Every finding on record at Redwood Cove Healthcare Center

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program to provide a safe environment for all residents of the facility when the facility failed:1.implement and follow enhanced barrier precautions (EBP, an infection control intervention, primarily used in nursing homes, that involves the use of gowns and gloves during high-contact resident care activities to reduce the transmission of Multidrug-Resistant Organisms (MDRO)- microorganisms, primarily bacteria, that are resistant to one or more classes of antimicrobial agents) for Resident 7 and Resident 78, and 2. to review and revise, at least annually, the facility's infection prevention and control (IPC) policy and procedure (P&P).These failures increase the risk of infection, potentially leading to outbreaks (the occurrence of more cases of disease or health events than is normally expected in the facility, often appearing suddenly or in a cluster), that may cause severe health complications. Not reviewing IPC policies annually had the potential to hinder response to emerging threats and infection prevention.Findings:1. A review of Resident 7's baseline care plan, initiated 8/29/25, indicated resident 7 had wounds to his lumbar (lower back) and left buttocks areas.A review of Resident 78's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated resident admitted to the facility in 9/2025 with a colostomy (a surgical opening, called a stoma, created for waste to exit into a collection bag).During an interview on 09/23/2025 at 9:15 AM, the Resource Nurse (RN) verified residents who had a colostomy and/or open wounds should have an EBP signage posted outside their room to notify staff to wear proper personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when proving high contact care with these residents. The RN stated it was important to ensure EBP was followed to lessen the risk of spreading infection in the facility. During a concurrent observation and interview on 09/23/2025 at 2:01 P.M., Resident 78 was noted to have a colostomy. Resident 78 stated staff did not wear a gown when changing her linens or during toileting hygiene.During an interview on 09/24/2025 at 5:23 PM, The Director of Nursing (DON) confirmed Resident 7 had an open wound and Resident 78 had a colostomy, both requiring EBP signage to alert staff to use appropriate PPE (gloves and gown) and follow protocols. The DON added, that failure to follow EBP could lead to infection outbreaks.During a concurrent observation and interview on 09/25/2025 at 9:45 AM, the interim Infection Preventionist (IP) was observed providing wound care to Resident 7 without wearing a gown. The IP acknowledged not following EBP and confirmed that gowns should be worn during high-contact care, including for residents with wounds or indwelling devices like colostomies. The IP stated this lapse could lead to cross-contamination and infection. She also confirmed there was no EBP signage inside or outside Resident 7's room.During a concurrent observation and interview on 09/25/2025 at 10:05 AM, The interim IP confirmed there was no EBP signage inside or outside Resident 78's room. IP stated staff should wear gloves and gowns when changing linens or providing toileting hygiene, and emphasized the importance of signage to remind staff to use proper PPE for residents with colostomies or open wounds.A review of the facility's P&P titled Enhanced Barrier Precautions, revised December 2024, indicated, . Enhanced barrier precautions apply when. a resident.has a wound or indwelling medical device. EBPs employ targeted gown and glove use .during high contact resident care activities. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include. changing briefs or assisting with toileting. changing linens. [and] wound care (any skin opening requiring a dressing). Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required.2.During a concurrent interview and record review on 09/24/2025 at 5:23 PM, with the DON, the Infection Prevention and Control P&P binder was reviewed. The DON verified the QA committee approved the Infection Prevention and Control P&P on 1/31/24 and there was no review done for 2025, indicating the IPC P&P missed the annual review. The DON stated it was important to review the Infection Prevention and Control P&P annually because policy could change, treatment, procedures and systems should be updated. The DON stated not reviewing the Infection Prevention and Control P&P could put the residents at risk for increased infection in the facility and ineffective policy.During an interview on 09/25/2025 3:25 p.m., the Minimum Data Set coordinator (MDSC) stated the Infection Prevention and Control P&P should be reviewed at least annually. The MDSC stated it was important to review Infection Prevention and Control P&P at least annually to be able to adapt to evolving infection risk and threats.A review of the facility's P&P titled Policies and Procedures- Infection Prevention and Control, revised date 12/2023, the P&P indicated, . Policies and Procedures are reviewed and revised as necessary at least annually.

Based on interviews and record reviews, the facility failed to designate at least one qualified infection preventionist (IP), for all residents of the facility, when the those performing the role of the IP had not completed specialized training or obtained certification in infection control and prevention. Lack of a qualified IP could lead to an increased risk of infections spreading among residents and staff. Findings:During an interview on 09/24/2025 at 5:23 PM, the Director of Nursing confirmed the facility did not have a designated certified IP for approximately one month. The DON stated he and the interim IP were currently assuming the IP position but neither of them were certified. The DON stated it was important to designate a certified IP at the facility to ensure proper infection control protocol was being followed. The DON stated not having a certified IP could result in increased infection rate at the facility.During an interview on 09/25/2025 at 9:45 a.m., the interim IP stated the facility did not have a designated certified IP onsite. She stated she was the interim IP but was still training as an IP and was not a certified IP at this time. The interim IP stated it was important to have a certified IP at the facility to ensure an effective infection control program. During an interview on 09/25/2025 at 3:25 p.m., the Minimum Data Set coordinator (MDSC) stated she was a certified IP however she clarified that her job was focused on being the MDSC not the IP. The MDSC denied that she organized, developed, or directed the facility's infection control program. The MDSC clarified she was not performing tasks for the IP role. She confirmed the facility did not have a qualified IP for some time now. The MDSC stated it was important to have a certified IP to ensure reduced risks of infection at the facility and improve residents' health and safety.A review of the facility's Job Description: Infection Control Nurse, dated 2/2024, indicated, The primary purpose of [the] job position is to plan, organize, develop, coordinate and direct [the facility's] infection control program and it's activities.

Based on observation and interview, the facility failed to provide a safe and sanitary kitchen environment for all 63 residents of the facility, when the kitchen had cracked and broken floor tiles.This failure can increase the risk of trips and falls from the uneven surfaces and create an environment for molds and mildew growth.Findings:During an initial tour of the kitchen on 09/22/25 at 12:24 p.m., the kitchen had several cracked and broken floor tiles. Photos were taken to document the finding.During a concurrent review of photos of the kitchen floor and interview with the Dietary Manager (DM) on 09/22/25, at 12:36 a.m., the DM confirmed the kitchen had several cracked and broken floor tiles.A review of Title 42 of the Code of Federal Regulations section 483.90(i), Other Environmental Conditions, indicated: The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Based on observation, interview and records review, the facility failed to have an effective pest control system for all 63 residents of the facility, when cockroaches were observed in the kitchen under the dish washing sink. This failure had the potential to cause food contamination and endanger the vulnerable residents of the facility.Findings:During the initial tour of the kitchen on 9/22/25 at 12:21 p.m. insects that looked like cockroaches were observed crawling under the dishwashing sink. A video was taken of the observation.During an interview on 09/22/2025 at 2:08 p.m., Unlicensed Staff A reported seeing a large cockroach in the hallway near the shower room the previous week. She also acknowledged being aware of cockroach activity in the kitchen. She also emphasized that it is the facility's responsibility to ensure the kitchen and overall environment remain free of cockroaches, noting that cockroaches carry diseases that could potentially make residents ill.During a concurrent observation and interview with the Dietary Manager (DM) on 09/22/2025 at 2:50 p.m., the DM confirmed observing multiple cockroaches beneath the kitchen sink, on the floor behind the pipes, and around the grease trap. The DM acknowledged the facility was aware of the cockroach infestation, noting that it had also been identified during the previous year. The DM expressed concern about the presence of cockroaches in the kitchen, stating that they are unsanitary and could contribute to foodborne illness (any illness resulting from eating contaminated/spoiled foods). She further acknowledged that the facility's efforts to eliminate the infestation had been ineffective, as evidenced by the continued presence of cockroaches in the kitchen.During a concurrent observation and interview with Kitchen Staff B on 09/22/2025 at 3:03 p.m., Kitchen Staff B confirmed seeing multiple crawling cockroaches underneath the dish washing sink. Kitchen Staff B stated this was a constant and daily occurrence. Kitchen Staff B stated whatever the facility was doing to eliminate the cockroaches in the kitchen was ineffective.During an interview on 09/22/2025 at 6:02 p.m., the Registered Dietitian (RD) stated that cockroaches in the kitchen are unacceptable due to the risk of disease transmission, which could further compromise residents' health. The RD noted the presence of cockroaches indicated the facility's pest control measures were ineffective and emphasized the need to adopt a new or alternative pest management approach to eliminate the infestation.During an interview on 09/23/2025 at 9:15 AM, the Resource Nurse (RN) stated the facility was aware of the cockroach problem.During an interview with the County of Mendocino Environmental Health Program Manager (PM) on 09/23/2025 at 11:22 a.m. the PM stated the facility was responsible to keep cockroaches out of the kitchen as part of their food permit (an official authorization from a government health department that allows a business or individual to handle, prepare, store, or sell food). The PM confirmed seeing cockroaches during her inspection earlier in the day. The PM added, it was concerning seeing cockroaches during the day, since cockroaches were nocturnal, which indicated there was severe cockroach infestation.During an interview on 09/23/2025 at 10:37 a.m., a representative from the pest control company that serves the facility, confirmed the facility had a severe infestation of a German variety of cockroach. She attributed the issue largely to poor kitchen sanitation. The representative further explained that, prior to this date, cock roach treatments were conducted only on an as-needed basis when scheduled by the facility, rather than the recommended frequency of service every seven to 10 days. The representative stated she had advised the administrator that while pest control treatments can help, maintaining a clean kitchen and addressing moisture and leaks are essential to preventing infestations.A review of the facility's policy titled, Pest control, revised 5/2008, indicated the facility will maintain an effective pest control program to ensure that the facility is kept free of insects and rodents.

Based on interviews and record reviews, the facility failed to ensure that one out of 16 sampled residents (Resident 10) was informed in advance of the risks and benefits associated with a proposed treatment, when an informed consent (a voluntary agreement to accept treatment or procedures after receiving education about the associated risks, benefits, and available alternatives) was not obtained prior to the facility administering Resident 10 medication for depression.This failure placed Resident 10 at risk of receiving medication she might have declined had she been fully informed, potentially compromising her right to make informed decisions about her care.Findings:A review of Resident 10's face sheet (front page of the chart that contains a summary of basic information about the resident), indicated she was admitted to the facility in March of 2023 with a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 10's order summary, for the month of September 2025, indicated on 8/10/25, Resident 10 was prescribed Trazadone HCl (a medication to treat depression) Oral Tablet 50 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), to be given half a tablet by mouth every evening for Depression manifested by inability to sleep.During a concurrent interview and record review conducted on 9/25/25 at 3:35 p.m. with the facility's Resource Nurse (RN H), Resident 10's medical records were examined. RN H confirmed that the chart did not contain any informed consent documentation indicating that Resident 10 or her responsible party had been provided with information regarding the risks and benefits of Trazodone. A review of Title 42 of the Code of Federal Regulations section 483.10(c)(5), indicated residents have, The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Based on interview and record review, the facility failed to provide one of 16 sampled residents (Resident 46) with the opportunity to exercise her right to make a choice when her room was changed without her consent.This failure resulted in Resident 46 feeling upset and as though she didn't have a choice.Findings:A review of Resident 46's admission record indicated she was admitted to the facility in May 2020 with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 46's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 6/17/25, indicated Resident 46 had no memory impairment.During an interview on 9/23/25 at 1:54 p.m., Resident 46 stated she had to change rooms because the facility needed her room for a new admission. Resident 46 stated the change of her room upset her and she felt like she didn't have a choice.During an interview on 9/25/25 at 12:41 p.m. with the Director of Nursing (DON), the DON confirmed Resident 46 was moved to another room. A request was made to the DON to provide documentation regarding the reason for the room change and evidence the room change was discussed and agreed upon with the resident. The requested documents were not provided.During a review of the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment, dated 2001, indicated, .Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered .During a review of the facility's P&P titled, Resident Self Determination and Participation, dated 2001, indicated, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life.Residents are encouraged to make choices about aspects of their lives in the facility.

Based on interviews and record reviews, the facility failed, for three out of 16 sampled residents (Residents 1, 7 and 9), to ensure a written summary of the baseline care plan (BCP, a document created within 48 hours of a resident's admission, outlining the initial care needed, focusing on basic needs and resident-specific information) was provided to the resident and or the responsible party (RP, a person who is designated in making decisions about health care and financial matters) .This failure could compromise residents' safety, hinder effective communication, and could lead to adverse events, especially during the critical initial days of admission.Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 8/21/25 with a diagnosis of muscle weakness and dysphagia (difficulty swallowing). A review of Resident 1's Baseline Care Plan-Person Centered Care Planning-V3.1 form, with an effective date of 8/21/25, did not indicate the BCP summary was provided to the resident or their RP.A review of Resident 7's face sheet indicated an admission date of 8/29/2025 with a diagnosis of muscle weakness and difficulty walking.A review of Resident 7's Baseline Care Plan-Person Centered Care Planning-V3.1 form, with an effective date of 8/29/25, did not indicate the BCP summary was provided to the resident or their RP. The form also indicated it was completed by facility staff on 9/2/25. A review of Resident 9's face sheet indicated an admission date of 8/21/25 with a diagnosis of hypothyroidism (underactive thyroid gland) and hyperlipidemia (high cholesterol).A review of Resident 9's Baseline Care Plan-Person Centered Care Planning-V3.1 form, with an effective date of 8/21/25 did not indicate the BCP summary was provided to the resident or their RP.During an interview on 09/24/2025 at 3:34 PM, the Director of Rehabilitation (DOR) stated she was one of the team members that fills out the Baseline Care Plan-Person Centered Care Planning-V3.1 form. The DOR stated it was important that the BCP is completed timely and added, not completing the BCP timely could result in staff miscommunication and delayed intervention for the resident's safety.During a concurrent interview and record review on 09/24/2025 at 3:37 PM, with the Director of Nursing (DON), the Baseline Care Plan-Person Centered Care Planning-V3.1 forms for Residents 1, 7, and 9 were reviewed. The DON stated it was important to complete the BCP within 48 hours of admission to establish support for residents as early as day 1, ensuring safe care was coordinated and provided to the residents. The DON stated not completing the BCP within 48 hours of admission could result in miscommunication and unsafe care. The DON stated, if the BCP was not done within 48 hours of admission and /or if the BCP summary was not provided to the resident or the RP, then it indicated the facility's BCP policy was not followed. The DON verified the BCP summary was not provided to Residents 1, 7, and 9 or their RPs. The DON also verified Resident 7's BCP was completed late, over 48 hours after their admission.A review of the facility's policy and procedure (P&P) titled Care Plans-Baseline, undated, indicated, . a baseline plan of care to meet the resident's immediate health and safety needs to be developed for each resident within 48 hours of admission.resident and or representative are provided a written summary of the baseline care plan.provision of the summary to the resident and or resident representative is documented in the medical record.

Based on observation, interview and record facility failed to ensure its medication error rate was less than 5 percent (% a unit of measure) when there were two errors out of 33 medication administration opportunities for a 6.06% medication error rate. This failure decreased the facility's potential to safely administer medications per physician's orders and prevent the risk of adverse outcomes.Findings:During a concurrent observation and interview on 9/25/25 at 08:18 a.m. with Licensed Nurse E (LN E), LNE was observed giving Resident 1 Metoprolol Tartrate (a heart medication) 25 milligrams (mg, a unit of measurement) tablet, and Amiodarone (a medication to regulate the hearts rhythm) 100 mg tablet. LN E confirmed she gave Resident 1 both medications when Resident 1's systolic blood pressure (SBP, the maximum pressure the heart generates when it beats) was 122 millimeters of mercury (mmHg, a measurement of pressure) and the diastolic pressure (DBP, the minimum pressure the heart generates when it beats) was 72 mmHg.During a record review of Resident 1's Order Summary Report, dated 9/18/25, indicated, Metoprolol Tartrate oral tablet. Give 25 mg. do not give if. diastolic blood pressure (DBP) less than 90 mmHg . notify MD [medical doctor], and Amiodarone give 100 mg . do not give if SBP less than 100 mm Hg . and notify MD.In an interview on 9/5/25 at 10:28 a.m. with the Director of Nursing (DON), the DON confirmed the medication order indicated to not give Resident 1 the medications when SBP was less than 100 mmHg. The DON acknowledged the administration of medication outside ordered parameters could lower the resident's blood pressure (BP) and potentially cause a hypotensive crisis, (a life-threatening condition where BP drops dangerously low).During a review of the facility's policy and procedure titled Preparation Guidelines Medication Administration-General Guidelines, dated May 2022 indicated, . Prior to administration of any medication. the physician's orders are checked for the correct dosage schedule. current directions .

Based on observation, interviews and record reviews, the facility failed to ensure medications were stored safely for one out of 16 sampled residents (Resident 6), when Resident 6 was allowed to self-administer aspirin (ASA) and antacid tablets as well as keep the ASA and antacid tablets at her bedside with no assessment or physician's order.These failures put Resident 6 at risk for medication error and misuse. Findings:A review of Resident 6's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in 12/2021 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, lung disease, such as asthma or emphysema) and essential Hypertension (high blood pressure).A review of Resident 6's Physician Order Summary (POS, a healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive, active as of 9/24/25, the POS indicated an order for ASA 81 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) daily. There were no orders for antacid tablets or for self-administration of either medication.During a concurrent observation and interview on 09/23/2025 at 2:07 p.m., in Resident 6's room, ASA 325 mg was found in her bedside drawer and antacid tablets 1000 mg on her overbed table. Resident 6 stated she had no physician order for either medication, staff had not assessed her ability to self-administer the medications, and she had been using and storing them in her room for over a month without staff intervention. Resident 6 added, she took the ASA whenever she had a headache and the antacid when she had an upset stomach.During a concurrent interview and record review on 09/25/2025 at 3:52 PM, with the Director of Nursing (DON), Resident 6's POS was reviewed. The DON stated only residents with a completed assessment may self-administer medications or keep them at bedside. She confirmed Resident 6 had ASA 325 mg and antacid tablets at her bedside without such an assessment. The DON acknowledged this was not permitted, posed a risk for medication errors or misuse, and that the POS lacked orders for antacid tablets and for self-administration. She also confirmed the ASA order was for 81 mg, not 325 mg.A review of the facility's policy and procedure (P&P) titled Medication Labeling and Storage, undated, indicated, . the facility stores all medications and biologicals in locked compartments.the nursing staff is responsible for maintaining medication storage.A review of the facility's P&P titled Administering Medications, undated, indicated, .medications are administered in accordance with prescriber's order.

Based on interview and record review, the facility failed to treat one resident (Resident 1) out of three sampled residents with dignity and respect when facility staff entered Resident 1's room without announcing themselves or being invited in.This failure caused Resident 1 to feel anxious and unsafe in his room.A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Chronic Venous Hypertension (a condition characterized by high pressure inside the veins, most commonly in the legs) with ulcer (an open sore on the skin) of left lower extremity (leg) and Chronic Post Traumatic Stress Disorder (a mental health condition that can develop after experiencing a terrifying or dangerous event).A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 6/20/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment used to measure cognition (a person's ability to process information and understanding)) score of 14 which indicated Resident 1's cognition was intact.A review of Resident 1's Care Plan, dated 2/17/25, indicated Resident 1's risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills. Resident 1's goals were to express or exhibit relief of pain after alternative comfort measures were administered. The staff were expected to implement interventions that included encouraging Resident 1 to express his emotions, help Resident 1 to identify triggers that prompt symptoms and to observe for signs and symptoms of distress.A review of Resident 1's Progress Notes dated 8/11/25 at 12:50 p.m., indicated the Director of Nursing (DON) spoke with Resident 1 regarding an incident in which Resident 1 yelled at a staff member for entering Resident 1's room without knocking. The DON indicated to Resident 1 the staff will make their presence known before entering his room to ensure comfort and avoid startling him.there will be instances where we will not wait for his approval to enter, particularly in emergencies or situations where he is unable to respond.A review of Resident 1's Progress Notes dated 8/11/25 at 2:27p.m., indicated Resident 1 was observed becoming visually and verbally upset that the Certified Nursing Assistant [CNA] did not wait to be welcomed into the room, despite the door being open.During an interview on 8/27/25 at 11:25 a.m., in the conference room, Resident 1 stated he spoke to the DON about his request to allow staff into his room at his discretion. Resident 1 stated the DON told him he would honor the request with understanding that in cases of emergency, the staff would not wait for an invitation to enter. Resident 1 stated he understood but the staff continued to walk in without knocking, announcing or being invited in. Resident 1 also statedthat because he occupied the bed farthest from the door, staff would often open the curtain that separated Resident 1 from his roommate without permission. Resident 1 further stated, They [the staff] have no sense of privacy. I could be using the commode. It gives me anxiety. I need to feel secure in my own room. I need my privacy.During an interview on 8/27/25 at 12:17 p.m., the Director of Staff Development (DSD) stated both nursing and CNAs receive Resident Rights education during the orientation process. Thereafter, it is presented quarterly to all staff providing direct care. The DSD stated she taught the correct way to enter a resident's room was to knock, while stating knock, knock out loud so the resident hears you. Specific requests such as waiting for an invitation to enter would be handed off during shift-to-shift report.During an interview on 8/27/25 at 12:34 p.m., the DON stated, We will cater to their [residents] wishes, as long as it is reasonable, or won't hurt themselves or others. The DON stated Resident 1's request was reasonable and understood Resident 1 needed his privacy.A review of facility policy titled Resident Rights, dated 2001, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence.be treated with respect, kindness, and dignity.

Based on interviews and document reviews, the facility failed to ensure Certified Nursing Assistants (CNA) possessed a current and active certificate in accordance with applicable State laws when one CNA (CNA A) of a sample of nine CNAs had an expired certificate. This failure decreased the facility's potential to provide safe resident care within CNA A's scope of practice. Findings: A review of nine CNA certificate verifications which were provided by the Director of Staff Development (DSD) was conducted on [DATE] and indicated CNA A's certificate expired on [DATE]. A review of the daily nursing schedule dated [DATE] indicated CNA A was scheduled to work that afternoon from 3 p.m. until 7 a.m. on [DATE]. During an interview on [DATE] at 11:10 a.m., the DSD acknowledged CNA A had been working with an expired certification. A review of the daily CNA schedule between [DATE] and [DATE] indicated CNA A worked with an expired certificate from [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]. During an interview on [DATE] at 1:40 p.m., the Administrator stated he just became aware that CNA A's certification expired on [DATE]. The Administrator stated the facility would not allow a CNA to work at this facility with an expired certification. A review of the facility's document titled Staffing, Sufficient and Competent Nursing, dated [DATE], indicated, All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.

Based on interview and record review, the facility failed to carry out a physician ' s order for one resident (Resident 1) of two sampled residents when nursing staff did not document they were monitoring Resident 1 ' s Peripherally Inserted Central Catheter (PICC line, a long, thin, flexible tube inserted into a vein in the upper arm and guided to a large vein near the heart used to deliver medication) insertion site every shift from 3/28/25 to 4/11/25. This failure increased the potential for a delay in identification of infection and negatively affect the health of Resident 1. Findings: A review of Resident 1 ' s admission record indicated she was admitted on [DATE], and her medical diagnoses included acute osteomyelitis (infection of the bones), right tibia and fibula (two long bones of the lower leg) and Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium resistant to many antibiotics) infection. A review of Resident 1 ' s order summary report dated April 2025 indicated an active order for a PICC line on the right brachial vein (a deep vein in the upper arm that accompanies the brachial artery, draining blood from the arm's deep tissues back to the heart). This report also indicated an order written on 3/28/2025 which specified, Monitor site RUA [right upper arm] for signs and symptoms of infection including redness, drainage, pain at insertion site every shift for monitor until 4/13/2025 at 11:59 p.m. Alert MD [physician] if signs of infection are noted. A review of Resident 1 ' s IV Administration Record, dated 3/28/25 to 4/11/25, indicated the PICC line had not been documented as monitored for signs and symptoms of infection by a licensed nurse. During an interview on 4/11/25 at 12:05 p.m., the Director of Nursing (DON) stated the documentation for Resident 1 ' s PICC line monitoring had not been completed because it was located on the IV Administration Record and not the Medication Administration Record (MAR). The DON stated the monitoring should have been placed on the MAR so the licensed nurses could see it. During an interview on 4/11/25 at 1 p.m., the Infection Preventionist (IP) nurse stated nurses were expected to monitor the IV insertion site daily and it should be documented. The IP nurse stated if the monitoring was not done, there would be a potential of infection to resident. A review of a facility policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections dated 2001 indicated, Nursing Practice Guidelines to Prevent Catheter-Related Infections .Observe the insertion site .on every shift, on admission, and with dressing changes .If signs and symptoms of catheter-related infection are present, contact the Physician .The following information should be recorded in the resident ' s medical record. Objective information regarding appearance of insertion site, catheter, and dressing .

Based on interview and record review, the facility failed to ensure one resident (Resident 1) of two sampled residents was free from a significant medication error when a dose of intravenous (IV- administered into a vein) antibiotic was not documented as administered on 4/5/25 per the physician's order. This failure had the potential to result in incomplete treatment and increase the risk of antibiotic resistance, making further infections harder to treat. Findings: A review of Resident 1's admission record indicated she was admitted on [DATE], and her medical diagnoses included acute osteomyelitis (infection of the bones), right tibia and fibula (two long bones of the lower leg) and Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium resistant to many antibiotics) infection. A review of Resident 1's order summary report indicated an order for daptomycin-sodium chloride (an antibiotic used to treat complicated skin infections) IV solution 700-0.9 milligrams (mg)/100 milliliters (ml) every evening shift for the left lower extremity wound infection. A review of Resident 1's Medication Administration Record (MAR) dated April 2025, indicated on 4/5/25, the daptomycin-sodium chloride dose had not been indicated as administered. A review of Resident 1's progress notes dated 4/5/25 indicated Resident 1 was currently receiving an IV antibiotic. During an interview on 4/11/25 at 12:05 p.m., the Director of Nursing (DON) stated he reviewed the missing entry on Resident 1's MAR. The DON further stated because the IV antibiotic had not been documented as administered, it would be difficult to verify it had been given. A review of the facility's policy and procedure titled, Medication Administration-General Guidelines, dated May 2022, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .The individual who administers the medication dose records the administration on the resident's MAR/eMAR [electronic MAR] directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications .The resident's MAR/eMAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.

Based on interview and record review, the facility failed to ensure it designated a person to serve as the Director of Food and Nutrition Services who was certified, when the Registered Dietician (RD) was not employed full-time. This failure indicated the facility did not meet the Federal guidelines and did not follow the job description, when hiring a Dietary Manager (DM). During an interview on 4/29/24 at 10:01 a.m., the Dietary Manager (DM) stated she was not a Certified Dietary Manager. The DM stated the Registered Dietician (RD) only came in once every week on Wednesdays. The DM stated she did not receive consistent in-services and training's from the RD. During an interview on 4/30/24 at 3 p.m., the DM stated she was not a Certified DM. The DM also stated she was not a graduate of a Dietetic Technician Training Program approved by Academy of Nutrition and Dietetics (AND, an organization of dietetic professionals committed to improving the nation's health). The DM stated she also did not receive six hours of Title 22 (State regulations on health and safety standards for licensed care facilities) training, was not a graduate of a College Degree Program with major studies in food or nutrition, nor did she have any military equivalent. The RD stated she was not a graduate of a State Dietetic Approved Program. The DM stated the RD was contractual staff, was not hired full time and only came to the facility on ce a week on Wednesdays. When asked what her tasks were, she stated she oversaw the kitchen and the Dietary Department. When asked what the risks for residents were if the facility hired a non-certified Dietary Manager, the DM was did not answer. When asked if she met the requirements as stated on the job description for a Dietary Manager, she stated she did not know. During an interview on 5/1/24 at 2:33 p.m., the RD verified she was contractual staff who came in the facility once a week. The RD stated she was not a full-time RD for the facility. During an interview on 5/2/24 at 3:45 p.m., a request was made to the Human Resources Department (HRD) to provide a copy of the DM's file, but it was not provided. A review of the facility's job description for DM, prepared by the HRD, dated 1/2019, the job description indicated under qualification, A DM must be a graduate of an approved DM's course that meet the State regulations (set of rules and regulations that govern a particular state) and Federal regulations (a set of requirements issued by a federal government agency to implement laws passed by Congress).

Based on observation, interview and record review, the facility failed to ensure the Resident Rights of 13 Sampled Residents (Resident 200, Resident 16, Resident 28, Resident 164, Resident 264, Resident 22, Resident 5, Resident 42, Resident 14, Resident 53, Resident 38, Resident 30 and Resident 31) were honored, when: 1. Ten Sampled Residents (Resident 200, Resident 16, Resident 28, Resident 164, Resident 264, Resident 22, Resident 5, Resident 42, Resident 14, and Resident 53) reported call light response times of up to two hours. This failure resulted in delay in care and a loss of dignity, when residents were not assisted with timely brief changes when soiled and had the potential to result in incontinent accidents, falls resulting in broken bones, soft tissue injuries, pressure ulcers, psychosocial harm, feelings of despair and depression. 2. The facility did not ensure two sampled Residents (Resident 200, Resident 16) had useable prescription glasses. This failure resulted in the inability of Residents to read, be able to watch television, see what they were eating, or engage in activities that provided them with joy. This failure made the Residents feel like they did not matter and were unimportant to the facility. 3. One Sampled Resident (Resident 28), had not received communication about a request for a room change, resulting in her feeling like she was being ignored and she did not matter. 4. One sampled resident (Resident 28), was not offered or provided a facility phone to make private phone calls. This failure to honor her right to make private phone calls resulted in psychosocial harm from feelings of isolation and increased depression. 5. Two out of two sampled residents' (Resident 14 and Resident 30) urinary catheter drainage bags were not covered with a privacy bag. 6. One sampled resident (Resident 31) was not provided translated documents or translator services during medication administration, activities, nutritional choices and the ability to make decisions about health care. This failure to honor Resident Rights had the potential for depression, psychosocial harm, and result in frustration, miscommunication, misinterpretation of resident's report of symptoms which could lead to misdiagnosis and inappropriate action taken in an emergency situation. Findings: 1. During an observation on 4/29/24, at 10:58 a.m., at the nurse station, a call light alarm lit up and alarmed on the call light room board. Licensed Nurse N was working at a computer and did not respond to the sound of the resident call light. She did not look up, try to see if there was someone answering the light, or talk on a walkie talkie to tell someone about the call light. During an observation on 4/29/24, at 11 a.m., the call bell for room [ROOM NUMBER] started at 10:57 a.m. The Administrator walked past room [ROOM NUMBER] two times, without stopping to see what the resident's concerns were. The Facilities Manager also walked past room [ROOM NUMBER] twice, with the call bell light still ringing. During an observation on 4/29/24, at 11:03 a.m., a call light in room [ROOM NUMBER] started at 11:03 a.m. One Unlicensed Staff walked past room [ROOM NUMBER] without entering the room to see what the resident's concerns were. During an observation on 4/29/24, at 11:03 a.m., room [ROOM NUMBER]'s call light indicated a resident needed assistance. Three unlicensed staff walked past room [ROOM NUMBER] without stopping. Staff at the nursing station remained seated and did not provide assistance to room [ROOM NUMBER]. At 11:19 a.m., an unlicensed staff walked into room [ROOM NUMBER], then room [ROOM NUMBER], before answering the Resident call light in room [ROOM NUMBER]. During an interview on 4/29/24, at 12:10 a.m., Resident 38 stated call lights always took a long time for staff to answer. During an observation on 4/29/24 at 12:17 p.m., the call light in room [ROOM NUMBER] went on. Licensed Nurse N, the Administrator, and Unlicensed Staff Q walked past the room without stopping to see what the resident's concern was. During an observation and interview on 4/29/24, at 12:45 p.m. Unlicensed staff Q entered Resident 28's room. Unlicensed Staff Q stated, Honey we need to change your position, lunch will be here soon. When she repositioned Resident 28, Resident 28 shouted, OW OW OW. Unlicensed Staff did not stop, did not ask her if she wanted pain medications, did not offer water, and did not place the call light within reach. The call light was hanging from the bed rail on Resident 28's left side, where her hand had a rolled washcloth in the palm of her left hand, which had a contracture. Resident 28 stated she could not reach her call light. She stated she could not use her left hand. She stated, if she needed help she would either have to wait until they came back or she would have to yell for help. During an observation on 5/1/24, at 7:40 a.m., Resident 28's call light was out of reach, hanging off the bedside railing on Resident 28's left side. During an observation and interview on 5/1/24, at 8:25 a.m., in Resident 28's room, Licensed Staff P stated unlicensed staff should have put the call light in her right hand. During an interview with the Director of Nursing, on 5/1/24, at 10:45 a.m., she stated she expected everyone to answer call lights immediately. She stated, if residents had to wait, it could result in a fall, broken bones, incontinence. She stated the facility Policy and Procedure stated to answer call bells as soon as possible. During an interview on 5/1/24, at 11 a.m., Licensed Nurse B stated there was enough staff to meet needs of residents. He stated call lights were to be answered by everyone immediately. During an observation on 5/1/24, at 11:03 a.m., Resident 16 stated call lights always take so long. She stated she just needed some help with a new incontinence brief, and when the unlicensed staff came in, she just gave her a new brief and did not help her change her soiled brief. She stated she did it herself. She stated she just wanted some help and it always took so long. She wanted a Depends brief, and the CNA just gave her one and did not assist her with a change. During an interview on 5/1/24, at 11:35 a.m., Resident 5 stated call lights could take a while. They come in and turn off lights but do not come back. During an observation 5/1/24, at 11:40 a.m., Resident 28's call light was not within reach. The call light was hanging off Resident 28's left bed rail. During a phone interview, on 5/2/24, at 11:43 a.m., the Ombudsman stated the residents have said the same things about staff running around, not enough staff to answer call lights. She stated she had informed the Administrator about the residents' concerns. She stated she attended the Resident Council Meetings and they have consistently stated the residents had to wait for a long time for staff to answer call lights which would stay on for at least 30 minutes. She stated the usual amount of time residents stated they had to wait was 30 minutes. During an interview with the Administrator on 5/3/24, at 11:30 a.m., he stated the expectation of all staff was to answer call lights immediately. He stated no one should ever walk past a call light. He stated the facility was not monitoring call light response times, but the facility Policy and Procedure was to answer them as soon as possible. A review of the facility Policy and Procedure, titled CALL LIGHT, not dated, indicated, All personnel will respond to resident requests and needs. Call lights are answered promptly. Call lights are kept within resident's reach. 2. During an observation and interview on 4/29/24, at 11:19 a.m., Resident 16 was laying in her bed, with the curtains pulled shut and no lights on. She was on her back, in a patient gown, not wearing glasses. A bedside table with a paperback book, an embroidery project and an eyeglass case were on her right side. She stated she wore glasses and pointed to her eyeglass case. There were a pair of yellow metal eyeglass frames missing the right lens. Resident 16 stated she did not know if anyone ordered her a new pair of glasses. She stated she told staff about it, and no body had followed-up with her for a while. She stated she could not use them without a lens. She stated it was hard to read for long periods of time or do needlework. She stated she could not watch TV without a lens. She stated she would get headaches trying to do those things without glasses or if she wore the glasses with only one lens. She stated they were useless. During an observation and interview on 4/29/24, at 11:25 a.m., Resident 200 was laying on her bed, with the curtains closed, in a dark area, in a patient gown and did not have eyeglasses on. The television was on without any volume. She stated she used glasses but did not know where they were. She stated she would love to have the volume of the television turned up but would just listen to the television because she could not see it without her glasses. During an observation and interview on 4/29/24 at 12:59 p.m. Unlicensed Staff entered Resident 21's room and set a lunch tray in front of Resident 200. Unlicensed Staff took off the dish lid, cut up the food and left the room without asking Resident 200 if she needed to wear her glasses. During an observation and interview on 4/30/24, at 10:28 a.m., Resident 16 was on her back in bed with the curtain closed and the lights off. Her bedside table held a paperback book and her eye glass case, which contained one pair of bifocal glasses missing one lens . Resident 16 stated, I feel vulnerable and neglected because I don't have my glasses fixed. I can only read for a few minutes before I get a headache. Resident 16 stated she had glasses, but she did not know where they were, and she needed them for reading and watching television. During an observation and interview on 4/30/24, at 1:48 a.m., Resident 200 was laying on her back in bed, her eye closed, not wearing glasses while the television was on. Resident 200 was in her bed with the curtains pulled around the bed, no light on, in a patient gown, with the television on. The television was ceiling mounted, at the foot of Resident 200's bed. She stated she needed glasses and really could not see the television without them. Resident 200's bedside table held personal belongings but there were no eyeglass case or glasses. Resident 200 stated she did not know how long they had been gone. She stated she was lost without them. During an observation and interview on 5/1/24, at 7:58 a.m., Unlicensed Staff Q entered Resident 16 and Resident 200's room to serve breakfast trays. She placed the trays in front of the residents, removed the lids and left the room without an offer to help them put on their glasses. Unlicensed Staff Q stated, part of getting residents ready for breakfast was to make sure they had glasses on so residents could see what they were eating or to help them watch television. She stated she did not know if Resident 16 and Resident 200 needed glasses. She stated she would know the needs of the residents at her morning report. She stated the morning report did not include information that Resident 16 and Resident 200 needed glasses. During an observation and interview on 5/1/24 at 8 a.m., Resident 200 was eating breakfast and not wearing glasses. A brown eye glass case was on her bedside table located next to her closet. She stated she would love to have her glasses, that she had begged for them, and staff never gave them to her. Resident 200 cried when she was handed the eye glass case, and when she opened the eye glass case the eyeglasses were missing one of two prescription lenses. Resident 16 stated she was missing one lens from her glasses and had told the nurses about, but no one ever told her about whether or not she was getting a new pair. Resident 16 stated, All I have is reading and needlework. Without them I cannot read or sew. Resident 200 stated, without her glasses she felt incomplete, and she could not see anything without them. During an observation and interview on 5/1/24 at 8:05 a.m., in the hallway outside of Resident 16 and Resident 200's room, Unlicensed Staff Q stated she did not know Resident 200's glasses were broken. The Social Services Manager walked past and state loudly, What? I never knew that. She told Unlicensed Staff Q If glasses were broken just slip me a note under my door and I would get them fixed. During an interview on 5/1/24, at 8:25 a.m., Licensed Staff DSD stated, If a resident wears glasses staff should offer her glasses before activities or dining. She stated it was undignified and could increase loss of appetite and increase depression. She stated, if staff discovered a resident's eyeglasses were broken, Social Services would have been informed so the glasses could have been repaired. During an interview and record review on 5/01/24, at 10 a.m., the Director of Nursing reviewed Resident 16 and Resident 200's care plans, and stated there was nothing in the residents' care plans for vision impairment and the need for prescription eyeglasses. She stated the care plans were not individualized and did not reflect their need for eyeglasses. She stated Resident 16 and Resident 200 were not getting the care they needed. During an interview and record review on 5/1/24, at 11:05 a.m., the Social Services Manager stated she could not locate the Inventory Lists for Resident 16 or Resident 200. She stated, if the resident were admitted to the facility with glasses, it should have been documented on the Inventory List in the medical record. She stated she did not know anything about their glasses, and staff were supposed to tell her when things were broken. She stated staff did not tell her Resident 16 and Resident 200's glasses were broken. A review of a document titled, ADMISSION RECORD, for Resident 16, indicated she was 93-years-old, admitted [DATE], with diagnoses that included Epilepsy (A neurological disorder that results in seizures), Chronic Pain, and Gout (Severe Inflammatory arthritis that impacts a person's joints and results in severe pain and swelling). A review of a document titled, Care Plan, indicated, (Resident 16 ) had altered visual ability related to: Macular Degeneration. At risk for: may impacts ability to; self-feed, participate in ADL (Activities of Daily Living like eating, brushing teeth, taking care of own needs), Appliances used: Eyeglasses. Date initiated: 8/10/2011. Interventions - Keep glasses within reach as indicated: 8/10/2011 .she is very social to staff /peers. (Resident 16) has multiple activity routines but not limited to: crossword puzzles, word searches, reading romance novels, adult color pages, embroidery projects and visiting with her roommate. A review of a document titled, Inventory of Personal Items, dated 5/9/17, indicated 1 set of Glasses glass case. A review of a document from the Minimum Data Assessment (MDS) (An assessment required upon admission to a nursing facility and periodically to assist the facility in being able to provide the services necessary for a resident to achieve their highest practicable level of functioning), titled, Section B - Hearing, Speech, and Vision, indicated, B1000. Vision Ability to see in adequate light (with glasses or other visual appliances) Adequate - sees fine detail such as regular print in newspapers / books .B1200. Corrective Lenses Yes. Section C - Cognitive Patterns, indicated C0500 BIMS (Brief Interview for Mental Status)(An assessment to determine how mentally intact a person is) Summary Score 12, (0-7 severe impairment, 8-12 moderate impairment, 13-15 cognitively intact). A review of a document titled, ADMISSION RECORD, for Resident 200 indicated she was 93-years-old, admitted [DATE], with diagnoses that included Dementia (A decline in brain functioning, that impacts a person's ability to perform daily activities), Muscle Weakness, and Low Back Pain. A review of a document titled, Care Plan, indicated, VISION CARE PLAN, dated 5/4/21, indicated, Resident 200 had altered visual ability related to: the gaining process. At risk for: pain, and localized irritation. Appliances used: Eyeglasses Interventions If glasses, Prosthetic eye and/or Magnifying glass keep within reach as indicated. Date initiated: 5/4/21. Activities .Resident 200 has identified the following as, 'Very important': reading. A review of a document titled, Inventory of Personal Items, dated 5/28/21, indicated nothing for, Glasses & Cases. A review of a document from the Minimum Data Assessment (MDS) (An assessment required upon admission to a nursing facility and periodically to assist the facility in being able to provide the services necessary for a resident to achieve their highest practicable level of functioning), titled, Section B - Hearing, Speech, and Vision, indicated, B1000. Vision Ability to see in adequate light (with glasses or other visual appliances) Adequate - sees fine detail such as regular print in newspapers / books .B1200. Corrective Lenses Yes. Section C - Cognitive Patterns, indicated C0500 BIMS (Brief Interview for Mental Status)(An assessment to determine how mental intact a person is) Summary Score 8, (0-7 severe impairment, 8-12 moderate impairment, 13-15 cognitively intact). A review of a facility Policy and Procedure titled, Sensory Impairments - Clinical Protocol, revised March 2018, indicated, The staff will try to minimize complication of sensory impairments; for example, optimize lighting in the resident's room and the hallway, refer for corrective lenses . 3. During a phone interview, on 1/2/24, at 11:43 a.m., the Ombudsman stated she had informed the facility Administrator and Social Services that Resident 28 had requested a room change several times. She stated they would tell her they were, Working on it. She stated she had informed the facility about Resident 28's request for a room change since last year. She stated Resident 28 was cognitively intact enough to know she did not like being against the wall, by the door, in a four-bed room with other residents who make a lot of noise. She stated Resident 28 never saw the outside, and it was not respectful to Resident 28 to not address her request for a room change. During an interview, on 5/1/24, at 9:15 a.m., Resident 3 stated she would tell the nurses if she had any problems, but they would never follow-up with her. She stated it made her feel like she did not matter. During an interview with Unlicensed Staff A, on 5/1/24, at 9:50 a.m., she stated, when a resident had a problem, she would tell the nurse or the Director of Nurses. She stated, if the facility never resolved a resident problem, it might make residents feel like they were not being heard. During an interview and record review on 5/1/24 at 11:10 a.m., the Social Services Manager stated she knew Resident 28 had requested a room change, but there were not any rooms available to move her to. During a review of the Grievance Binder, the Social Service Manager did not find any grievances documented from 2022 to 1/5/24. She stated she never knew Resident 28 wanted a room change or had ever requested the use of a facility phone. During an observation and interview on 5/1/24, at 11:40 a.m., Resident 28 was in a bed directly to the left of the door. The bed was against a small nightstand against the wall. Resident 28 stated she had asked to be moved to another room because the crying and noise from the other residents in the room was very disturbing to her and her sleep. She stated, when staff came in for other resident needs it disturbed her sleep. She stated she had asked the Administrator and the nurses all the time to move to another room, and no one ever come back and told her if she could move. During an interview on 5/1/24, at 12:10 p.m., Unlicensed Staff C stated he did not know Resident 28 wanted to change rooms. During an interview with Unlicensed Staff E, on 5/1/24 at 12:25 p.m., she stated, if a resident had an issue, she would tell the nurse. She stated, if a resident wanted to change rooms, she would tell the nurse. She stated she did not know Resident 28 wanted to change rooms. During an interview and record review with the Director of Nursing, on 5/1/24 at 1:30 p.m., she stated she was unsure where the Resident Rights were posted in the facility. She stated all residents got that information when they are admitted , but was not sure if residents ever reviewed it or were educated or reminded during their stay. Resident 28 was not mentally aware enough if she had asked someone for a room change. She stated she could not find documentation in the medical record that Resident 28 or the Ombudsman had requested a room change. She stated she knew Resident 28 wanted to have a room change but stated there were no rooms available. She was unable to locate documentation by the facility of any attempts made to try and make the room change for Resident 28. She stated the census indicated seven open rooms. She stated the open rooms were needed for new admissions. She stated she could not locate documentation Resident 28 had requested a room change or what the facility had done to try and provide her with a room change. She stated Resident 28 had a right to a room change. She stated the observations today made it appear the facility had not provided Resident 28 with those rights. She stated, denial of those rights could have made Resident 28 more depressed and could have made other residents and family members not have confidence in the care the facility provided. Review of a document titled, ADMISSION RECORD, indicated Resident 28 was 79-years-old, admitted on [DATE], with diagnoses that indicated, Hemiplegia (Severe or complete loss of strength or paralysis affecting one side of the body after a stroke) and Hemiparesis (Weakness in one side of the body) Following Cerebral Infarction affecting Left Non-Dominant Side (If you write with your right hand then your left side would be non-dominant), Major Depressive Disorder, (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Insomnia (Inability to sleep), and Primary Osteoarthritis (Cartilage in a joint wears down and results in pain, stiffness and reduced range of motion), Right Shoulder. Review of a document titled, BRIEF INTERVIEW FOR MENTAL STATUS, (A screening tool that uses a 15-point system to evaluate memory and orientation. A score of 13 to 15 indicates that cognition is intact) dated 2/19/2024, indicated a summary score of 15. Review of a document titled, Care Plan, dated 3/27/24, indicated, MOOD CARE PLAN (Resident 28) is at risk for Altered Mood R/T: Depression, Overall Health status. At risk for little interest or pleasure in doing things .Interventions Manage environmental factors to optimize comfort. Review of a facility Policy and Procedure, titled, Resident Rights, dated 2016, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity Communication with and access to people and services, both inside and outside the facility .Be supported by the facility in exercising his or her rights .Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; have the facility respond to his or her grievances .Share a room with his or her roommate of choice when practicable Inquiries concerning residents' rights should be referred to the Social Services Director. Review of a facility P&P titled, Room Change/Roommate Assignment, revised May 2017, indicated, Changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. Review of a facility P&P titled, Grievances/Complaints, Filing, revised April 2017, indicated, The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative .A copy of our grievance/complaint procedure is posted on the resident bulleting board The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is _______________________ and can be contacted by ___________ The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The administrator, or his or her designee, will make such reports orally within _____ working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. 4. During a phone interview, on 1/2/24, at 11:43 a.m., the Ombudsman stated Resident 1 was cognitively intact. She stated Resident 28 had told her she had requested to use a phone to contact friends and family, and no one at the facility would help her get a phone and make a call. She stated Resident 1 had notified her that the facility did not provide a phone she could use. The Ombudsman stated she had never observed Resident 1 using the facility phone. She stated it was undignified for Resident 1 to not be able to call friends or family. During an interview with Unlicensed Staff A, on 5/1/24, at 9:50 a.m., she stated, if the facility never resolved a resident problem, it might make them feel like they were not being heard. During an interview on 5/1/24, at 11 a.m., with Licensed Nurse B, he stated if a resident had a grievance, they would tell the nurse or staff, and they would take care of it. He stated Social Services was told about resident problems too. He stated, if a resident wanted to make a phone call, he would bring them a facility phone. During an interview and record review on 5/1/24 at 11:10 a.m., the Social Services Manager stated she guessed she was in charge of taking care of resident grievances. She stated she never knew Resident 28 had ever requested the use of a facility phone. During an interview with Resident 28 on 5/1/24, at 11:40 a.m., she stated she did not have a phone to call anyone. She stated she asked a lot of staff, and no ever gave her a phone to use. She stated she would ask, and they would never come back to let her make a phone call. She said staying at this facility made her sad, and this place did not feel like a home. During an interview on 5/1/24, at 12:10 p.m., Unlicensed Staff C stated most residents had their own phones, but the facility had phones to give to residents if they wanted to make a phone call. During an interview with the Director of Nursing, on 5/1/24 at 12:55 p.m., she stated there were two phones available for residents to make phone calls. She stated one phone was broken and the other phone was missing. She stated, without the phones, residents might not be able to communicate with friends or families. During an interview, the Director of Nursing asked Resident 28 if she wanted to use the phone, and Resident 28 stated, Yes. During an interview with the Director of Nursing, on 5/1/24 at 1:30 p.m., she stated the observations today made it appear the facility had not provided Resident 28 with her right to use a phone to make phone calls. She stated there was no facility Policy and Procedure on phone calls and the use of facility phones by residents. She stated, denial of those rights could have made Resident 28 more depressed and could have made other residents and family members not have confidence in the care the facility provided. Review of a facility Policy and Procedure, titled, Resident Rights, dated 2016, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity Communication with and access to people and services, both inside and outside the facility Be supported by the facility in exercising his or her rights. 48660 During an interview on 4/30/24 at 9:11 AM, Resident 264 stated she waited for two hours to have soiled undergarments changed. Resident 264 further stated her bottom was red after two hours, and staff told her it was because she had diarrhea. Resident 264 stated she did not have diarrhea. During an interview on 4/30/24 at 3:27 PM, Resident 22 stated staff did not always come quickly to answer the call light. Sometimes when I needed them 'right now' they didn't show up. I usually had to wait for a change. I was wet most of the time. I had a lot of skin irritation from being wet because they didn't come in enough to change me. I had to sit in a bowel movement occasionally because they did not come in and change me or put me on a bed pan. During an interview on 5/2/24 at 2:05 PM, during the Resident Council Meeting, Residents 5, 42, 14, and 53 stated they had waited a long time for help or care after using their call lights. Resident 5 stated wait times were up to 45 minutes. Resident 5 further stated they all had that problem. Resident 14 stated wait times were up to one hour. 46132 5. A review of Resident 14's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, an elevated level of lipids - like cholesterol and triglycerides - in your blood), Dysphagia (swallowing difficulties), and Depression (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world). Her Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 4/11/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13, indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 14's functional status indicated she needed moderate up to maximum assistance when performing her Activities of Daily Living (ADL, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 14 used a urinary catheter (a tube placed in the body to drain and collect urine from the bladder). A review of Resident 30's face sheet indicated he was initially admitted to the facility on [DATE]. His diagnoses included HLP, Muscle Weakness and Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). His MDS, dated [DATE], BIMS score was 15, indicating intact cognition. Resident 30's functional status indicated he needed up to maximum assistance when performing his ADLs. Resident 30 used a urinary catheter. During a concurrent observation and interview on 4/30/24 at 10:12 a.m., Resident 30 stated staff were not consistently putting a cover on his catheter urinary drainage bag. When asked if he refused to cover his catheter urinary drainage bag, he stated, No. Unlicensed Staff W verified Resident 30's catheter drainage bag was not covered. Unlicensed Staff W stated the catheter drainage bag should be covered, per facility policy, and was important for a resident's dignity. When asked if the catheter drainage bag not being covered meant the facility policy was not followed, Unlicensed Staff V stated, Yes, the facility policy was not followed when the catheter drainage bag was not covered. During a concurrent observation and interview on 4/30/24 at 11:22 a.m., Resident 14 was noted with a catheter urinary drainage bag that was not covered. Resident 14 stated the facility did not consistently provide covers for their c [TRUNCATED]

Based on observations, interview and record review, the facility failed to ensure a safe and sanitary environment for residents, when hand hygiene was not offered to residents before meals, when the hand hygiene P&P was not followed during medication administration, and cross-contamination risks were observed in linen storage and laundry processing areas. Findings: (Reference F 880) During an observation on 4/29/24, at 11:33 a.m., in the housekeeping closet next to Resident room [ROOM NUMBER], the floor, walls, sink and equipment, door and door jamb appeared to have a black, gray residue on all surfaces. The black, gray substance felt greasy to the touch. Under the sink was what appeared to be a calcified, wet, plumbing leak originating from the hopper sink. (See Photos) During an observation on 4/29/24, at 11:34 a.m., the resident Shower Room, located in the hallway across from staffing, had multiple unlabeled razors, lotions, and shampoo sitting on a shower shelf. An insect was on a resident shower seat. The Shower Room closest to the Administrator's office had a sharps disposal box mounted on the wall which had had razors sticking out of the top, had no gloves, and the call light was attached to a plastic glove hanging from the wall. (See Photos) During an observation on 4/29/24, at 12:25 p.m., staff passed lunch trays into rooms [ROOM NUMBERS], and did not offer hand hygiene before meal service. During an observation on 4/29/24, at 2:25 p.m. the Oxygen Storage room had black streaks on floor. During an observation 4/29/24, at 2:30 p.m., the Clean Utility room had gray particulate matter on the counter, in storage bins, and on the floor. The floor had large quantities of dark particulate and gray particulate matter. In a red bin on the counter, which contained resident soaps, and hand lotion, an insect that resembled a cockroach was laying on its back with the legs up. During an observation and interview on 4/29/24, at 2:35 p.m., with the Administrator and Facilities Manager outside the Clean Utility Room, the Facilities Manager stated the room was cleaned daily by Housekeeping staff. He stated it was considered clean, not dirty. Inside the Clean Utility room, the Facilities Manager took a moist paper towel and wiped the floor. Gray and black particulate residue and matter was left on the towel. He stated the room looked like no one had cleaned it. He stated it was supposed to be cleaned daily. He looked in the red bin with the bug, and stated it was a cockroach. He stated there had been reports of spiders. The Administrator stated the facility had a monthly pest control, but there was no facility monitoring process to indicate how many sightings there were of insects or spiders. The Administrator was unable to state how many reports of insects and cockroaches there had been and if the pest control company had been informed or had any suggestions for reduction of pest infestations. The Facilities Manager stated he would use a can of insect spray if someone stated they had seen insects between facility pest management visits. He stated he was not sure if the insect spray was approved for use in healthcare facilities, by the Environmental Protection Agency. The Administrator stated there was no Policy and Procedure for pest and rodent control in the facility. He stated there was no plan on how the facility was to ensure no insects or rodents in the facility. (See Photos) A request was made for the photo of the insect taken by the Administrator. It was not received by the end of survey. During an observation and interview on 5/1/24, at 7:15 a.m., outside the resident Dining Room, Licensed Nurse N and unlicensed staff provided breakfast meal trays to 11 residents in the dining room, without offering hand hygiene. Licensed Nurse N stated, before providing meal trays to residents, to offer hand hygiene. She stated staff offered it. She stated staff had to go to kitchen to get the hand wipes for hand sanitation. An observation of the meal trays that were used by residents and the trash can, did not indicate any disposable hand wipes were used. She stated they had offered, but all the residents refused. She stated the risk to residents who did not engage in hand hygiene, would have been food-borne illness. During an observation on 5/1/24, at 9 a.m., the carpeting near the double doors leading into the kitchen appeared to have a dark gray stained area that was as wide as the hallway and extended to the hallway in front of the Resident dining area. The carpet was stained in all the hallways throughout the length and distance of the hallway from the back entrance of the facility to the front door of the facility and in the hallways leading to all patient rooms. (See Photographs) During an observation on 5/1/24, at 9:05 a.m., the hallway walls appeared to have gray black smudges and streaks on and above the floorboards with exposed plaster and chipped paint throughout the hallway. (See Photographs) During an observation and interview, on 5/1/24, at 9:15 a.m., the bathroom in a resident room had more stained than unstained tiles on the floor. The tile on the floor was chipped and cracked. The walls had exposed plaster, marks, and gray-black marks on all four walls around the floor. The doorways had chipped paint with exposed rust. The base of the toilet had a rough, messy caulk line with rust, brown and gray black stains. Under the hand washing sink was a pile of dirty linen rolled up and placed beside the trash can. The under-sink area had stained tiles that were cracked and chipped. (See photographs). Resident 3 stated the floors looked awful. She stated the bathroom looked terrible. She stated, This is not how my home was. I feel like I am living in a ghetto. During an observation and interview, on 5/1/24, at 9:34 a.m., the linoleum tiles in the doorway of another resident room were stained and discolored, chipped, and broken. The bathroom floor had fist-sized areas of torn and missing linoleum. The bathroom had rough, messy, and black stained caulking around the base of the toilet. The bathroom area under the sink had trash on the floor and linen thrown on the ground. (See Photographs). Resident 5 stated no one ever cleaned. He stated the stains on the floors and walls made him feel depressed that he was not in his own home. During an observation and interview, on 5/1/24, at 9:45 a.m., the linoleum tile in another resident room was stained, chipped, and cracked. There were dark gray-black marks consistently along the walls. (See Photographs). Resident 6 stated the stained tiles or marks on the wall did not look good, and it would be nice to have things look better. During an interview with Unlicensed Staff A, on 5/1/24, at 9:50 a.m., she stated, if something needed to be repaired, staff were supposed to contact the Facilities Manager. She was unable to state what the infection prevention concerns were for chipped and cracked floor tile, exposed plaster, or chipped paint. During an observation on 5/1/24, at 10 a.m., the resident linen closet in the hallway across from room [ROOM NUMBER] had unfinished plywood on the wire shelves, and had folded linen placed on top of the plywood. The floor of the resident linen closet had chipped, cracked, and stained linoleum tiles. A view of the floor underneath the linen cart showed clear plastic bags with assorted pieces of paper and masks in them and gray dust-like particulate, dirt and strings of gray web-like substance along the floorboards and up the wall. (See Photographs) During an interview and observation with the Facilities Manager, on 5/1/24 at 10:45 a.m., he stated he did not know why chipped paint, rust, exposed plaster, and un-sealed plywood, was an infection issue. He was unable to state if the cleaning solutions used by housekeeping were approved by the infection prevention committee. He stated he oversaw housekeeping and just ordered what the facility told him to order for cleaning solutions or disinfectants. The Facilities Manager stated he had not provided infection prevention in-services for the housekeeping staff. He stated the process for reporting items or areas that needed repair was to write it in the binder at the front desk. A review of a binder titled, Repairs, indicated there were no requests for fixing wheelchair arm rests, bathroom floors, or chipped paint. He stated the housekeeping staff were supposed to report to him when they observed anything that needed to be repaired, painted, or fixed. There were two wheelchairs outside the Human Resources office. (See Photographs) The arm rests were extensively cracked and lifted. He stated he was not aware they needed repair. He stated he thought that physical therapy took care of the wheelchairs. He stated he was unaware that cracked arm rests could not be disinfected and had the potential to irritate the exposed skin on the residents who had very thin, delicate skin and potential bleeding issues from medications. During observations of Resident Rooms 1, 2, 4, and 7, he stated the floors were stained and cracked. He stated the walls had exposed plaster and chipped paint. He stated the floors in the bathrooms were not repaired properly. He stated repairs needed to be done so that the surfaces could be cleaned and appeared in good repair. He stated the bathrooms were, Unsightly and were not cleanable. Regarding the linen closet in the hallway across from room [ROOM NUMBER], the Facilities Manager saw the linen cart with the plywood, and stated he did not know that unsealed plywood could not be disinfected. He stated, Residents could get splinters of wood that were stuck to the linens too. He looked underneath the linen cart and stated, Yeah, that doesn't look like it has been cleaned in a while. He stated the dirt could get onto the linens and possibly cause residents to get sick. During an interview on 5/1/24, at 11 a.m., with Licensed Nurse B, he stated the stains on the floors were, Pretty bad, could make family and residents think it is dirty. He stated he would call the Facilities Manager for repairs of anything. He stated he never called about the flooring because someone was always cleaning it. He stated he did not know the bathrooms had any infection control issues. During an interview on 5/1/24 at 11:15 a.m., Unlicensed Staff R was unable to state who was responsible for cleaning the Clean Utility room, Housekeeping Closet, the clean and dirty side of the Laundry Room, and the Linen Storage Closets. She stated the Housekeeping Closet looked dirty, and it had a lot of grime, black smudges, and resident toilet paper was stored closed to the dirty sink. (See Photos). During an observation and interview on 5/1/24, at 11:40 a.m., a resident room had a built-in white dresser with three drawers, a countertop and closet doors painted white. There were gray, black scuff marks from the level of the floor up to the second drawer across the front of the drawers and the closet doors. The countertop contained a pair of gray and pink tennis shoes placed on top of a box of gloves and against a stack of white towels. The bathroom of Resident room [ROOM NUMBER] had stained, cracked, and chipped floor tiles. There was exposed plaster behind the toilet. There was chipped paint around the doorway with gray black material around the floor and up the wall. The base of the toilet had a thick, rough, messy line of caulk, and the toilet bowl appeared to have fecal material on the inside. An unidentified bed pan was stuck between the wall and a handrail. Under the sink area there was stained, chipped, and cracked tiles, exposed plaster and chipped paint, and a blanket rolled up and placed under the sink next to the trash can. (See Photographs). Resident 1 stated no one ever came in and cleaned. She stated, when they do come in, they never pick up her things off the floor and put them where she could reach them. She stated, whoever owned this place did not care about whether things were broken or needed painting. She stated the facility was falling apart and looked terrible. She stated it made her feel very sad because she lived in a home that was beautiful, and this was not like a home. During an observation and interview on 5/1/24, at 12:10 p.m., Unlicensed Staff C stated he did not know how to report when wheelchair arm rests needed to be repaired. He stated he had never told anyone about anything that needed to be repaired. He observed the wheelchairs in the Hallway of room [ROOM NUMBER] and stated they look pretty bad. He stated he did not know the arm rests could not be disinfected if the material was cracked. He stated the residents could scratch themselves on the arm rests if they did not have a long-sleeved shirt on. He stated the residents had really thin skin, and they could scratch themselves pretty easily on the cracked arm rests. During an interview on 5/1/24, at 12:10 p.m., the Infection Preventionist stated surfaces needed to be, Intact for cleaning and disinfection to occur. She reviewed facility environmental photographs of the bathrooms, hallway rugs, and wheelchairs and stated, Broken linoleum, wheelchair arm rests, would be at risk for cross contamination if surfaces were in disrepair. She stated, Exposed plaster could not be cleaned or disinfected. She stated the conditions of the bathroom were an infection control concern and had the potential for cross-contamination and potential resident infection risk. During an interview with Unlicensed Staff E, on 5/1/24 at 12:25 p.m., she stated the rugs in the hallway looked really bad. She stated it would not be something she would want to have in her home. She said, It looked dirty. During an interview and document review on 5/1/24, at 12:45 p.m., a document titled, Maintenance Log, dated 10/4/(23) to 12/29/23, indicated, 10/4/(23) Toilet leaks water through tiles, requested 10/4 and completed 10/9/23 11/10/23 TOILET OVERFLOW, requested 11/10/23, and completed 11/13/23. The Facilities Manager stated he had reviewed the Maintenance Log from October 2023 to January 2024, and there were no reports from staff about bathroom issues, broken linoleum, chipped paint for Resident Rooms 2, 4, 7, or 23 or wheelchair arm rests that needed to be repaired. He stated his assistant did not know about the Maintenance Log. The Maintenance Log indicated 45 Requests / Repairs and 14 Requests / Repairs were not completed. The Facilities Manager stated he had forgotten to write the completed date. He stated his assistant did not know about the log, and he did not know why staff were not using it. He stated the Maintenance Log was important so staff would communicate issues that needed to be repaired, to him or his assistant. During an interview and observation with the Director of Nursing, on 5/1/24 at 12:55 p.m., she stated she was unaware the wheelchair arm rests were cracked. She stated the condition of the arm rests were an infection control risk for residents because they could not be disinfected. In room [ROOM NUMBER] she observed the bathroom, and stated linen on the floor was not supposed to be in the bathroom. She stated the linen on the floor was an infection control risk to patients. She stated the cracked tiles, rough caulk around the base of the toilet and the exposed plaster could have been an infection control risk for residents from cross-contamination and the spread of infection. During and observation and interview on 5/2/24, at 9 a.m., in the clean laundry area folding room, with Unlicensed Staff S, Infection Preventionist and Facilities Manager, the Facilities Manager stated the outside vents by the dryers were cleaned weekly. Unlicensed Staff S stated she cleaned the countertops used to fold resident linen and clothing, every time she folded laundry, with bleach wipes. She was unable to state how long the surface needed to stay wet to produce bacterial kill to eliminate cross-contamination. No hand hygiene gel or hand hygiene sink was in the room. Unlicensed Staff S stated she used wipes for countertops and hand hygiene. She stated there were none on the countertop because she just threw them away. When asked why there were no empty containers observed in the trash, she stated she just emptied the trash. She used a step ladder to retrieve the last large container of bleach wipes and last remaining small container of hand wipes from the top shelf of a closed cupboard that was attached to the ceiling. During an observation and interview on 5/2/24, at 9:10 a.m., in a room that contained washers, dryers and equipment, a red line ran diagonally from the right side of the doorway between the laundry folding room, to the middle of the room with the washers and dryers. The concrete floor was chipped and had gray particulate matter that looked like lint or dust distributed around the room on equipment, behind equipment, and on the floor. Unlicensed Staff S indicated the red line was dirty on the right side where the washers and bins were, and the left side by the dryers was clean. Behind the washer and dryers, screened vents led to the outside. The vents were heavily encrusted with black, gray particulate that resembled dust, dirt and / or lint. The Facilities Manager stated the vents on the walls, leading outside, were cleaned weekly. He stated it did not look like they had been cleaned. The floors behind the washers and dryers had larger quantities of the same gray particulate matter. Unlicensed Staff S stated she cleaned the lint traps, located under each dryer, at 9:30 a.m. and 1:30 p.m She stated she did not write it down on a log. The lint trap under the dryers had a large sheet of dryer lint in the trap and on the floor. Unlicensed Staff S stated she used a broom to clean the dryer lint traps and walked over the red line to get a broom that was stored on the wall in the, Dirty side of the laundry, then walk back into the, Clean Side, and demonstrated how she cleaned the lint traps. She walked back across the red line and hung up the broom, then walk back into the laundry folding area, without having used hand hygiene. The Infection Preventionist stated she was unaware of the infection prevention practices in the laundry area and having a dirty and clean side. She stated she thought it had the potential for cross-contamination and the spread of infection to residents and staff. The Facilities Manager stated he was not oriented to the infection prevention concerns about clean and dirty in the laundry area. Unlicensed Staff S stated the dirty laundry was sorted on the right side of the red line and transferred into the washing machines. She stated she wore an apron. She pointed to the doorway that separated the laundry folding area from the laundry washer and dryer room, and one sleeveless white plastic apron hanging. She stated it was clean. She stated she used a clean one every time and then threw it away. An observation of the trash can on the right side of the red line did not contain an apron. She stated she had already emptied the trash. There were multiple bottles and buckets of laundry detergent solutions and a large jug of bleach and a mop bucket with solution, which sat between the washer and dryer area of the washer room. Unlicensed Staff S stated she used bleach in the bucket to mop the floors of the entire laundry area. She stated there was no sink in the dirty or clean sides of the laundry area, and she went to the Housekeeping Closet outside the department to get water so she could mop the floors. The Facilities Manager stated he did not know if any of the cleaning solutions or laundry chemicals had been approved for use by the Infection Control Committee. The infection Preventionist stated she did not know if the solutions had been approved for use and were EPA approved. She stated she did not know if the solutions and detergent chemicals were providing the bacterial kill required to prevent the risk of cross-contamination in a laundry process area. The Facilities Manager stated there was no hand hygiene sink in the department, and if staff had to wash hands they would have to leave the department and use the public bathroom outside the area. The Infection Preventionist stated gastrointestinal food-borne illness like C-differential required staff to wash their hands, as alcohol-based hand sanitizers were ineffective. She stated hand hygiene was done before and after putting on and taking off gloves and the apron. Unlicensed Staff S she wore an apron and gloves when she sorted dirty laundry. She stated she did not wear eye protection. Unlicensed Staff S stated, if her face and eyes were splashed with contamination from dirty laundry or laundry chemicals, she would use bottled eye wash to rinse her eyes. She was unable to state how long she had to rinse her eyes. The Facilities Manager was unaware if there was a Policy and Procedure for how long to rinse eyes after a bodily fluid exposure. He was reviewing Safety Data sheets and was unable to locate how long to rinse eyes if bleach splashed into them. He stated one bottle of eye rinse was not enough to rinse eyes after an exposure. He stated staff had the potential to have physical harm to their eyes if they could not rinse their eyes long enough. He stated laundry staff did not know how long to rinse their eyes in case they were exposed. The Facilities Manager stated he did not know when the washers were serviced. He stated he did not know what the washing machines' water temperature was. He stated there were no logs for anything in the laundry area. He stated he thought the water temperature might have been between 140 to 160 degrees Fahrenheit but was not certain. The Infection Preventionist stated she did not know why the water temperature was important for bacterial kill and use of detergent efficacy. She stated she used the Centers for Disease Control (CDC) as a resource for information. During an interview 5/2/24, at 10:55 a.m., the Infection Preventionist stated the CDC was the resource for the facility Infection Control program. She stated she did not know what the facility compliance rate was for hand hygiene compliance. She stated she completed informal visual audits when she had time. She stated the Infection Control program did not have an established goal for hand hygiene compliance. She stated there was no Infection Control Committee that formally met and reviewed the Infection Control program. She stated she did not meet with the Medical Director and had no epidemiological resource person who provided her with support and resources. She stated she had completed the CDC Infection Prevention online training, but was unaware of environmental rounds and risks of infection in laundry processing. She stated the Infection Control program did not have any goals for hand hygiene compliance. Review of a facility Policy and Procedure, titled Resident Rights, dated 2016, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence: Review of a facility Policy and Procedure (P&P) titled, Homelike Environment, reviewed February 2021, indicated, Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment; .c. Inviting colors and decor. Review of a facility P&P titled, Laundry and Bedding, Soiled, revised September 2022, indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control . Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used) .Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. Review of a document titled, CDC Guidelines for Environmental Infection Control in Health-Care Facilities 2003, dated 7/2019, page 96, indicated, From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities Insects should be kept out of all areas of the health-care facility, especially OR's and any area where immunosuppressed patients are located. A pest-control specialist with appropriate credentials can provide a regular insect-control program that is tailored to the needs of the facility and uses approved chemicals and/or physical methods. Review of a document from the CDC titled, Appendix D - Linen and laundry management Best Practices for Environmental Cleaning in Global Healthcare Facilities with Limited Resources, dated 5/4/23, indicated, Best practices for management of clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Each floor/ward should have a designated room for sorting and storing clean linens.

Based on interviews and record reviews, the facility failed to ensure: 1. Staff were aware of what a Basic Care Plan (BCP, a plan that promotes continuity of care and communication among nursing home staff which should be completed within 48 hours of resident admission and contain the minimum healthcare information necessary to care for resident safely) was and its completion time frame. 2. The BCP was completed for one out of one sampled resident (Resident 216) and completed timely for seven out of eight sampled residents (Residents 10, 14, 20, 30, 31, 216, and 265). These failures had the potential to put residents' safety at risk and for residents not receiving the care they need. Findings: A review of Resident 10's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (HTN, high blood pressure) and Type 2 Diabetes Mellitus (DM, disease caused by a problem in the way the body regulates and uses sugar as a fuel). His Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 4/1/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 15, indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 10's functional status indicated he needed moderate up to maximum assistance when performing his Activities of Daily Living (ADLs, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). His BCP was completed late on 5/12/21. A review of Resident 14's face sheet indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, an elevated level of lipids - like cholesterol and triglycerides - in your blood), Dysphagia (swallowing difficulties), and Depression (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world). Her MDS, dated [DATE], BIMS score was 13, indicating intact cognition. Resident 14's functional status indicated she needed moderate to maximum assistance when performing her ADLs. The portions of her BCP completed late on different times were: Nursing Services on 4/25/24, Social Services on 2/23/24, Food and Nutrition Services on 10/17/23, and Activities on 10/12/23. A review of Resident 20's face sheet indicated he was initially admitted to the facility on [DATE]. His diagnoses included HLP, HTN and Schizoaffective disorder (a mental health problem where you experience psychosis - symptoms that happen when a person is disconnected from reality, as well as mood symptoms). His MDS, dated [DATE], BIMS score was 4, indicating severely impaired cognition. Resident 20's functional status indicated he needed supervision up to moderate assistance when performing his ADLs. His BCP was completed late on 3/6/22. A review of Resident 30's face sheet indicated he was initially admitted to the facility on [DATE]. His diagnoses included HLP, Muscle Weakness and Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). His MDS, dated [DATE], BIMS score was 15, indicating intact cognition. Resident 30's functional status indicated he needed up to maximum assistance when performing his ADLs. His BCP effective date on 3/28/24, was completed late: Nursing services was blank, Rehabilitation Services was completed on 4/25/24, and Activity Services was completed on 4/2/24. A review of Resident 31's face sheet indicated he was initially admitted to the facility on [DATE]. His diagnoses included HTN, Muscle Weakness and Dysphagia. His MDS, dated [DATE], BIMS indicated severe cognitive impairment. Resident 31's functional status indicated he was dependent on staff when performing his ADLs. His BCP was completed late: Nursing services was blank, Social Services, Rehabilitation Services, Food and Nutrition Services were completed on 2/23/24, and Activity Services was completed on 1/12/24. A review of Resident 216's face sheet indicated he was initially admitted to the facility on [DATE]. His diagnoses included HTN, HLP and Dysphagia. His MDS, dated [DATE], BIMS indicated severe cognitive impairment. Resident 216's functional status indicated he needed up to maximum assistance from staff when performing his ADLs. His BCP, dated 1/22/21, was not completed at all. A review of Resident 265's face sheet indicated she was initially admitted to the facility on [DATE]. Her diagnoses included HLP, Dysphagia and Anxiety. Her MDS, dated [DATE], BIMS score was 15, indicating intact cognition. Resident 265's functional status indicated she needed up to moderate assistance from staff when performing her ADLs. Her BCP was completed late on 4/29/24. During an interview on 5/2/24 at 12:21 p.m., Licensed Staff G stated she did not really know what a BCP was. When asked if it was important to create BCP for residents, she stated, Yes. Licensed Staff G stated it was important to make sure staff were taking care of the residents safely. Licensed Staff G stated she did not know the timeframe was for completing a BCP. When asked what could the risk for residents if a BCP was not completed timely, Licensed Staff G stated staff may be providing care to the residents that was not safe. During an interview on 5/2/24 at 12:29 p.m., Licensed Staff F stated a BCP was important to ensure staff were providing appropriate and adequate care for the residents. When asked what the timeframe was for completing a BCP, Licensed Staff F stated within 24 hours. When asked what the risks were for a resident if a BCP was not completed timely, Licensed Staff F stated, if BCP were not completed timely, it could lead to providing inadequate care to the residents. Licensed Staff F stated it was a safety issue. During an interview on 5/2/24 at 3:53 p.m., Licensed Staff T stated she did not know what BCP was and did not know the timeframe for completing a BCP. During an interview on 5/3/24 at 9:37 a.m., the Social Services Director (SSD) stated BCPs help staff to care for residents safely. The SSD stated it was important to create a BCP for residents, so staff knew what the residents needs were. When asked what the risk were for residents if a BCP was not completed timely, the SSD stated staff may not meet the residents' needs. During an interview on 5/3/24 at 12:17 p.m., the DSD stated it was important to create BCPs for residents, so staff knew the basic care they needed to provide for the residents. When asked what the timeframe was for completing a BCP, the DSD stated BCPs should be completed within 48 hours of resident's admission. The DSD stated, if the BCP was not done within 48 hours of admission, the facility policy was not followed. When asked what the risks were for residents if a BCP was not completed timely, the DSD stated staff would not meet residents needs safely. During an interview on 5/3/24 at 1:29 p.m., the Director of Nursing (DON) stated it was important to create BCP for residents so staff were aware of what residents' needs were and to provide safe care to the residents. The DON stated, if the BCP was not completed within 48 hours of residents' admission, then the facility policy was not followed. When asked what the risks were for the residents if a BCP was not completed timely, the DON stated staff may not provide safe care to the residents. A review of the facility's policy and procedure (P&P) titled, Care Plan-Baseline, revised 12/2022, the P&P indicated a baseline plan of care should be developed for each resident within 48 hours of admission.

Based on observations, interviews and record reviews, for a resident who had a tube feeding (method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories when you cannot eat or drink safely by mouth), the facility failed to: 1. periodically evaluate the amount of feeding being administered for one out one sampled resident (Resident 265), when staff did not know to calculate how much formula was given and how much formula should be left in the feeding bag in a period of time. 2. monitor Resident 265's input and output (I &O, important to help evaluate a person's fluid and electrolyte balance, to suggest various diagnosis, and allows for prompt intervention to correct the imbalance) to ensure she was receiving the calculated amount of tube feeding consistent with practitioner's orders. These failures could put Resident 265 at risk for fluid and electrolyte imbalance (occurs if the body has too much or too little water), dehydration (a condition that results when the body loses more water than it takes in) and malnutrition (getting too little or too much of certain nutrients). Findings: A review of Resident 265's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Dysphagia (difficulty swallowing) and Anxiety (a feeling of fear, dread, and uneasiness). His Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 4/19/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 15, indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 265's functional status indicated she needed up to moderate assistance from staff when performing her Activities of Daily Living (ADLs, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 265 received nutrition through tube feeding. A review of Resident 265's Physician Order Summary indicated a formula feeding to run at 60 centiliters (cc, a unit of measure) for 16 hours, 960 cc volume, 1,728 calories, 78 grams (gr, a unit of measurement used to measure very light object) protein. During an observation on 4/29/24 at 4:29 p.m., Resident 265 was sitting in her wheelchair in the Rehabilitation Therapy room. The tube feeding was running at 60 milliliter (ml, unit of measurement) per hour. The bag indicated it was hung at 4:45 a.m. The feeding tube was running for about 12 hours now. Resident 265 should have received 720 ml of formula by this time, however, there was a little over 500 ml of formula left on the bag. The bag should only have 240 ml of formula left in the bag. During a concurrent observation and interview on 4/29/24 at 4:49 p.m., Licensed Nurse H verified Resident 265's formula was hung at 4:45 a.m. Licensed Nurse H verified there was a little over 500 ml of formula remaining in Resident 265's tube feeding bag. When asked if she knew how much formula should be left in Resident 265 at this time, she did not answer. During a concurrent observation and interview on 4/30/24 at 8:37 a.m., Licensed Staff G verified Resident 265's tube feeding formula was hung at 5 a.m., and there was about 900 ml of formula left in the bag. When asked how long Resident 265's tube feeding had been running since it was hung, Licensed Nurse G stated three and a half hours. When asked how much formula Resident 265 should had received from 5 a.m. to 8:37 a.m., she did not answer. When asked what the amount of formula should be left in the bag between 5 a.m. and 8:30 a.m., she did not answer. When asked if the staff were monitoring intake and output for Resident 265, she stated she did not know. During an observation on 5/1/24 at 11:49 a.m., it was noted a 1000 ml of formula was hung at 5 a.m. It indicated that at this time, the tube feeding had been running for about seven hours now, and there was about 750 ml of formula left in the bag. Per calculation, there should only be 540 ml of formula left in the bag. During an interview on 5/1/24 at 2:48 p.m., the Registered Dietician (RD) stated Resident 265's tube feeding order was to run 60 ml for 16 hours and off for eight hours. The RD stated, if the formula was hung at 4:45 a.m., in 12 hours, Resident 265 should have received 720 ml of formula, and there should be about and 240 ml left in the tube feeding bag, not 500 ml. The RD stated she would question this and would ask, Is Resident 265 receiving the amount of tube feeding she was supposed to be receiving? During a concurrent observation and interview on 5/1/24 at 3:00 p.m., the RD verified there was 600 ml of formula left in the tube feeding bag, and Resident 265's tube feeding had been running for ten hours now. The RD stated Resident 265 should have received 600 ml of the formula by now. The RD stated 600 ml of Formula left at this time was more than what was supposed to be left in the bag. During an interview on 5/1/24 at 3:06 p.m., Licensed Staff G stated, if the tube feeding showed there was more formula left in the bag, it probably meant the resident was not receiving the appropriate amount of formula in a given time and could result in impaired nutrition. During an interview on 5/1/24 at 3:18 p.m., Licensed Nurse H stated, if the feeding bag had more formula than it should, it could mean the resident was not receiving the appropriate amount of formula in a given time, which could result in malnutrition. During an interview on 5/2/24 at 11:21 a.m., the Nurse Consultant (NC) stated staff were not monitoring Resident 265's I&O. When asked why, she stated it was because there was no physician order to monitor Resident 265's I&O. When asked why there was an intervention in Resident 265 Dehydration Care Plan, dated 4/17/24, directing staff to monitor Resident 265's I&O, the NC stated it must have been clicked by mistake. During an interview on 5/2/24 at 12:29 p.m., Licensed Staff F stated it was the facility's policy to ensure residents on tube feeding were placed on I&O monitoring. When asked if staff should be monitoring Resident 265's I&O, he stated, We should be. Licensed Staff F stated I&O monitoring was a nursing intervention and did not require a physician's order. When asked what the risk was if staff were not monitoring I&O, Licensed Staff F stated it could place residents at risk for dehydration, malnutrition and fluid overload. During an interview on 5/02/24 at 3:53 p.m., Licensed Staff T stated all residents who were on tube feedings should have an I&O monitoring. When asked what the risk was if staff were not monitoring I&O, she stated it could place residents at risk for electrolyte imbalance, constipation and impaired nutrition. During a telephone interview on 5/3/24 at 10:43 a.m., when asked if the facility should be monitoring a resident's I&O when they were receiving tube feedings, the Medical Director (MD) stated, absolutely. The MD stated it was important staff knew they were administering the right formula and the residents were receiving the correct amount of formula in a given time. During an interview on 5/3/24 at 11:30 a.m., Licensed Nurse I stated I&O should be monitored for all residents on tube feedings. Licensed Staff I stated I&O monitoring did not need a physician order. When asked what the risk was if staff were not monitoring I&O, Licensed Nurse I stated it could put the resident at risk for malnutrition and weight loss. During an interview on 5/3/24 at 12:17 p.m., the DSD stated staff should be monitoring residents' I&O if they were on tube feedings. During a telephone interview on 5/3/24 at 12:54 p.m., the RD stated staff should be monitoring residents' I&O if they were on tube feedings. A request for I&O monitoring policy was requested but not provided. A review of the facility's policy and procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, revised 11/2018, the P&P indicated the person performing this procedure should record in residents' medical record the average fluid intake per day. For residents receiving enteral feeding, the National Institute of Health recommend that fluid intake and output be determined every eight hours, on a daily basis.

Based on interview and record review, the facility failed to: 1. Follow its Policy and Procedure for Medication Regimen Review. 2. Ensure staff knew what a glycoprotein-colony stimulating factor (G-CSF, used to increase the number of white blood cells in the blood, which helps your immune system fight infections and heal injuries, in patients receiving anticancer drugs) injection was. 3. Ensure the monthly Medication Regimen Review by the Pharmacist for Resident 14 was thorough and accurate, when the medication G-CSF injection was not listed on Resident 14's current medications, and staff did not notify the pharmacist Resident 14 was receiving G-CSF injection weekly. These failures had the potential to: 1. Cause serious physical and/or psychosocial harm when the facility did not forward pharmacy recommendations to any facility physician for five months, September 2023 through March 2024. 2. Prevent the Pharmacist from identifying an irregularity that might require an urgent action to protect Resident 14. Findings: 1. During an interview and record review on 05/1/24 at 2:35 PM, the Director of Nursing (DON) provided a loose-leaf binder titled, Medication Regimen Review 2023 (MRR), and a loose stack of documents, dated April 2024. The MMR 2023, binder was missing pharmacy review documents from September, October, November, and December 2023. The DON stated she had the MRR for the month of April 2024. The DON stated the recommendations had been reviewed for April 2024, but it was too soon to determine which recommendations had been followed. The DON further stated she did not have the MRR pharmacy review documents for January, February, or March of 2024. During an interview and record review on 5/2/24 at 8:30 AM, the DON stated there was no records documenting action taken by medical or nursing staff on pharmacy recommendations from September 2023 through March 2024. The DON provide a loose stack of documents, dated 11/1/23 through 3/28/24. The documents were titled, Pharmacist's Executive Summary, Medical Director Report, Pharmacist's Recommendation to Prescriber, Pharmacist's Report to Nursing, Resident's Reviewed with No Recommendation, and, Resident's with MRR Activity. All of the documents were signed by the Pharmacist. None of the documents contained a response (agree, disagree, or other), comments, or a signature with a date from the prescriber. During an interview on 5/2/24 at 11:50 AM, the DON stated the MRR process was the following: The Pharmacist reviewed records monthly and then emailed a summary and recommendations to the DON. The DON printed the recommendations and gave them to the Doctor for review. The process has a snag with the pharmacy, and they are looking to make a change. The DON stated the only thing she had was the pharmacy recommendations. The DON further stated no MMR pharmacy summaries or recommendations had been sent to any facility Doctors from October 2023 through March 2024. The DON stated the documents were in a, holding pattern. The DON also stated the pharmacy review was sent to only one person, the DON. When new orders were obtained from a Doctor following the Pharmacist recommendations, the DON gave the new orders to Medical Records for scanning, they were uploaded to Point Click Care (PCC, an electronic documentation system), and the new orders were given back to the DON to place in the MRR binder. The DON stated the risks for not following the MRR process included adverse drug effects from unmanaged polypharmacy (the simultaneous use of multiple drugs by a single patient, for one or more conditions) and lack of follow-up for dose reduction recommendations. During an interview on 5/2/24 at 2:45 PM, via telephone, the Pharmacy Consultant (PC) stated he reviewed each patient's medications monthly. He sent a report to the facility each month. He stated the process was for the facility to send his report to the Doctor(s). He further stated the format stayed the same every month, and he had no idea if the facility sent the report to the Doctor(s) and whether a response was received. The PC stated he reviewed the patient's medical records the month after he sent recommendations, and he determined whether the Doctor followed his recommendations. He did not receive any direct communication from the Doctor(s) or the DON concerning action taken or not taken. During a record review on 5/3/24, a document titled, Medication Regimen Review Policy and Procedure, revised 3/4/14, indicated in Section F. 1) The MRR comments will be delivered to the DNS (Director of Nursing Services, another term for DON) for timely follow through with the prescriber and/or nursing staff. Section G. indicated, Recommendations are acted upon and documented by the facility staff and/or the prescriber. Section G. 1) indicated, Physician accepts or acts upon suggestion or rejects and provides an explanation for disagreeing. Section G. 3) indicated, The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention . 46132 2. A review of Resident 14's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Hyperlipidemia (HLP, an elevated level of lipids - like cholesterol and triglycerides - in your blood), Dysphagia (swallowing difficulties), and Depression (a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world). Her Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 4/11/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13, indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 14's functional status indicated she needed moderate up to maximum assistance from staff when performing her Activities of Daily Living (ADLs, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of Resident 14's Physician Order Summary did not indicate she was receiving G CSF injection weekly. A review of the electronic medical record indicated there was no MRR completed which included G CSF injections on her medication list nor a care plan for G CSF injection for Resident 14. During an interview on 5/2/24 at 3:53 p.m., Licensed Staff T stated the Pharmacist should know Resident 14 was receiving G CSF injections weekly even if she was receiving this medication from the Oncology Clinic. When asked what the risk could be if the Pharmacist was not able to conduct an accurate Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, including medications prescribed and over the counter administered by any route with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with a medication) for the Resident 14 while she was receiving G CSF injection, she stated it was a safety issue because the Pharmacist would not be able to review this medication for interaction with other medications and would not know what side effects staff should be monitoring Resident 14 for. When asked if Licensed Staff T knew what medications a negative interaction with G CSF injection could possibly have, she did not answer. When asked if she knew the specific side effect of G CSF injections and what to do in case Resident 14 exhibited a side effect or adverse effect from G CSF injection, Licensed Staff T stated she did not know. During an interview on 5/2/24 at 4:58 p.m., Licensed Staff F thought a G CSF injection was a chemotherapeutic drug. Licensed Staff F stated the expectation was for staff to notify the Pharmacist of all the medications residents were receiving so the Pharmacist could check for drug-to-drug interaction. When asked what the risks could be if the Pharmacist was not able to conduct an accurate MRR for Resident 14 while she was receiving G CSF injections, Licensed Staff F stated the Pharmacist would not be able to conduct a thorough and accurate medication review and could not see if G CSF injections would interact negatively with other medications. When asked if he knew what medications a negative interaction with G CSF injection could possibly have, he did not answer. When asked if he knew the specific side effects of a G CSF injection and what to do in case Resident 14 exhibited side effect or adverse effect from G CSF injection, Licensed Staff F did not answer. During an interview on 5/3/24 at 8:17 a.m., when asked to provide G CSF injection use policy and procedure, Resident 14's MRR which included G CSF injection on her medication list and a care plan for G CSF injection, the Nurse Consultant (NC) stated the facility did not have these items since Resident 14 was receiving G CSF injections from outside which meant the facility was not responsible for ensuring there was G CSF injection use policy and procedure. Resident 14's MRR by the Pharmacist, which included G CSF injection on her medication list was completed, and a care plan was created for G CSF injection usage. During a telephone interview on 5/3/24 at 10:36 a.m., the Consultant Pharmacist (CP) stated G CSF was a specialized medication and had specific instruction and precautions. The CP stated it would be beneficial for Resident 14 and staff if he was notified Resident 14 was receiving this medication to ensure he was conducting a thorough and accurate Medication Regimen Review for Resident 14. During a telephone interview on 5/3/24 at 10:43 a.m., the Medical Director (MD) stated he expected the facility to ensure the Pharmacist was aware Resident 14 was receiving G CSF injections, regardless of whether she was receiving it at the facility or from the outside, for residents' safety. The MD stated he expected the staff to ensure Resident 14 was monitored for side effects as well. He stated coordination of care between the facility, the Pharmacist and the Physician was very important. During an interview on 5/3/24 at 1:29 p.m., the Director of Nursing (DON) stated the Pharmacist should be made aware Resident 14 was receiving G CSF injections regardless of whether she was receiving it at the facility or from the outside. The DON stated staff may not know which side effects to look for while Resident 14 was receiving G CSF injection weekly, and that was where the Pharmacist came in- to educate staff and for Resident 14's safety. The facility did not have a documentation to indicate they were monitoring Resident 14 for side effects or adverse effects while she was receiving G CSF injections. The facility did not have a policy and procedure for G CSF medication usage. A review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Report, revised 3/4/14, the P&P indicated in the MRR: The Pharmacist performs a comprehensive review of each residents MRR at least monthly .the MRR includes evaluating the residents' response to medication therapy to determine the resident maintains the highest practicable level of functioning and prevents or minimize adverse consequences related to medication therapy .the Pharmacist identifies irregularity including prescriber's orders .residents were monitored for cumulative effects of multiple medications .resident is monitored for adverse consequences when there is an addition or deletion of medication .side effects and interactions are evaluated and modifications or alternatives are considered.

Based on observations, interviews and record reviews, the facility failed to ensure food was palatable, and served at temperatures in accordance with resident preferences, for four out of five sampled residents (Residents 5, 14, 42 and 53), and the food temperature was not taken prior to serving to one out of 5 sampled residents (Resident 47). These failures could result in residents not eating the food served, which could result in weight loss and further compromise their medical status. Not taking the food temperature prior to serving to the resident could result in accidents such as burns. Findings: A review of Resident 14's face sheet (demographics) indicated she was admitted to the facility on [DATE], with a diagnoses of Dysphagia (swallowing difficulties), Hyperlipidemia (HLP, abnormally high levels of fats (lipids) in the blood) and Essential Hypertension (HTN, high blood pressure). Resident 14 reported she had Breast Cancer (Cancer that forms in tissues of the breast) which was being treated outside the facility. A review of her Minimum Data Sheet Assessment (MDS, a federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 4/11/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13, indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 14's functional status indicated she needed maximum assistance when performing her Activities of Daily Living (ADLs, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet) such as bathing, dressing and putting on/removing footwear. A review of Resident 5's MDS assessment, dated 3/19/24, indicated she had a BIMS score of 13, indicating intact cognition. Her diagnoses include Heart Failure (HF, occurs when the heart muscle doesn't pump blood as well as it should), HTN and Diabetes Mellitus (DM, a chronic (long-lasting) health condition that affects how your body turns food into energy). A review of Resident 42's MDS assessment, dated 2/17/24, indicated she made decisions that were consistent and reasonable. Her diagnoses include Anxiety (a feeling of fear, dread, and uneasiness) and Schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality). A review of Resident 53's MDS assessment, dated 2/18/24, indicated she had a BIMS score of 15, indicating intact cognition. Her diagnoses include Asthma (a chronic condition that inflames and narrows the airways in the lungs) and Respiratory Failure (RF, a serious condition that makes it hard for you to breathe on your own). During an interview on 4/30/24 at 2:38 p.m., Residents 5, 14, 42 and 53, stated hot foods were served cold and had no taste. Residents 5, 14, 42 and 53, stated vegetables were overcooked, mushy and had no taste. During a concurrent observation and interview on 5/1/24 at 7:06 a.m., [NAME] 1 was noted to warm up three cups of liquid meals for Resident 47, in the microwave for one minute and 30 seconds. [NAME] 1 did not take the food temperature prior to putting it on Resident 47's tray. When asked if she should take the food temperature prior to putting it on Resident 47's tray, she did not answer. During a concurrent observation and interview on 5/01/24 at 8:02 a.m., the Dietary Manager (DM) took the temperature of the food included in the test tray. The temperature results were as follows: Pureed eggs temperature was 136.5, pureed pancake temperature was 107, sausage temperature was 128.4, and the pancake temperature was 139.6. Upon tasting these food items, it was noted they were slightly cold in temperature, and the pureed egg and pancake had thick consistency and it tasted pasty, floury and doughy. The DM also tasted the food items and stated the pureed egg and pancake was slightly thickened in texture and tasted pasty and floury. When asked if the pureed eggs and the pureed pancake should be this thick in texture, tasted pasty and floury and the pancake tough and chewy, she stated, No. The DM stated this could be due to the cook adding thickener on these items. The DM stated the pancake was difficult to slice, and residents could have a hard time eating the pancake. During an interview on 5/1/24 at 2:40 p.m., the Registered Dietician (RD) stated staff should take the temperature of the food items warmed in the microwave, prior to serving it to the residents, to ensure residents' safety from accidents and burns. The RD stated food items' temperature should be in a range that was safe for the residents consumption. The RD stated, if food was not palatable and the temperature was not in range, residents may not eat the food, which could result in weight loss and impaired nutrition. During an interview on 5/2/24 at 10:20 a.m., the DM stated the test tray food temperatures for pureed at 136.5, pureed pancake temperature of 107, the sausage temperature of 128.4, the pancake temperature of 139.6, during test tray, was not appropriate and did not meet the food temperature guidelines. The DM stated, serving food that did not have the right temperature could cause food-borne illness. The DM also stated, if food were not served at a right temperature, it could lead to residents not eating the food which could result in weight loss or malnutrition. During an interview on 5/2/24 at 10:50 a.m., the DM stated, if food items were placed in the microwave to warm it, staff should have taken the temperature before placing it on the resident's meal tray, to ensure resident safety from burns or accidents and to ensure the resident did not get sick from food-borne illness. During an observation on 5/2/24 at 10:55 a.m., the DM made another batch of pureed eggs. She stated she would use two-thirds (2/3, an amount that is two out of three equal parts of it) cups of eggs which was equal to three eggs and would add one-forth (1/4, an amount that is one out of four equal parts of it) cup of milk. The DM stated, per their pureed eggs menu, they were allowed to use between 1/3 to 3/4 cups of milk. The DM stated the pureed eggs she prepared appeared very lumpy so she had to put them back in the blender. The DM was noted to add milk in the blender. When asked how much milk she added on the pureed eggs, the DM stated she added a splash of milk which resulted in the pureed eggs appearing watery with some clumps. When asked what a splash of milk meant, she did not answer. She stated she should not have added more milk. A review of recipe titled, Pureed eggs, indicated puree should reach a consistency slightly softer than whipped topping. Based on the facility's policy and procedure (P&P) titled, Food Preparation and Service, revised 11/2022, the P&P indicated, Food and Nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling services .the following internal cooking temperatures/times for specific foods are reached to kill or sufficiently inactivate pathogenic microorganism, 155 degrees for eggs held for service, mechanically tenderized meat .previously cooked food is reheated to an internal temperature of 165 for at least 15 seconds before holding for hot service .mechanically altered hot foods prepared for modified consistency diet remains above 135 degrees during preparation or they are reheated to 165 degrees for at least 15 seconds.

Based on observation, interview, and record review the facility failed to follow the care plan and implement the use of an assistive device (mechanical lift) to prevent avoidable accidents, for one of 14 sampled residents (Resident 14), identified by the facility as at risk for falls, when transferring the non-ambulatory (not able to walk) resident from the bed to a shower chair. Two CNA's (certified nurse assistants) transferred Resident 14 by hand. Resident 14 became too heavy for the two CNA's to hold and had to be lowered to the floor. Resident 14 sustained a right femur (long bone of the thigh) spiral fracture (a break in a bone that typically occurs when a rotating force is applied along the length of the bone.) Resident 14 required hospitalization and surgical repair of the fracture. Findings: Resident 14 was a [AGE] year old female originally admitted to the facility on [DATE]. Resident 14's Face Sheet (an admission record) indicated she had multiple [DIAGNOSES REDACTED].) that occurs when the flexible tissue (cartilage) at the ends of bones wears down.) Resident 14's Care Plan for falls, dated 3/2/14, indicated Resident 14 was at risk for falls secondary to history of fall, dementia, impaired mobility with need for extensive assist with cares. Approaches to prevent falls were to monitor factors causing prior falls, and to place a fall mat beside bed to minimize impact of falls. An updated approach to prevent falls, dated 4/10/15, directed staff to use two person assist with mechanical lift (use of a sling, attached to a hydraulic lift device, which is placed under the patient and once firmly secured can move a patient from one place to another). The long term goal indicated, Resident 14 would remain free of injury as evidenced by being free of falls or accidents every day for 90 days. Long term goal target dates were updated and entered as 5/27/16, 9/7/16, 11/24/16, 2/3/17, and 2/22/17. Resident 14's quarterly fall risk assessment dated [DATE], indicated a score of 17. A score of greater than 13 indicated a high risk for falls, per the Johns Hopkins Health System Fall Risk Assessment Tool, which the facility utilized. Resident 14's quarterly Minimum Data Set (MDS - a resident assessment tool) dated 11/27/16, indicated Resident 14 did not ambulate and required total dependence of two or more staff persons during transfers. Resident 14 was not able to complete a Brief Interview for Mental Status (BIMS) due to her cognitive impairment and was rarely/never understood. The nursing progress note dated 12/25/16 at 11:19 p.m., (recorded as a late entry on 12/30/16 at 3:12 p.m.) indicated the licensed nurse (LN D) was called to Resident 14's room on the evening of 12/25/16. The progress note indicated, Staff sitting on floor with resident keeping her in semi-Fowler's position (sitting upright at a 30-45 degree angle.) Staff stated they went to the floor with resident during transfer from bed to shower chair. LN D assessed Resident 14 and no deformity of her arms, legs, spine or neck was observed. Resident 14's level of consciousness and range of motion to her legs was described as per baseline, (same as before the fall.) LN D did not observe signs or symptoms of injury or pain during subsequent every 30 minutes assessments. It was noted that Resident 14 was non-ambulatory, bedbound, with limited verbalization. LN D's progress note also noted, to be endorsed (reported) to oncoming nurse (next shift licensed nurse) for continued assessment. Will continue to monitor. The nursing progress note dated 12/29/16 at 5:57 a.m., indicated LN E was called, by a CNA, to Resident 14's room around 4:40 a.m. on 12/29/16. Resident 14's right leg had yellowish discoloration on the right knee and reddish discoloration to the right shin. LN E noted, upon assessment of Resident 14's right leg, Resident 14's facial reaction was in pain by moaning and grimacing. LN E documented Resident 14's right leg was shorter than the left leg. The progress note indicated Resident 14's physician and family were notified. Review of an Interdisciplinary Team (IDT) note for Resident 14, dated 12/30/16, indicated the IDT met on 12/30/16 at 10:25 a.m. to review Events, 12/25/16 Falls / Found on Floor. The team consisted of the Administrator, DON, MDS nurse, DSD (Director of Staff Development) nurse, an Occupational Therapist, the Activities Director, and the Medical Records Director. The IDT progress note indicated Resident 14 had no significant changes noted prior to the intercepted (to obstruct or catch someone or something) fall on 12/25/16. The IDT note documented Resident 14 sustained a right femur acute spiral and displaced fracture of the mid femoral shaft. The Root Cause, (the most basic cause that can be identified, and when fixed, will prevent or significantly reduce the likelihood of the problem's recurrence) evaluated by the IDT revealed, Two CNA staff attempting to get res (resident) up when res slipped during transfer, assisted to floor with R (right) leg impact. There was no mention, in the IDT's Root Cause evaluation, of the CNA staff not using the mechanical lift for Resident 14's transfer, as per her care plan. A rehab post (after) fall screen for Resident 14 was performed by Occupational Therapist F on 12/29/16 at 11:36 a.m. Details of the report revealed no assistive device was used on 12/25/16 during Resident 14's transfer from bed to shower chair. Concurrent review of Occupational Therapist F's progress note dated 12/29/16 at 11:37 a.m., (recorded as late entry on 12/30/16 at 9:40 a.m.), indicated, during the rehab post-fall screen on 12/29/16, Resident 14 had facial grimacing and cried out with PROM (Passive Range of Motion - moving the joints through a range of motions without help from a resident) to her RLE (right lower extremity). The RLE was in external rotation (turning outward or away from the midline of the body). During an interview on 1/25/17 at 11:55 p.m., the Director of Nursing (DON) stated, on 12/25/16, during the evening shift (typically 2:30 p.m. to 11 p.m.) Resident 14 was being transferred manually (by hand) from her bed to a shower chair by two CNA's. Resident 14's knee buckled (collapsed) and the two CNA's assisted her to the floor. A few days later, on 12/29/16, the DON stated a night shift nurse (LN E) noticed Resident 14's legs were not even. When asked if Resident 14 indicated she was in pain, the DON stated at times it was difficult to tell if Resident 14 had pain due to her dementia. The DON stated an X-ray of Resident 14's right leg/hip was taken on 12/29/16 which revealed an acute (sudden onset) spiral and displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the right femur. The DON confirmed Resident 14 was sent to the hospital on [DATE]. Review of the hospital's surgery notes titled, Surgery and Procedure Reports, dated 12/31/16 at 12:02 p.m., indicated on 12/30/16, Resident 14 underwent an open reduction and internal fixation (ORIF) of the right femur. ORIF is surgery to fix the broken bone. Open reduction means the bone is moved back into the right place with surgery. Internal fixation means that hardware (such as rods or pins) is used to hold the broken bones together (www.allinahealth.org). Resident 14's surgery to repair and stabilize the fractured right femur required surgical placement of a plate, screws, and cables. During an interview on 1/25/17 at 2 p.m., when asked if all two-person transfers utilized a mechanical lift, Licensed Nurse S (LN S) stated, Yes, but therapy (physical or occupational) determines the level of transfer and it depends on the resident (condition/diagnosis). During an interview on 1/25/16 at 2:15 p.m., when asked when a mechanical lift was used, CNA A stated, when a resident is not able to stand or bear weight. During an interview and observation on 2/8/17 at 3:15 p.m., CNA B stated she was assigned to take care of Resident 14 on the evening shift of 12/25/16. CNA B stated it was Resident 14's shower day and CNA B pressed the call light for help to transfer Resident 14 from her bed to the shower chair. CNA C responded to the call light. When asked what type of transfer the two CNA's performed, CNA B stated, we do it manually (by hand). CNA B stated she and CNA C had Resident 14 under her arms during the transfer, when CNA B stated Resident 14 was too heavy. CNA B stated, so we lowered her (Resident 14) to the floor. When asked if Resident 14's knee's buckled, CNA B stated, No, she was just heavy so we slowly let her down and one of us stayed with her and the other one called for the nurse. When asked if Resident 14 showed any signs of being in pain, CNA B stated, No, she seemed as usual . she didn't hit the ground. CNA B demonstrated the position that Resident 14 was in after being lowered to the floor: a sitting position with both legs bent or folded to one side. During an interview on 3/9/17 at 11:15 a.m., when asked why a mechanical lift was not used on 12/25/16 when transferring Resident 14 to the shower chair, the DON stated she consulted with the Director of Staff Development (DSD), who interviewed CNA B and CNA C after the fall, and the CNA's stated, because it was quicker to do it manually. During a subsequent interview on 4/11/17 at 9:30 a.m., the DSD confirmed no mechanical lift was used to transfer Resident 14 because CNA B and CNA C told her it was faster to do it manually. When asked if Resident 14 was always transferred manually the DSD stated, If it was with those two (CNA's), probably. During an interview on 3/13/17 at 3:30 p.m., Resident 14's nursing progress notes, dated between 12/26/16 and 12/28/16, were requested of the DON. The DON stated there were no nursing progress notes for this time period (except for a weekly summary dated 12/28/16 at 3:51 a.m. that did not mention Resident 14's fall.) The DON stated she became aware of Resident 14's assisted fall of 12/25/16 when, on 12/29/16, Resident 14 showed bruising and licensed staff had obtained a physician's orders [REDACTED]. The DON stated she asked her nursing staff, What happened? The DON stated that was when LN D informed her of Resident 14's intercepted fall on 12/25/16. The DON stated she told LN D to document the event in the progress notes (refer to progress note above, dated 12/25/16 at 11:19 p.m., recorded as a late entry on 12/30/16 at 3:12 p.m.) During concurrent review of Resident 14's nursing progress notes, the DON confirmed it was on 12/29/16 that the progress notes reflected the development of pain and bruising to Resident 14's right leg with the subsequent order for an X-ray which revealed an acute fracture of the right femur. During an interview on 3/14/17 at 8:19 a.m., LN E stated she was called into Resident 14's room on 12/29/16 between 4:30 and 5 a.m. by a CNA who asked her to check the resident's right leg. LN E stated she discovered discoloration to Resident 14's right knee and shin and the right leg was shorter than the left leg. LN E stated she assessed Resident 14 with PROM to her right leg and Resident 14's face grimaced and she moaned. LN E stated Resident 14 did not have a response to PROM to her left leg. LN E stated she faxed a report to Resident 14's physician and requested an X-ray be taken. LN E also informed Resident 14's family. When asked if any staff reported Resident 14's fall on 12/25/16, LN E stated, No, I had no knowledge she had a fall. During an interview on 3/14/17 at 3:20 p.m., LN D stated she was called into Resident 14's room by a CNA on the evening of 12/25/16 (exact time unknown). LN D stated there were three to four CNA's in Resident 14's room, to help, but Resident 14 was on the lap (the flat area between the waist and the knees) of one of the CNA's and they were sitting on the floor. LN D described Resident 14's position as a sitting position with her knee's bent to one side. LN D stated Resident 14's position did not look malformed. LN D stated a CNA's told her, she gave out, referring to Resident 14's transfer, and the CNA's went down with her and she never hit the floor. LN D stated she assessed Resident 14, while still on the floor, for any deformity of extremities, bruising, pain and her level of consciousness and there were no indications of injury. Resident 14 was then lifted to the shower chair, given a shower, and LN D stated she checked Resident 14 visually and physically every 30 minutes and no changes were observed. When asked if she documented the incident, LN D stated, No . I didn't chart on time and confirmed she wrote a late entry note dated 12/30/16 of the incident that occurred on 12/25/16. When asked if she documented Resident 14's every 30 minute assessments after the fall on 12/25/16, LN D stated, No, not documented . LN D stated she did not inform the DON or Resident 14's physician at the time of the incident on 12/25/16. When asked if she reported the event to the oncoming night shift nurse (LN E), LN D stated, I want to say yes 100% but I can't recall the conversation . I can't imagine not telling the next nurse. When asked if the CNA's used a mechanical lift when transferring Resident 14 from the bed to the shower chair, LN D stated the CNA's did not use the mechanical lift. According to Potter and Perry's Fundamentals of Nursing, ninth edition, 2017, Principles of Safe Patient Transfer and Positioning, Mechanical lifts and lift teams are essential when a patient is unable to assist. During a telephone interview on 4/12/17 at 8:40 a.m., when asked if she assessed Resident 14 as requiring a mechanical lift for transfers, Occupational Therapist F stated Not previously (before the fall), it was used after (the fall). Review of the hospital's examination report, titled History and Physicals, dated 12/29/19, indicated Resident 14 was brought to the Emergency Department (ED) on 12/29/16 due to severe right leg pain after a mechanical fall. Upon physical examination, Resident 14's right hip was painful to palpation (touch) and had swelling. There were ecchymoses (bruises) over her upper body. Concurrent review of the orthopedic surgeon's Consultation, dated 12/30/16, indicated Prior to the fracture, the patient (Resident 14) did not ambulate. Review of the acute care hospital's interfacility (from one facility to another) transfer record dated 1/3/17 (the date Resident 14 was discharged from the hospital and readmitted to the skilled nursing facility) indicated Resident 14's prior level of function (before being admitted to the hospital) was documented as Dependent and she was Unable to transfer independently. The facility's policy titled, Safety and Supervision of Residents, revised 12/07, indicated a policy statement, Resident safety and . assistance to prevent accidents are facility-wide priorities. The Resident-Oriented Approach to Safety, indicated #4. Implementing interventions to reduce accident risks and hazards shall include . communicating specific interventions to all relevant staff, and #5. Monitoring the effectiveness of interventions shall include . ensuring that interventions are implemented correctly and consistently. The facility's policy and procedure titled, Falls and Fall Risk, Managing, revised 12/07, indicated a Policy Statement, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The Policy Interpretation and Implementation/Prioritizing Approaches to Managing Falls and Fall Risk, indicated, The staff . will identify appropriate interventions to reduce the risk of falls, and . staff will identify and implement relevant interventions . to try to minimize serious consequences of falling. The section of the policy and procedure subtitled, Monitoring Subsequent Falls and Fall Risk, indicated The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on interviews and record review, the facility failed to ensure the necessary care and services were provided to attain the highest practicable physical well-being for one resident (Resident 1), identified by the facility as at risk for dehydration, when: Recommendations made by the registered dietician (R.D.) for increased fluids was not implemented; and when licensed staff (Licensed Nurse B) failed to follow the facility's policy and procedure to notify the physician of Resident 1's significant change in condition. Resident 1 had a low intake of fluids, three episodes of liquid diarrhea, had increased weakness, paleness confusion and low blood pressure. Resident 1 was transferred to the acute care hospital and diagnosed with [REDACTED]. Findings: Review of the admission nurse's notes for Resident 1, dated 2/20/16, documented Resident 1 had [DIAGNOSES REDACTED]. Resident 1 was described as alert and oriented x3 (oriented to person, place, time) and capable of giving consent .and was able to sign all paperwork without difficulty. Review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 2/27/16, Section B, Hearing, Speech, and Vision, indicated Resident 1 had adequate vision and hearing (had a hearing aid), and clear speech. Resident 1 was able to make self understood and understood others. Section C, Cognitive Patterns, indicated a Brief Interview for Mental Status (BIMS) score of 14 (scores of 13-15 denoted intact cognition/mental processes.) Section G, Functional Status, indicated Resident 1 required extensive assistance of two or more persons for positioning in bed, transfers from bed and/or wheelchair, dressing and personal hygiene. Resident 1 was dependent upon one person to assist with eating and drinking. Review of a progress note for Resident 1, dated 3/23/16, Dietary Staff E noted Resident 1 had a decrease in fluid and meal intake and Resident 1 needed assistance with eating and drinking due to muscle weakness. Review of Resident 1's Care Plan for Nutritional Status, dated 3/28/16, indicated Resident 1 was at risk for dehydration. The goal was for Resident 1 to have >75% po (oral) intake of food and fluids served. Approaches (interventions) to reach the goal included RNA (restorative nurses aide) dining and assistance with meals. Concurrent review of the facility's Dehydration Risk Assessment, also dated 3/28/16, indicated Resident 1's risk factors contributing to the potential for dehydration included the need for physical assistance with fluid intake/eating, history of urinary tract infection [MEDICAL CONDITION], depression, was taking a diuretic (medication that promotes the production of urine) and had a history of [REDACTED]. During the Interdisciplinary Team meeting (IDT- a meeting of facility department heads and nursing staff to discuss the status of the residents) on 3/29/16, the nursing department notes indicated Resident 1's Dehydration Risk assessment score was 6 (at risk for dehydration). Review of the R.D.'s assessment / progress note, dated 4/4/16, indicated Resident 1's average intake of fluids was [PHONE NUMBER] milliliters (mL) per day - about 3-1/2 to 4 cups. Using a formula of 30-35 mL/kg (milliliters per kilogram of weight) the R.D. calculated Resident 1's daily fluid needs was 2700-3150 mL per day, or approximately 11-13 cups of fluid per day. The R.D.'s recommended intervention was to have licensed nurses offer an additional 240 mL three time a day to Resident 1, to support hydration status. During an interview, on 5/13/16 at 12:10 p.m., when asked if Resident 1's Care Plan was updated to include the addition of 240 mL of fluids three times a day recommended on 4/4/16, the R.D. stated, I believe I communicated with (Administrative Staff A) regarding this. When asked if she documented the communication, the R.D. stated, If I fax the (physician) an order request, then it would get documented in the orders. Review of the physicians' orders dated between 4/4/16 and 4/7/15 did not contain any new orders for increasing Resident 1's fluid intake. Additional record review indicated the R.D.'s progress note, with the recommendation (for additional 240 ml of fluids three times a day), was sent, date unknown, to Resident 1's physician's office, however, the physician who approved the recommendation did not date the order and it was not signed off (noted) by the facility until 4/8/16, the day after Resident 1 was transferred to the hospital. Review of Resident 1's Vitals Report, (a flow sheet that documented intake of fluids, meals, supplements; number of bowel movements (BM's) and urination) from 4/1/16 to 4/7/16, indicated Resident 1 averaged a fluid intake of 1006 mL per day. In addition, the Vitals Report indicated the following: 4/6/16 at 12:26 p.m., Resident 1 had a medium amount of liquid BM. 4/6/16 at 19:32 (7:32 p.m.) Resident 1 had a large amount of liquid BM. 4/6/16 at 22:27 (10:27 p.m.) Resident 1 had another large amount of liquid BM. There was no documentation Resident 1's physician was notified of her diarrhea. Review of Mayo Foundation for Medical Education and Research (MayoClinic.org/Dehydration 1998-2016) when a person becomes dehydrated, the body loses more water than it takes in. Even mild dehydration can cause weakness, dizziness and fatigue. Fever, vomiting, severe diarrhea, overuse of diuretics, decreased fluid intake and strenuous exercise can all lead to dehydration. Complications can include kidney failure and hypovolemic (low blood and fluid volume in the body) shock, a life-threatening complication of dehydration, which occurs when low blood volume causes a sudden drop in blood pressure and a reduction in the amount of oxygen reaching your tissues. If untreated, severe hypovolemic shock can cause death within a few minutes or hours. A Physical Therapy note, dated 4/6/16 at 4:11 p.m. documented Resident 1 reported feeling unwell and reported diarrhea throughout the day. Review of Licensed Nurse B's progress note, dated 4/6/16 at 10:22 p.m., indicated Resident 1 was weak, speech difficult to understand .color pale .confused . blood pressure 94/58. (Current guidelines identify normal blood pressure as 120/80.) Licensed Nurse B documented she, Suggested (Resident 1) go to Hospital for evaluation, but resident adamantly refused x3 (three times). On 4/7/16, at 7 a.m., Licensed Nurse B documented Resident 1 continued to be very weak, disoriented through the night (night shift) when awakened .Continues very pale. There was no documentation Resident 1's physician was informed of her decline, change in condition and refusal to go to the hospital. A progress note for Resident 1, dated 4/7/16 at 12:22 p.m., Administrative Staff A documented at 9:15 a.m. staff had requested she see Resident 1, patient's blood pressure was low 71/46, had dysarthria (difficult or unclear expression of speech), left arm was flaccid (weak or limp)patient had trouble following simple commands, was unable to stick out tongue. Covering physician was contacted at 9:27 a.m. and received order to transfer resident to the emergency department. Resident was transferred to the emergency department at 9:50 a.m. A physical therapy aide note, dated 4/7/16 at 12:51 p.m. documented Resident 1 had continued to look very pale, had difficulty forming words, was very disoriented and had increased difficulty with her right hand grip. Reported to nursing and resident was taken to the hospital within the hour. During an interview, on 5/5/16 at 3:20 p.m., after reading Licensed Nurse B's progress note dated 4/6/16 (above) with Administrative Staff A present, Administrative Staff A was asked if the resident's physician should have been called for the change of condition Resident 1 was experiencing. Administrative Staff A stated, Yes. During a telephone interview, on 5/4/16 at 9:40 a.m., Family Member D stated she saw Resident 1 (on 4/5/16), two days prior to being sent to the hospital, and she was fine. On 4/7/16, Family Member D stated she received a call from the facility with a report that Resident 1 might be having a stroke and the facility was transferring Resident 1 to the hospital. At the hospital, Family Member D described Resident 1 as being out of it. Family Member D stated the emergency room physician reported (Resident 1) presented (came into the hospital) with severe dehydration and [MEDICAL CONDITION]. The decision was made to provide Resident 1 with intravenous (IV) fluids and Family Member D stated Resident 1, Started getting more lucid and started getting better. Review of the hospital's Emergency Department (ER) Report, dated 4/7/16, indicated Resident 1 arrived at the hospital, .at times .able to answer questions with some difficulty speaking and dysarthria .then a short time later .would be .nearly totally obtunded (decreased level of consciousness/hard to arouse) unable to answer questions or obey simple commands. This was further assessed, by the ER physician as altered mental status. On exam, Resident 1's mouth was dry and the tongue was furrowed, and her blood pressure was low at 98/61 and she had had diarrhea again. Concurrent review of laboratory data collected on 4/7/16 indicated Resident 1's renal function was compromised with BUN (blood urea nitrogen) and creatinine (the primary tests used to check how well the kidneys are able to filter waste products from the blood) levels of 63 and 2.92, respectively. Normal BUN levels are generally between 7-20 and creatinine levels are between 0.5-1.5. According to The National Kidney Foundation, when kidney function slows down, the creatinine .and BUN levels rise. Review of Resident 1's hospital Discharge Summary, dated 4/12/16, indicated Resident 1 was quite dehydrated, her initial presentation of altered mental status was, .likely related to dehydration, and After gentle fluid resuscitation, (Resident 1's) mentation (mental activity) cleared. Resident 1 was diagnosed with [REDACTED].BUN and creatinine (blood tests for kidney function) normalized with .IV hydration. During a telephone interview, on 5/20/16 at 8 a.m., when asked if the physician was called or alerted to Resident 1's episodes of diarrhea, Administrative Staff A stated no. During an interview on 5/20/16 at 8 a.m., Licensed Nurse B stated Resident 1 had complained of feeling sick during the night of 4/6/15 through 4/7/16 (night shift) however, Resident 1 was not specific to what symptoms she was having. Licensed Nurse B acknowledged Resident 1 was in a decline and stated she observed her closely. When asked if the physician was called and informed of Resident 1's decline in health, and her refusal to go to the hospital, Licensed Nurse B stated, If it's not documented, then, no. Review of the facility's Policy and Procedure titled, Change in a Resident's Condition or Status, revised April 2007, the Policy Interpretation and Implementation section, #1, indicated The Nurse .will notify the resident's Attending Physician or On-Call Physician when there has been: .A significant change in the resident's physical/emotional/mental condition; Refusal of treatment; A need to transfer the resident to a hospital . #2, indicated, A 'significant change' of condition is a decline .in the resident's status that: .Will not normally resolve itself without intervention .

Based on interview, and record review, the facility failed to ensure Resident 1 was free from verbal abuse when Staff 1 shouted at Resident 1 and told Resident 1 to shut up This behavior subjected Resident 1 to verbal abuse and had the potential to cause Resident 1 emotional distress and fear whereby a reasonable person would be humiliated. Findings: On 5/22/14 the facility reported to the Department an incident that on 5/21/14 at 5:30 p.m., Staff 1 entered Resident 1's room and raised her voice to Resident 1 and told Resident 1 to shut up. During a review of the clinical record for Resident 1, the progress note dated 4/25/14 indicated Resident 1 had [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS) (an assessment tool), dated 2/26/14 indicated this was an annual assessment. The facility documented Resident 1 exhibited verbal, behavioral symptoms directed towards others such as screaming at others, cursing at others. The resident's most recent Brief Interview Mental Score (BIMS) was 15/15 (reference: 15/15 indicated oriented with good short term recall). During an interview on 5/23/14 at 11:45 a.m., Resident 1 stated he did not remember someone yelling at him, nor did he remember Staff 1 yelling at him on 5/21/14. Review of Staff 1's written statement, Staff 1 wrote that on 5/21/14 at around 5 p.m., she could hear Resident 1 yelling "Nurse Nurse." She entered the room and said, "What the hell, (Resident 1), if your (sic) not on the floor bleeding or dying you don't need to yell like that, I mean seriously what the hell ..." Staff 1 further wrote that Licensed Staff 2 and Staff 3 entered the room and coached her that she was wrong and could not talk like that to the resident. Staff 1 then left the room to take a breath, came back in and apologized to Resident 1. During an interview with Staff 1, on 5/23/14 at 10:50 a.m., she stated it was late Wednesday (5/21/14), she was not feeling well and while she was in the restroom she heard yelling. She came out of the restroom and entered Resident 1's room as he was yelling. Staff 1 stated she raised her voice telling the resident he should not speak to the staff this way and for the resident to shut up. She stated Licensed Staff 2 and Staff 3 entered the room and stated Staff 1 should not speak this way to Resident 1. Staff 1 stated she apologized to Resident 1 and left the room. During an interview with Licensed Staff 2, on 5/23/14 at 2:20 p.m., she stated she was outside of the staff development office at the medication cart speaking with Staff 3. Staff 2 stated she could hear the resident yelling, "nurse nurse." She stated she then heard Staff 1 yelling at the resident. Licensed Staff 2 and Staff 3 went to Resident 1's room and observed Staff 1 at the foot of Resident 1's bed yelling at him. Licensed Staff 2 told Staff 1 it was not appropriate to yell at the resident and Staff 1 left the room. During an interview with Staff 3, on 5/23/14 at 11:30 a.m., she stated she was speaking with Licensed Staff 2 outside the staff development office and heard Resident 1 yelling, and then she heard someone yelling at Resident 1 loudly. She entered the room and observed Staff 1 standing at the end of Resident 1's bed yelling at him. She stated it was louder than someone raising their voice. It was like someone who might be on a baseball field yelling at their team member to catch a ball. She stated that she and Licensed Staff 2 told Staff 1 this was not right and Staff 1 left the room. During a review of the facility's investigative report, dated 5/23/14, indicated the facility had substantiated Staff 1's inappropriate attitude and unprofessional conduct towards Resident 1. The facility policy and procedure titled, "Abuse Prevention Program" revised November 2010 indicated, "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion." The policy defines "Verbal abuse" as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability.