Every finding on record at Redding Post Acute

Based on observation, interview, and record review the facility failed to maintain food safety requirements regarding a clean and sanitary kitchen environment for food preparation for all residents who consumed food prepared by the kitchen when:1.The perimeter of the kitchen's walls at the height of the counters and below including pipes, drains, electrical coverings, and flooring were spackled with a filth buildup of food particles and adhered grime.2.The paint was chipped, peeling and worn out on walls, sink, and around flooring.3.The exterior of the stove/oven was unclean with cooked on grime.4.Rolling dollies with buckets of kitchen supplies were dirty with black filth.5.The walk-in refrigerator's flooring was found to be buckled and uneven with a vein of rust expanding down the un-joined seam of the flooring, and when cleaned the rust material puddled from under and between the seam spreading on the flooring.These failures had the potential to incite harmful growth of unhealthy microorganisms resulting in food borne illness amongst the residents that consume products produced from the kitchen which could lead to sickness and disease.During a review of the facility's policy titled, General Cleaning of Food & Nutrition Services Department, dated 2023, indicated, Floors.must be.maintained in good condition. Walls and ceilings must be washed thoroughly.Heavily soiled surfaces must be cleaned.as necessary.During a review of the facility's policy titled, Sanitation, dated 2023, indicated, All .equipment shall be kept clean, maintained in good repair .During an observation of the kitchen on 2/17/26 at 11:00 am, the perimeter walls in the kitchen were observed; multiple areas on the walls approximately the height of the counters, and under the counters to and including the floor, as well as pipes and electrical coverings were spackled with filth buildup of food particles and adhered grime, paint chipped, peeling and worn out on walls, sink, and around flooring, the exterior sides of the stove/ oven was dirty displaying cooked on grime, rolling dollies with buckets of kitchen supplies were dirty with black filth, and the flooring in the walk-in refrigerator was buckled and uneven with the seam down the middle open and unjoined which revealed a vein of rust that puddled along the floor with the cleaning process.During a concurrent observation and interview on 2/17/26 at 11:30 am, with the Food and Nutrition Manager (FNM), in the kitchen, FNM confirms the kitchen's perimeter walls, pipes and drains, electrical coverings, flooring, rolling dollies, and exterior of the stove was dirty, paint was chipped, peeling and worn out on walls, sink, and around flooring, and the flooring in the walk-in refrigerator was buckled, uneven, and has a vein of rust running down the mid-seam that oozes out and puddles when cleaned.During an interview on 2/18/26 at 3:30 pm, with the Registered Dietician (RD), in the Director of Nursing's (DON) office. The RD confirmed the kitchen was dirty and she had written reports about its lack of general cleanliness and sanitation.

Based on observation, interview, and record review the facility failed to maintain a safe environment for all residents who use the shower room when a spray bottle of bleach cleaner solution was observed in shower rooms one and two on wing three within unlocked cabinets above the toilets amongst toiletry essentials.This failure had the potential to result in physical injury and negatively impact the overall health for residents utilizing the common space.During a review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, Residents are provided with a safe.environment.During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated Revised July 2017, indicated, Resident safety.and assistance to prevent accidents are facility wide priorities.During an observation on 2/17/26 at 2:00 pm, on wing three, shower rooms one and two were observed to have spray bottles of bleach in unlocked cabinets above the toilet, mirroring one from the other. No lock was visually present or available.During a concurrent observation and interview on 2/17/26 at 2:05 pm, with Assistance Director of Nursing (ADON), in shower room two on wing three, the unlocked cabinet is observed with the spray bleach bottle present, with the additional observation of a photo provided by the surveyor of shower room one on wing three of the unlocked cabinet with the spray bleach bottle present. ADON stated shower room one is used as a shower/tub for residents while shower room two is used as a storage room for equipment by staff. Only shower room one affects the residents as a safety concern, but both rooms are set up in the exact same manner, so that appears to be the normal setup. We usually do lock the cabinets, but neither was locked now, and no lock is visually present.During a concurrent observation and interview on 2/19/26 at 09:00 am, with Director of Nursing (DON), in DON's office, DON confirms the cabinet should have a lock on the door, when there is a chemical such as bleach stored, for resident safety.During an interview on 2/19/26 at 10:30 am, with Administrator (Adm), in Adm office, Adm stated the spray bottle of bleach should be in a locked cabinet.During an interview on 2/19/26 at 2:30 pm, with Housekeeping/Laundry Supervisor (HLS), in hall outside of HLS office, HLS stated the spray bleach is used by Certified Nursing Assistants (CNA) and nursing staff. Housekeeping keeps it in the cupboards in the shower rooms for their cleaning use. HLS confirms the spray bottle of bleach should be in a locked cabinet.

Based on observation, interview, and record review, the facility failed to ensure one of six residents sampled (Resident 36), right to a dignified existence was protected when her eyeglasses were not clean.This failure could have resulted in a decrease in Resident 36's vision and emotional well-being.Findings:Review of a facility policy titled, Resident Rights revised October 2025, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence.Review of Resident 36's medical record indicated that she was admitted to the facility on [DATE] with diagnoses including muscle weakness, and difficulty walking.Review of Resident 36's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) section B (part of MDS pertaining to vision) dated 1/8/26 indicated that Resident 36 wore glasses. Review of Resident 36's MDS Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) indicated a score of 10 out of 15 indicating moderate cognitive impairment.During a concurrent observation and interview on 2/17/26 at 11:33 am, with Resident 36, Resident 36's eyeglasses were covered in smears. Resident 36 indicated that she had told staff that her eyeglasses needed to be cleaned, but no one cleaned them and that it made it hard for her to see.During an interview on 2/18/26 at 4:13 pm, with the Director of Nursing (DON), the DON indicated that her expectation is that staff clean residents' eyeglasses daily.

Based on observation, interview, and record review the facility failed to ensure the care plan was revised for one of 18 sampled residents (Resident 6) when the care plan did not include the use of TED hose (tight socks that prevent swelling in the legs).This failure had the potential to cause severe leg swelling, delayed healing and an increased risk of blood clots, which could place this resident at risk for negative clinical outcomes.During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated April 2009, indicated, goals and objectives are reviewed and/or revised: when the resident has been readmitted to the facility from a hospital or rehabilitation stay.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including which professional services are responsible for each element of care.Resident 6 was admitted originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses that included pulmonary edema (buildup of excess fluid in the lungs), irregular heart rate, and muscle weakness.A review of Resident 6's Minimum Data Set (MDS, a standardized resident assessment), dated 2/17/26, indicated that Resident 6 was cognitively intact (able to think and reason).During a concurrent observation and interview on 2/17/26 at 10:30 am, with Resident 6 in her room, Resident 6 said, I am supposed to have TED hose on when I get out of bed every morning.During an interview on 2/17/26 at 11:16 am, with Certified Nurse Assistant (CNA) 1, CNA 1 said, I have been working with [Resident 6] for two months and didn't know she was supposed to get TED hose on in the mornings.During a concurrent interview and record review on 2/17/26 at 11:47 am, with Licensed Nurse (LN) 1, Resident 6's, Medication Administration Record (MAR), dated February 2026 was reviewed. The MAR indicated on 2/17/26 for the 9:00 am administration time, TED hose were applied to Resident 6's legs by CNA 1. LN 1 confirmed he charted the TED hose were on Resident 6 when they were not. During a concurrent observation and interview on 2/18/26 at 9:15 am, with Resident 6 in her room, Resident 6 said, They did not put my TED hose on this morning when I got up.During a concurrent interview and record review on 2/18/26 at 9:40 am, with LN 2, Resident 6's MAR was reviewed. The MAR indicated, LN 2 had charted that Resident 6 had TED hose on when she did not. LN 2 said, There was a CNA in the room getting her dressed and I assumed the CNA put them on. I did not see them on [Resident 6].During a concurrent interview and record review on 2/18/26 at 4:00 pm, with Director of Nursing (DON), Resident 6's MAR dated February 2026, was reviewed. The MAR indicated that LN's 1 and 2 both documented that CNA's had applied the TED hose on Resident 6. DON confirmed the TED hose were not applied.During a concurrent interview and record review on 2/18/26 at 4:11 p.m. with DON, Resident 6's Care plan dated 11/17/26 was reviewed, DON confirmed the application of TED hose had been resolved on the previous Care Plan and they did not revise the current Care Plan to include the application of the TED hose by the CNA.During a concurrent interview and record review on 2/18/26 at 4:13 pm, with DON, Resident 6's physician orders dated 2/18/26, were reviewed. DON confirmed there was an order for the CNA to place TED hose on Resident 6 in the morning and take them off in the evening. During a review of Resident 6's, Physician Order (PO), dated 3/6/24 and 2/8/26, the PO indicated, Ensure CNA has applied the below the knee TED hose daily - On in am and off in pm.During a review of Resident 6's MAR, dated February 2026, the MAR indicated, Resident 6 had pitting edema (swelling where pressing the skin creates an indication about 3-4 millimeters deep that takes up to 15 seconds to disappear) in her legs for 11 out of 17 days.

Based on observation, interview, and record review, the facility failed to ensure the safe storage of medications for two of five residents sampled (Resident 64 and Resident 85) when:1. Resident 64's medications from home were stored in paper bags in a cabinet in the medication room (a locked room in a healthcare facility used to store, organize, and prepare medications).2. Resident 85's medication was stored loose in a medication cup (a small, disposable cup used for measuring and administering medications) in the medication cart (a wheeled cart used in healthcare to store, medications, and supplies).These failures could have resulted in lost medications or medication errors for Resident 64 and Resident 85.Findings:1.Review of a facility policy titled, Medications Brought to the Facility by the Resident/Family revised April 2007, indicated The facility shall ordinarily not permit residents and families to bring medications into the facility.Review of Resident 64's medical record indicated that she was admitted to the facility on [DATE] with diagnoses which included lower leg fracture (broken bone) and diabetes (high blood sugar).Review of Resident 64's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) indicated that Resident 64 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out 15 indicating she had good decision making ability.During a concurrent observation and interview on 2/18/26 at 12:20 pm, with Licensed Nurse (LN) 3, in the medication room, stapled store pharmacy bags were observed on the top, right hand side of a locked cabinet. LN 3 indicated that the stapled store pharmacy bags had Resident 64's name on them. LN 3 indicated that the facility did not usually store outside medications inside a store's pharmacy bag or inside a cabinet in the medication room and that he did not know how it got there.During an interview on 2/18/26 at 1:38 pm, with the Director of Nursing (DON), the DON indicated that when a family member brings in medication from home the facility asks them to take the medications back home. The DON indicated that she did not know why Resident 64's medications were stored in store pharmacy bags in a cabinet inside the medication room and they should not be stored there.2. Review of a facility policy titled, Storage of Medications revised November 2020 indicated, 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.Review of Resident 85's medical record indicated that she was admitted to the facility on [DATE] with diagnoses which included depression and high blood pressure.Review of Resident 85's BIMS score of 13 out 15 indicating she had good decision making ability.During a concurrent observation and interview on 2/18/26 at 12:30 pm, of medication cart 1 with LN 2, upon opening the top righthand drawer of the medication cart there was a medication cup with pills inside of it sitting in the drawer. LN 2 indicated that the medications were for Resident 85 who would not take them earlier in the day.During an interview on 2/18/26 at 1:45 pm, with the DON indicated that no medications should be kept in a medication cup inside the medication cart and that when a resident will not take medications, the medications should be disposed of.

Based on interview and record review, the facility failed to follow up and promptly report the results of an x-ray for one of three sampled residents (Resident 1) who were sampled due to falls in the facility when Resident 1 fell on her knee and her physician ordered an x-ray and the facility did not recognize they had not received the x-ray results for two days. This resulted in Resident 1 experiencing unnecessary severe left knee pain and a delay in treatment for two days due to a broken bone. This delay in treatment had the potential for Resident 1 to experience ongoing severe pain and negatively impact her physical, emotional, and psychosocial well-being. Findings: Review of a facility policy titled,Change in a Resident's Condition or Status dated July 2024, indicated 1. The nurse will notify in a reasonable timely manner the resident's attending physician or physician on call when there has been a(an): e. need to transfer the resident to a hospital/treatment center. Review of admission records for Resident 1 indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a condition that changes how the brain works and can cause confusion, memory loss, and loss of consciousness), fracture of right ankle and fibula (a long bone in the lower leg positioned on the outer side of the calf), effusion right knee (an abnormal accumulation of fluid in a body cavity or body tissues), asthma, acute respiratory failure, dementia (loss of memory and ability to make sound decisions), dysphagia (difficulty swallowing), difficulty walking, muscle weakness, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness). Review of Resident 1's BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) Admission assessment dated [DATE], showed a score of 8 out of 15, which indicated Resident 1 had a moderate cognitive impairment. During an interview on 3/6/25 at 12:16 PM, with Resident 1 in her room, Resident 1 stated that she had pain from her knee down related to her fall. Review of Resident 1's Progress Note dated 3/1/25 at 8:45 PM, written by Licensed Nurse (LN) C, indicated that Resident 1 had a fall in her room and had pain in her left knee with redness and swelling. Review of Resident 1's, Post Fall Evaluation dated 3/2/25 at 4:18 AM, completed by LN C, indicated that Resident 1's left lower leg had bruising, swelling, redness, pain. Review of Resident 1's, Pain Evaluation dated 3/2/25 at 4:18 PM, completed by LN C, indicated that Resident 1 described her pain as aching. Review of Resident 1's Progress Note dated 3/2/25 at 9:56 AM, written by LN D, indicated that an order for left knee x-ray (images taken of the bones) was requested from the physician. Review of Resident 1's, Physician's Orders dated 3/2/25 at 10:44 AM, indicated that an x-ray to Resident 1's left knee/shin was ordered by the Medical Doctor (MD). Review of Resident 1's x-ray results that were done on 3/2/25, no time, indicated, Left Tibia/Fibula [the shin bone and the calf bone] X-Ray results were, Acute avulsion of the tibial tuberosity [a break in the bony bump at the top of the tibia where the knee is connected] the front of the tibia just below the kneecap) with effusion [swelling]. Review of Resident 1's Progress Note dated 3/4/25 at 5:53 PM, written by LN E, indicated, Resident vocal complaint of continuous pain 8-10 [10 being the worst pain imaginable], in LLE [left lower extremity]. Bruising, and swelling noted. Orders to send to the hospital. During a concurrent interview and record review of Resident 1's x-ray report dated 3/2/25, with the Director of Nursing (DON) on 3/6/25 at 2:44 PM, in the DON's office, the DON confirmed that a physician's order for an x-ray of Resident 1's left knee was obtained on 3/2/25 at 10:45 AM. The DON confirmed that an x-ray of Resident 1's knee was completed on 3/2/25 and the x-ray had indicated that Resident 1 had a broken tibia. DON confirmed that the facility had not received the x-ray report for Resident 1 on 3/2/25, and had not followed up on getting those results. DON confirmed Resident 1's physician was not notified of the x-ray results until 3/4/25, when the facility recognized they never received the x-ray report from 3/2/25. The DON indicated her expectation would be if the facility does not receive x-ray results within 24 hours, they should call and ask the imaging company about the x-ray results in order to prevent a delay in getting treatment for a resident.

Based on observation, interview, and record review, the facility failed to protect the rights for one of three sampled residents (Resident 1) when Resident 1 did not receive a written notice of a proposed room change. This failure resulted in Resident 1 experiencing distress, frustration and the feeling of not having control over anything in her life. Findings: A review of the facility's policy titled Room Change/Roommate Assignment revised March 2021, indicated Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., [example] residents and their representatives) is given a notice of change prior to the transfer. A review of Resident 1's Admission Record (undated), indicated she was admitted [DATE] with diagnoses that included a fracture of the right leg, history of falling, and pain. A review of Resident 1's Admission Minimum Data Set (MDS, a clinical assessment) dated 11/13/24, indicated a Brief Interview for Mental Status (BIMS, an assessment of mental capacity) was conducted and Resident 1 scored a 15 out of 15 indicating her cognition was intact. Resident 1 was her own responsible party (RP, makes her own decisions about health care). During an interview on 1/17/25 at 10:50 am, Resident 1 stated They moved me from my room. I did not want to move. I was crying when I came over here because I did not have my door decorations. There were more drawers and a bigger closet (in the previous room). I am just a line item; it is a business. I did not want to move. They said I did not have a choice (and) it was happening. We have no control over anything in our lives. Resident 1 indicated that she did not receive a written notice indicating the move or the reason why. During an interview on 1/17/25 at 11:30 am, Social Service Director (SSD) indicated that the move for Resident 1 was decided by the Admission Department and the Social Service Department because they needed the room for new residents. During an observation and interview on 1/17/25 at 11:51 am, Resident 1 was observed laying in her bed and Resident 1's Personal Therapist (PT) was sitting in a chair next to her bed. There were boxes, papers, clothes and many other items heaped on the floor next to her bed. PT indicated she was present when the facility asked her to move to a new room. PT stated She (Resident 1) was first asked if she wanted to move, and she said no. Then she was told she had to move, and she threw a fit. She did not want to move. She did not agree to move. She has such a short time left (in the facility) and so much stuff to move, now it is in disarray. A review of Resident 1's nursing progress notes dated 1/14/25 at 10:19 am, indicated SSD noted Spoke with resident and requested her to move rooms to 17 A, (Resident 1's name) was not happy about the move but did agree to move rooms. During an interview on 1/17/25 at 12:26 pm, SSD indicated she spoke with Resident 1 about the room change. SSD stated, I did have to work with her, but she did finally agree to try. SSD indicated they needed to do the room change because they needed a room to admit males into and there was no other choice for that situation. During an interview on 1/17/25 at 12:32 pm, Certified Nursing Assistant (CNA) A indicated that the Staffing Coordinator (SC) and herself went into Resident 1's room to talk with her about the move. CNA A indicated that Resident 1 was upset (about having to move) and throwing things and that someone had already come in and asked her about the move. CNA A did not know who that was. CNA A indicated that she then asked for SSD to speak to Resident 1 about the move because Resident 1 was upset. During an interview on 1/17/25 at 12:40 pm, the SSD and Director of Nursing (DON) indicated that they did not give a written notice to Resident 1 about the move and did not know they had to. SSD and DON reviewed the Federal Regulations and confirmed that a written notice was required and that they should have done this, and they did not.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #65 and Resident #72) of 19 sampled residents. Findings included: During an interview on 11/20/2024 at 10:16 AM, the Director of Nursing (DON) indicated the facility did not have a policy on MDS accuracy. 1. An Admission Record revealed the facility admitted Resident #72 on 10/12/2024. According to the Admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. An admission MDS, with an Assessment Reference Date (ARD) of 10/19/2024, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed that the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. A letter from the California Department of Health Care Services, dated 09/26/2024, revealed a Level II evaluation was conducted on 09/26/2024 and specialized services were recommended. During an interview on 11/21/2024 at 8:43 AM, the MDS Coordinator stated she reviewed the electronic and paper chart, observed the resident, and interviewed the resident and staff to complete an accurate MDS. The MDS Coordinator indicated that to complete the admission MDS she reviewed the hospital documentation and the resident's history and physical. During an interview on 11/21/2024 at 9:35 AM, the DON stated she expected for the MDS to be accurate. The DON stated it was important for information to be true and accurate because the MDS needed to reflect the actual state of the resident. During an interview on 11/21/2024 at 9:54 AM, the MDS Coordinator stated Resident #72's PASRR Level II was missed and should have been coded on the resident's admission MDS. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated he expected the MDS to be completed accurately and in a timely manner. The Administrator stated it was important to capture the correct information so the MDS would be accurate. 31524 2. An Admission Record indicated the facility admitted Resident #65 on 07/02/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, chronic peptic ulcer, and hypertension. An admission MDS, with an Assessment Reference Date (ARD) of 07/09/2024, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Per the MDS, Resident #65 did not use tobacco at the time of the assessment. Resident #65's care plan included a focus area initiated 09/19/2024 that indicated the resident was a smoker. Interventions directed staff to educate the resident regarding the facility's smoking policy, designated smoking areas, and the storage of smoking materials. Resident #65's Progress Notes dated 07/02/2024 indicated the resident was a current smoker and was interested in the facility smoking schedule. During an interview on 11/20/2024 at 8:50 AM, Resident #65 stated they had been a smoker since before admission to the facility. During an interview on 11/21/2024 at 8:43 AM, the MDS Coordinator stated she reviewed the resident's chart and interviewed staff and the resident when completing their MDS. The MDS Coordinator further stated she thought when she interviewed Resident #65 upon admission that they were not smoking, but the resident was in fact smoking with the activities department. During an interview on 11/21/2024 at 9:35 AM, the DON stated she expected the MDS to be completed to accurately reflect the resident's status to ensure facility staff provided the appropriate care for each resident. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated he expected the MDS to be completed accurately and in a timely manner.

Based on interview, record review, and facility policy review, the facility failed to initiate a Level I Preadmission Screening and Resident Review (PASRR) for a resident who received a psychiatric diagnosis, prior to readmission, for 1 (Resident #16) of 3 residents reviewed for PASRR. Findings included: An undated facility policy titled, PASRR Completion Policy revealed, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. An Admission Record revealed the facility originally admitted Resident #16 on 01/10/2024 and readmitted the resident on 08/01/2024. According to the Admission Record, the resident had a medical history that included diagnosis of dementia with behavioral disturbance. A Medicare 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active psychiatric diagnoses of anxiety and psychotic disorder. Per the MDS, the resident received antipsychotic and antianxiety medication during the assessment timeframe. Resident #16's care plan included a focus area revised on 01/29/2024, that indicated the resident had the potential to be physically aggressive towards staff. Interventions directed staff to analyze the time of day, place, circumstances, triggers, and what de-escalates the behavior (initiated 01/29/2024); to assess and address for contributing sensory deficits (initiated 01/29/2024); and when the resident becomes agitated, intervene before agitation escalates (initiated 01/29/2024). The care plan included a focus area initiated on 06/07/2024, that indicated the resident used psychotropic medications related to psychosis, as evidenced by verbal and physical aggression, sexual outbursts, and the inability to redirect. Interventions directed staff to administer psychotropic medications as ordered by the physician, and to monitor for side effects and effectiveness (initiated 06/07/2024). Resident #16's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 12/28/2023, prior to Resident #16's first admission to the facility, indicated the resident did not have a serious diagnosed mental disorder. The Level I Screening indicated a Level II Mental Health Evaluation was not required. Resident #16's Census List, dated 11/19/2024, revealed Resident #16 was transferred to the hospital on 07/12/2024 and discharged from the facility after seven days, on 07/19/2024. The Census List further revealed Resident #16 was readmitted to the facility on [DATE]. An IDT [Interdisciplinary Team] Review note dated 07/11/2024 revealed Resident #16 was sent to a facility for psychiatric care for two to four weeks because of aggressive behaviors and would return to the facility when completed. A General Note dated 08/02/2024 revealed Resident #16 arrived back at the facility and was adjusting well. A hospital Discharge Summary dated 08/01/2024, revealed Resident #16 had a new diagnosis of unspecified psychosis, in addition to an existing diagnosis of dementia with behavioral disturbance. Resident #16's medical record revealed no other PASRR had been completed since re-admission to the facility on [DATE], and no evidence that indicated a referral was made to the appropriate state-designated authority after receiving a new psychiatric diagnosis. During an interview on 11/20/2024 at 10:16 AM, the Director of Nursing (DON) stated a new PASRR should have been completed when Resident #16 was readmitted to the facility in August 2024. During a subsequent interview on 11/20/2024 at 11:15 AM, the DON stated she was going to have the Social Services Director (SSD) submit a new Level I Screening, as it should have been done when the resident returned from a psychiatric stay with a diagnosed mental illness of psychosis. During an interview on 11/21/2024 at 8:23 AM, the SSD stated the Level I Screening was to be completed at the hospital prior to a resident's admission to the facility, and the Business Office Manager (BOM) would make sure the paperwork was present prior to admission. During an interview on 11/21/2024 at 8:27 AM, the BOM stated the hospital completed the PASRR prior to a resident coming to a skilled nursing facility. The BOM stated that the accuracy of the PASRR was assessed by the DON, and if the resident had an issue with mental illness after admission, the facility would initiate an additional PASRR. She also stated if the resident triggered a positive Level I PASRR and required a Level II assessment, both should be completed at the hospital prior to admission. During an interview on 11/21/2024 at 8:32 AM, the DON stated all admissions were reviewed for medications and diagnoses that would trigger a positive Level I PASRR prior to admission. She stated the Admissions Director would bring the PASRR to her to review if it did not match the diagnoses available in the resident's medical history. The DON stated that if the PASRR was incorrect, the facility would notify the hospital's PASRR department so they could educate their team on what was incorrect. The DON stated there was a lack of training regarding Resident #16's PASRR. The DON stated the facility Resident #16 was sent to for psychiatric inpatient care did not participate in the PASRR program and did not complete a Level I assessment prior to discharge. She stated it was the responsibility of the facility to complete the Level I PASRR when the resident returned. The DON stated they should have completed another assessment for Resident #16, and the facility would start the assessment process. The DON stated her expectation going forward was for the PASRR to be reviewed by the Admissions Director, who is a nurse, prior to admission. The DON stated if there was a question or concern regarding a medication or diagnosis, she could get clarification. She stated she reviewed admissions as well and corrected or initiated a new PASRR if needed and notified the hospital of errors. The DON stated the PASRR system needed work and more training so the facility could have a good and functioning PASRR program. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated the PASRRs should come from the hospital, and if a Level II was needed, it should happen at the hospital prior to admission. He stated the PASRRs needed to be accurate with proper psychiatric diagnoses and he would defer to the DON on the importance of the PASRR process.

Based on interview, record review, facility document review, and facility policy review, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for 1 (Resident #24) of 3 residents reviewed for PASRR. Specifically, Resident #24 had a diagnosis of schizophrenia that was not captured on their Level I PASRR. Findings included: An undated facility policy titled, PASRR Completion Policy, indicated, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. An Admission Record indicated the facility admitted Resident #24's on 06/03/2024. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia with an onset date of 06/03/2024 and major depressive disorder with an onset date of 06/03/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, Resident #24 was not considered by the state Level II PASARR process to have a serious mental illness. Resident #24's care plan included a focus area initiated on 06/03/2024 that indicated the resident used psychotropic medications related to schizophrenia as evidenced by auditory hallucinations. Interventions directed staff to monitor for any adverse reactions of psychotropic medications and to monitor and record the occurrence of target behavior symptoms. Resident #24's Order Summary Report contained an order dated 08/24/2024, for Aripiprazole (antipsychotic) oral tablet 30 milligrams (mg) with instructions to give 30 mg by mouth one time a day as evidenced by auditory hallucinations related to schizophrenia. Resident #24's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/03/2024, indicated the resident had a serious diagnosed mental disorder of depression. The screening revealed schizophrenia was not listed as a diagnosed mental disorder. A letter from the State of California Health and Human Services Agency Department of Health Care Services dated 06/03/2024 indicated the state was unable to complete a Level II evaluation because Resident #24 had no serious mental illness. During an interview on 11/21/2024 at 8:24 AM, the Social Services Director (SSD) stated the Level I PASRR was completed at the hospital prior to admission. During an interview on 11/21/2024 at 8:25 AM, the Business Office Manager (BOM) stated the hospital completed the Level I PASRR and the Director of Nursing (DON) was responsible for ensuring the accuracy of these screenings. The BOM further stated the facility accepted the hospital-completed Level I PASRR for admission. During an interview on 11/21/2024 at 8:32 AM, the DON stated the BOM had access to the PASRR screening system, and she reviewed them prior to a resident's admission for accuracy. The DON further stated Resident #24's schizophrenia diagnosis was not listed on their Level I PASRR and that it needed to be redone and resubmitted to include that diagnosis. During an interview on 11/21/2024 at 10:06 AM, the Administrator stated that Level I PASRRs were completed at the hospital prior to admission, and they needed to accurately reflect a resident's mental health diagnosis.

Based on interview and record review, the facility failed to ensure that one of six residents who were sampled for quality of care (Resident 1), received care that was in accordance with professional standards and consistent with Resident 1's preferences and goals and at the level of assistance he needed. Resident 1 was admitted for Comfort Care (end of life care) on the afternoon of 9/14/24, and requested not to be put into a brief (adult diaper). During the night shift on 9/14/24, Certified Nursing Assistant (CNA) D had left Resident 1 in a soiled night gown, soiled brief, wet sheets, and the television (TV) in his room blaring and had not assisted Resident 1 in eating his supper. Resident 1 was found on 9/15/24 around 6:45 am, by his Family Member (FM) A and CNA C, in a soiled and soaking wet brief and hospital gown with dried brown rings on his bed sheets and the TV blaring. These failures resulted in Resident 1 having a horrible experience and lack of sleep and he left the facility that morning and returned to the hospital. These failures had the potential for residents to experience an undignified existence, discomfort, skin breakdown, nutritional declines, loss of sleep and inability to attain or maintain their highest practicable level of physical and emotional well-being. Findings: Resident 1 was admitted to the facility on [DATE] around 4 pm, from the hospital with conditions ranging from thrombocytopenia (low platelets, inability of the blood to clot), an infected pacemaker (an implanted device that regulates the heart beat), and was terminally ill (dying). Resident 1 was admitted to receive comfort care (support of a resident ' s emotional and physical needs while at the end of life, focusing on comfort rather than treatment). Resident 1 requested to return to the hospital on 9/15/24, after about a 12 hour stay at the facility. A review of the, National Institutes of Health Information, Providing Care and Comfort at the End of Life, (undated), indicated, physical comfort (e.g. soft lighting, soft sounds) are a critical part of comfort care. A review of the facility ' s policy titled, Resident Rights dated 12/2021 indicated that various rights are guaranteed to all residents by federal and state law including, to be treated with respect, kindness, and dignity and to be free from .neglect. Resident 1's Progress Notes were reviewed. On 9/14/24, Licensed Vocational Nurse (LVN) B documented that Resident 1 was admitted around 4 pm, for end of life comfort care related to multiple comorbidities [many illnesses]. Further review of that record indicated under continence (ability to hold/control stool and urine) that Resident 1 had mixed continence of bladder (occasions where a loss of control may happen). Resident 1's Progress Notes were further reviewed. On 9/15/24 at 9:15 am, LVN B documented, Family had concerns about resident care and thought comfort care was questionable, resident alert and able to express himself, family arrived early this am and was told by resident that he had not received any care all night, and roommate yelled out most of the night, TV on and loud volume all night. Review of the record titled, Admission Assessment for Resident 1 dated 9/14/24 indicated Resident 1 was aware of person, place, and time and was continent (full control) of his bowel and bladder and had an indwelling urinary catheter (sometimes called a Foley catheter, a tube inserted into the urethra to drain the bladder). Review of a statement written and signed by CNA C, dated 9/15/24, was provided by the Administrator (ADMIN) and indicated, I was checking rooms at 0645 when I noticed that room [ROOM NUMBER]A resident's [FM A] was upset at the current state of her father. Upon entering the room, I noticed 25A was soaked as well as dried ooze over his entire bed and gown. There wasn't much water. 25A told me that no CNA came in all night and he has been sitting in his filth for more than 8 hours. The [FM A] was extremely upset, I changed the bedsheets, gave the client more water, took off the diaper and left it off, and let the nurse know exactly what had happened. Review of a document signed by CNA D was provided by the facility ADMIN titled, Employee Warning/Discipline/Coaching Memo dated 9/16/24. The record indicated that Resident 1 was left heavily soiled, that CNA D ' s last interaction with the resident was at 3 am, while his shift was not over until 7 am. The record indicated that corrective action was taken regarding performing two-hour rounding (checking) on rooms, making sure walking rounds (where the on-coming and off-going CNAs inspect the residents together), at change of shift and coaching in incontinence care. In an interview on 9/18/24 at 4:46 pm, FM A stated that Resident 1 was placed in a diaper after telling the night nurse he was not incontinent and didn ' t want to wear a diaper. FM A stated that when she came into the facility early in the morning of 9/15/24, Resident 1 was in a messy diaper and the bed was saturated. FM A stated that Resident 1 was not incontinent. FM A further stated that Resident 1 appeared frightened when she arrived early morning on 9/15/24. His TV was so loud that I had to put my mouth to his ear and yell. He was telling me that he complained at night for them to turn the TV down, but it was just as loud at 7 am as it was the night before. He was a mess in a room with a blasting television; he had asked the night staff to turn it down and they responded to him that his roommate liked it that way. I asked [Resident 1], Do you want me to get you out of here? He said, Ok, get me out of here. FM A stated, Based on what I saw, there was a total lack of compassion. In an interview on 9/19/24 at 4:45 pm, Resident 1 was interviewed by telephone in his home. Resident 1 stated that being at home and being cared for by his daughters, was precisely the situation he had tried to avoid by being admitted to the facility and that his daughters were now caring for him as he was actively dying. The hospital sent me to the facility so I could get ready to pass on. I didn't want my daughters to take care of me, so I went to [the facility]. All I wanted was to be comfortable and rest, but it was a horrible experience. The television was on all night long and the person next to me was screaming. I told the CNA taking care of me that I was uncomfortable, that the TV was too loud, and he told me my roommate liked it that way and did nothing about it. I asked if they had any earplugs, but he never brought them. Resident 1 also stated that he was placed in a diaper after stating to staff that he was not incontinent and had requested a bedpan, I had never had to be in a diaper before. I just figured this is what they do. I'm [AGE] years old and dying, I assumed that at least they'd give me a bedpan if I asked for one. Resident 1 stated that during that night shift he was unable to eat or drink and received no assistance, I didn't get to eat my meal. I was slumped down in the bed and couldn't even see or reach the food. The aide just plopped it down on the table and it stayed there all night, there was no way I could get to it. It was a terrible night. I asked for water and never got it. I felt like I was just 'somebody in a home,' here today and gone tomorrow. In an interview on 9/23/24 at 11:50 am, LVN A stated, Our protocol for admitted residents is to monitor their bowel and bladder habits from the moment they get here to determine continent versus incontinent and their needs. Nutrition is the same, it is the facility's responsibility to observe how a resident is eating their food from the first meal they get. It's obvious when you go into a room that the patient hasn't touched their food, it's questionable why they aren't eating. We should be taking note of that from their first meal here. LVN A stated that a resident's request should never be ignored. In an interview on 9/23/24 at 12:00 pm, Assistant Director of Nursing (ADON) A stated that she was aware of the situation with Resident 1 and heard about him asking for earplugs and and a request for a bed pan, instead of diapers. ADON A stated, They should have given him a bedpan, it's a basic nursing intervention for his dignity. Regarding ear plugs, ADON A stated, We have ear plugs and offer them to residents when requested. I know earplugs are available. In a concurrent record review of Resident 1 ' s hospital discharge summary that was provided to the facility on [DATE], ADON A confirmed Resident 1 was continent of bowel and that he could not walk to the restroom, not ambulatory. In an interview on 9/15/24 at 12:15 pm, LVN B stated that she was aware of Resident 1 ' s concerns. The CNA who was assigned that morning saw that he was very soiled, laying in head to toe urine. He had a wound on his right side that had covered the sheet in dried pus. I know this happened that night [9/14/24]. Also, when urine sits for more than a few hours on a sheet, it makes a brown recognizable 'ring.' I could tell the urine had been there all night. The night shift CNA was CNA D. LVN B confirmed that Resident 1 was alert and oriented and could make his needs clearly known. LVN B indicated that CNAs work according to a scheduled routine rounding every two hours, concluded by rounds on the night shift about 4:30 am, preparing for the next shift. LVN B stated that CNA D, could not have done those rounds or he would have noticed the sheets. Regarding the room noise, LVN B stated, We usually have a rule, 10 pm, the television needs to be turned down. This patient hadn't been with us that long and his roommate tends to yell out at night, which was another problem. I was not aware he requested a bedpan. He came to us incontinent per his records, it was for him, not for the convenience of staff. He appeared able to feed himself, he was able to hold a cup. He wasn't with us long enough to do a full assessment or lengthy evaluation. In an interview on 9/23/24 at 12:45 pm, CNA C confirmed that he came in to find Resident 1, filthy and saturated with urine. CNA C stated that Resident 1's bed had not been changed, and that bed pans were always available to residents if they wanted one, we have three types of them. CNA C further stated, When we came in that morning, the room lights were all on, the TV was loud in the room, to the point where the resident across the hall closed their door. I ended up finding the remote and turning it down. [Resident 1] had a wound on his right side that had pus all over the sheet and the bed was saturated. CNA C confirmed that the night shift CNA was CNA D. CNA C stated, The family was unhappy and there was nothing I could do to console them, and I didn't blame them. In an interview on 9/23/24 at 12:55 pm, Director of Staff Development (DSD, nurse who trains CNAs) E stated, I spoke to [CNA C] after the situation. He came on shift and stated that he had been doing room rounds and went in to see [Resident 1] whose [FM A] was upset. [CNA C] had to change the bed, it was heavily soiled. I had to contact CNA D to educate him about room rounds, thorough documentation, and taking residents to the restroom or changing them every two hours. DSD E stated, regarding Resident 1's supper meal tray, When a resident first arrives, we have to assist at the bedside to assess if they're eating their meals. If he hadn't eaten his food, it would have been determined immediately and we should have intervened by either offering an alternative or determining why he wasn't eating. Regarding ear plugs, DSD E stated, We are pretty quick to respond, we have headphones and earplugs for residents. In an interview on 9/26/23 at 5 pm, with LVN F, she confirmed that she assumed the care of Resident 1 on 9/14/24 at 10 pm. LVN F indicated that she had taken over for another nurse who had completed the nursing assessments and did the initial rounds. LVN F stated, It was a busy night, 3 admits lots of comfort care residents, and only 2 aides; [CNA B] and a CNA from a registry [temporary staffing agency]. LVN F indicated that CNA B was in Resident 1's room a lot because the roommate needed a lot of care and there was a lot going on, but could not confirm that she witnessed CNA B actually giving care to Resident 1. LVN F stated, I went in to listen to [Resident 1's] lungs and give him pain medication if he needed it. His daughter gave me information about him being hard of hearing, requiring feeding assistance with meals because he couldn't eat on his own. LVN F was not able to confirm whether or not Resident 1 had eaten supper. LVN F confirmed that Resident 1 had an indwelling urinary catheter, and I don't recall what he was wearing, usually if they have a foley it's their own clothes and chux [pad for the bed]. He was alert and oriented and able to use a bedpan, but I don't know if [Resident 1] had a bedpan, because I didn't see what supplies were taken into the room that night. LVN F indicated that there were two TVs in Resident 1's room, she did not recall the TV being loud but stated that resident's roommate was very loud and yelling out when care was provided to him. LVN F indicated that she was unaware of Resident 1's request for earplugs or for a bedpan and that Resident 1 never complained to her about anything. LVN F indicated that she had not seen what Resident 1's bedsheets looked like. LVN F indicated that she left the facility at 7 am the next morning, on 9/15/24, and no staff had approached her about problems with Resident 1's care. In an interview on 9/26/24 at 6 pm, CNA D stated, I was surprised about it. I told the [ADMIN] the night I was on duty that I was in that room a lot when I came into work, I had to remove all the trays and went to him [Resident 1] he refused feeding and asked me to leave the tray. Asked if he wanted something else, grilled cheese, he said to leave the tray there, would have given to him. Asked him several times during night he said leave it there. He called me at midnight BM [bowel movement] and I cleaned him, nothing else happened, I checked him, he called me by name and I said thank you. I attended to him every two hours. I was so busy that night. Second bed TV on but wasn't too loud, he [Resident 1] didn't complain. By the time I got my last rounds at 5 am, got to him, discovered he had a little BM, made me change his brief again, turn him on his strong side, not leaking, no complaint. No pus. First thing I would have done is to report to nurse. He was friendly to me. Of course I supplied fresh water. Saw him drinking, no issues, if he had complained about anything I would have done it.

Based on observation, interview and record review, the facility failed to ensure that water temperatures for resident bathroom sinks were in a safe range to avoid burns when the water temperature exceeded 120F (degrees Fahrenheit). This failure placed residents at risk for burns caused by scalding hot water. Findings: During a review of the facility ' s policy titled, Safety and Supervision of Residents dated 7/2021, the policy indicated, Our facility strives to make the environment as free from accident hazards as possible. During a review of the facility ' s policy titled, Water Temperatures, Safety of dated 12/2009, the policy indicated, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120F degrees Fahrenheit, or the maximum allowable temperature per state regulation. During an observation on 12/5/22 at 11:48 am, in the facility ' s lobby bathroom, the sink water temperature was 129.4F after a few seconds of running. During an observation and interview on 12/5/22 at 2:10 pm, resident room handwashing sink water temperatures were tested . room [ROOM NUMBER], 4, 7, and 8 had hot water that was 129.4F. Resident 1 and Resident 2 indicated the water was too hot for them, but they were able to put the cool water on to cool it down (separate knobs for hot and cold water). They denied receiving a burn because of it. During an observation and interview on 12/5/22 at 2:20 pm, in rooms [ROOM NUMBERS], the handwashing sinks hot water was 122.3F, and Resident 3 indicated that the water was too hot for him and one time he remembered it hurting his finger. During an observation and interview on 12/5/22 at 2:30 pm, of resident bathroom sinks; rooms [ROOM NUMBERS]'s hot water was 124.6F and rooms [ROOM NUMBERS]'s hot water was 129.4F. Resident 4 indicated that the water was too hot sometimes, but she did not use it that long. During an observation and interview on 12/5/22 at 2:50 pm, with the Director of Nursing (DON) in the lobby bathroom, the DON confirmed the hot water to the bathroom handwashing sink was 129F degrees and that it should not be that hot. During an interview on 12/5/22 at 3:11 pm, with the Treatment Nurse (TN), she confirmed that the hot water in bathroom sinks throughout the facility did get too hot. During an interview and observation on 12/5/22 at 3:17 pm, with the Interim Maintenance Director (IMD), the IMD indicated that he had just started filling in at this facility 3 days a week beginning in December 2022. The IMD had not done any water temperature checks and did not know when they were last checked. The IMD was unable to find any temperature logs that had been done for this year. He added that the regular Maintenance Director had been off for the past 90 days and he was not sure if anyone had done maintenance checks on hot water temperatures or other equipment since September 2022. During an observation and interview on 12/5/22 at 3:25 pm, in rooms [ROOM NUMBERS] with IMD, he confirmed that the hot water was over 120F degrees. During an interview on 12/5/22 at 3:40 pm, with the Administrator, he indicated that the boilers (hot water tanks) were serviced on 9/6/22, but was unable to provide hot water temperature logs for the past 90 days. During an interview on 12/7/22 at 2:10 pm, with the IMD, he indicated that the hot water temperatures in the rooms were still as high as 122F in some rooms. He confirmed that their policy indicated that hot water should have been no more than 120F.

Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained while changing a dressing on a Stage 4 (Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI) pressure ulcer for one of two sampled residents (Resident 6). This had the potential to contaminate Resident 6's wound with harmful and unwanted bacteria and place him at a high risk for wound infection and cause a delay in the wound healing process, which could negatively impact Resident 6's physical and emotional well-being. Findings: During a review of the facility ' s policy titled, Wound Care dated October 2010, the policy indicated The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. A review of Resident 6 ' s Medical Record indicated Resident 6 was admitted to the facility on [DATE] with the diagnoses of dementia, high blood pressure, heart attack, history of falling, and muscle weakness. During his stay on 9/13/22, he aquired a right heel pressure ulcer. Resident 6 ' s quarterly Minimum Data Set (MDS, clinical assessment) dated 11/6/2022, indicated he required extensive assistance, with the help of 2 staff, for transfers and toileting and required extensive assistance, with the help of 1 staff, for bed mobility and dressing. Resident 6 ' s Brief Interview for Mental Status (BIM ' s, a brief evaluation of attention, level of orientation, ability to recall information) score was a 3 out of 15 which indicated he was severely cognitively impaired and not able to make his own decisions. During an observation on 12/5/22 at 2:15 pm, the Treatment Nurse (TN) was observed doing a dressing change on Resident 6 ' s Stage 4 pressure wound on his right heel. The TN did hand hygiene and put on clean gloves, she entered the room with the wound dressing equipment on a clean tray. She removed the old, soiled dressing and set it on Resident 6's bed instead of placing the dirty dressings in an appropriate receptacle, such as a plastic bag to contain the infectious bacteria. The wound had light brown colored drainage inside of the wound bed. With the same, now soiled gloves, TN proceeded to clean the wound with wound cleanser and wiping the wound bed with gauze. TN then placed her contaminated gloved finger inside the wound to physically removed dead tissue and drainage. She wiped the wound with her contaminated gloved finger repeatedly until all of the drainage was removed. She then applied the clean dressings without washing her hands or changing her contaminated gloves. The TN then gathered up the soiled dressings (unbagged) with her gloved hands and while she was leaving the room, she pulled the privacy curtain open with her dirty gloves. TN returned to the treatment cart and discarded the dirty soiled dressings into the open trash can on the cart. During an interview on 12/5/22 at 2:18 pm, the TN confirmed she had not changed her gloves and performed hand hygiene after she removed the soiled dressings and before she cleaned and redressed Resident 6's wound, and she should have. TN confirmed that she put her soiled gloved finger inside the wound to remove drainage after she cleaned it and she should not have. The TN indicated she rushed during the treatment because she had been pulled to the floor do another person ' s job as well as her own. She stated she does not have time to get everything done. TN confirmed that this practice contaminated Resident 6's wound and placed him at risk for an infection in his wound. During an interview on 12/5/22 at 5:00 pm, the Director of Nursing (DON) confirmed that to prevent infections and cross contamination during a dressing change, gloves should be changed, and hands washed between removing a soiled dressing and redressing a wound and that dirty dressings should be bagged up at the bedside before being carried out of a resident's room.

Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP-care customized to an individual resident's needs) for one of three sampled residents (Resident 5) when Resident 5's: 1. Care plans were not developed for two areas of skin breakdown. 2. Comprehensive care plans were not implemented when Resident 5 displayed behaviors which indicated pain. These failures resulted in unmet care needs and a decline Resident 5's health status. Findings: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered revised December 2016, indicated 8. The comprehensive care plan will: a. includes measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being. g. Incorporate identified problem areas; h. incorporate risk factors associated with identified problems; M. Aid in preventing or reducing decline in the resident ' s functional status 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident ' s conditions change. 15. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team must review and update the care plan: a. when there has been a significant change in resident's condition. A review of the facility's policy titled, 1. Change in Resident's Condition or Status revised 2016, was provided by the Medical Records Director and reviewed. The policy directed, change of condition is a major decline or improvement in the resident ' s status that; Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; Impacts more than one area of the resident ' s health status; Requires interdisciplinary review and/or revision to the care plan . 1. A review of Resident 5's medical record indicated that he was admitted on [DATE] with diagnoses that included a stroke, diabetes, pain, right sided paralysis, dysphagia (difficulty swallowing), aphasia (trouble speaking), contractures (drawn up muscles) of the right hand, right knee, left hand, and left foot. Resident 5's annual Minimum Data Assessment (MDS, a standardized assessment tool), dated 6/11/22, showed that he had moderately impaired decision-making skills and required 2 people to help with bed mobility, transfers, dressing and toileting. His son was his responsible party. A review of Resident 5's Pressure Ulcer at Risk care plan showed that on 8/4/22, the Treatment Nurse (TN) added the intervention, DTI (Deep Tissue Injury, Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to Lateral Right Malleolus(ankle) (over boney prominence). Site measures 2cm (centimeters) x 2cm. Dark purple tissue. UTD [undetermined] depth at this time. There were no other problems, goals, or interventions added to Resident 5's care plan for the management of Resident 5's right ankle pressure injury. On 8/5/22 at 10:30 am, (a day after the wound was identified) the TN created an SBAR (Situation, Background, Observation/Evaluation Assessment and Response, a change in condition nursing assessment) and documented, Re-occurring DTI to the lateral Right Malleolus [ankle bone] 2cm [about the size of a peanut] x 2 cm. It started as some discoloration, and he had previously had foam dressing placed 3x (times) a week as a preventative but now it is an actual DTI and is likely to turn into a pressure injury over the ankle bone. Skin is already so thin I am very concerned that this will deteriorate quickly. At initial observation some discoloration was noted on wed [Wednesday] 8/3/22. Site still had skin fully intact .[Resident 5] fights staff and continues to put pressure on the area There were no interventions, added to Resident 5's care plan, for fighting with staff, possible refusal of care and TN's concern that the wound might deteriorate quickly. On 8/6/22 at 9:21 pm, Licensed Nurse (LN) 6 created an SBAR (Situation, Background, Observation/Evaluation Assessment and Response, a change in condition nursing assessment) for a newly discovered pressure injury, sore to Resident 5's right buttock that measured 2cm x 3cm. No care plan was developed to manage the newly discovered pressure injury. During an interview on 12/28/22 at 1:45 pm, the TN confirmed no care plans were developed for these wounds that had measurable objectives, risk factors and specific interventions to aid in the healing of these wounds and prevent them from getting worse. 2. The facility's policy titled, Wound Care dated October 2010, was provided by the DON and reviewed. The policy directed, Review the resident ' s care plan to assess for any special needs of the resident. A review of Resident 5's At risk for Pain care plan revised 6/18/22, indicated a goal of, will not experience a decline in function related to pain with interventions to include Administer pain medication as ordered and evaluate need to provide medications prior to treatment or therapy. A review of Resident 5's Behavior care plan revised on 6/18/22, revealed a focus area indicating he sometimes had behaviors which included yelling during care, yells ow, ow, shouting, screaming when he does not want to get out of bed or take a shower during the course of care or when he is joking around with staff. Interventions included to make sure he was not in pain or uncomfortable. On 8/9/22 at 3:47 pm, LN 4 entered a Late Entry progress note for 8/8/22 at 3:40 pm, despite multiple attempts and education and coaxing to comply resident refused wound Tx, resident refused wound care to right foot, refused repositioning, oral care and incontinence care resident was yelling out, grabbing staff, squeezing nurse and CNA wrists, and kicking, resident was approached multiple times this shift . Resident 5 was not evaluated for pain, as indicated in the above care plans. On 8/9/22 at 3:53 pm, LN 4 documented, resident refused wound care as ordered despite multiple attempts. Resident was not evaluated for pain as indicated in care plans above. On 8/9/22 at 4:01 pm, LN 4 documented a late entry note for 8/7/22 at 3:54 pm, Resident was noncompliant with wound care as ordered today, resident was approached multiple times, education and encouragement offered, resident allowed Tx to buttocks/coccyx, offloading boots in place per order, but resident refused wound care to right foot, dressing intact to wound, did not appear soiled. Resident would not allow repositioning, resident would yell hold up a fist indicating he would hit staff if attempted, grabbing at staff, flailing with attempts and kicking, staff would leave, and re-approach and this behavior continued. Resident was not evaluated for pain as indicated in care plans above. A review of Resident 5's Medication Administration Record (MAR) for August 2022, revealed he had not been given any pain medication prior to wound treatments. During an interview and record review on 12/5/22 at 4:00 pm, of Resident 5's MAR, the DON confirmed that pain medication was not given prior to wound treatments. During an interview on 12/5/22 pm at 4:30 pm, the TN confirmed that care plans were not developed for 2 newly discovered pressure injuries and that Resident 5's care plans for behavior and pain were not implemented, and should have been.

Based on interview and record review, the facility failed to provide care and services which promoted healing and the prevention of infection and evaluate the basis for the refusal of care, for one of three sampled residents (Resident 5), when a Deep Tissue Injury (DTI-Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface), was discovered on his right outer ankle on [DATE], and a treatment order was not obtained until [DATE]; and he was not evaluated for alternative treatment options when he refused treatments for 3 consecutive days and his physician and responsible party were not notified; and he was not evaluated for pain related to his DTI; and no care plan was developed. (Refer to F636 and F697) This resulted in Resident 5's DTI quadrupling (4 times larger) in size and worsened to an infected Stage 4 pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough [infection] and/or eschar [dead tissue] may be visible on some parts of the wound bed), which required an emergent hospital admission for treatment. Findings: The facility's policy titled, Requesting, Refusing and/or Discontinuing Care or Treatment revised 2017, was provided by the Medical Records Director and reviewed. The policy directed, Treatment is defined as services provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. 6. If a resident requests, discontinues or refuses care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with the resident to: determine why the resident is requesting, refusing or discontinuing care or treatment; try to address the resident's concerns and discuss alternative options .9. The interdisciplinary team will assess the resident's needs and offer the resident alternative treatments .12. Documentation pertaining to a resident's request, discontinuation or refusal of treatment shall include at least the following: The date and time the care or treatment was attempted; the type of care or treatment; the resident's response and stated reason (s) for request, discontinuation or refusal; the name of the person attempting to administer the care or treatment; that the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication/or treatment; the resident's condition and any adverse effects due to the request; the date and time the practitioner was notified as well as the practitioner's response. 13. The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request. The facility's policy titled, Prevention of Pressure Injuries dated [DATE], was provided by the DON and reviewed. The policy directed, Review the interventions and strategies for effectiveness on an ongoing basis. The facility's policy titled, Wound Care dated [DATE], was provided by the DON and reviewed. The policy directed, Review the resident's care plan to assess for any special needs of the resident. A review of the facility's policy titled, 1. Change in Resident's Condition or Status revised 2016, was provided by the Medical Records Director and reviewed. The policy directed, The nurse will notify the resident's Attending Physician or physician on call when there has been a need to alter the resident's medical treatment significantly, refusal of treatment or medications two (2) or more consecutive times, change of condition is a major decline or improvement in the resident's status that; Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; Impacts more than one area of the resident's health status; Requires interdisciplinary review and/or revision to the care plan .3. Prior to notifying the Physician .the nurse will make detailed observations and gather relevant and pertinent information for the provider .4. A nurse will notify the resident's representative .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of Resident 5's medical record indicated that he was admitted on [DATE] with diagnoses that included a stroke, diabetes, pain, right sided paralysis, dysphagia (difficulty swallowing), aphasia (trouble speaking), contractures (drawn up muscles) of the right hand, right knee, left hand, and left foot. Resident 5's annual Minimum Data Assessment (MDS, a standardized assessment tool), dated 6 /,d+[DATE], showed that he had moderately impaired decision-making skills and required 2 people to help him with bed mobility, transfers, dressing and toileting. His son was his responsible party. A review of Resident 5's Pressure Ulcer at Risk care plan showed that on [DATE], the Treatment Nurse (TN) added the intervention, DTI to Lateral Right Malleolus (over boney prominence). Site measures 2cm (centimeters) x 2cm. Dark purple tissue. UTD [undetermined] depth at this time. There were no other problems, goals, or interventions added for the management of Resident 5's right ankle pressure injury. Resident 5's Progress Notes were reviewed. There was no documentation by the TN regarding her discovery of Resident 5's right ankle pressure ulcer on [DATE], or that his physician was notified for a treatment order. On [DATE] at 9:03 am, the Interdisciplinary Team (IDT-facility managers who discuss resident care and services) documented that Resident 5 had been exposed to Covid (a serious respiratory virus), however, had not included any discussion regarding his newly discovered pressure injury. On [DATE] at 10:30 am, (a day after the wound was identified) the TN created an SBAR (Situation, Background, Observation/Evaluation Assessment and Response, a change in condition nursing assessment) and documented, Re-occurring DTI to the lateral Right Malleolus [ankle bone] 2cm [about the size of a peanut] x 2 cm. It started as some discoloration, and he had previously had foam dressing placed 3x (times) a week as a preventative but now it is an actual DTI and is likely to turn into a pressure injury over the ankle bone. Skin is already so thin I am very concerned that this will deteriorate quickly. At initial observation some discoloration was noted on wed [Wednesday] [DATE]. Site still had skin fully intact .[Resident 5] fights staff and continues to put pressure on the area .The tissue appears to be more broken down but I am not able to determine how deep this injury goes. Resident 5's physician (PMD), responsible party (RP), and the wound physician (WP-a physician who specializes in wound care) were notified. On [DATE] at 9:21 pm, Licensed Nurse (LN) 6 created another SBAR for a newly discovered pressure injury, sore to Resident 5's right buttock that measured 2cm x 3cm, and documented, recommending treatment nurse evaluate and treat. LN 6 had not documented that he notified the PMD for treatment orders, or that the RP was notified, and no care plan was developed. There was no documentation regarding Resident 5's right ankle pressure injury or that the treatment was done. On [DATE], there was no documentation regarding the condition of Resident 5's right ankle pressure injury or that the treatment had been done. On [DATE], there was no documentation regarding the condition of Resident 5's right ankle injury or that the treatment had been done. On [DATE] at 7:36 am, LN 5 documented that Resident 5 was sent to the hospital by ambulance at 6:30 am, as recommended by the WP for evaluation and treatment of his right ankle pressure injury and that the WP had notified the PMD and RP. On [DATE] at 3:47 pm, after Resident 5 was already at the hospital, Registered Nurse (RN) 4 entered a Late Entry progress note for [DATE] at 3:40 pm, despite multiple attempts and education and coaxing to comply resident refused wound Tx, resident refused wound care to right foot, refused repositioning, oral care and incontinence care resident was yelling out, grabbing staff, squeezing nurse and CNA wrists, and kicking, resident was approached multiple times this shift . There was no documentation that his PMD or RP were notified. On [DATE] at 3:53 pm, RN 4 documented, resident refused wound care as ordered despite multiple attempts. Resident 5's PMD and RP were not notified. At this point, Resident 5 had been at the hospital for over 9 hours. On [DATE] at 4:01 pm, RN 4 documented a late entry note for [DATE] at 3:54 pm, Resident was noncompliant with wound care as ordered today, resident was approached multiple times, education and encouragement offered, resident allowed Tx to buttocks/coccyx, offloading boots in place per order, but resident refused wound care to right foot, dressing intact to wound, did not appear soiled. Resident would not allow repositioning, resident would yell hold up a fist indicating he would hit staff if attempted, grabbing at staff, flailing with attempts and kicking, staff would leave, and re-approach and this behavior continued. There was no documentation that Resident 5's PMD or RP had been notified. On [DATE] at 10:47 am, LN 3 created a late entry SBAR for [DATE] at 10:30 am, DTI right malleolus measurement 9 cm x 7.5 cm x 2.5 cm [about the size of an orange], dressing removed Wound MD eval area darkened area right malleolus with open area at base of malleolus 2.5cm depth scant amount of drainage clear in color resident refused treatment for 2 days prior to MD wound assessment. MD recommended acute transfer for eval and treat . A review of Resident 5's Physician's Orders reflected that an order was obtained on [DATE], for DTI to Lateral Right Malleolus. Cleanse site w/WC [with wound cleanser]. Apply Iodosorb Gel [antimicrobial wound gel] to WB [wound bed], cover with Adaptic [a non-adhering dressing], then place a square of Calcium Alginate [a moisture absorbing dressing] over the Adaptic and cover entire site with foam dressing every day and PRN [as needed] until healed/resolved. Please make sure site is always off-loaded. Every day shift for Wound Care, monitor for any s/sx [signs or symptoms] of infection and notify MD of any abnormalities noticed. A review of Resident 5's Treatment Administration Record (TAR) for [DATE], showed that no treatment was done on [DATE], and no reason was recorded. On ,d+[DATE] and [DATE], RN 4 recorded that Resident 5 refused the treatments and had a pain level of 5 (out of a possible 10 with 10 being the worst) on [DATE]. There was no documentation that alterative options were evaluated or that his PMD and RP were notified, and the care plan was not updated. On [DATE], Resident 5's PMD documented a History and Physical note which indicated that a DTI to the right ankle was present and that a WD consult was needed. There was no documentation regarding a wound observation or assessment and nothing to indicate that alternative treatment options were necessary due to Resident 5's refusals. On [DATE], 5 days after the pressure injury had been discovered and after 3 days of refused treatments, the WD evaluated Resident 5. According to the WD's Progress Note, dated [DATE], a right outer ankle Stage 4 pressure injury was present that measured 9 cm x 7.5 cm x 2 cm deep. The tissue in the wound bed was 60% [percent] necrotic [dead] and had an odor. The WD documented, Assessment of wounds .extensive damage .worked up for osteo [bone infection] at acute, possible amputation .Reportedly, pt [patient] has been non-adherent to offloading and dressing change schedule. A review of Resident 5's hospital History and Physical dated [DATE], was conducted. According to the hospital record, Resident 5's white blood cell count (WBC) was 13.5 (normal is 4,000 to 11,000) which indicated that he had an infection in the bloodstream, and he was treated with intravenous (IV) Vancomycin and Rocephin (strong antibiotics). On [DATE], Resident 5 was taken to surgery with the intention of cleaning out the dead tissue from the wound and applying a Wound Vac (a machine that helps pull fluid from a wound and promotes healing), however, he had a heart attack while in surgery and died . On [DATE] at 4:40 pm, an interview and concurrent Treatment and Medication record reviews was conducted with the TN. The TN confirmed that the wound was discovered on [DATE] by a night shift nurse and she received a text message about it and the night nurse expected her to do the SBAR, charting and assessment and notify the physician. She confirmed that the nurse did not call the physician or get a treatment at that time and the nurse should have. The TN confirmed that Resident 5's right ankle treatment was not done on [DATE] and refused on ,d+[DATE] and [DATE]. The TN indicated that an ankle wound can be very painful and could have contributed to Resident 5's treatment refusals. TN indicated that Resident 5 should have been assessed and medicated for pain prior to attempting to do the treatments. The TN added that she was out on leave over the time period when Resident 5 had refused his treatments and there had not been a dedicated treatment nurse to take her place. The TN confirmed that there was no documentation that Resident 5's PMD or RP had been notified of his refusals and that there had been no evaluations conducted to determine if there were alternative options, and there should have been because facility staff were aware that Resident 5 had a history of refusing cares. The TN confirmed that no care plan had been created which described the care and services that were to be furnished in order to heal Resident 5's right ankle pressure injury. During an interview on [DATE] at 3:45 pm, the Director of Nursing (DON) confirmed that the TN first noticed a reddened area on Resident 5's right ankle on [DATE], then the night shift nurse discovered a DTI on [DATE], but no action was taken until the morning of [DATE]. The DON indicated that her expectation was for an SBAR progress note to be entered, a care plan developed, and for the PMD and RP to be notified upon the initial discovery of any pressure injury, and that was not done for Resident 5. The DON confirmed that there were 3 consecutive days of missed treatments and no documentation of physician or family notification or discussions about alternative treatment options. The DON confirmed that Resident 5 was not assessed for pain or offered pain medication prior to attempting dressing changes. The DON spoke with RN 4 about Resident 5's pain. RN 4 indicated that she could not remember if Resident 5 was in pain or not, however, RN 4 had recorded on Resident 5's TAR on [DATE], that he had a pain level of 5.

Based on interview and record review, the facility failed to asses for pain and administer pain medications as ordered by the physician and in accordance with the resident's plan of care, for one of three sampled residents (Resident 5), when nursing did not assess pain during a wound treatment and administer available pain medications when he complained of pain. This failure resulted in unrelieved pain for Resident 5 and a decline in his health status. Findings: A review of the facility's policy titled, Pain-Clinical Protocol dated June 2013, indicated, 2. The nursing staff will assess each individual for pain . whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain. 3.a. The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed. 4. The nursing staff will identify any situations or interventions where an increase in the resident ' s pain may be anticipated; for example, wound care, ambulation, or repositioning. A review of Resident 5's medical record revealed he was admitted to the facility on [DATE] with diagnoses of stroke, diabetes, pain, right sided paralysis, dysphagia (difficulty swallowing), aphasia (trouble speaking), and contractures (drawn up) of the right hand, right knee, left hand and left foot. Resident 5's annual Minimum Data Assessment (MDS, a comprehensive standardized assessment), dated 6/11/22, revealed his ability to make decisions was moderately impaired. He required extensive assistance with 2 staff for bed mobility, transfers, dressing and toileting. A review of Resident 5's At risk for Pain care plan revised 6/18/22, indicated that the goal was, will not experience a decline in function related to pain and interventions included, Administer pain medication as ordered and evaluate need to provide medications prior to treatment or therapy. A review of Resident 5's Behavior care plan revised on 6/18/22, revealed a focus (problem) area which indicated that he sometimes had behaviors which included yelling during care, yells ow, ow, shouting, and screaming when he does not want to get out of bed or take a shower during the course of care, or when he is joking around with staff. Interventions included to make sure he was not in pain or uncomfortable. A review of Resident 5's Physician's Orders revealed that on 5/16/2021, Tylenol 650 mg (milligrams) by mouth every 12 hours as needed for pain (rated from a 1 to 3 on a scale of 1-10) was ordered. On 6/3/2021, for Ibuprofen 600 mg by mouth every 6 hours as needed for pain was ordered. A review of Resident 5's Progress Notes dated 8/5/2022 at 10:30 am, by the Treatment Nurse (TN), revealed a change of condition observed on 8/3/22 with some discoloration on the lateral right malleolus (outside right ankle), then on 8/5/22 the wound had progressed to a Re-occurring DTI (Deep Tissue Injury, an injury caused from pressure to the area), 2 cm [centimeters] X2 cm, about the size of a peanut. A review of Resident 5's August 2022 Medication Administration Record (MAR), revealed that on 8/3/22, Licensed Nurse (LN) 4 documented that Resident 5 rated his pain at a 2 (mild pain), and no pain medication was given. On 8/7/22, LN 4 documented that Resident 5 rated his pain at a 5 (moderate pain), and no pain medication was given. A review of Resident 5's Progress Notes dated 8/9/22 at 4:01 pm, by LN 4 revealed a late entry for 8/7/22 that indicated, Resident was noncompliant with wound care as ordered today. There was no documented pain assessment or record that pain medication was offered. A review of Resident 5's Progress Note dated 8/9/22 at 3:47 pm, by LN 4 revealed a late entry for 8/8/22, that indicated, despite multiple attempts and education and coaxing to comply resident refused Tx (treatment), resident refused wound care to right foot, refused repositioning, oral care and incontinence care, resident was yelling out, grabbing staff, squeezing nurse and CNA [certified nursing assistant] wrists, and kicking . resident was compliant with all medications this shift. There was no mention that pain was assessed for this behavior, as described as an intervention in Resident 5 ' s care plans above. There was no record that pain medication was given. During an interview on 12/5/22 at 1:20 pm, the Director of Staff Development (DSD) indicated that Resident 5 was non-verbal, and they used the nonverbal pain scale to assess his pain. If Resident 5 was in pain, he would let you know by his actions like slapping your hand away, grimacing or pushing you away. During an interview and record review on 12/5/22 at 4:00 pm, of Resident 5's MAR, the Director of Nursing (DON) confirmed that Resident 5 had complained of pain on 8/3 and 8/7/22, and that pain medication was available but not given. The DON confirmed that when Resident 5 refused wound treatments, the facility policy was not followed by not offering pain medication, nor were Resident 5's care plans. During an interview and record review on 12/5/22 at 4:30 pm, of Resident 5's MAR, the TN confirmed that an ankle wound would be very painful and since Resident 5 complained of pain, he should have been medicated for pain.

Based on interview and record review, the facility failed to ensure medications were administered per physician's orders when one of two sampled residents (Resident 1) was given 7 medications in error. This failure had the potential for Resident 1 to experience adverse medication reactions and have a decline in health status. Findings A review of the facility's policy titled, Administering Medications dated December 2012, indicated, Medications must be administered in accordance with the orders , The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. A review of Resident 1's Admission Record revealed Resident 1 was admitted on [DATE] with diagnoses of Alzheimer's, stroke, high blood pressure, muscle weakness, and contractures. A review of Resident 1's Physician's Orders dated 10/4/22, revealed her medication list included, Bisacodyl suppository as needed for constipation, Fleet Enema as needed for constipation, Oral Anesthetic Paste as needed for mouth discomfort, and a Tylenol tablet by mouth every 6 hours as needed for pain. Resident 1 had no known medication allergies. A review of Resident 1's Progress Notes dated 9/26/22 at 4:09 pm, reflected that the Director of Staff Development (DSD) documented, On 9/22/22 resident was administered another residents medications crushed in applesauce including Norco (an opioid pain medication that can slow or stop breathing) 5/325mg (milligram) tablet, cyclobenzaprine (medication for muscle spasms that can cause drowsiness, dizziness, fatigue or nausea) 5mg tablet, Metformin (used for diabetics to control blood sugar, side effects include a a buildup of lactic acid which can cause death, hypothermia, low blood pressure and slowed heart beats) 500 mg tablet, Labetalol (medication for high blood pressure that can cause drowsiness, insomnia and fatigue) 100 mg tablet, Zoloft (an antidepressant) 75 mg tablet, Atorvastatin (used to lower blood cholesterol, side effects include joint pain, diarrhea, heart burn and nausea) 80 mg tablet, Melatonin (used for sleep) 9mg During an interview and concurrent record review on 12/22/22 at 11:24 am, Resident 1's progress notes were reviewed with the Director of Nursing (DON). The DON confirmed that Licensed Nurse (LN) A confessed she administered Resident 1 medication that was meant for another resident but did not tell anyone until 4 days later, when she was confronted by the DON. The DON indicated that LN A stated she only looked at the picture and assumed it was the same person. She did not verify the name of resident by an arm band or by asking another staff member. LN A indicated to the DON that after she gave Resident 1 some of the medication that was crushed up in applesauce, she realized it was the wrong resident because of identifying articles in the resident's room. The DON confirmed that LN A was a traveling nurse and did not know the residents very well and she should have used two methods of identification before administering the medication.

Based on interview and record review, the facility failed to ensure accepted professional standards were followed when one of two residents (Resident 1) was given seven medications in error and the physician and resident's representative (RP), were not notified timely, and the resident was not monitored for adverse reactions. These failures had the potential for Resident 1 to experience adverse reactions and have a decline in health status. Findings A review of the facility's policy titled, Adverse Consequences and Medication Errors dated April 2014, indicated, 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professional(s) providing services. 9. Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur .f. Medication error. 13. The Attending Physician is notified promptly of any significant error or adverse consequence. a. The physician's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. A review of Resident 1's Admission Record revealed Resident 1 was admitted on [DATE] with diagnoses of Alzheimer's, stroke, high blood pressure, muscle weakness, and contractures. Resident 1 did not have the capacity to make health care decisions. A review of Resident 1's Physician's Orders dated 10/4/22, revealed her complete medication list included, Bisacodyl suppository as needed for constipation, Fleet Enema as needed for constipation, Oral Anesthetic Paste as needed for mouth discomfort, and a Tylenol tablet by mouth every 6 hours as needed for pain. Resident 1 had no known medication allergies. A review of Resident 1's progress notes dated 9/26/22 at 4:09 pm, by the Director of Staff Development (DSD), the DSD documented, On 9/22/22 resident was administered another residents medications crushed in applesauce including Norco (an opioid pain medication that can slow or stop breathing) 5/325mg (milligram) tablet, cyclobenzaprine (medication for muscle spasms that can cause drowsiness, dizziness, fatigue or nausea) 5mg tablet, Metformin (Used for diabetics to control blood sugar, side effects include a a buildup of lactic acid which can cause death, hypothermia, low blood pressure and slowed heart beats.) 500 mg tablet, Labetalol (medication for high blood pressure that can cause drowsy, insomnia and fatigue) 100 mg tablet, Zoloft (an antidepressant) 75 mg tablet, Atorvastatin (used to lower blood cholesterol, side effects include joint pain, diarrhea, heart burn and nausea) 80 mg tablet, Melatonin (used for sleep) 9mg During an interview and record review on 12/22/22 at 11:24 am, Resident 1's progress notes were reviewed with the Director of Nursing (DON). The DON confirmed that Licensed Nurse (LN) A confessed she administered Resident 1 medication that was meant for another resident but did not tell anyone until 4 days later when she was confronted by the DON. LN A confirmed to the DON that she did not tell anyone, call the doctor or notify the resident's responsible party. She indicated to the DON that she did not know what to do but that she did keep an eye on the resident and there were no changes in her condition after the medication error. The DON confirmed that LN A did no documentation of the event and there was no documentation of monitoring Resident 1 for unwanted side effects of the medications. The DON indicated LN A was a registry nurse and her contract was terminated.

Based on observation and interview, the facility failed to ensure food was prepared in a clean sanitary manner. This had the potential to cause food borne illnesses to the residents. Findings: During an observation on 1/25/22 at 10:15 am, the trash can in the food prep area had a lid, without foot controls, so staff had to use their hands to open and close the lid. The facility cook (FC) opened the trash can lid with her hand, threw away trash, closed the trash can lid with her hand, then picked up spices and continued in her meal prep, without hand hygiene. During an interview on 1/25/22 at 10:20 am, this was discussed with the Dietary Services Manager (DSM)who agreed they needed a trash can with a lid that could be opened with foot controls. He said he would talk to the Administrator about getting a new one. During an observation on 1/25/22 at 2:40 pm, the gas line-valve next to the stove/oven was covered with dust and what appeared to be spider webs (see pictures). This was immediately showed to the DSM who confirmed the observation and said he would make sure it was cleaned right away.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, and sanitary environment and to help prevent the transmission of infections with the census of 54 when: 1. Two out of two medication carts (a mobile cart used to store the medication and supplies for quick access for administration to residents) had unclean pill cutter (a small device that splits individual pills) shared among residents. 2. Licensed Nurse 4 (LVN 4) did not follow infection control practices when entered resident's rooms without following facility's policy on Transmission Based Disease (or same as TBP or Transmission Based Precaution used to help stop the spread of germs from one person to another by using protective measures such as putting gloves, sanitizing hand and putting on the gown and mask) before entering the rooms on three resident's rooms (Resident 41, Resident 23, Resident 36) with census of 54. 3. The shared glucometer (a device that measured blood sugar by using resident's blood droplet) was not sanitized based on standards of care and the manufacturer recommendations in one of 54 residents (Resident 23). 4. Hand sanitizers were not located in a convenient location for quick and safe access by staff caring for residents. 5. Personal Protective Equipment (PPE)d, used to protect transmission of infection was not fully available and accessible in the facility's hallway prior to entrance to resident rooms. These failures had the potential for all residents in the facility to contract infectious diseases. Findings: 1. During an observation on 1/14/22 at 10:15 AM with Licensed Vocational Nurse (LVN) 3, in facility's Zone 3 hallway, the pill cutting device inside the medication cart was noted to have white color powder debris inside from prior use. LVN 3 confirmed that it was dirty and needs to be cleaned. During an observation on 1/24/22 at 2:15 PM with Licensed Vocational Nurse (LVN) 2, in facility's Zone 2 hallway, the pill cutting device inside the medication cart was noted to have white color powder debris inside from prior use. LVN 2 confirmed that it looks like it needed to be cleaned. During an interview with the Director of Nursing, (DON), on 1/27/22 at 9:30 AM, the DON stated the pill cutters should be cleaned after each use to prevent cross contamination. Review of the facility's policy titled General Infection Control Practices, last revised on 1/2012, the policy on page 29 under 7 b, indicated If use of common items is unavoidable, then adequately clean and disinfect them before use for another resident. 2 a. During a medication pass observation with LVN 4, on 1/26/22 at 6:45 AM, LVN 4 entered Resident 41's room without putting on gloves before entering the room. LVN 4 was observed touching surfaces, curtains, and Resident 41 with bare hands. Resident 41 was in a room that required Transmission Based Precautions (TBP) which included to use of gown, gloves, and eye protection in addition to hand sanitizing when entering and exiting the room. 2 b. During a medication administration observation with LVN 4, on 1/26/22 at 6:51 AM, LVN 4 did not put on gloves before entering Resident 23's room. LVN 4 touched curtains, bedrails surfaces and the resident with bare hands. 2 c. During a medication administration observation with LVN 4, on 1/26/22 at 7:00 AM, LVN 4 did not put on gloves before entering Resident 36's room. LVN 4 put on gloves prior to insulin shot (a medication used to treat diabetes or blood sugar disease) administration without hand sanitization while inside resident's room and after touching surfaces and bedrails. During an interview with LVN 4, on 1/26/22 at 3:30 PM, LVN 4 acknowledged that she should have been putting gloves on and using hand sanitizer before and after entering the residents' rooms. During an interview with the Director of Nursing (DON), on 1/27/22 at 9:30 AM, the DON stated that the nursing staff should have followed the facility's policy on hand hygiene and glove use prior to entering TBP rooms. During an interview with Infection Control Nurse (IP), on 1/26/22 at 2:10 PM, IP stated that the residents in Zone 1, 2 and 3 were in Transmission-Based Precautions (a form of isolation), and that signs were posted outside all the rooms to remind staff and visitors of the requirements. IP confirmed that TBP would include hand sanitizing, putting on gown, gloves, and eye protection in addition to mask before entering residents' rooms. IP stated that spot audits (random checks on following the procedure) were performed regularly, however, there was no formal process to document the audits. 3. During a medication pass observation with LVN 2 on 1/25/22 at 11:09 AM, LVN 2 used a shared device called glucometer (device used to measure blood sugar) to measure Resident 15's blood sugar. LVN 2 entered the Resident 15's room and measured the blood sugar by poking the fingertip with a needle and then administered the insulin (a medication to help lower blood sugar) as ordered by the doctor. LVN 2, after exiting the resident's room, wiped the glucometer surface with sanitizing wipe labeled Bleach Germicidal Wipes for less than 30 seconds. LVN 2 subsequently placed the glucometer in the drawer on top of a clean tissue. In an interview with the LVN 2 on 1/25/22 at 11:13 AM, LVN 2 stated that she was instructed to leave the glucometer on a surface to dry out after wiping. During an interview with the Director of Nursing (DON), on 1/27/22 at 9:30 AM, the DON stated the policy on shared devises was to sanitize the device appropriately in-between residents' use. The DON stated the nursing staff should have followed the facility's policy on glucometer cleaning and sanitization in-between resident use. The DON stated facility's IP nurse should have given feedback and monitored the compliance. Review of the facility's policy titled Blood Sampling, Capillary (Finger Sticks), last revised on 9/14, the policy indicated 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. Review of the glucometer manufacturer information sheet for ASSURE ®PLATINUM BLOOD GLUCOSE MONITORING SYSTEM( the name of glucometer brand), last accessed on 2/1/22, the information sheet indicated The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood, and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens. Review of the facility's sanitization wipe instructions for this product Clorox, Healthcare Bleach Germicidal Wipes, last accessed on 2/1/22, the manufacturer's product instruction indicated the following steps for effective sanitization: *Remove gross soil if present . *Wipe the surface until completely wet. *Wait for the contact time (3 minutes for all pathogens listed on the product label). *Discard the wipe. 4. On 1/24/22 12:56 PM During rounding on the above residents observed isolation carts for rooms 1-7, 33 & 34. Closest hand sanitizer is inside the resident rooms behind privacy curtains making it impossible to sanitize appropriately before and after donning/doffing. 01/24/22 04:40 PM Interview with the Assistant Facility Administrator (AFA) regarding availability of hand sanitizer on isolation carts. There is sanitizer in each room and also along the hallways near the nurses station. When asked about the process of donning and doffing PPE the AFA did not know sanitizing was part of the process. The AFA stated he would get sanitizer placed on the isolation carts and install more dispensers on the hallway walls. 5. During observations on 1/24/22 at 9:35 am, there were no gloves in the isolation carts in front of rooms [ROOM NUMBERS], and only one gown left in the isolation cart for room [ROOM NUMBER]. During an interview on 1/24/22 at 10 am, the Director of Nurses (DON) confirmed the above and said they had personal protective equipment (PPE) in the carts earlier but staff have been going through them a lot, to go into the rooms and answer call lights. During observations on 1/24/22 at 9:35 am, there was no hand sanitizer in the hallway outside rooms [ROOM NUMBER] and none on the isolation carts in front of these rooms. The hand sanitizer for these three rooms was located inside the room on the wall for the bed closest to the hall. However, it was so far inside the room, that one had to enter the room a few feet, and push the resident privacy curtain aside, before having access to the hand sanitizer. During an interview on 1/24/22 at 10 am, the lack of access to hand sanitizer was discussed with DON who confirmed the above observations and said she thought there was some in the hallway outside the rooms at one time. During an observation on 1/25/22 at 8 am, there was no hand sanitizer seen on isolation carts in front of rooms 30, 31 and 32. This was immediately discussed with the Infection Preventionist (IP) Nurse. In room [ROOM NUMBER], the resident's bed prevented access to the hand sanitizer on the wall, in room [ROOM NUMBER] a decoration on the wall prevented access to hand sanitizer, and in room [ROOM NUMBER], the privacy curtain would have to be opened, to have access to the hand sanitizer. The IP confirmed these observations and said the Administrator was bringing sanitizer containers to place on the walls in the hallway outside the room.

Based on observation, interview and record review, the facility did not ensure one of 15 sampled residents (Resident 4) received the necessary routine nursing skin assessments, repositioning, and weekly skin assessments consistent with professional standards to identify the development of a Stage IV pressure ulcer (bed sore, a full thickness tissue loss with exposed bone, tendon or muscle) from developing. This failure resulted in the development of a Stage IV pressure ulcer which subsequently resulted in sharp debridement procedures (the cutting away of dead tissue), the use of a urinary catheter (a tube inserted in the bladder to drain urine), and documented increased pain over a four month period, with a potential for further decline in the overall health and well-being to occur to residents. Findings: On 6/6/17 at 10:10 pm, during an observation of Resident 4's coccyx (tail bone) pressure ulcer Licensed Treatment Nurse (LTN) was observed changing the dressing to the coccyx. Resident 4 required the assistance of two staff for repositioning, and was observed to be cooperative. There was no open area observed. LTN confirmed the pressure ulcer had healed, and stated she believed the pressure ulcer developed around 1/2017, approximately four months ago. Resident 4's clinical record was reviewed. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/7/17 at 10:15 am, during a concurrent interview and record review LTN stated that Resident 4 had no previous history of pressure ulcers, and developed the Stage IV pressure ulcer on 1/25/17 while at the facility. LTN stated the facility had identified Resident 4 as being at risk for skin breakdown. LTN stated Resident 4's skin was not assessed routinely to have all of a sudden developed a Stage IV measuring measuring 14 centimeters (cm, unit of measure) long (L) by 9.5 centimeters wide (W). A review of a Clinical Health Status document dated 7/23/16 at 11:37 am, indicated that upon admission, a nurse documented that Resident 4 had no pressure ulcers. A Braden Scale (a document used to aid in the assessment of pressure ulcer risk) indicated Resident 4 scored 14 (a moderate risk) due to poor sensory perception, skin was occasionally moist, limited mobility, and required moderate to maximum assistance with mobility. Resident 4 was assessed to have occasional back pain with a scale numeric rating of number of 2 (a standardized pain scale used to determine severity where 0 is the least, and 10 is the worst pain). A review of Resident 4's Minimum Data Sets (MDS, a standardized comprehensive assessment of each resident's functional capabilities that helps nursing home staff identify health problems) dated 8/5/16, and 10/29/16, had identified that Resident 4 was a high risk for developing pressure ulcers. These MDSs also indicated that Resident 4 required extensive assistance with transfers, and bed mobility, and occasionally was incontinent (inability to control bladder) of urine. The next MDS dated [DATE], indicated Resident 4 was always incontinent of urine and had developed an unstageable pressure ulcer due to eschar (black dead tissue). A review of a care plan titled, Pressure ulcer actual or at risk due to assistance required in bed mobility and obesity, dated 11/3/16, indicated the facility goal was that Resident 4's skin would remain intact. The interventions included nursing to conduct weekly skin inspections, provide thorough skin care after incontinent episodes, and turn and reposition per assessment and schedule. A review of a nursing progress note dated 1/25/17 at 12:51 pm, indicated that a nurse's aide was toileting Resident 4 and noticed a dark circular mushy black area with redness around the wound on her coccyx measuring 14 cm L by 9.5 cm W. A review of Resident 4's physician's orders [REDACTED]. This order was written two days after Resident 4's pressure ulcer was identified on 1/25/17. On 6/7/17 at 11:30 am, a Family Member (FM) was interviewed. FM stated she felt the skin blister to Resident 4's coccyx was due to improper cleaning after she was incontinent of feces (stool). FM stated on two occasions Resident 4 was observed to have dried stool on her skin during the month of 12/2016, before Christmas. FM stated the facility was observed to be short staffed, especially on the day shift and weekends, with only two Certified Nursing Assistants (CNAs) on the floor. FM stated she heard staff state they were shorthanded and observed them running to get their work done. A review of a Consultant Dietician's Resident Summary, dated 12/16/16, indicated the Dietician had added a banana to every breakfast and apple sauce every lunch to help with Resident 4's loose stools. On 6/7/17 at 11:40 am, during an interview with LTN and the Director of Nurses (DON), the DON stated that it was her professional expectations that residents were to be turned every two hours. The DON stated the above physician's orders [REDACTED]. A review of Wound Doctor (WD) initial evaluation, dated 2/1/17, indicated that Resident 4's coccyx pressure ulcer was assessed as unstageable due to necrosis (dead tissue) measuring 3.5 cm L by 3 cm W. The evaluation read that the surgical debridement was performed removing 9.6 cm of necrotic tissue. A review of nursing progress notes indicated, that on 3/3/17 at 3:16 pm, a urinary catheter was inserted per physician's orders [REDACTED]. A review of the WD notes, dated 3/22/17, indicated Resident 4's pressure ulcer had worsened and 3.6 cm of necrotic tissue was debrided. A review of the WD notes, dated 4/5/17, indicated Resident 4 had moisture associated [MEDICAL CONDITION] (a condition where tissue was reddened and inflamed). On 4/6/17 at 12:44 pm, an Interdisciplinary Team Note (IDT, a group of professionals that meet to discuss resident care and services) was reviewed and indicated that Resident 4 had exhibited pain during her wound debridement procedures and the nurses would be educated to administer pain medication to the resident prior to her dressing changes. A review of the WD notes, dated 5/7/17, indicated Resident 4's Stage IV pressure ulcer was healed. A review of the WD notes, dated 5/24/17, indicated Resident 4's IV pressure ulcer had reopened measuring 1 cm by 0.4 cm. A review of of Resident 4's, Shift Documentation Form completed by the CNAs indicated a section for pressure redistribution devices used to include cushions or mattresses used during each shift. The form directs CNAs to document every shift what was used. There was no documentation that these devices were used for the entire day for 1/22, 1/23, and the day shift for 1/24 and 1/25/17 prior to Resident 4's pressure ulcer being identified. There was no area on these forms to document that Resident 4 had been repositioned every 2 hours from 12/1/16 to 1/25/17. On 6/8/17 at 9:50 am, during an interview with the DON she confirmed that there was no documented evidence from the CNAs that Resident 4 had been repositioned every two hours prior to her development of a Stage IV pressure ulcer. The DON stated there was not a space for the CNAs to indicate that this was done during their shift. The documents titled Comprehensive C.N.A. Shower Review (shower sheets) dated from 12/1/16 through 5/31/17, were concurrently reviewed with the DON. The DON stated the shower sheets were to be completed weekly during resident showers and were signed by the licensed nurses. While reviewing the shower sheets, the DON confirmed the sheets were not correctly filled out. The shower sheets did not indicate if Resident 4's skin was intact or not, because the Y for yes or N for no was not documented. The DON confirmed the shower sheets for 12/13, 12/16, 12/23, 12/30/16 were incorrect. A review of Resident 4's Progress Notes, dated 9/22/16 to 1/25/17, indicated that there was no documented evidence that nursing conducted daily or weekly skin inspections and every two hour repositioning. During a concurrent interview, on 6/8/17 at 10:10 am, the DON confirmed that there was no documentation for daily or weekly skin inspections and repositioning by the licensed nurses until after the Stage IV pressure ulcer was identified. The DON also confirmed that Resident 4 required a urinary catheter to keep urine from getting into the pressure ulcer and that Resident 4 required pain medication prior to dressing changes. The weekly wound notes dated from 2/1/17 to 5/31/17, were reviewed and indicated Resident 4 had a total of seven debridements of the pressure ulcer, with a sharp instrument, where necrotic (dead)tissue was removed by the WD. Resident 4's Physician's monthly progress notes, called a documentation dated from 1/25/17 to 6/5/17 were reviewed. There was no documentation by the Attending Physician (AP) that Resident 4's Stage IV pressure ulcer was evaluated or described as unavoidable. Twelve out of 62 History & Physicals only indicated Resident 4 had a ulcer (1/26, 2/6, 3/8, 3/9, 4/6, 4/8, 4/10, 5/16, 5/21, 6/3, 6/4, and 6/5/17. On 6/7/17 at 4 pm, Resident 4's AP provided A History & Physical dated 6/7/17 indicating that Resident 4's acquired pressure ulcer was unavoidable, after the above findings were identified. On 6/8/17 at 8:50 am CNA G was interviewed, and concurrently at 9:20 am, CNA H was also interviewed. Both CNAs stated they cared for Resident 4 before her pressure ulcer was identified. They both stated she never refused to be repositioned while in bed. A review of the facility undated, Pressure Ulcer Prevention and Treatments policy and general guidance was reviewed and instructed that all residents' skin with a Braden score of 18 or below were to be kept clean and dry. When the residents were incontinent of bowel and bladder they were to be washed and rinsed immediately, and their bedding changed. Skin barrier (cream to prevent moisture build up) would be applied as indicated and turning and repositioning would occur at a minimum of every two hours or as necessary to prevent friction and the formation of pressure ulcers. A facility policy(NAME)Clinical Services Skin Integrity Guideline dated 2011, instructs that residents at risk for skin breakdown would be assessed on a weekly basis by the licensed nurses. Additionally Residents will be observed by the CNAs daily for reddened open areas. Changes would be reported to the licensed nurses and documented.

Based on interview and record review, the facility failed to ensure Resident 1 received adequate supervision when he received excessive doses of Ativan (antianxiety medication), then suffered the adverse consequence of a fall with fracture to his left (L) humerus (upper arm bone). Refer to F 329 for additional information. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/3/12, Resident 1's At Risk For Falls care plan, dated 1/14/12, showed he had an extensive fall history, impaired balance, poor safety awareness, and used medications that increased his fall risk. Resident 1's record included nurse Progress Notes, dated 9/16/12 at 9:46 pm, that read,"...DON (Director of Nursing) was called regarding residents behavior and was permitted to call in a 1 on 1 sitter (1:1 monitoring) to be with resident at all times to ensure his and other residents safety..." Resident 1's nurse Progress Notes, dated 9/17/12 at 3:19 pm, read, "Resident has more behaviors on nightshift then other times of the day when there is less staff to redirect him." Resident 1's nurse Progress Notes, dated 9/18/12 at 10:39 pm, showed the following: Resident 1 had a verbal confrontation with a resident and hit them with a cloth napkin at 6 pm; At 6:15 pm, Resident 1 lunged at another resident and threatened her; Resident 1 then attempted to slap a third resident in the face and ended up slapping her arm; The nurse contacted Resident 1's physician for a "one time" order of 1 mg of Ativan "to calm his aggression;" Resident 1 slept for one and one half hours, then wandered around the facility; 1:1 care had to be provided to ensure everyone's safety. Resident 1's physician orders [REDACTED]. Resident 1's orders also included 0.5 mg of Risperdal (antipsychotic medication) every night at bed time. A review of Resident 1's Medication Administration Records (MARs) for 9/2012 showed he received the following Ativan doses on 9/18/12: 0.5 mg at midnight between 9/17 and 9/18/12; 0.5 mg at 8 am; 0.5 mg at 12 noon; 0.5 mg at 6 pm; 0.5 mg PRN dose at 3:15 pm; and the "one time" 1 mg dose, for a total of 3.5 mg in less than a 24 hour period. The facility's Verification of Investigation report showed that Resident 1 was given the additional "one time" 1 mg Ativan dose at 7:45 pm and documented the 1:1 staff assignment with a Certified Nurse Assistant (CNA), at that time. Resident 1's record included nurse Progress Notes, dated 9/19/12 at 12:53 am, that revealed that Resident 1 got up out of bed and had an "unwitnessed fall" in his doorway at 11 pm on 9/18/12. The documented assessment revealed that "resident had pain to left shoulder and left hip red mark behind left ear and left shoulder VS (vital signs) were unavailable due to resident refusing. MD was called no response, called DON got approval to send to acute." The Progress Note, dated 9/19/12 at 4:33 am, read, "Pt returned from (acute hospital) ER at 0400....pt has a fractured Left humerus (arm bone) from fall earlier. Pt came back with order for pain meds but was medicated with norco (narcotic) at hospital before returning..." There was no documented evidence that there was a 1:1 sitter with Resident 1 when he sustained the fall on 9/19/12. According to Lexicomp Online 2012, warnings and precautions for Ativan include special considerations for the elderly that include, "... increase the risk of impaired cognition, delirium, falls, fractures, and motor vehicle accidents. Due to increased sensitivity in this age group, avoid use for treatment of [REDACTED]." Lexicomp Online's Geriatric Considerations for Ativan read, "This medication is considered to be potentially inappropriate in the patient population (Beers Criteria: Quality of evidence - high; Strength of recommendation - strong)." On 10/3/12 at 3:30 pm, the facility's Pharmacist (RPh) was interviewed about Resident 1's Ativan dosing on 9/18/12. RPh stated that a dose between 2 and 2.5 mg could contribute to falls and oversedation and also confirmed that Ativan doses greater than 2 mg contribute to a lack of coordination (ataxia). On 10/3/12 at 3:45 pm, the DON stated the facility had had a 1:1 sitter until the night shift (10 pm to 6 am) started. DON stated that they had pulled the sitter at the change of shift (between the afternoon and night) due to staffing constraints. On 1/8/13 at 9:45 am, Resident 1's medical doctor (MD) was interviewed about the one time dose of 1 mg of Ativan on 9/18/12. He stated that facility staff had informed him that Resident 1 was agitated and aggressive towards staff and was difficult to control. MD stated that Ativan does affect balance and that it could have contributed to Resident 1's fall. A review of Resident 1's Physical Therapy Progress Notes, dated 9/21/12 at 2 pm, read, "Therapy Screen reveals that fall was not due to prominent balance deficits, but rather due to compromised balance from medication (Ativan) given to resident for agitation..."

Based on interview and record review, the facility failed to ensure Resident 1 was free of unnecessary drugs, when he received excessive doses of [MEDICATION NAME] (antianxiety medication), was not adequately monitored for the excessive dose amount, then suffered the adverse consequence of a fall with fracture to his left (L) humerus (upper arm bone). Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a record review, on 10/3/12, Resident 1's At Risk For Falls care plan, dated 1/14/12, indicated he had an extensive fall history, impaired balance, poor safety awareness, and used medications that increased his fall risk. Resident 1's physician's monthly order sheet for 10/12, showed 0.5 milligrams (mg) of [MEDICATION NAME] was ordered every 6 hours, with an additional 0.5 mg [MEDICATION NAME] ordered PRN (as needed) every 12 hours. Resident 1's orders also included 0.5 mg of [MEDICATION NAME] (antipsychotic medication-reduces/calms the distortion and disorganization of a person's mental capacity) every night at bed time. Resident 1's record included nurse Progress Notes, dated 9/16/12 at 9:46 pm, that read,"...DON (Director of Nursing) was called regarding residents behavior and was permitted to call in a 1 on 1 sitter (1:1 monitoring) to be with resident at all times to ensure his and other residents safety..." Resident 1's nurse Progress Notes, dated 9/17/12 at 3:19 pm, read, "Resident has more behaviors on nightshift then other times of the day when there is less staff to redirect him." Resident 1's nurse Progress Notes, dated 9/18/12 at 10:39 pm, indicated the following: 1. Resident 1 had a verbal confrontation with a resident and hit them with a cloth napkin at 6 pm; At 6:15 pm, Resident 1 lunged at another resident and threatened her; Resident 1 then attempted to slap a third resident in the face and ended up slapping her arm; The nurse contacted Resident 1's physician for a "one time" order of 1 mg of [MEDICATION NAME] "to calm his aggression;" 2. Resident 1 slept for one and one half hours, then wandered around the facility; and 3. 1:1 care monitoring had to be provided to ensure everyone's safety. Resident 1's record included nurse Progress Notes, dated 9/19/12 at 12:53 am, which indicated he had been involved in several altercations the previous evening (9/18/12), given his scheduled 0.5 mg dose of [MEDICATION NAME] (at 8 am, 12 pm, and 6 pm), a PRN 0.5 mg dose of [MEDICATION NAME] (at 3:15 pm), and the additional "one time" 1 mg dose of [MEDICATION NAME] (at 7:45 pm). The note revealed that Resident 1 got up out of bed and had an "unwitnessed fall" in his doorway at 11 pm on 9/18/12. The documented assessment revealed "resident had pain to left shoulder and left hip red mark behind left ear and left shoulder VS (vital signs) were unavailable due to resident refusing. MD was called no response, called DON got approval to send to acute". The Progress Note dated 9/19/12 at 4:33 am, read, "Pt returned from (acute hospital) ER at 0400....pt has a fractured Left humerus (arm bone) from fall earlier. Pt came back with order for pain meds but was medicated with [MEDICATION NAME] (narcotic) at hospital before returning..." A review of Resident 1's Medication Administration Records (MARs) for 9/2012 showed he received the following [MEDICATION NAME] doses on 9/18/12: 0.5 mg at midnight between 9/17 and 9/18/12; 0.5 mg at 8 am; 0.5 mg at 12 noon; 0.5 mg at 6 pm; 0.5 mg PRN dose at 3:15 pm; and the "one time" 1 mg dose, for a total of 3.5 mg in less than a 24 hour period; in addition to 0.5 mg of [MEDICATION NAME] (sedating-an extra dose to reduce an extreme emotional/aggressive state of his mental condition). The facility's Verification of Investigation report, dated 9/19/12 at 6:11 pm, showed that Resident 1 was given the additional "one time" 1 mg [MEDICATION NAME] dose at 7:45 pm and documented the 1:1 staff assignment with a Certified Nurse Assistant (CNA), at that time. According to Lexicomp Online 2012, warnings and precautions for [MEDICATION NAME] include special considerations for the elderly that include, "... increase the risk of impaired cognition, [MEDICAL CONDITION], falls, fractures, and motor vehicle accidents. Due to increased sensitivity in this age group, avoid use for treatment of [REDACTED]." Lexicomp Online's Geriatric Considerations for [MEDICATION NAME] read, "This medication is considered to be potentially inappropriate in the patient population (Beers Criteria: Quality of evidence - high; Strength of recommendation - strong)." On 10/3/12 at 3:30 pm, the facility's Pharmacist (RPH) was interviewed about Resident 1's [MEDICATION NAME] dosing on 9/18/12. RPh stated that a dose between 2 and 2.5 mg could contribute to falls and oversedation confirmed that [MEDICATION NAME] doses greater than 2 mg contribute to a lack of coordination (ataxia). On 10/3/12 at 3:45 pm, the DON stated that the facility had had a 1:1 sitter until the night shift (10 pm to 6 am) started. DON stated that they had pulled the sitter at the change of shift (between the afternoon and night) due to staffing constraints. On 1/8/13 at 9:45 am, Resident 1's medical doctor (MD) was interviewed about the one time dose of 1 mg of [MEDICATION NAME] on 9/18/12. He stated that facility staff had informed him that Resident 1 was agitated and aggressive towards staff and was difficult to control. MD stated that [MEDICATION NAME] does affect balance and that it could have contributed to Resident 1's fall. A review of Resident 1's Physical Therapy Progress Notes, dated 9/21/12 at 2 pm, read, "Therapy Screen reveals that fall was not due to prominent balance deficits, but rather due to compromised balance from medication ([MEDICATION NAME]) given to resident for agitation..." There was no evidence in the record that the use of [MEDICATION NAME] for Resident 1 was being monitored.

Based on observation, interview, and record review, the facility failed to provide supervision and care that was adequate in the prevention of avoidable, repetitive falls with injuries for five of five residents (Residents 1, 2, 3, 4, and 5). The facility failed to implement its "Falls Management" policy by failing to complete "Change in Condition Report-Post Fall/Trauma" reports and ensuring that the Interdisciplinary Team (IDT) reviewed the reports and made recommendations to prevent further falls, as required by policy. 1. Resident 2 had sustained 12 falls, five resulted in head injuries and two emergency room visits, while ambulating unassisted. 2. Resident 3 had sustained 5 falls, one resulted in a broken left humerus (upper arm bone) and a lacerated chin, which required stitches, while ambulating unassisted. 3. Resident 4 had sustained 4 falls, one resulted in left hip pain and bruising and required an emergency room visit, from falling out of his wheelchair. 4. Resident 5 had sustained 3 falls, one fall resulted in his falling against and breaking the sliding glass door in his room, when he transferred himself, unassisted. 5. Resident 1 had sustained 12 falls, one resulted in an abrasion to his back, from ambulating unassisted. These failures resulted in Residents 1, 2, 3, 4, and 5 repeatedly falling and sustaining injuries, from the same situations and activities, and had the potential to result in continued serious avoidable falls and injuries to the residents, potentially preventing them from reaching their highest practicable level of well-being. Findings: 1. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 2/18/12, reflected that Resident 2 had memory problems, decision making difficulties, balance problems, and required one person to physically assist her with transfers and ambulation. Resident 2 shared a room with her husband (Resident 1), who had also sustained 12 falls since their admission. Their daughter was their decision maker. On 3/22/12, Resident 2's Nursing Progress Notes were reviewed from 2/22/11 through 3/22/12. The Progress Notes reflected that Resident 2 had sustained 12 falls over ten months, between 4/22/11 and 2/18/12, five of which had resulted in head injuries. The Nursing Progress Notes contained the following documentation: On 4/23/11 at 4:20 am, "...fell backwards, hitting head..has a "goose egg" on the right lateral head." On 9/16/11 at 2:56 pm, "...fell by bathroom door...assessed head and noted a bump bruised and a little swollen...Resident stated her head hurt." A follow up note on 9/22/12 at 1:37 pm, described, "...right side of her forehead...fading bluish discoloration, measuring roughly 8.5 x 8.5 centimeters," (equivalent to three and one half inches). On 9/30/11 at 10:21 pm, "...resident was found on the floor. There was a large amount of blood on the floor. Resident had split open the back of her head. Called 911." On 11/23/11 at 11:40 am, "...fell in her doorway. Moderate size lump found on lt. (left) side of head." On 11/26/11 at 2:08 pm, a follow up note described, "...bruising to left side of head extending down back of head to neck." On 2/18/12 at 7:10 pm, "...fell backwards hitting her head. Minimal amount of blood on floor...transport to (local hospital)." On 3/22/12 at 1 pm, the Change in Condition Report-Post Fall/Trauma (Post Fall) reports for Resident 2 were reviewed with the Assistant Director of Nurses (ADON). The ADON confirmed that, although Resident 2 had sustained 12 falls between 4/22/11 and 2/18/12, only seven Post Fall reports had been completed. The IDT recommendations included, "Therapy will screen" (four times), "speak with daughter re: alarm", (recommended on 11/29/11, but the alarm had already been in place since 10/1/11, per her care plan), and "continue to educate" (despite her [DIAGNOSES REDACTED]. The ADON confirmed that four times the IDT had made the same recommendation of "therapy will screen" even when therapy was already in progress. The Restorative Nursing Program (RNP) had been recommended once after the 2/8/12 fall, but Resident 2 had already been in that program since 9/11, and had refused to participate. The ADON confirmed that the IDT had repeatedly made the same ineffective recommendations without new interventions, therefore, Resident 2 continued to fall and be injured. On 3/23/12 at 1 pm, an interview and concurrent record review was conducted with the Occupational Therapist (OT). The OT confirmed that Resident 2 had participated in Physical Therapy (PT) from 11/5 to 12/30/11. The PT had documented that, "Goal met-the patient is able to complete all functional transfers requiring SBA (stand by assist)..." The OT confirmed that Resident 2 had four falls while receiving PT and three falls after PT had discharged her. The OT confirmed that on 12/30/11, PT discharged Resident 2 to the RNP services, which had been an ineffective intervention in the past, as Resident 2 had refused to participate in that program. The OT confirmed that the "therapy screen" recommendation by the IDT was a redundant intervention which had not resulted in the effective prevention of repeated falls, and added, "the residents need nursing supervision, not therapy." The OT stated, "we are aware that this is a problem and our Director is working on that." On 3/27/12 at 1:10 pm, during an observation and interview with Licensed Vocational Nurse (LVN) R, she confirmed that Resident 2's bed alarm was not in place. LVN R stated that Resident 2 frequently removed the alarm, which was supposed to be clipped on to her pillow. LVN R stated that, "we find it (the alarm) at the foot of the bed or in her nightstand drawer." LVN R confirmed that there was no system in place to monitor Resident 2's bed alarm use. On 3/27/12 at 7:20 am, an interview was conducted with Certified Nursing Assistant (CNA) D. CNA D stated that she had taken care of Resident 2 for the first time, on 2/18/12. CNA D stated that Resident 2 got out of bed by herself to use the toilet and did not have a bed alarm in place. CNA D stated that she was unaware that Resident 2 was to have a bed alarm, and had been given no instructions on how to care for Resident 2, prior to assuming her care. CNA D stated, "there's nothing available to tell us (CNAs) how to take care of a resident-how they eat, walk, or if they are continent or incontinent." On 3/27/12 at 8:40 am, an interview was conducted with the Director of Nurses (DON). The DON stated that the CNAs did not have access to resident care plans, which were kept in an electronic record (computer). The DON stated that CNAs gave report on resident care needs to each other every shift, however, the report could be an unreliable source of information, if both CNAs were unfamiliar with the resident. The DON stated that the facility had used a "Kardex" system which was designed for direct care staff and easily accessed by the CNAs. The Kardex described all resident care needs based on the MDS assessment, and was kept at the nurses station in a binder. The DON stated that the Kardex was generated and printed out by the computer, however, when the "new computer" system was added "a year ago" the populated Kardex could not be printed. The DON stated that she could have hand written the information on the Kardex form, but preferred to get it from the computer, "I've been working on that for the past year." The DON confirmed that the CNA staff had not been provided with resident care information, for one year. The DON added that resident care needs used to be posted in each resident's closet but, "no one kept the information up to date" and that system had been discontinued, as well. The DON could not explain how a CNA would obtain an adequate amount of accurate information to safely provide care to the residents. 2. Resident 3 was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 3/23/12 at 4 pm, Resident 3 was observed ambulating in the hallway just outside of her room, unsupervised. Resident 3 was wearing a sling to her left arm and hanging on to the railing with her right hand, her balance was impaired. On 3/23/12, Resident 3's Nursing Progress Notes were reviewed. From 2/15/12 to 3/22/12, one month, Resident 3 had sustained five falls while ambulating, unsupervised, and one fall had resulted in a broken arm and lacerated chin, which required stitches. The Nursing Progress Notes contained the following documentation: On 3/4/12 at 1:29 pm, "Residents roommate called someone into room saying resident (Resident 3) fell . ...hit her right side on dresser." On 3/9/12 at 8:15 pm, "...resident lost balance...hit chin...4 cm (one and one half inch) wound...c/o (complaining of) severe pain to lt (left) upper arm and shoulder...laceration to bottom lip." On 3/11/12 at 9:16 am, a follow up note documented that, "Received 4 stitches (to chin)...abrasion on bottom lip...fracture to left shoulder (humerus)..." On 3/22/12 at 9:21 pm, "...found sitting (on the floor) next to chair in dining room..." On 3/23/12 at 3 pm, a review of Resident 3's Post Fall reports was conducted with the ADON. Of five falls, only one Post Fall report had been completed, dated 3/9/12. The IDT recommendation was, "Pt (patient) screened by therapy." The ADON confirmed that four Post Fall reports, which were to include IDT recommendations to prevent further falls, had not been completed for Resident 3. On 3/23/12 at 5 pm, Resident 3's Physical Therapy notes were reviewed with the Rehab Director (RD). A PT "Discharge Summary", dated 1/30/12, reflected that Resident 3, "...is able to ambulate independently in facility..." Resident 3 sustained five falls which included a broken arm and lacerated chin, after the PT department had discharged her as being capable of ambulating independently. The RD confirmed that Resident 3 had been discontinued from PT on 1/30/12, and had not received therapy since, despite the IDT recommendation and five falls. The RD could not explain why Resident 3 had not been evaluated by therapy after the 2/15 and 3/4/12 falls, but stated that Resident 3 could not be seen for physical therapy until her broken left arm healed. 3. Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], reflected that Resident 4 had memory problems, balance problems, and required extensive assistance with two people for transfers. On 3/22/12, Resident 4's Nursing Progress Notes were reviewed. From 1/15/12 to 2/26/12, Resident 4 had sustained four falls, one with a hip injury which required an emergency room visit, from repeatedly falling out of his wheelchair. Nursing Progress Note documentation included the following: On 1/15/12 at 9:56 pm, "Resident was attempting to ambulate independently... tripped over side of wheelchair...Erythemic (red and warm) area to the left hip...called 911 and asked them to send an ambulance... On 1/28/12 at 1:05 pm, "Seemed like resident had fallen asleep and fell out of w/c (wheelchair)." On 2/26/12 at 6:20 pm, "Fall in fireside dining room witnessed by a guest." On 3/23/12 at 11:45 am, an observation of Resident 4 was conducted. Resident 4 was observed sitting in his wheelchair in the doorway of his room, unsupervised. There was no alarm on his wheelchair and he was not wearing the self releasing seat belt, as care planned. During the observation, CNAs, Licensed Nurses, and the Activity Director had passed by Resident 1, without noticing that his seat belt and wheelchair alarm were not in place. After 15 minutes of observation, at 12:00 noon, the Surveyor located and interviewed Resident 1's caregiver, CNA O. CNA O stated that Resident 4 must have "switched chairs," however, was unable to explain how he could do that without setting off the alarm. CNA O confirmed that Resident 4's wheelchair that contained the alarm and seat belt, was in his room parked next to the window. On 3/27/12 at 9:30 am, Resident 4 was observed sitting in his wheelchair, unsupervised, in front of the nurses desk without the alarm or seat belt, again. Numerous staff members were observed to pass by Resident 4, and a few even spoke to him, however, none had noticed that he was not wearing his seat belt or that the wheelchair alarm was missing. A half hour later, at 10 am, the Housekeeping Supervisor (HS) began to clean the nurses station where Resident 4 was sitting. The HS had observed the Surveyor observing Resident 4. Within seconds the HS intervened, but not the nurses, and went into Resident 4's room, retrieved the fall prevention safety devices, and applied them. On 3/27/12 at 10:10 am, the HS confirmed during an interview that Resident 4 was in a wheelchair without a seat belt or alarm in place. On 3/23/12 at 3 pm, Resident 4's Post Fall reports were reviewed with the ADON. The ADON confirmed that the IDT repeatedly recommended "fall will be addressed in therapy," on all four Post Fall reports even though since 1/12, Resident 4 had already been receiving PT and OT services. The ADON confirmed that the IDT recommended that a self releasing seat belt and wheelchair alarm be placed on Resident 4 after he fell on [DATE], but the facility had not initiated those measures until 3/12/12, a month and a half later. 4. Resident 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], reflected that Resident 5 required extensive assistance with two people to transfer, and had balance problems while sitting. On 3/23/12 at 4:20 pm, Resident 5 was observed outside in the smoking area, unsupervised. Resident 5 had an alarm attached to his wheelchair that was clipped to the back of his shirt. On 3/23/12, Resident 5's Nursing Progress Notes were reviewed. Between 12/24/11 and 1/8/12, Resident 5 sustained three falls while transferring himself, unassisted and unsupervised. Nursing Progress Note documentation included the following: On 12/24/11 at 2:22 pm, "Patient fell while transferring to w/c (wheelchair). Hit sliding glass door and it broke." Follow up documentation on 12/25/11 at 5:51 pm, included "...post fall and complaining of pain in the coccyx (tailbone) and surrounding area." On 1/2/12 at 2 pm, "...fall alarm going off. Found resident sitting on floor...soreness to buttocks from previous fall." On 1/8/12 at 1:15 pm, "Resident found lying on floor in room...No injuries noted..." In a post fall follow up note on 1/9/12 at 5 pm, a nurse documented that Resident 5 was, "complaining of left rib and left side back pain 8/10 (severe- on the pain scale)." On 3/22/12 at 4:50 pm, Restorative Nursing Assistant (RNA) G stated during an interview, "when the alarms go off and you're in a room the resident can fall before you get to them." On 3/23/12 at 4 pm, the ADON stated during an interview that the IDT had discovered that the "brake was broke" on Resident 5's wheelchair when he fell on [DATE], which had not previously been identified with the nursing post fall assessment. The ADON confirmed that the Post Fall nursing assessments had not included whether or not Resident 4 had the safety alarm in place when he fell on [DATE] and 1/8/12. The ADON confirmed that the use of an alarm to Resident 4's wheelchair was not care planned and was unable to determine if the alarm had been a contributing factor to Resident 4's repeated falls. 5. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], reflected that Resident 1 had severe balance problems and required one person to physically assist him with transfers, ambulation, and toilet use. On 3/22/12, Resident 1's record was reviewed. Since admission, on 2/22/11, Resident 1 had sustained a total of 12 falls while ambulating unassisted and unsupervised. On 10/7/11, Resident 1 fell while trying to elope from the facility and sustained an abrasion to the middle of his back. On 3/22/12 at 1 pm, a review of Resident 1's Post Fall reports was conducted with the ADON. The ADON confirmed that out of 12 falls, only 8 fall reports had been completed, which resulted in four missed opportunities for the IDT to make recommendations to prevent Resident 1 from continuing to fall. On 1/26/12, a review of Resident 1's care plans was conducted. The "At risk for repeated falls" care plan reflected that on 1/12/12, after 11 falls, a bed alarm had been placed. On 1/26/12 at 11:05 am, the ADON stated during an interview that the facility had "never tried an alarm" on Resident 1's bed as care planned, and "it won't work on his chair (personal recliner)." On 3/22/12 at 11:50 am, an observation of Resident 1 and concurrent interview was conducted with CNA L. There was no alarm on Resident 1's bed. CNA L confirmed that there was no alarm on Resident 1's bed and stated, "he (Resident 1) has never had a bed alarm." On 3/23/12, the facility's policy titled, "Falls Management", dated 4/24/06, was reviewed. The policy directed: 1. "The interdisciplinary team evaluates the fall prevention plan of care for residents "at risk" for falls." 2. "Following a resident's fall: Appropriate interventions are implemented." 3. "Continue ongoing assessment and documentation by licensed nurses per facility practice." 4. "The Interdisciplinary Team reviews the Change of Condition Report-Post Fall/Trauma and makes additional recommendations within 72 hours of the fall." 5. "IDT assessment is completed on the Change of Condition Report-Post Fall/Trauma." On 3/23/12 at 3:30 pm, the facility Administrator confirmed that Resident 1, 2, 3, 4, and 5's falls were avoidable and that their injuries could have been prevented with proper supervision and care planning. The Administrator stated, "Residents with alarms should not be falling that often." On 3/27/12 at 8:40 am, the DON confirmed that the facility had not followed their "Falls Management" policy by not developing appropriate interventions that prevented avoidable resident falls and injuries. The DON confirmed that the IDT's recommendations had been redundant and ineffective and were not based on each Residents' specific needs. The DON confirmed that the lack of available resident care information to the CNA staff had contributed to avoidable falls with injuries to Residents 1, 2, 3, 4, and 5.

Based on observation, interview, and record review, the facility failed to ensure Resident 20 received adequate supervision to prevent an accident, when she was found alone, crying, frightened and injured, outside the facility in the street on 9/2/12. Resident 20 wandered outside of the facility, fell out of her wheelchair into the street and sustained injuries. Findings: The facility's Elopement Policy and Procedure Guide, dated 1/11, included the definition "Elopement, for purposes of the policy and procedure, is defined as that situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety, needs and therefore at risk for injury outside the confines of the living center, has left the living center without knowledge of staff." The policy showed the purpose was to identify residents at risk for elopement, minimize episodes of elopement, and protect residents that are not capable of protecting themselves. The policy's Documentation Guidelines section included..."Care plan that addresses potential to wander or exit living center and the measures taken to prevent wandering/elopement...Bracelet alarm/device is in place (per TAR (treatment authorization record)." The policy's Initial Review section read, "Upon admission, each resident is assessed for the potential for elopement." The policy's prevention section indicated staff would observe that each resident's bracelet alarm/device was still in place each shift and document these findings on the TAR. The policy's reporting section showed the Executive Director (ED/Administrator) was responsible for notifying the State Agency (Department), as necessary by state requirement. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS, an assessment tool), dated 8/9/10, described her as having memory problems, rarely being understood by others, and able to walk independently. Resident 20's record was reviewed. A nurses note, dated 9/2/12, documented, "At 0610, found pt. (Resident 20) outside in front of facility out of w/c (wheel chair), sitting on sidewalk. Noticeable abrasions on Right elbow, RFA (right forearm), Left hand (2nd middle finger)." In an interview on 10/2/12 at 4 pm, when asked about Resident 20 being found outside of the facility on 9/2/12, Executive Director (ED) M stated he had not considered Resident 20's accident an "elopement." ED M stated that Resident 20 had no signs of wandering and the facility had not considered her an elopement risk. In an interview on 10/2/12 at 4:05 pm, Assistant Director of Nursing (ADON) P stated Resident 20's accident was an elopement and should have been reported to the Department. During an interview with certified nurse assistant (CNA) R on 10/3/12 at 9:10 am, she stated she got Resident 20 up for breakfast on 9/2/12 at about 5:55 am and left her outside of her room (Room 7C). In an interview on 10/3/12 at 9:45 am, Staff N stated she was sitting in her car the morning of 9/2/12, prior to starting her shift. Staff N stated she was waiting for the facility to unlock the front door at 6 am. Staff N stated it was dark outside (sunrise was at 6:38 am on 9/2/12). She stated she heard someone crying, "Help me, help me." Staff N stated she was not able to clearly see who was crying because it was dark and a tree was obstructing her view. She stated she was "scared" to exit her vehicle in the dark because of recent vandalism and crimes in the area. Staff N stated she heard someone crying again, "Help me, help me, please" and recognized the voice to be that of Resident 20. Staff N stated she asked, "Is that you (Resident 20)?" and Resident 20 confirmed that it was her. Staff N observed Resident 20 sitting on the asphalt in a parking place in the street in front of the facility, with blood on her nose, hands and right elbow. Staff N stated that Resident 20 was crying and frightened. She stated she was uncertain how long Resident 20 was outside; that Resident 20 was out there long enough for all of her blood to dry. Staff N stated that Resident 20's wheelchair was laying in the street broken and that there was visible blood on the ground around where she was. She stated that the right arm piece of Resident 20's wheel chair was broken off from the accident. The distance from the facility's front door to where Staff N stated she found Resident 20, was concurrently observed to be approximately 45 feet down the street and approximately 9 feet out into the street's parking spaces. Staff N stated Resident 20 could have ended up down the steep street (a down hill slope); that the only thing stopping her was the one car in the parking space, next to where she was found. Staff N stated she tried to help Resident 20 up but was not able to and felt it was unsafe, so she ran in to the facility for help and told licensed nurse (LN) O that Resident 20 was injured outside. She stated two certified nurse aides (CNAs) and Resident 20's nurse brought Resident 20 into the lobby and checked her over. Staff N stated that when she asked LN O if the incident needed to be reported, LN O stated no; that it was no big deal. Staff N stated she wrote up a report that detailed her finding Resident 20 injured and submitted it to LN O and ED M. Resident 20's record contained physician orders, dated 8/25/10 and 3/5/11, for a Wanderguard transponder (departure alert system) to be applied, due to her "exit seeking behavior." A Grand Rounds/Care Plan Conference, dated 3/12, showed Resident 20 frequently moved throughout the facility in her wheelchair. Behavior Observation Detail reports showed that in March 2012, Resident 20 had 84 behaviors including wandering 13 times and in April 2012, she had 94 behaviors including wandering three times. The March 2012 report included an observation that Resident 20 wandered into the front lobby (adjacent to the street). The facility's MDS, dated [DATE], described her as severely cognitively impaired, able to ambulate, with daily wandering behaviors. Resident 20's CAA (care assessment area) Worksheet, dated 4/20/12, showed she wandered on a regular basis. The CAA Worksheet included a Care Plan Considerations section that read, "Will Behavioral Symptoms - Functional Status be addressed in the care plan? Yes" indicating the facility would develop a care plan for Resident 20. One of the objectives selected was "Avoid complications." The objective of "Minimize risks" was left unchecked. There was no care plan found in Resident 20's record for her wandering behavior, prior to her 9/2/12 elopement. Clinical Health Status assessments, dated 5/4/12 and 7/5/12, included a Risk for Elopement section that asked if Resident 20 was able to leave the building on her own. The Risk for Elopement section was inaccurately marked "No." The remaining Risk for Elopement assessment questions and consideration for a preventative plan of care were left unanswered. (However, Resident 20 wandered nearly every day of 3/2012 and 4/2012, and was assessed as able to walk and move both on and off the unit in her wheelchair). On 10/3/12 at 10:50 am, Resident 20's Treatment Administration Records (TARs) for 9/12 and 10/12 were concurrently reviewed with LN Q, who confirmed there were no documented entries to demonstrate that Resident 20's tab alarms (an alarm sounds when resident moves from chair or bed) were checked, as ordered by the physician. LN Q stated he did not think Resident 20 had a tab alarm and was uncertain whether she used one any longer. On 10/3/12 at 12:15 pm, Medical Records Staff (MRS) M confirmed there was no Elopement Risk Assessment form completed or care plan developed for Resident 20's wandering behavior, prior to her elopement on 9/2/12. MRS M confirmed that on 9/2/12 (following Resident 20's elopement), Resident 20's physician had ordered her Wanderguard be checked for placement every shift. However, MRS M stated there was no 10/2012 TAR created for Resident 20's Wanderguard, and therefore, no documentation that the nurses had checked it, as ordered. On 10/3/12 at 1 pm, LN O stated she did not consider Resident 20's accident an "elopement." When LN O was asked whether Resident 20's tab alarm was on when the accident occurred, she stated no; that it would have alarmed if it had been on. On 10/3/12 at 1:40 pm, CNA R stated that she had written a statement about Resident 20 being found in the street on 9/2/12 and submitted it to LN O. On 10/3/12 at 1:45 pm, ED M stated he had not obtained statements from staff that found Resident 20 in the street or from those that assisted her back into the facility and cleaned/dressed her wounds. The facility had not reported Resident 20's elopement to the Department, prior to discovery by the Department on 10/2/12.