] level of 3.4 (norm 3.6 to 5.1). There was no evidence that a Fasting Lipid Panel was done on Resident 2 in the past year. No other laboratory results were presented by the end of the survey. During an interview on 8/3/16 at 10:30 am, Resident 2's Physician (also the Medical Director) stated he was not aware that Resident 2's weights had not been obtained in a year and that she was refusing her laboratory blood tests. He stated Resident 2 could not verbally refuse but could be resistive. The Physician confirmed, she (Resident 2) has not been weighed in a year. The Physician stated he felt that the facility did not try enough to obtain Resident 2's weights and when a plan failed they needed to at least try a new approach. On 8/3/16 at 2:30 pm, Material Data Set Nurse (MDS) 1, a Registered Nurse, was interviewed. MDS 1 stated she thought it was the facility policy to obtain monthly weights, and there were no other specified weight orders by the physician for Resident 2. MDS 1 stated no one came to her to ask her to assist them with obtaining Resident 2's weights, and she did not know that Resident 2 had not been weighed in a year. She stated the computer does not allow staff to input that Resident 2 refused her weights. No documented evidence of Resident 2's refusal were presented prior to exiting the facility. On 8/3/16 at 3 pm, MDS 1 stated Resident 2's ,Potential risk for nutritional decline care plan was not followed for obtaining her labs and weights, or revised with new interventions for her refusals of both. MDS 1 stated without the weights or laboratory values the Registered Dietician could not do a clinical assessment of Resident 2's nutritional needs. During an interview with Restorative Nursing Aide (RNA, a certified nursing assistant with additional training in restoring physical mobility) 2 on 8/5/16 at 10 :30 am, he stated he was instructed not to weigh Resident 2 because they could not obtain an accurate weight because of her jerking movements. On 8/5/16 at 11:20 am, The Director of Nursing (DON) was interviewed. She stated she was unaware that Resident 2 had not weighed in the last year. DON stated that Resident 2's care plan was not followed and should have been updated. A Comprehensive Plan of Care policy dated 8/31/12, instructed that resident's care plans shall be re-evaluated and modified as necessary to reflect changes in the care and treatment. The policy instructed that resident care plans would be revised with quarterly and significant change assessments. The MDS Coordinator along with the IDT Team were responsible to evaluate the care plan to ensure the resident is progressing towards the planed goals.

Based on observation, interview and record review the facility failed to prevent an avoidable pressure ulcer (PU) for one of 20 sampled residents (Resident 1) when it did not: 1. Identify and evaluate the resident's specific clinical risk factor of a contracted (impaired mobility due to frozen joints) left hand for PU risk. 2. Define and implement interventions to address PU risk of Resident 1's contracted left hand. 3. Assess and develop interventions when Resident 1 developed a reddened area on 11/20/15, indicative of a pressure point. These failures resulted in Resident 1 developing a Stage IV (Full thickness skin and tissue loss) with bone exposure PU, causing pain, requiring treatments, and intravenous (IV - into a vein) antibiotics. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An observation of Resident 1 and concurrent interview was conducted on 8/2/16, at 2 pm, with licensed nurse (LN) 2. Resident 1's left had was observed to be wrapped in gauze, curled at the wrist and held in a closed fist posture. LN 2 stated Resident 1's left hand and fingers were contracted (stiff with impaired joint mobility). LN 2 stated Resident 1 had recently developed a PU in the palm of her left hand due to pressure from the continuously closed and tightened fist, had required treatments to the PU and weeks of IV antibiotics for a subsequent infection due to the PU. The facility policy titled, Pressure Ulcer, dated 7/23/16, was reviewed. It indicated a pressure ulcer was defined as, Skin alteration caused by unrelieved pressure . a serious medical condition Pressure ulcers are staged according to the extent of tissue destruction and wound depth. The policy defined a Stage I as non blanchable (skin loses redness with pressure; unblanchable skin does not) redness on intact skin and a Stage IV as full thickness skin and tissue loss. The policy indicated prevention was an interdisciplinary (a team of health care professionals who work in a coordinated fashion toward a common goal for the resident) approach, Risk assessment is a key component, and Must be tailored to the specific risk profile of each patient. Assessment includes assessment of Color changes such as redness and signs of pain. The policy indicated interventions to address risk factors would be developed and monitored to validate implementation and effectiveness. The policy also indicated communication between nurses and other members of the team was crucial and staff would regularly collaborate with the therapist for any skin related issues and risks. Resident 1's admission Minimum Data Set, (MDS- a standardized comprehensive assessment of each resident's functional capabilities that helps nursing staff identify health problems) dated 11/9/15, was reviewed. It indicated Resident 1 was severely cognitively (ability to think and reason) impaired and required staff assistance for activities of daily living (ADL). It also indicated Resident 1 had no episodes of rejection of care and no limitation in range of motion that interfered with her daily functions or placed her at risk of injury. It indicated Resident 1 was at risk for PUs, but had none upon admission. The MDS, dated [DATE], was reviewed and it also indicated Resident 1 had no episodes of rejection of care and no limitation in range of motion that interfered with her daily functions or placed her at risk of injury. It also indicated Resident 1 had a Stage II (partial thickness skin loss) and a Stage IV PU. On 8/4/16, at 11:30 am, an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated Resident 1's left hand was severely contracted when she was admitted to the facility and she would have expected the MDS assessments to have documented the impaired mobility of Resident 1's left hand and interventions to have been developed on the care plan. The DON stated MDS assessments help guide care plan development and intervention strategies to reduce not only PU development, but any further decline in function related to impaired mobility. Resident 1's current and discontinued care plans, and MDS assessments of 11/9/15 and 5/11/16 were reviewed with the DON. The care plan titled, Risk for Nutritional Decline, dated 11/9/15, indicated Resident 1 had a left hand contracture. After review of the record, the DON confirmed the two reviewed MDS assessments were incorrect because they did not note Resident 1's left upper extremity impairment affecting her ADL and producing a PU risk and could find no care plans with interventions to address Resident 1's impaired mobility in her contracted left hand prior to the development of a PU in 4/2016. DON stated a Restorative Nursing Assistant (RNA-a specially trained Certified Nurse Assistant that provides restorative and specialized maintenance programs at the direction of nursing, therapy or the physician) program had been being given to Resident 1 prior to her PU development to prevent further decline and minimize risk of PU development in her hand. During an interview on 8/4/16 at 3:10 pm, with the RNA manager (RM), she stated RNA's receive specific instruction on what tasks to perform with residents assigned to the RNA program. RM confirmed the PT recommendation of 1/6/16 through 4/2016 for Resident 1 was specifically for ROM and strengthening of the lower extremities. An interview was conducted on 8/4/16, at 3:45 pm, with RNA 1. RNA 1 stated she had been working consistently with Resident 1 since early 1/2016. RNA explained she assisted and encouraged Resident 1 to perform lower body range of motion and movement per the instructions to RNA. RNA instructions did not include any upper body ROM, and she had not done any ROM with Resident 1's left arm or hand as it was not included in her instructions and she could visually see it was quite impaired when she started working with her in 1/2016. RNA confirmed Resident 1 had complained to her of a painful left hand and she had reported it to nursing. A record review of the RNA progress note dated 4/17/16, untimed, indicated Patient left hand is very stiff and painful. Patient does sometime complain about pain, mostly in her left hand. A record review of the nursing progress notes dated 4/17/16 through 4/25/16 were reviewed, and indicated the following: 4/18/16, at 3:06 pm, occasionally complains of pain (no location). 4/23/16, 11:33 am, initial observation of a pressure area between small and ring finger, complaining of uncomfortable. 4/25/16, at 10:15 am, left Hand is contracted and causing resident pain with touch. When touched resident yells out in pain .states I don't want you to touch it, it hurts too much and after the nurse explained the need for treatment and assessment Resident 1, Yells, I don't care, I would rather have you chop my arm off. A record review of the wound physician notes dated 4/27/16 through 5/25/16, indicated the following: 4/27/16, wound physician initial evaluation, Stage III (full thickness skin loss) PU of the left little finger. 5/11/16, little finger wound progressed to a Stage IV with exposed bone 5/25/16, little finger Stage IV had been diagnosed with [REDACTED]. During an interview on 8/4/16, at 5:15 pm, Certified Nurse Assistant (CNA) 3 stated when he gave a shower to Resident 1, no range of motion (ROM) care was provided. During an interview on 8/5/16, at 8:30 am, Certified Nurse Assistant (CNA) 1 stated that she had been Resident 1's CNA in previous months and she does not now provide or in the past had provided any range of motion (ROM) with Resident 1's left hand in the shower or otherwise. CNA 1 explained, The nurse does that. A record review of the Occupational Therapy Plan of Care, dated 11/3/15, indicated Resident 1 was able to complete up to 75% of normal ROM on her left upper extremity. It also noted Resident 1 had decreased movement in the fingers of her left hand. The OT note of 11/20/15, indicated passive range of motion (PROM - therapist performs with no active participation by the resident) was performed in an attempt to, Increase ROM (Range of Motion), skin redness on little finger and ring finger noted. Reported to nursing. An interview was conducted on 8/5/16, at 9:10 am, with the Nurse Consultant (NC). The NC stated that she would have expected the nurse to conduct an assessment and document findings in the nurse progress notes when the OT reported the reddened area on Resident 1's finger. The NC stated a reported reddened area could be a possible pressure point area or Stage I pressure area and would need nursing assessment and care plan development. The NC confirmed no nursing documentation and no development of a plan of care to prevent decline of function of and prevent a PU to Resident 1's impaired left hand. An interview was conducted on 8/5/16 at 11:30 am, with the Director of Rehabilitation (DOR). DOR explained that occupational therapist (OT) typically deals with upper body and the physical therapist (PT) deals with lower body concerns. The DOR stated that Resident 1 was assessed by therapy during the month of her admission, 11/2015. The DOR stated at that time, Resident 1's first three fingers (thumb, index and middle fingers) were functional and working fairly well, but her little and ring fingers were, curled and impaired. The DOR explained the percentage of normal ROM refers to the extremity (arm) as a global unit, the arm percentage includes the shoulder, elbow, wrist and finger joints. An interview was conducted on 8/5/16, at 11:45 am, with the OT who had worked and discharged Resident 1 from OT services in 11/2015. OT stated of Resident 1's current level of contracture in her left hand, She wasn't that bad when she first came in. OT stated she reported the red areas on Resident 1's fingers to nursing for assessment and follow up as red areas are potential PU or other problems and it is the nursing departments job to assess and develop a plan to address skin concerns and a RNA program for PROM if needed. An interview and concurrent record review of nurse progress notes dated 11/20 through 11/27/15, was conducted with the DON on 8/5/16, at 12:20 pm. The DON confirmed that there was no documentation nursing skin assessments of the two red areas between Resident 1's ring and little fingers as reported by the OT to nursing was present. The DON stated the standardized skin risk assessment record reflected Resident 1 was assessed as the following risk for skin related issues: On 11/2/15, not at risk On 2/3/16, at risk On 5/3/16, at moderate risk Refer to F 278, F 279, F 318 and F 514

Based on observation, interview, record and policy review, the facility failed to implement their infection control program (ICP) designed to help prevent the transmission of infectious diseases and provided a safe and sanitary environment for all the residents who reside in the facility when: 1. The facility placed two residents in a room that was not cleaned to prevent the spread of a contagious infection. (Residents 12 and 13) The housekeeping staff (Hsk), the Licensed Nurse (LN), and the Infection Control Nurse, (ICN) did not ensure room (Rm) C, a room known to have [DIAGNOSES REDACTED]icile (C. diff, a contagious bacterial infection that causes severe diarrhea, and can be life threatening), was cleaned according to the facility policy or procedures to prevent the spread of [DIAGNOSES REDACTED]. Rm C was occupied by a resident who was infected with [DIAGNOSES REDACTED], and when Resident 4 was transferred out of Rm C, Residents 12 and 13, were allowed to move into Rm C, when the room had not been disinfected and cleaned per the facility's policy, to prevent the spread of infection. This failure exposed Residents 12 and 13 and potentially all the residents of the Memory Care Unit (MCU, a 20 bed special unit for residents with memory or behavioral issues related to loss of ability to make decisions and function independently and require 24 hour care from diseases affecting the brain such as stroke, dementia, or Alzheimer's) to [DIAGNOSES REDACTED] from cross contamination. 2. The facility's Infection Control Nurse (ICN) did not provide surveillance, education, and oversight to ensure the nursing and housekeeping staff were educated and aware of the necessary procedures to ensure infection control protocols were followed and the potential for the spread of [DIAGNOSES REDACTED]. infection (CDI) was contained. This failure put the staff and the residents they cared for at risk for exposure to infection and cross contamination. Due to the facility's system failures, the inability of the facility to ensure infection control practices were followed and ensure all residents were safe from cross contamination, and not at risk for exposure of infection(s), an Immediate Jeopardy (IJ) was called on [DATE] at 4:15 pm, with the Administrator (Admin), and the Director of Nurses (DON) who were verbally notified. On at [DATE] at 5:15 pm, the facility provided an acceptable corrective action plan which included: to clean Rm C, educate the nursing and housekeeping staff in the policies and procedures to clean an infected room with [DIAGNOSES REDACTED], and the process to prevent the spread of infection and identify and provide care for infected residents. On [DATE] at 4:50 pm, the IJ's immediacy was removed, in the presence of the Administrator and the DON, when the facility provided evidence of implementation of the above corrective action plan. Additional infection control issues include: 3. The room (Rm D) where Resident 14 lived was not properly cleaned after Resident 14 developed CDI, and Resident 14 developed reoccuring CDI infections. 4. Residents 4 and 15 were both admitted to Rm D, a room known to have a history of [DIAGNOSES REDACTED], and both residents became infected with reoccuring CDI. Resident 15, who was admitted for short term rehab eventually died while at the facility. Findings: 1. During an investigation of a complaint, Resident 4 was interviewed on [DATE], and her record was reviewed. Resident 4 was re-admitted to the facility on [DATE], to Rm D with a [DIAGNOSES REDACTED]. Resident 4 was dependent for her care, and had a Foley catheter (fc, a tube inserted into the bladder to drain urine), was incontinent bowel, and required maximum assistance for all transfers. She was alert, oriented, with intermittent period of confusion, and able to make most of her needs known. Resident 4 had intermittent aggressive behaviors towards staff, would resist care and strike out intermittently. The Nurses Notes indicated on [DATE] Resident 4 developed loose stool (feces), was put on isolation precautions, and a stool sample was sent to the lab to evaluate for [DIAGNOSES REDACTED] infection. On [DATE], the lab notified the facility Resident 4's test was positive for [DIAGNOSES REDACTED] and physician ordered medication ([MEDICATION NAME]) to treat the infection. On [DATE], Resident 4 transferred to a private room. Resident 4 continued to have loose stools, and on [DATE], the physician ordered [MEDICATION NAME] to treat the [DIAGNOSES REDACTED]. infection for another 14 days. The progress notes indicated Resident 4 was later transferred on [DATE] to Room C (a shared room with Resident 12) on the MCU to provide her with a more controlled environment and meet her needs for frequent assistance. On [DATE] at 1 pm, Resident 4 was interviewed. Resident 4 stated she had an, accident and needed to have her briefs changed at this time, because she had a loose bowel movement (bm). Certified Nurses Aide (CNA) D was informed immediately of Residents 4's situation and request to be changed. On [DATE] at 1:25 pm, Licensed Nurse (LN) B was questioned if Resident 4 had any episodes of loose stools or diarrhea, and she stated, Resident 4 had diarrhea after recent antibiotic treatment for [REDACTED]. She stated when the CNA had changed Resident 4 today that she had loose stool, but it was the first one today. LN B was then questioned if Resident 4's physician and the ICN was aware of her intermittent loose stools due to her history of previous episodes of [DIAGNOSES REDACTED], and LN B stated it was not necessary to check her loose stool because Resident 4's stool did not look like it had [DIAGNOSES REDACTED]. A review of the 34 page Nursing Care Plan did not include any information about Resident 4's ,[DATE] [DIAGNOSES REDACTED]. infection, or what steps to take if Resident 4 developed loose stools/diarrhea again. On [DATE] at 10:40 am, the DON confirmed that the Nursing Care Plan did not have any information about Resident 4's [DIAGNOSES REDACTED] infection, and confirmed the finding. She stated, it was missed and it was up to the ICN or charge nurse to update the care plan. On [DATE] at 10 am, Resident 4 was observed in another section of the facility in a private room, Rm E. There was a table with gloves and gowns outside Rm E, the room door was open, and did not have any information posted on it. A review of Resident 4's record contained a fax, dated [DATE], the previous day and indicated, Resident 4 time one episode of diarrhea. Would like to do [DIAGNOSES REDACTED] sample for lab to rule out [DIAGNOSES REDACTED]. Have sample this moment. A physician's orders [REDACTED]. diff. Another physician's orders [REDACTED]. for 14 days for [DIAGNOSES REDACTED]. Contact isolation (a form of isolation in which anyone entering the patient's room and having direct contact with the patient wears gloves and gowns) for 14 days. A review of the MCU census dated [DATE], indicated on [DATE], Resident 13 moved from Rm E into Rm C by the door where Resident 4 had lived, and Resident 12 remained in Rm C by the window. On [DATE] at 10:10 am, LN B was interviewed. She stated she had received a call from the lab on [DATE] at 6 pm, and was informed by the lab that Resident 4's stool test was positive for [DIAGNOSES REDACTED]. She stated she moved Resident 4 and her bed out of Rm C to Rm E, and moved Resident 13 and her bed from Rm E into Rm C. She stated that Resident 12 remained in Rm C by the window. LN B stated Rm C was cleaned prior to Resident 13 moved into Rm C. On [DATE] at 2:40 pm, the Hsk Manager (HM) was asked about the procedure the housekeeper had used to clean Rm C, a [DIAGNOSES REDACTED]. room. She stated she was aware that residents were moved last night ([DATE]), and that the evening Laundry staff, who was also the evening Hsk dealt with the situation. HM stated she had no information or documentation of how Rm C was cleaned but was told, it was done. HM was asked if there was a procedure to verify that Rm C, a room contaminated with [DIAGNOSES REDACTED], had been cleaned per facility policy or procedure. She stated the Hsk fills out a form, titled, Environmental Cleaning Checklist for Isolation Rooms (ECC form). HM was then asked to review the completed ECC form filled out when Rm C was cleaned. She stated after she reviewed the ECC forms, she would not keep them and threw the form away. She stated in the past the ICN would verify the room cleaning but now no one asked to see the forms, for over six months, so she throws them away each day. HM stated the Hsk staff will also inform her when they have cleaned a room. The HM stated the staff that had cleaned Rm C was not at the facility, and she would get further information about how Rm C had been cleaned. A concurrent review of the undated form, titled, ECC, was conducted with HM. The form indicated the room and bathroom was cleaned with 1 to 10 bleach solution (1 part bleach to 10 parts water), and reviewed the steps to take for both an occupied room and terminal cleaning (unoccupied room). There was a space for staff signature and date/time. HM stated the Hsk staff also performed a second step not listed on the ECC form, and applied a germicidal/disinfectant solution, Quat (Quaternary ammonium, a disinfectant), after the bleach solution had dried. HM stated this was done each time when a residents moves out of a room that was infected with [DIAGNOSES REDACTED]. HM stated Quat was not listed on the facility's ECC form, and that she followed the instructions from the contracted company (Health Care Services Group, HCS) she worked for because she knew the proper procedure was to use two solutions, bleach and Quat to clean a room contaminated with [DIAGNOSES REDACTED]. HM stated there had been inservices for the housekeeping and laundry staff in April and [DATE], that included instructions from both the facility and HCS. On [DATE] at 3:10 pm, the ICN was interviewed with the Admin present. She stated she was informed there was a resident with [DIAGNOSES REDACTED], and that the resident was moved to a private room for isolation. She stated she had not yet followed up with Resident 4's transfer, isolation room set-up and the previous room Resident 4 had been in. The ICN stated her role was to provide oversight so that things are done correctly. She stated [DIAGNOSES REDACTED] was a contact precaution isolation, and that gown and gloves were required with resident contact. The ICN was asked about how she monitored or provided oversight about the cleaning of an isolation [DIAGNOSES REDACTED] room. She stated the entire room is deep cleaned by the housekeeping staff on duty, and that she, trusted the Hsk to clean the room per protocol, and sometimes observes the room when they are finished cleaning. The ICN stated, they (Hsk) know what to do and they are well aware of their role. The ICN stated she, had never observed or watched the housekeeping staff clean an isolation room, and has just have gone past, and seen them in there. On [DATE] at 3:13 pm, LN B stated the Hsk staff was required to clean just the, dirty side of a room and the bathroom infected with [DIAGNOSES REDACTED], and not the entire room. She stated the bed cubicle curtains were removed and cleaned, and half of Rm C was cleaned per her directions. LN B stated Resident 4 was moved to Rm E, along with her bed, and Resident 13 was moved with her bed into Rm C. On [DATE] at 3:15 pm, a concurrent observation of Rm E with the ICN was conducted. She verified the outside of the room did not identify that Rm E was now an isolation room, or instructed the type of necessary precautions to prevent the spread of infection, or instructed visitors not to enter the infected room and to check-in at the nurses station for further instruction. The ICN stated all isolation rooms should have a sign posted on the door or by the resident's room to indicate the type of isolation (contact, respiratory or other) and the necessary personal protective equipment (PPE) to be worn to prevent the spread of infection to the residents who lived at the facility and the staff that cared for the residents. The ICN also stated the sign should instruct all visitors to check-in at the nurses station before entering an isolation room. On [DATE] at 3:30 pm, Hsk E was interviewed. She stated she worked the evening shift in laundry and was the evening housekeeper. She was asked to describe how she would terminally clean (a process to disinfect a contaminated room when a resident is transferred out of the infected room) an isolation room. Hsk E stated she would take the privacy curtains around the infected resident's bed down and send them to laundry, and then clean only the infected resident's side of the room from top to bottom. Due to the facility's system failures, the inability of the facility to ensure infection control practices were followed and ensure residents were safe from cross contamination, and not at risk for exposure of infection, an Immediate Jeopardy (IJ) was called on [DATE] at 4:15 pm, with the Administrator (Admin), and the Director of Nurses (DON). On [DATE] at 5:45 pm, HM stated the two housekeeping (Hsk) staff that cleaned Rm C on [DATE], a contaminated room with [DIAGNOSES REDACTED], admitted they did not clean the entire shared room according to facility and housekeeping procedure before the residents were allowed to be moved into the room. HM stated except for the floor and the curtains, half of the contaminated room was cleaned. She stated they did not follow the procedure and the instructions given at the last inservices. HM stated the residents in Rm C (Residents 12 and 13), needed to be removed from the room, and the entire room needed to be disinfected (with bleach and Quat) according to the facility's and HSC's procedure. A review of the facility's policy, dated [DATE], and titled, Managing Patient with [DIAGNOSES REDACTED] Infection, indicated, under the section, Transmission, Ideally, any patient with diarrhea or confirmed [DIAGNOSES REDACTED] Infection (CDI) should be placed in a private room or cohorted (shared) with a similar patient (with the same infection). Equipment Sanitation, use bleach 1 to 10 solution or agent with sporicidal activity. Cubical curtains should be changed at a minimum upon transfer or discharge of all [DIAGNOSES REDACTED] infection (CDI) patients. Recurrent CDI treatment; treatment of [REDACTED]. Development of CDI after Admission: Generally development is considered to be at three days after admission. Precautions may be initiated based on initial ordering for CDI testing or upon a positive result; and based on the facility risk assessment. Precautions may be discontinued after treatment and cessation of symptoms, diarrhea/unformed stools or precautions may be continued for the duration of the facility stay. The policy indicated, Asymptomatic (without symptoms) colonized patient with a positive toxin assay (a lab test to check for CDI) may not require contact precautions; however decisions should be guided by the facility risk assessment since asymptomatically colonized patients can be a source of transmission of [DIAGNOSES REDACTED]. A facility policy titled, Med-Pass dated, ,[DATE], instructed under routine environmental disinfection, A quaternary (quat) ammonia compound can be used for routine disinfection of rooms for residents with [DIAGNOSES REDACTED]. An undated policy, titled, Healthcare Services Group Isolation Cleaning [DIAGNOSES REDACTED]., indicated, cleaning procedures to protect from the spread of infection. All surfaces, horizontal in resident rooms will be disinfected twice. First cleaning will be with the recommended bleach solutions, 1 part bleach to 10 part water. The second cleaning will be with the recommended germicide. After cleaning with bleach, you need to wait 10 minutes and then disinfect the area with germicide (Quat). On [DATE] at 6:50 pm, Hsk F stated she worked on [DATE], and was asked by Hsk G to assist her with the cleaning an isolation room at 6:30 pm, Rm C, a shared resident two bed room. She stated she came with bleach water (1:10) and a wall washer. They took down the curtains, and cleaned Rm C's A bed and area around the bed as an isolation room, and the other side of the room, the B bed, bedside stand and table were not cleaned. She stated LN B told them to clean half the room and the bathroom. Hsk F stated she knew the correct procedure to clean a contaminated room, and that the whole room needed to be, deep cleaned. She stated the resident's were moved, and everything hurried, and things were missed. On [DATE] at 6:55 pm, Hsk G stated LN B instructed to clean the bathroom, and only half of Rm C, the side by the door, (A bed area). She stated they did things quickly, and cleaned half the room as if contaminated and the other half of the room was cleaned as a regular room without the special cleaning normally used for an isolation contaminated room. On [DATE] at 11:30 am, the ICN was interviewed with the DON present. She stated she had started at the facility in ,[DATE] as the wound nurse, and was then asked to be the ICN. She stated that she did not have any previous experience in infection control and the nurse consultant gave her some information. She stated she had many binders with references and infection control procedures, but she had not had the time to review them and she then pointed to a bookshelf with binders and manuals. She stated she filled out the infection control log (ICL), on a daily basis, and at the end of the month entered the information from the ICL into a computer program, and then the corporate office could see the facility's information. She stated that she also gave the information to the DON each month. The ICN stated she reported daily to a meeting where all the Department Heads were present and sometimes she would hear about a resident with an infection and she would then follow-up. She stated the nurses did not always keep her in the loop and that it was difficult to get the necessary information from the nurses to do her job. She stated she was not involved with antibiotic stewardship (the process to educate and ensure the proper use of antibiotics only when necessary, and avoid the over use of antibiotics) in the facility, and did not work with the facility's pharmacist to review the resident's antibiotic use and infections. The ICN further stated she was never oriented by the facility to the ICN position, and often when there was a problem, she did not receive the help she needed to effectively do her job. She stated she was not aware of any Quality Improvement Projects (QIP) at the facility, or any specific projects for infection control prevention. She also stated she had never attended a QIP meeting and could not demonstrate how she was maintaining an effective infection control program. The ICN was asked to review her infection surveillance and tracking of resident infections or symptoms. She stated if a resident developed an infection within 72 hours, it was considered that it was acquired from the community or hospital, and if the resident developed symptoms 48 to 72 hours after admission to the facility, then it was considered facility acquired. She stated it depended on the situation. She stated information was difficult to obtain to establish when a resident had actually developed symptoms or an infection to complete the ICL due to the lack of cooperation from the nurses. The ICN stated she was aware of the Center of Disease Control (CDC) to get infection control information, but she was not skilled working with a computer, and had not looked into CDC resources to help her with her role as the ICN. The DON also concurrently confirmed the above information stated by the ICN. 3. Resident 14's record was reviewed. Resident 14 was admitted to Rm D on [DATE] for the treatment of [REDACTED]. The most recent MDS, dated [DATE], showed that Resident 14 was usually continent (had fairly good control) of her bowels. On [DATE], Resident 14 aquired a [DIAGNOSES REDACTED] infection as evidenced by laboratory testing of her stool, and treatment was started. Further record review of Resident 14's infection history obtained from history and physical reports (H&Ps), progress notes and lab results, revealed that she was again positive and treated for [REDACTED]. On [DATE], she was moved out of Rm D and into Rm Y but nursing documentation reflected that sometime in [DATE], she was back in Rm D and on isolation again for [DIAGNOSES REDACTED]. In the interim, two other residents were at different times, were directly admitted into Rm D with Resident 14 and contracted [DIAGNOSES REDACTED] as well. (Refer to Residents 4 and 15 under findings 4a and 4b) On [DATE], after four recurring [DIAGNOSES REDACTED] infections, Resident 14 was sent to the hospital for a fecal transplant (a procedure where healthy stool is implanted into the colon to replace the stool infected with [DIAGNOSES REDACTED], an alternative treatment when the infection does not respond to antibiotics). On [DATE], Resident 14 tested positive for [DIAGNOSES REDACTED] for the fifth time. According to the facility's policy and procedure titled, Clostridium Difficile Associated Diarrhea revised [DATE], residents who have or are suspected to have [DIAGNOSES REDACTED] are to be placed in private rooms. If a private room is not available then another resident with the same [DIAGNOSES REDACTED] infection can be placed together. The policy further indicated that [DIAGNOSES REDACTED] infections can spread from person to person on contaminated equipment. On [DATE] at 2:50 pm, Hks F was interviewed. Hks F stated that she had many times observed Resident 14 removing her brief (adult diaper) and smearing feces on the toilet seat and floor of the bathroom which was shared with the other resident in the room. Hsk F stated she had observed CNA staff throwing Resident 14's soiled briefs on the floor of her room and putting soiled briefs in the shared bathroom trash can as well. Hsk F stated that she had brought this poor infection control practice to Registered Nurse Supervisor (RNS) G's attention, but nothing changed. Hsk F confirmed that Resident 14's wheelchair was never disinfected while she had [DIAGNOSES REDACTED] and stated, there was no plan for disinfecting wheelchairs. On [DATE] at 10:10 am, an interview and concurrent record review was conducted with RNS G. RNS G confirmed that Resident 14 had aquired [DIAGNOSES REDACTED] at the facility and was treated for [REDACTED]. RNS G stated that it was not until [DATE], that she recognized that the facility had not been properly cleaning Rm D and Resident 14's wheelchair, which could also have [DIAGNOSES REDACTED] spores on it, was never disinfected. 4. a Resident 4's record was reviewed. Resident 4 was admitted directly to Rm D on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 4 was frequently incontinent (no control) of her bowels and had a catheter (tube in the bladder to drain urine). Further record review obtained from H&P reports, progress notes and lab results, revealed that Resident 4 acquired a [DIAGNOSES REDACTED] infection on [DATE], less than four months after being placed in Rm D. On [DATE], Resident 4 was moved out of Rm D and into Rm Z. On [DATE], she was moved from Rm Z to Rm V. On [DATE], she was moved from Rm V to Rm U and then to Rm W, on that same day, with no documented rationale. According to the facility's policy and procedure titled, Clostridium Difficile Associated Diarrhea revised [DATE], toilet facilities ideally should not be shared among residents with [DIAGNOSES REDACTED] infections. Because [DIAGNOSES REDACTED] is a spore-forming bacteria (the spore provides extra protection against disinfectants), shared toilets must be disinfected with bleach (alcohol and standard disinfectants won't kill [DIAGNOSES REDACTED] spores), after each use. On [DATE] at 10:10 am, an interview and concurrent record review was conducted with RNS G. RNS G confirmed that Resident 4, who did not have [DIAGNOSES REDACTED], was directly admitted into Rm D while Resident 14, who had [DIAGNOSES REDACTED] twice, also resided in that room. RNS G stated that Resident 4 aquired the [DIAGNOSES REDACTED] infection at the facility and that both residents had shared the bathroom. RNS G stated, they should have been given bedside commodes to help prevent the spread of the [DIAGNOSES REDACTED] infection. RNS G had no explanation for the numerous room changes, I don't have any say in that and confirmed changing rooms increased the risk of spreading the [DIAGNOSES REDACTED] infection in the facility. 4.b Resident 15's record was reviewed. Resident 15 was a [AGE] year old admitted directly to Rm D on [DATE], the day after Resident 4 who had [DIAGNOSES REDACTED] was moved out and Resident 14 who had [DIAGNOSES REDACTED] four times was still in the room. Resident 15 was admitted for short term intravenous (IV) antibiotic therapy for a bone infection (osteo[DIAGNOSES REDACTED]) following the surgical amputation of a toe and rehab. Resident 15 had a peripherally inserted central catheter (PICC line, an IV for antibiotics with a long tube inserted in the upper arm so it can reach a larger vein near the heart). PICC lines are required to be covered with sterile (no germs) dressings which are changed weekly, under sterile conditions. Resident 15's plan was to return home. The most recent MDS, dated [DATE], showed that Resident 15 was fully oriented, required one person to physically assist her with hygiene, and incontinent of both bowel and bladder. According to the facility's policy and procedure titled, Clostridium Difficile Associated Diarrhea revised [DATE], residents who are at high risk for contracting [DIAGNOSES REDACTED] are; of advanced age, using antibiotics, have serious underlying medical conditions, and/or are immunocompromised (arthritis, cancer, allergies [REDACTED]. Both Resident 4 and 15 met the above criteria for being at high risk to contract [DIAGNOSES REDACTED], if exposed to it. According to the facility's policy titled, Disease Specific Information revised [DATE], it is only acceptable to cohort (share rooms with) another resident with a [DIAGNOSES REDACTED] resident if they are at low risk for contracting [DIAGNOSES REDACTED] and do not have lines (IV's), tubes (catheters), or drains, and have their own toilet or a bedside commode. Further record review obtained from H&P reports, progress notes and lab results, revealed that on [DATE], after three weeks in Rm D, Resident 15 was moved to Rm T, with no documented reason. On [DATE], she was moved to Rm S and RNS D documented, Resident is being moved to room (S) for precaution measure, her old roommate has a new [DIAGNOSES REDACTED]. Resident 15's roommate was Resident 14 and the new diagnosis was [DIAGNOSES REDACTED] although that was not, new because Resident 14 had already had [DIAGNOSES REDACTED] four times by that date. On [DATE], less than one month after being in Rm D, Resident 15 acquired the [DIAGNOSES REDACTED] infection, lost 27 pounds, developed a pressure ulcer, and died on [DATE]. On [DATE] at 3 pm, the Case Manager (CM, a Registered Nurse) was interviewed. The CM explained that her duties were to oversee and ensure that the short term rehab residents received quality care from the time of admission until they were discharged . The CM was not able to explain how the facility determined that it was appropriate to admit Resident 15 who was of advanced age, had an infection, on antibiotics, and had a PICC line, directly into Rm D, a room known to have on-going [DIAGNOSES REDACTED] contamination for over six months. The CM could not explain how Resident 15's sterile dressing changes could safety be done to her PICC line, in a room contaminated with [DIAGNOSES REDACTED]. The CM had no explanation why the facility placed Resident 4, who had [DIAGNOSES REDACTED] and a catheter, in Rm D. The CM stated that she had not agreed with placing Resident 15 in Rm D, but confirmed she had not advocated for her, it was talked about many times but my hands were tied. The CM stated that those, which she would not name, who were assigning residents to rooms upon admission at that time, no longer worked at the facility. The CM had no explanation for or who had directed the multilple room changes that were made for Residents 14, 4, and 15 and stated, I had no say. The CM could not define her roll in the prevention of the spread of [DIAGNOSES REDACTED] infections in the facility, but stated no other resident should have ever been admitted into Rm D with Resident 14.

Based on observation, interview, record review and facility policy review, the facility failed to ensure that all residents were adequately supervised, safe and secure, received appropriate assessment and treatment when an accident/injury had occurred, and that all elopements (leaving the facility without telling anyone) were reported to the appropriate agencies when: 1. Four residents who lived in the facility's locked Alzheimer's (type of dementia that affects memory and the ability to think clearly) unit, Reflections, were allowed repeatedly to be outside of the facility unsupervised by staff for extended periods of time. This repeated failure put residents at risk for injury, elopement, exposure to the elements and the public. (Residents 3, 9, 10, and 11) 2. Resident 17 fell and sustained severe injuries, and was not assessed by the nurse for her injuries for over three and half hours later. Resident 17 was eventually sent to the emergency room (ER), received sutures (stitches) for her head laceration (deep cut), and an x-ray indicated she also had a fractured (broken) neck. 3. Resident 16, a resident who was at high risk for falls, fell and was not evaluated by the nurse until three days later, for his injuries related to the fall, and the completion of his fall risk assessment (an assessment done within the first 24 hours of admission to establish if a resident is at risk for falls) was completed on the fifth day after his fall. Resident 16's physician and the responsible party was not notified of Resident 16's fall. These failures put the residents at risk for health complications and delayed healing from their injuries. On 7/27/15, Resident 3, a [AGE] year old with dementia (brain disease that affects memory and ability to think clearly) who resided in the facility's locked Alzheimer's unit was found by facility staff at 5:15 pm, in the facility's parking lot near the street. She had attempted to elope and, find a way home. At the time of her elopement, the temperature was considered, hot and the temperature was 98 degrees Fahrenheit (F). Resident 3 was, tired, hot and very thirsty when she was found. On 8/19/15, during the complaint investigation of the above elopement, it was discovered that the facility had continued with the same practice, and allowed four residents (Residents 3, 9, 10 and 11) who lived in the locked unit, to be left outside of the facility without direct supervision. On 8/19/15 at 1:40 pm, an Immediate Jeopardy (IJ) was called with the Acting Administrator (AAdmin), the Director of Nurses (DON) and the Social Service Director (SSD), due to the continued risk to the health and safety of residents. On 8/19/15 at 4:35 pm, a plan of action was accepted. The IJ's immediacy was removed on 8/20/15 at 1:15 pm, with the AAdmin, DON, and Nurse Consultant (NC), after the facility had demonstrated evidence of facility compliance to ensure the health and safety of the residents who resided in the locked Memory Care Unit, and the entire facility. The facility ensured that all the residents in the Memory Care Unit would remain on the unit under staff supervision and only be allowed in outside couryards that were secured by a fence. The facility stopped using the Reflections courtyard until the fence had been replaced. All staff were in-serviced on elopement risk and care plans revised for Residents 3, 9, 10 and 11 and all residents on the Reflections unit to reflect that direct staff supervision was needed. Findings: 1. On 8/19/15 at 10 am, an interview and concurrent observation of the locked unit inside and outside area was conducted with Licensed Nurse (LN) B. She stated that four residents (Residents 3, 9, 10, and 11) were allowed currently to go outside of the locked unit and, sit by a tree to get some fresh air. LN B stated previously there had been a fenced and locked courtyard outside the unit, and that the fence had been removed months ago. She stated there were four residents who wanted to go outside, and they had never wandered away, until Resident 3 had wandered, on 7/27/15. LN B stated the residents were trusted to wait for the staff or would knock on the door (that was locked from the inside) and staff would let them back in. She stated the staff would check on the residents frequently and bring them water while they were outside. The locked unit was observed inside and outside concurrently with LN B. There were two doors that exited to the outside of the facility (where the courtyard had been), and both doors had alarms that would sound if opened without entering a code first. Both doors were locked from the outside and could not be opened unless the staff opened them from the inside. Outside, there was a sidewalk and the ground was uneven when off the sidewalk. There was a tree approximately 60 feet away from the back doors where there were two chairs and a small portable table. Access to the tree area required to be off the sidewalk. LN B stated the residents from the unit like to be under the tree. The ground around the tree was uneven. LN B stated on 7/27/15 Resident 3 had become confused, and went the wrong way while she was trying to get back inside the unit. LN B stated that the staff now watch her, closely from an inside window, when she goes outside of the locked unit. LN B stated that she still trusted the other three residents, Residents 9, 10, and 11, to return to the unit when they are, done being outside. LN B stated the four residents had been out earlier that day, and she sat at a table and watched them from a window inside the unit. LN B stated that she worked with two other Certified Nurses Aides (CNA) during her shift. LN B was asked what would happen if while she or her staff was watching the residents who were outside the unit and she/they were called away to help with other residents or an emergency. She stated they would have to respond to residents or emergency needs, and the residents who were outside and away from the locked unit would no longer be watched. LN B stated the residents wanted to go outside for fresh air, and when the fence was removed from the previously enclosed courtyard/patio, the residents became, bored with being inside. She stated the Director of Nurses (DON) instructed she did not want the residents from the locked unit outside of the facility, and that she (LN B) had then asked the Previous Administrator (PAdmin) and he gave her permission to let the residents from the unit go outside. LN B stated the only resident who did not follow the directions not to wander off was Resident 3, and the other three residents knew how to go to the door and knock at the outside door to come back in. On 8/19/15 at 11 am, LN B stated that Resident 11 had improved behavior with the medications she received for her depression and behaviors, and that she could, trust Resident 11 not to try to leave when she was outside of the locked unit. On 8/19/15 at 12:37 pm, an interview with the Social Service Director (SSD) and LN B was conducted. The SSD stated it was not acceptable for residents on a locked unit to be outside unsupervised, in an unsecured area. SSD stated there were other outside courtyards or secured outside areas to use. LN B stated there were not enough staff to do one to one supervision when residents were away from the unit or outside of the unit. LN B acknowledged the residents (Resident 3, 9, 10 and 11) who were allowed to be outside of the locked unit were monitored from the inside of the facility looking out a window. Confidential Admin (CA) B, C and D interviews were conducted on 8/19/15. CA B stated the PAdmin did not follow the recommendations from the corporate office or the Professional Consultants who advised and made recommendations for the Administration to follow. CA B stated PAdmin had stated he did not have to do what had been recommended for facility operations, quality performance or staff concerns. If a resident was found outside of the building, that it was not considered an elopement because the resident was still on the facility property and therefore did not require reporting the elopement to the Ombudsman's office or the CDPH office. CA C stated residents from the locked unit were, left outside exposed to the parking lot, weather, and anything out there without supervision. CA C stated residents who had wandered away had to be guided back to the unit's back door, knock on the door, and staff would let the resident(s) back in. CA D stated PAdmin did not respond to the elopement issues or show concern about the safety of the residents who lived in the facility's locked unit. CA D stated he/she had been informed by LN B it was acceptable to have the residents from the locked unit outside the facility and that PAdmin had approved residents from the locked unit to be outside. During multiple confidential staff interviews (CSI) conducted on 8/19 and 8/20/15 the following was reported: CSI E stated residents from the locked unit had been found multiple times by different facility staff (who did not work in the locked unit) and even a non-staff person, when the residents had wandered away, undetected, from the outside of the locked unit and needed to be returned to the unit when they tried to get back in or became confused how to return to the inside of the facility. CSI F stated the residents from the unit would be seen outside for extended periods of time (over an hour and longer), without supervision. CSI F and G stated when they returned residents back to the locked unit that LN B would become upset with them (the staff who had returned the resident) and say that the residents were safe, and they (the locked unit staff) had checked on the residents who were allowed outside. CSI G stated on 7/27/15, the day Resident 3 had eloped, Resident 3 was seen alone outside the locked unit at 1:15 pm. CSI G stated she had heard over four hours later, that Resident 3 was found by staff wandering on the other side of the building in the parking lot. On 8/19/15, CSI H stated Resident 3 was found outside on 7/27/15 after 5:30 pm, in the parking lot near the street in her wheelchair. CSI H stated Resident 3 appeared unhurt but was, very tired, hot and thirsty. CSI H stated it was very hot outside when Resident 3 was found and the temperature was around 100 degrees F. According to Accuweather (a weather reporting company) the high temperature on 7/27/15 was 98 degrees F. On 8/19/15 at 1:15 pm, the DON stated that she had repeatedly told LN B not to allow any of the residents who lived in the locked unit outside without facility staff present. The DON stated the residents were in a locked unit for a reason and allowing them to go outside unattended had been unacceptable. She stated LN B would not listen and did what she wanted to do, and allowed the residents (Residents 3, 9, 10 and 11) to go outside of the facility in an unsecured area, even after Resident 3 had eloped on 7/27/15, and was found by other staff on the other side of the building near the street. The DON stated residents had been found outside by facility staff who had wandered away from the outside area and had to be guided back by staff, multiple times. The DON also stated that Previous Admin A had stated when the residents had wandered away from the facility (elopement), that they were still considered safe, and it was not considered, an elopement because they were found on the facility's property. On 8/19/15 at 1:30 pm, the AAdmin stated none of the facility residents should be outside the facility without direct supervision. He stated the current practice of allowing residents outside the locked unit was not acceptable, against corporate policy and rules, and was unsafe. He stated there were two courtyards/patio areas at the facility that were secure and safe without access to the parking lot and street. On 8/19/15 at 1:40 pm, an Immediate Jeopardy (IJ) was called with the Acting Administrator (AAdmin), the Director of Nurses (DON) and the Social Service Director (SSD), due to the continued risk to the health and safety of residents. On 8/20/15 at 11:20 am, during an observation and interview, Resident 10 was observed pushing his wheelchair backwards with his right foot. He stated he wanted to go outside and there was no television on. He stated when he goes outside he does not go to the, other side and stays close. In an interview on 8/20/15 at 11:45 am, CNA D stated she had questioned if it was appropriate for residents (Resident 3, 9, 10 and 11) to be outside of the locked unit in a unsecured area. CNA D stated the other CNAs and LN B said residents were was allowed outside in the unsecured area. She stated in the past she was concerned for Resident 10's safety because he pushes his wheelchair backwards, and has rolled over the edge of the sidewalk, and got stuck when he was outside. CNA D also stated that when Resident 3 was informed it was time to come back into the locked unit, that she had behaviors and resisted coming back inside. CNA D and stated that Resident 3 and 10 would stay outside all day if they could. On 8/27/15 at 1 pm, LN C stated residents on the locked unit were not allowed outside unsupervised. LN C stated she had informed LN B the residents were not safe left outside and they needed to come inside. She stated that she would instruct the CNAs to bring the residents (Resident 3, 9, 10 and 11) back into the facility and not to take them out when she was the nurse in charge. LN C stated the DON had instructed the facility nurses that residents were not permitted to go outside of the facility in an unsecured area, and that the residents could not leave the unit without direct supervision. LN C stated she followed her DON's orders, and ensured the residents remained on the unit or were supervised if they went to other unsecured areas of the facility. LN C stated even after Resident 3's 7/27/15 elopement, she was shocked to find Resident 3 outside on multiple occasions when she came to work, and that LN B still allowed her and the other residents (Residents 9,10 and 11) outside without direct supervision. Residents 3, 9, 10, and 11 records were reviewed. a. Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/24/14, Resident 3's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated, 8/15/15 indicated her memory was impaired. The Care Plan (CP) initiated on 9/18/14, and revised on 7/21/15, indicated Focus: altered thought process due to dementia, unable to make own decisions, will send SOS messages on scraps of paper. Confusion, seems normal to thought but after sitting and talking with her she loses her thoughts and says confusing things. Will try to send messages or put little signs up that she needs help and wants to fly out of this place. Will write signs that state help me . help me. The CP goal included: . Will remain safe. Interventions dated 9/18/14 and revised on 3/5/15 indicated: . Allow resident to sit outside with supervision. Responsible position: LN (Licensed Nurse) and CNA (Certified Nursing Assistant). A CP dated 4/21/14 and revised on 6/4/15, indicated, Focus: Resident 3 has a behavior problem related to repetitive statements and beliefs of discharging to home. She, had exit behavior on 6/14/14, was able to remove wanderguard (ankle alarm that sounds when triggered) on right ankle and was found outside the facility's door, on facility grounds. She, leaves notes on doors and windows that she is held hostage and wants to go home, . stating, Help me, Help me. The Goals indicated: Resident will have no evidence of behavior problems, repetitive statements dated 8/26/15. Resident will have fewer episodes of exit behavior weekly by target date, 8/26/15. The Interventions included: Keep eye out for notes (date initiated 6/4/15. Monitor behavior episodes. Responsible position: LN, CNA, and Activities. A Progress Note for Resident 3, dated 6/29/15 at 8:56 pm indicated, Resident asked to sit outside for fresh air or she might throw up. After dinner, the nurse sat with her outside for couple of minutes when resident started to wheel self further away and refused to turn around to go inside. As I tried to wheel her back inside, she came up from her chair and sat down on ground in front of wheelchair, refusing to budge. With help of CNA we were able to sit her in her chair and bring her inside. A Weekly Progress Note dated, 7/2/15, documented by LN B, indicated, Elopement attempts daily if not supervised. Another Progress Note dated, 7/23/15, documented by LN B indicated, Resident tries to think of ways to elope daily. Leaves notes around unit about going home. Needs redirection with activities or sitting out in patio so that she will forget about going home. A Progress Note dated 7/24/15, documented by LN G, indicated, Resident wanted to go outside for a while. It took her a few minutes. she kept saying why she is not able to go home and that she has a house. When told resident we needed to come inside, she did not want to go. She wanted to stay there. I told her that I was not going to leave her there by herself due to there was not fence. She said that she has been there before. Tried to explain that I was in charge if any thing happened out there, it was on me. The Progress Notes for Resident 3 dated 7/27/15 at 6:32 pm indicated, Resident stated she needed air that she was feeling sick. We let her go outside and she headed down driveway toward road. CNA brought her back. Stated she was sick and going home. Refused 5:30 pm meds this evening. Signed by LN B. The CP dated 7/27/15, indicated, Focus: Resident will wander off patio premises due to dementia, states wants fresh air, states nauseous and wants fresh air, looses sight of her boundaries on patio. Confused at times where she is at. Goal: Will be monitored outside on the patio. Intervention: Supervision while outside on patio. Remind her of her boundaries on patio. Responsible position: LN and CNA. b. Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 9 was on the locked unit. The CP for Resident 9, dated 4/13/14 indicated, Focus: Resident is an elopement risk/wanderer due to past history and confusion. Goal: safety will be maintained. Resident will not leave facility unattended. Intervention: Address wandering behavior by walking with or attempt to redirect from inappropriate area. Complete elopement risk assessment. Distract from wandering by offering pleasant diversions, structured activities, food, conversations, televisions, book and socialization with others. Photograph of resident in wander notebook . Apply wanderguard upon leaving unit and remove when she returns to unit. Alarms on unit doors. Identification band (ID) applied, but if removed by resident photos used for ID. Responsible position: LN, CNA and Activities. A CP for Resident 9, dated 4/13/14 indicated, Resident has impaired cognitive function/dementia or impaired thought processes due to short term memory loss, impaired decision making, dementia, difficulty making decisions. Poor attention span. Poor safety awareness, poor decision making. The CP Goal: Resident will develop skills to cope with cognitive decline and maintain safety. Interventions included: Keep routine consistent in order to decrease confusion. Honor resident choices whenever possible. Responsible position: LN and CNA. A CP dated 11/23/14 indicated, Resident 9 was at risk for falls due to impaired cognitive function, gait/balance problems, diminished safety awareness secondary to [DIAGNOSES REDACTED]. On 8/20/15 at 12:30 pm, Resident 9 was interviewed. She stated she has issues with the residents who lived at the facility on the other side of the locked doors where she lived. She stated when she went outside, she knows to come back, and does not want any trouble. c. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10 was on the locked unit. The CP for Resident 10 dated 3/21/15, revised on 4/5/15, indicated, Focus: Resident 10 used a wheelchair for mobility, tried to go out exit doors, wanted to go outdoor into patio, even when weather was bad. Goal: resident will have no incidents of elopement. Interventions: Staff will be aware of resident' location through out the shift. Take resident out to the patio when weather is good. Wanderguard place on Resident as precaution to elopement. Responsible position: LN, CNA, and RN (Registered Nurse). A CP dated 4/13/15, indicated, Focus: elopement risk due to wanting to go outside and sit. History of elopement in the past. Fluctuating cognitive levels. Early dementia. Goal: Will not leave facility unattended. Interventions: complete elopement risk, . wanderguard applied when leaving the unit. Responsible position: LN and RN. A CP dated 5/11/15, indicated, Focus: likes things done as soon as possible, no patience to wait for things, very demanding to staff and other residents. The CP dated 4/1/15, indicated, Focus: at risk for falls due to balance and decreased safety awareness, decrease mobility of left hand and arm, fall risk due to poor safety awareness at times. cognition levels fluctuate, does not always pay attention to surroundings. Goal: will be free of falls. d. Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 11 was on the locked unit. The 8/15 physician's orders [REDACTED]. A CP for Resident 11 dated, 8/21/14, indicated, Focus: Resident is an elopement risk. Has decreased cognition, decreased safety awareness. History of wandering, verbalization wanting to leave. Pain, disorientation to place, exit seeking, history of attempts to leave the facility unattended, intrusive wandering, wandering aimlessly. Goal: Will not leave the facility unattended. Interventions: Address wandering behavior by walking with or attempt to redirect from inappropriate area. Assess for fall risk. Disguise exits: cover door knobs and handles, tape floor. Distract from wandering. Evaluate the need for additional supervision. Identify pattern of wandering if purposeful, aimless, escapist or looking for something? Provide structured activities including . walking inside and outside. A CP dated, 1/20/15, indicated, Focus: depression and anger. Sundowners syndrome (causes increased confusion and aggression in the evening and night time). Throws things, . angry if she does not get her way. Interventions: Monitor behaviors, take for walk outdoors. Sit with her on patio on warm days. The CP dated, 5/7/15 and revised on 7/22/15, indicated, Focus: risk for elopement due to dementia. Goal: resident will have no elopement while at the facility. Interventions: activities, re-direct resident as needed when exit seeking. Wanderguard applied to resident's wheelchair for resident's safety on 5/7/14. The facility's policy dated 11/11/13, titled, Patient Elopement, indicated the following: Elopement is when a patient leaves the premises or a safe area without authorization. A patient who leaves a safe area may be at risk of, or have the potential to experience, heat or cold exposure, dehydration and/or other medical complications, drownings, or being struck by a motor vehicle. Revise care plan and implement interventions . Document date and time resident was found, assessment, document notification of physician, family/responsible party, ED, DON. Document notification of State Agency if appropriate. Complete Event Worksheet. Determine what area of egress the resident used. Resident's expression of what he/she was trying to do or where they were trying to go, going home, going to their room. What the resident was doing prior to the event such as: . was the resident in an activity outside the facility. Based on . cause, develop interventions and implement to reduce or prevent reoccurrence of an elopement event. Revise the resident care plan. Quality Assessment/Quality improvement (QI); Develop and implement an action plan on concerns identified. Follow-up and evaluate action taken for effectiveness. Document action taken in Performance Improvement (PI) minutes. Document PI Committee's action taken to reduce or prevent elopement through the PI process. The facility's policy dated 4/28/11, titled, Accidents and Supervision to Prevent Accidents, indicated the following: The Center (Facility) Admin directs resources to address safety concerns. Facility provides training to employee for identification of potential hazards, prevention of accidents, . The facility identifies hazards and risk through which the facility becomes aware of potential hazards in the resident environment and the risk of a patient (resident) having an avoidable accident. Supervision: . If assessment for falls, cognitive loss/dementia, restraints, and psychotropic drug use are triggered, assess the need of assistive devices, care plan and implement preventative measures resident's at risk for falls. Assess residents to determine whether supervision is necessary. Patient (Resident) Risks and Environmental Hazards: Resident's vulnerability to environmental hazards is based on risk factors including: functional status, medical condition, cognitive abilities, mood and health. Falls: Proper action following a fall includes: Ascertaining if there were injuries, and providing treatment as necessary. Addressing the factors for the fall. Revising the resident's care plan and/or center practices. Unsafe Wandering or Elopement: . addresses both safety and evaluates a resident exhibiting non-goal-directed or aimless wanders to identify root causes. Unsafe wandering may occur when the resident at risk enters an area that is physically hazardous or that contains potential safety hazard. Unsafe wandering and elopement can be associated with falls and related injuries. Facility clearly defines the mechanisms and procedure that can help to mitigate the risk of a resident from leaving a safe area without staff supervision. Residents are assessed for the risk of elopement. Residents identified at risk have interventions in their care plan for elopement. Physical Plant Hazards: Facility . identify when elements in the environment pose hazards . become hazardous when a vulnerable resident interacts with them: Temporary hazards such as construction . other natural material found in the . outdoor environment. Investigate accidents and develop an action plan to prevent from reoccurring. Track and analyze accidents to . determine patterns. 2. Resident 17's record was reviewed. Resident 17 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 17 was alert, oriented, and required the extensive assistance of one person to physically assist her with transfers and walking. On 2/11/15 at 9 am, an observation and interview was conducted with Resident 17. Resident 17 stated that she had sustained a fractured neck and broken left ankle from previous falls and in October she fell out of her wheelchair during an activity outing and had to have stitches to her right forehead. Resident 17 was observed wearing an orthopedic boot (enable walking with a reinforced heel, while keeping the immobilized area stable) to her left ankle and had a one inch healed scar on her right forehead. On 2/13/15 at 3:25 pm, the Activity Director (AD) was interviewed. The AD confirmed that on 10/29/14, she had taken Resident 17, along with four other residents, to lunch at a restaurant about 10 minutes away from the facility. At 1:30 pm, Resident 17 was sitting in her wheelchair on the sidewalk waiting to get back into the van, she was just five feet from me. At that point, Resident 17's wheelchair rolled off of the sidewalk, tipped over and she landed in the dirt. The AD stated that she and a Certified Nursing Assistant (CNA) picked Resident 17 up and put her back into her wheelchair, and stated no licensed nurse (an RN or LVN) was there to evaluate Resident 17. The AD stated that the CNA got the first aid kit from the van and applied gauze to Resident 17's forehead which was, bleeding pretty good. The AD stated that she drove Resident 17 back to the facility about a half hour later. The AD stated that she had no policy or procedures to follow when a resident was injured during an activity outside of the facility, and confirmed that licensed nurses are not present during those activities. The facility's policy titled, Fall Response and Management dated 7/16/14, was reviewed. The policy directed that when a resident has been injured from a fall, don't move the resident until he/she has been examined and call for assistance. Nursing Progress Notes dated 10/29/14, confirmed that Resident 17 was returned to the facility at 2 pm, and that she was not evaluated or examined by a Registered Nurse (RN). At 5:40 pm, three and a half hours later, Licensed Vocational Nurse (LN) C sent Resident 17 to the emergency room . Resident 17 required stitches to her right forehead and an x-ray was done which showed a neck fracture. Resident 17 returned to the facility at 11:55 pm, with a dressing to her right forehead and a bruised right hand and knee and was, stiff and sore from her fall. On 2/20/15 at 10 am, LN C stated during an interview that she did not remember this incident. On 2/13/15 at 4 pm, an interview and concurrent record review was conducted with the Previous Administrator (PAdmin). The PAdmin stated that the facility does not have a policy or procedure which directs how to handle emergencies and/or injuries when residents are out of the facility for activities and added, we need one. The PAdmin stated that neither the AD or the CNA were qualified to decide what treatment Resident 17 needed after she fell , and he would have expected them to call 911. The PAdmin stated, a nurse should be going on these outings. The PAdmin confirmed that Resident 17 was not physically assessed or examined by an RN after she fell and should have been. The PAdmin confirmed that Resident 17's emergency medical treatment was delayed for over three hours, which was not acceptable. 3. Resident 16's record was reviewed. Resident 16 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 16 had severe memory loss, did not walk, and required one person to physically assist him with transfers, toileting, and hygiene. A review of Nursing Progress Notes dated 5/9/15 at 1 am, revealed that, a noise was heard down the hall and Resident 16 was found sitting on his bedroom floor with a reddened left hip and left upper back. Further record review reflected that an RN had not evaluated or examined Resident 16 after his fall with injury until 5/12/15, three days later. The admission nursing assessment, which showed that Resident 16's fall risk score was high was also not completed until after 10 pm on 5/12/15, the night before he discharged to home. There was no documented evidence that Resident 16's physician or wife had been notified of his fall and injuries. There was no monitoring done of his reddened back and hip. On 7/23/15 at 3 pm, an interview and concurrent record review

Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was free of a significant medication error when Resident 1 was administered four doses of [MEDICATION NAME] (a medication used to stabilize moods) over a 24 hour period that was 10 times the dose that the physician prescribed for the resident. Resident 1 became increasingly unresponsive, resulting in him needing to be admitted to the hospital for toxic [MEDICAL CONDITION] (brain malfunction caused by toxins on the brain) secondary to incidental [MEDICATION NAME] overdose. Findings: During an observation on 5/21/14 at 10:45 am, Resident 1 was in bed, alert but confused. Per the record review, Resident 1, a [AGE] year old, was admitted in December, 2013 with multiple [DIAGNOSES REDACTED]. He received [MEDICATION NAME] 250 milligrams (mgs) twice per day since 1/21/14, as a mood stabilizer manifested by mood swings. On 5/7/14, the physician changed the [MEDICATION NAME] 250 mgs order from twice per day to three times per day. In an interview with RN 1 (Registered Nurse) on 5/21/14 at 12:45 pm, she confirmed that she obtained a verbal order from the physician to increase Resident 1's [MEDICATION NAME] from 250 mgs twice per day to three times per day. She stated that she wrote the new order on both the Medication Administration Record [REDACTED]. She acknowledged that the way she wrote the order in her handwriting "could be misunderstood." When the pharmacist called LVN A, the medication nurse, to clarify if the [MEDICATION NAME] dosage was 250 mgs or 2500 mgs, RN 1 remembers that she was very busy and that she could not recall the exact conversation, but remembers stating, "if it was supposed to be 2500 mgs we would change it on our end." RN 1 added in a written statement, "I cannot state for certainty that I added the extra zero to the MAR indicated [REDACTED]." During an interview with LVN A on 6/21/14 at 1:45 pm, she stated that she remembered asking the charge RN (RN 1) to clarify the order because it "seemed like a lot. The label on the medication bottle read 2500 mgs but the MAR indicated [REDACTED]. Later, RN 1 came over to LVN A's medication cart and told LVN A that "they had increased the [MEDICATION NAME] because they had changed the dosage of the antidepressant." It was then that LVN A saw RN 1 write an extra zero to the [MEDICATION NAME] order of 250 mgs on the MAR, making it 2500 mgs. LVN A confirmed that she administered three of the four doses of [MEDICATION NAME] 2500 mgs, on 5/8/14 at 2:00 pm and 5/9/14 at 8:00 am and at 2:00 pm. LVN B stated in an interview on 6/21/14 at 2:30 pm, that she did get report from LVN A on 5/8/14 that Resident 1's [MEDICATION NAME] order had been increased and that LVN A did get it clarified from charge nurse RN 1. LVN B did give one dose of [MEDICATION NAME] 2500 mgs on 5/8/14 at 8:00 pm. It was the following day, 5/9/14 after dinner that Resident 1's wife complained that Resident 1 was "sleepy but was able to be aroused." LVN B became concerned so she faxed a medication clarification for the [MEDICATION NAME] dosage to the physician. The physician responded that the dose was supposed to be 250 mgs three times per day and that the [MEDICATION NAME] dose should never be above 1000 mgs. According to LVN B, she called the physician to report the medication error and the decision was made to send Resident 1 to the hospital. In a review of the medical record on 5/21/14, the History and Physical from the hospital, a documented medical examination by the physician, indicated that the resident was admitted to the hospital with [REDACTED]." The notes read, "He was brought to the emergency department due to an inadvertent overdose of [MEDICATION NAME]. The patient initially had altered level of consciousness and was unresponsive. Here he was somnolent (sleeping for unusually long periods of time) and had ataxia (a neurological sign of a lack of voluntary coordination of muscle movements) on finger-to-nose testing. Initial [MEDICATION NAME] level here was high at 125." The final [DIAGNOSES REDACTED]." In an interview with the manager of the pharmacy company that supplies medications to the facility, on 5/21/14 at 12:15 pm, she stated that the pharmacist that received the new order misread the order to be [MEDICATION NAME] 2500 mgs instead of 250 mgs. The pharmacy labeled the medication bottle, "[MEDICATION NAME] sodium ([MEDICATION NAME]) 500 mg tab SR 24 hours. Take 5 tablets -2500 mg by mouth three times daily." During an interview with Pharmacist A on 6/25/14 at 10:00 am, she stated, "I did not call the facility to clarify the order. I was focused on doing the math to fill the order correctly. I would have been the one to call the facility and I did not." The facility failed to ensure that Resident 1 was free of a significant medication error which resulted in him being overmedicated with 10 times the ordered dose of [MEDICATION NAME] for a period of 24 hours that included four administrations of the incorrect dose. He became somnolent and unresponsive which resulted in him being admitted to the hospital for toxic [MEDICAL CONDITION] secondary to incidental [MEDICATION NAME] overdose.

Based on interview and record review, the facility failed to ensure sufficient fluids were provided, and nursing staff failed to follow physician's orders and provide the necessary care and services to prevent a decline in the health status of one of three sampled residents (Resident 1) when she was at risk for dehydration (excessive loss of body water that occurs when the amount of fluids leaving the body is greater than the amount of fluids taken in the body) due to an intestinal bacteria (C. Difficile) that causes severe watery diarrhea and dehydration. Resident 1's physician gave specific instructions to either hydrate (provide fluids) her with 2 liters (L) of oral fluids a day, or begin hydration with intravenous (IV-through a vein to the blood stream) fluids, and neither were sufficiently done. This failure contributed to the development of dehydration and a decline in Resident 1's condition, requiring transfer to a hospital for higher level of care for the treatment of [REDACTED]. Findings: Resident 1's record was reviewed. Resident 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], Resident 1 was readmitted to the facility after a five day hospital stay for the treatment of [REDACTED].diff. The Minimum Data Set (MDS), an assessment tool, dated [DATE], showed that Resident 1 was cognitively intact and required supervision with eating. On [DATE], Resident 1's physician ordered; "2 liters (2,000 cubic centimeters (cc)) of fluids, preferably some of which are re-hydrating fluids like Gatorade, per 24 hrs (hours)-must be documented OR start an IV with N.S. (normal saline-a liquid salt water solution) at 100 cc's per hour FAX me if IVF (IV Fluids) have to be started." A review of Resident 1's [DATE], Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On [DATE], Resident 1 had taken a 24 hour total of 1580 cc's of fluids. An IV was not started and the physician was not notified that Resident 1 had consumed less than the ordered 2000 cc's (2L) of fluids. On [DATE], Resident 1 took 600 cc's of fluid on the evening shift. The day and night shift recordings were blank. An IV was not started and the physician was not notified. On [DATE], Resident 1 took 700 cc's of fluids between the evening and night shift. The day shift recording was blank. An IV was not started and the physician was not notified. On [DATE], Resident 1 took 1820 cc's in 24 hours. An IV was not started and the physician was not notified. On [DATE], the MAR indicated see I&O sheet" (a record of how much actual fluid is taken in and how much is excreted out, through urination, diarrhea, or vomiting, and shows if fluid balance is adequate). There was no evidence of an "I&O" sheet in Resident 1's record. Resident 1's physician ordered the facility to ensure that Resident 1 consumed/received 2,000 cc's of fluid every day. For a five day period, this equaled 10,000 cc's. The documentation indicated that Resident 1 received 5,290 cc's in five days, only about half of the fluids that were ordered by the physician. Nursing notes contained no assessment or description of Resident 1's hydration status on ,[DATE], ,[DATE], ,[DATE], and [DATE]. There was no evidence that nursing efforts had been made to ensure that Resident 1 took the 2L (2000 cc's) of fluids that her physician had ordered. There was no evidence to demonstrate that nursing staff had recognized that an IV should have been started on [DATE], the first day that Resident 1 had taken an insufficient amount of fluids. On [DATE] at 6:30 pm, Resident 1's physician ordered, "N.S. IV at 120 cc per hour x 2" (means give 2 liters which equals 2 "bags"). After five days of insufficient fluid intake, Resident 1's physician had to reorder the IV fluids. Resident 1's MAR indicated [REDACTED].S. was infused, but by the next morning, [DATE] at 5:45 am, Resident 1's IV had come out and she did not receive the second liter. On [DATE] at 9:15 am, Resident 1's physician was notified that the administration of IV fluids in the amount that was ordered, had been unsuccessful. Resident 1's physician then gave orders to transfer Resident 1 to the hospital for the treatment of [REDACTED].diff with dehydration." The hospital's Discharge Summary, dated [DATE], reflected that Resident 1 was admitted to the hospital on [DATE], and given "several boluses" (bags of IV fluids given quickly) and died on [DATE], from pneumonia, acute [MEDICAL CONDITION], and C.diff. On [DATE] at 10:15 am, Registered Nurse (RN) A was interviewed. RN A stated that she had taken care of Resident 1 on the morning of [DATE], and when Resident 1 "pulled her IV out" it was not restarted because, "I could not find a vein." On [DATE] at 11 am, the Director of Nursing (DON) was interviewed. The DON stated that there was no "I&O" record for Resident 1. The DON stated that nursing staff had inadequately monitored and recorded Resident 1's intake of fluids and confirmed that Resident 1 had not received the 2L of fluids, as the physician had ordered. The DON confirmed that nursing staff had not followed the physician ordered treatment for [REDACTED].

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services for two of six residents having pressure sores in a sample of 22 residents. (Residents 5 and 8) After becoming aware that Residents 5 and 8 had developed pressure sores, the facility delayed providing treatment, which resulted in the worsening of the pressure sores and the development of new ones. *Resident 5 had acquired a pressure sore to her left heel that was identified by Physical Therapy Aide (PTA) J on 12/15/11. Treatment was not initiated until six days later, on 12/21/11, at which time the left heel sore had increased in size and a second pressure sore had developed to Resident 5's right heel. *Resident 8 had acquired a pressure sore to her right ring finger that was identified by Occupational Therapist (OT) L on 2/23/12. Treatment was not initiated until 3/7/12, sixteen days later, at which time two pressure sores were discovered. This failure had the potential to cause the residents unnecessary pain, infection, and a decreased level of well being. Findings: 1. On 3/6/12, Resident 5's record was reviewed. Resident 5 had been readmitted to the facility on [DATE] after having a left [MEDICAL CONDITION] repaired. The Minimum Data Set (MDS, an assessment tool) dated 12/22/11, reflected that Resident 5 had no memory or decision making problems, was dependent on staff to be repositioned in bed and to transfer, and was at risk for the development of pressure sores, but had none on admission. On 12/15/11, PTA J documented on a Rehab Addendum Note that Resident 5 had a pressure sore to her left heel that had "drainage" and that "nursing was notified." There were no pressure sores found on the resident's right heel. No further nursing documentation was found in Resident 5's record regarding the one pressure sore. However, six days later on 12/21/11, a physician's orders [REDACTED]. On 3/8/12 at 8:40 am in an interview, PTA J recalled that in the early afternoon on 12/15/11, she had visited Resident 5 to administer her therapeutic exercise treatment. PTA J stated that she lifted Resident 5's left foot and her sock was wet. PTA J stated that she immediately notified the nurse, LVN C. PTA J stated that LVN C accompanied her to Resident 5's room. LVN C removed the sock from Resident 5's left foot which exposed, "a blister on the left heel about the size of a quarter that was leaking fluid from one side." LVN C said he would notify the treatment nurse. On 3/8/12 at 11:30 am in a telephone interview, LVN C stated that he had no recall of any events surrounding the discovery of pressure sore on Resident 5's left heel. On 12/21/11, the 'Weekly Pressure Ulcer Condition Report' for Resident 5 was initiated and reflected that the left heel pressure sore measured 14.4 centimeters (cm). One inch equals 2.5 cm; therefore, the sore was approximately 5.7 inches in diameter. The right heel sore measured less than 4 square cm or less than one inch around. The report required that measurements were obtained by multiplying the length by the width of the sore. The pressure sores were determined to be Stage IV (four) pressure sores with eschar (dead tissue) covering 75%-100% of Resident 5's left and right heels. A Stage IV pressure sore has thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. On 3/6/12 at 2 pm, an observation of Resident 5's heels and concurrent interview was conducted with Wound Care Nurse (B). Resident 5's left heel had a round sore that was black (necrotic) in color, now approximately the size of a half dollar (worsened), and the edges had lifted which exposed a bed of loose yellow tissue. The right heel contained a round pressure sore, about the size of a pea, and was light brown in color. Wound Care Nurse B stated that she first became aware of Resident 5's pressure sores on 12/21/11, when "a CNA told me." During an interview on 3/8/12 at 9:10 am, the Director of Nursing (DON) confirmed that PTA J had provided documentation identifying Resident 5 as having a pressure sore on her left heel on 12/15/11. DON confirmed that treatment orders by Resident 5's physician had not been obtained until 12/21/11, six days later, and that there were orders to treat two pressure sores, one on Resident 5's left heel and one on her right heel. 2. On 12/11/08, Resident 8 was admitted with [DIAGNOSES REDACTED]. The 9/11 Minimum Data Set (MDS) assessment tool indicated that Resident 8 had a change in condition, which resulted in weight loss, muscle spasm and contractures in the legs, right arm, hand, and fingers in 9/11. The facility's MDS, dated [DATE], identified that Resident 8 was dependent on staff for all personal care needs, transfers and to move in bed. Resident 8 was also identified to be at risk for developing pressure sores due to immobility. On 3/5/12 at 2 pm, Resident 8 was observed seated in her wheelchair with pillow supports. Resident 8 had contractures of both upper extremities; the right extremity was worse. The right arm at the elbow, right wrist, and fingers were contracted. The fingers of the right hand were closed tightly together and slanted. Two of the finger tips were contracted in an upward position. Resident 8 had a right hand palm protector splint (a splint that fits into the hand to keep the contracted fingers from pressing into the palm of the hand) with a strap that went across the top of the hand. On 3/7/12 at 11 am, CNA O was observed providing care for Resident 8. CNA O stated he had just showered Resident 8 and was applying Resident 8's right hand palm protector splint. Resident 8's right ring (3rd) finger, on the side next to the little (4th) finger, had an open pressure sore that was over 1/2 inch long and 1/2 inches wide. The center of the pressure sore was white, slightly depressed, and measured 1/8 inch in diameter. CNA O stated that he was unaware that Resident 8 had skin breakdown between her fingers. A review of the occupational therapy (OT) notes, dated 2/15/12 through 2/29/12, indicated that Resident 8 received therapy for positioning. The therapist documented that Resident 8's had progressive worsening of hyper-tonicity (tight spasm) through her body and was worse in the right upper extremity with a contracted right elbow, hand and fingers. The weekly OT notes written by OT L, dated 2/22/12, indicated that Resident 8 was fitted with a new palm protector splint. A document, dated 2/23/12, and titled, "Rehab Addendum Note indicated the following: "...palm protector in hand. Small open area medial anterior to PIP joint (the side of the knuckle on the ring finger, next to the little finger). Reported to nursing who stated they are aware." On 2/29/12, Resident 8 was discharged from therapy. The facility's weekly "Skin Check Sheet," dated 2/17, and 2/24/12, indicated that Resident 8 skin was "intact" and had "no new skin issues." The next "Skin Check Sheet," dated 3/3/12, indicated that Resident 8 only had an abrasion on her right elbow. On 3/8/12 at 8:20 am, OT L was interviewed. OT L stated that Resident 8's hand was severely contracted and her fingers were tightly pressed together. She recalled that on 2/23/12, she had observed "blood" on Resident 8's right ring finger, wiped it off, and "saw a small, slightly larger than a pen point skin opening by the PIP joint." OT L stated she had informed LVN C about the open skin area on Resident 8's finger. On 3/7/12 at 2:30 pm, LVN C and the charge nurse, LVN A, stated that they were unaware that Resident 8 had a pressure sore on her right ring finger on 2/23/12, and unaware that the pressure sore was currently present on her finger. On 3/7/12 at 2:35 pm, the facility's wound care nurse (WCN) stated that she had not been informed that Resident 8 had a pressure sore on her right ring finger. On 3/7/12 at 4 pm, Resident 8's right hand was observed with WCN B. During the concurrent observation, WCN B found a second pressure sore on 3/7/12. WCN B identified that both, the right ring finger and the small finger, had open skin areas from the pressure of being pressed together. WCN took measurements of the ring finger pressure sore which was 1 centimeter (cm) long and 0.7 cm wide, and the little finger was 0.8 cm long and 1.3 cm wide. WCN B stated that both pressure sores were Stage II pressure sores, which is a damaged or lost outer layer of skin with part of the underlying layer of skin. On 3/7/12 at 5 :30 pm, Resident 8's physician ordered treatment for [REDACTED]. A Weekly Pressure Ulcer Condition Report, dated 3/7/12, had been completed by WCN B. On 3/8/12 at 3 pm, an interview and concurrent record review with the Director of Nurses (DON) was conducted. The DON acknowledged the above findings that Resident 8 had a pressure sore, that was identified on 2/23/12 by therapy, did not receive treatment until 3/7/12, 16 days later. She acknowledged that the original pressure sore had become worse and a second pressure sore had developed.