Every finding on record at Redwood Grove Post Acute

Based on observation, interview and record review, the facility failed to ensure, infection control prevention was maintained, to one of twenty-nine residents affected with coronavirus disease 2019 (COVID-19, contagious disease caused by the severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2), (Resident 1), when Resident 1 was allowed to go to his medical appointment without informing the receiving healthcare facility in advance that Resident 1 had a pending COVID-19 testing result. This failure affected the way the receiving healthcare facility handled Resident 1 who eventually tested positive for COVID-19, and this could potentially spread to the staffs and patients of the receiving healthcare facility. Findings:Review of Resident 1's clinical records indicated, Resident 1 was admitted to the facility on [DATE] with the principal diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung condition that blocks airflow and makes it hard to breathe) with acute exacerbation (sudden, sharp worsening of symptoms for a chronic health condition). Resident 1 was tested for COVID-19 for exposure to the disease on 7/15/26 and the specimen was sent to the laboratory. Further review of Resident 1's clinical records indicated, he went for his medical appointment to an outside healthcare facility (OHCF) on 7/16/26. His COVID-19 testing result was not received yet when he went out. After the facility got Resident 1's positive COVID-19 testing result, they then notified Resident 1's receiving outside healthcare facility (OHCF) about the result. The receiving outside healthcare facility (OHCF) was never informed of Resident 1's COVID-19 testing prior to the appointment and the pending result. During the interview with the infection preventionist (IP), on 7/23/26 at 2:20 p.m., IP verified that the facility nurse or staff should have informed, Resident 1's receiving healthcare facility (OHCF) that he was tested for COVID-19 for exposure and the result was still pending, so they would be aware and the necessary preventions would be implemented to prevent the spread of infection to the staffs and patients at the outside facility. During the interview with registered nurse A (RN A), on 7/23/26 at 3:15 p.m., RN A confirmed that she was not able to inform Resident 1's receiving healthcare facility prior to his appointment and before going there that he was tested for COVID-19 for exposure and would not do it next time to prevent the possible spread of infection. RN A further confirmed that Resident 1 tested positive for COVID-19 when the result came back. During the interview with the director of nursing (DON), on 7/23/26 at 4:30 p.m., DON acknowledged that the facility should have informed the receiving healthcare facility of Resident 1 prior to his medical appointment that he was tested for COVID-19 for exposure and that, he actually was positive when his result came back, to prevent spreading the infection. DON further acknowledged that she would remind staffs about this incident. Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Identification and Management of Ill Residents, revised September 2022 indicated, .Resident Placement.Information about residents with suspected or confirmed SARS-CoV-2 infection is communicated to appropriate personnel before transferring them.to other healthcare facilities.

Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for two of three sampled residents (Residents 1 and 2) when staff did not:1. accurately assess for fall risk and implement interventions to prevent further fall on 6/20/26 for Resident 1; and,2. implement interventions to prevent further falls for Resident 2.These failures led to Resident 1's unwitnessed fall on 6/20/26 which resulted in a left humerus fracture (broken upper arm bone) and Resident 2's unwitnessed fall on 6/29/26 which resulted in a cervical spine fracture (broken neck bone).Findings: 1. Review of Resident 1's Face Sheet (summary of a Resident's basic information) indicated Resident 1 was admitted on [DATE] and had diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness or limited movement) following cerebral infarction (when a blocked or narrowed blood vessel disrupts blood flow to an area of the brain), muscle weakness, and reduced mobility. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/10/26, indicated a brief interview for mental status (BIMS, a structured cognitive test) score of 15 (a score of 15 means cognitively intact). The MDS also indicated Resident 1 had impairment of the upper extremity (shoulder, elbow, wrist, and hand) on one side. Review of Resident 1's Nurses Notes contained a Fall SBAR (a communication format with sections for documenting the Situation, Background, Assessment, and Recommendations), dated 6/9/26, which indicated, At approximately 7:35 a.m. during shift change resident was noted by certified nurse assistant [CNA] to have unwitnessed fall. Intervention: Toileting schedule. Review of Resident 1's Fall Risk Assessment, dated 6/9/26 at 3:14 p.m., indicated a score of 5 out of a scale of 10 (A score of 5 out of a possible 10 indicates the patient has recognizable fall risk factors). A History of falls section of this assessment had No falls in past 3 months marked as a response. Review of Resident 1's care plans contained an item dated 6/9/26 that indicated, Resident has had an actual fall, which included toileting schedule as an intervention. Review of Resident 1's Occupational Therapy Treatment Encounter Notes, dated 6/18/26, indicated, Toilet transfer = Supervision or touching assistance, walk 10 feet = Supervision or touching assistance, Toilet/Commode Transfers = Supervision or touching assistance. Review of Resident 1's interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) notes, dated 6/10/26, indicated Resident Fall Investigation and Intervention. A new intervention has been implemented to place a bedside commode (a portable chair-like toilet for people with mobility issues) within reach to help reduce the need for unsupervised transfers and decrease fall risks. Review of Resident 1's medical records lacked documentation to indicate implementation of a toileting schedule and/or bedside commode to prevent further falls after Resident 1's fall on 6/9/26. Review of Resident 1's Fall SBAR, dated 6/21/26, indicated, Resident had an unwitnessed fall when getting assistance to the bathroom. While providing care, CNA stepped out of the room. while CNA was out of the room, Resident got out of the bathroom and, as she was leaving the bathroom, she collapsed and fell on the floor. Review of Resident 1's left shoulder X-ray (a radiation imaging test) report, dated 6/23/26, indicated Impression: Displaced fracture [when a bone snaps into two or more parts] of proximal humerus [the upper arm bone near the shoulder joint]. Review of Resident 1's Fall SBAR, dated 6/24/26, indicated, Resident 1 had a fall on 6/20/26, and an x-ray on 6/23/26 showed fracture, and the resident was transferred to emergency department (ED). During an interview and observation with Resident 1 in the bedroom on 7/1/26 at 12:30 p.m., Resident 1 sat up in her wheelchair and wore a left arm sling (a fabric support to immobilize and protect arm, shoulder, or elbow after surgery or injury). There was no bedside commode present. Resident 1 stated she fell a couple of weeks ago and broke her arm. Resident 1 stated a CNA assisted her to the bathroom and left. Resident 1 stated while trying to come out from the bathroom, her legs got loose, and she fell. Resident 1 stated there was no commode to use.During an interview and record review with the director of nursing (DON) on 7/1/26 at 2:10 p.m., she reviewed Resident 1's Fall Risk assessment dated [DATE] and confirmed the resident was not accurately assessed, because Resident 1 had a fall prior to the assessment on 6/9/26. The DON reviewed Resident 1's medical record and confirmed there was no documentation to indicate implementation of a toileting schedule and/or bedside commode to prevent further fall after Resident 1's fall on 6/9/26. The DON acknowledged the interventions were lacking for a toileting schedule and/or bedside commode and should have been implemented to prevent further falls. The DON stated the CNA should not have left Resident 1 alone in the bathroom because the resident required assistance for ambulation. During an interview and record review with licensed vocational nurse (LVN) A on 7/1/26 at 2:30 p.m., she confirmed she completed Resident 1's Fall Risk assessment dated [DATE], and that Resident 1 had a fall prior to the assessment on 6/9/26. LVN A acknowledged Resident 1 was not accurately assessed for the Fall Risk Assessment. During a phone interview with LVN B on 7/1/26 at 4:05 p.m., she confirmed she was assigned to Resident 1 on 6/20/26, and the CNA left the resident alone in the bathroom. LVN B stated the CNA told her leaving the resident alone in the bathroom was okay. LVN B stated she educated the CNA to not leave the resident alone after assisting the resident to the bathroom. LVN B stated Resident 1 did not have bedside commode in her room. During a phone interview with the director of rehabilitation (DOR) on 7/15/26 at 10:35 a.m., she confirmed the OT (occupational therapy) Treatment Encounter Note(s), dated 6/18/26, indicated Resident 1 required supervision for touching assistance with ambulation and/or toileting. 2. Review of Resident 2's Face Sheet indicated Resident 2 was admitted on [DATE] and had diagnoses including chronic kidney disease (CKD, a long-term condition in which the kidneys are damaged and have lost their ability to fully function), epilepsy (an abnormal activity in the brain that may cause uncontrollable jerking movements of the arms and legs, and/or loss of consciousness), muscle weakness, and abnormalities of gait and mobility. Review of Resident 2's MDS dated [DATE], indicated his BIMS (Brief Interview Mental Status, and assessment tool) score was 15 (a score of 15, out of 15 possible, means cognitively intact). Review of Resident 2's medical record contained Fall SBAR Nurses Notes dated for 5/18/26, 6/3/26, 6/15/26, 6/16/26, 6/26/26, 6/27/26, 6/29/26, and 7/4/26 each of which indicated Resident 2 had a fall and had a coinciding Fall Care Plan that indicated, Intervention: Pharmacy consult to evaluate medications, PT [physical therapist] consult for strength and mobility. Review of Resident 2's IDT regarding Resident 2's Fall Investigation and Intervention, dated 6/29/26, indicated, Date and time of incident: 6/27/26 18:45 (military time for 6:45 PM). Analysis of the fall: Resident fell because sudden lower-extremity weakness caused the legs to give out, triggered by a combination of physiological factors (muscle weakness, balance impairment, possible orthostatic hypotension [a sudden drop in blood pressure when standing up from a sitting or lying position] or neuropathy [damage or dysfunction of the nerves outside the brain and spinal cord]). New or Revised interventions: PT/OT [physical therapist/occupational therapist] to complete full mobility and strength evaluation, Nursing to monitor orthostatic [conditions, symptoms, or measurements associated with an upright posture, such as standing or sitting] BP [blood pressure] for 72 hours. Review of Resident 2's Fall SBAR Nurses Notes and communication, dated 6/30/26, indicated, unwitnessed fall. Resident unable to recall what happened, slurring speech. At 21:10 [military time for 9:10 PM], resident transferred to [hospital name]. Review of Resident 2's computed tomography (CT, diagnostic imaging) results, dated 6/30/26, indicated, Impression: Fracture involving the anterior aspect of C1 (first cervical vertebra, a neck bone). Review of Resident 2's IDT notes for fall investigation and intervention, dated 6/30/26, indicated, Describe if out of normal range: BP (Blood Pressure) 93/62 (values for readings of blood pressure; systolic over diastolic; systolic is the top number, measuring the pressure when your heart beats. diastolic is the bottom number, measuring the pressure when your heart rests between beats). Review of Resident 2's care plan Pt [patient] is s/p [status post = afterwards] unwitnessed fall, initiated on 7/2/26, included intervention of, Resident on 1:1 [one staff assigned to continuously monitor one resident] for safety tracking and monitoring. During observations on 7/9/26 from 11:16 a.m. to 11:22 a.m., Resident 2 was sitting in a chair alone in his room, and there was no staff providing 1:1. During an interview with LVN C on 7/9/26 at 11:26 a.m., she stated Resident 2 was placed on 1:1 sitter [a designated monitoring staff] because he had multiple falls. During an observation and interview with LVN C on 7/9/26 at 11:32 a.m. in Resident 2's room, LVN C confirmed there was no staff to provide 1:1 to Resident 2. LVN C stated a 1:1 sitter should be with Resident 2, and she did not know why the 1:1 sitter was not with the resident. During an interview with the director of staff development (DSD) on 7/9/26 at 11:55 a.m., she stated a CNA who was assigned as the 1:1 sitter for Resident 2 went on lunch break without informing LVN C. The DSD stated the CNA should have informed LVN C about taking her break to continue the 1:1 monitoring. During an interview and record review with the DON on 7/9/26 at 1:02 p.m., the DON reviewed Resident 2's medical records and confirmed there was no documentation to indicate the interventions of pharmacy consult and/or checking orthostatic BP to prevent further falls were ever implemented; and that, there was no record of PT/OT consultation documentation until after the fall on 6/16/26. The DON acknowledged these interventions should have been implemented and done so timely. During a phone interview with the DOR on 7/15/26 at 10:25 a.m., she confirmed Resident 2 had multiple falls in June 2026 and PT consultations were not timely performed as an intervention for the falls on 6/3/2026, 6/15/2026, 6/26/2026, and 6/27/2026. Review of the facility policy and procedure (P&P) titled Fall Risk assessment, revised 3/2018, indicated, The nursing staff. will seek to identify and document risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information. The nursing staff will ask the resident and/or his/her family about any history of the resident falling. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors. Review of the facility P&P titled Falls and Fall Risk, Managing, revised 3/2018, indicated, The staff. will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling. Review of the facility P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022, indicated, The intradisciplinary team (IDT). develops and implements a comprehensive, person-centered care plan for each resident.

Based on interview, and record review, the facility failed to ensure to develop and implement comprehensive (thorough) person -centered care plan (individual care, treatments, and goals to resident's cultural, personal values, and lifestyle) for discharge that included discharge target, measurable objectives, and interventions for three of three sampled residents (Resident 1, 2, and 3).Above failure had the potential for lack of opportunity for resident/ resident representative (RP, a legally assigned person, authorized to make day to day decisions on behalf of the resident) right to participate in develop and implement person-centered plan of care decisions for discharge for Resident 1,2, and 3. Findings:Review of Resident 1's face sheet (FS: a document that gives resident's information at a quick glance) indicated, Resident 1 was admitted to facility on 5/12/2026 and discharged from facility 6/3/2026. This FS also indicated Resident 1 was responsible for daily decisions while in facility. Review of Resident 1's minimum data set (MDS, resident assessment tool) assessment dated [DATE] indicated Resident 1's brief interview for mental status (BIMS) score indicated 15/15 (score of 0-7, severely impaired cognition, 8-12, moderately impaired cognition, 13-15, intact cognition).Review of Resident 1's care plans indicated there was no documented evidence of person centered care plan for discharge plans.Review of Resident 2's FS indicated, Resident 2 was admitted to facility on 5/27/2026 and Resident 2 currently residing in facility. Further review of this FS indicated Resident 2 self-responsible for daily decision making. Review of Resident 2's MDS assessment dated [DATE] indicated Resident 2's BIMS score of 15.Review of Resident 2's care plans indicated there was no documented evidence of person centered care plan for discharge plans.Review of Resident 3's FS indicated Resident 3 was admitted to facility on 12/14/2025 and Resident 3 currently residing in facility. This FS also indicated Resident 3 had assigned family member as RP.Review of Resident 3's care plans indicated there was no documented evidence of person centered care plans for discharge.During a concurrent record review of care plans for Resident 1,2, and 3 and interview with facility's social service director (SSD) on 6/8/2026 at 12:50 p.m., SSD confirmed Resident 1 was discharged from facility to community, plan for Resident 2 will be discharged to community when Resident 2 reaches goals for the treatments, and for Resident 3, long term placement with no discharge plan. SSD also confirmed there was no documented care plan developed with discharge plan for Resident 1,2, and 3. SSD stated social service department responsible to develop and implement discharge care plan. SSD also stated social service staff should have coordinated with interdisciplinary team (IDT, a group of healthcare professionals who collaborate to plan, deliver, and evaluate the care, treatments, and discharge plans for resident) along with resident/RP, developed and implemented discharge care plan for above three residents.During an interview with facility's director of nursing (DON) on 6/8/2026 at 1:43 p.m., DON stated social service staff responsible to develop and implement discharge care plan for residents. DON also stated social service staff should have developed and implemented discharge care plan for Resident 1, 2, and 3.Review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident

Based on interview and record review the facility failed to ensure pre-admission screening and resident review (PASRR- screening for residents with mental disorders and residents with intellectual disability) Level 1 screening was completed and submitted to state mental health authority for review for one of three sample resident (Resident 1) with significant change in mental illness (MI-a wide range of conditions that affect resident's mood, thinking, and behavior) and treatment plan. This failure had the potential for mentally ill Resident 1 not to received benefit from specialized health care and services. Findings:Review of Resident 1's face sheet (FS- a document that gives a resident's information at a quick glance) indicated Resident 1was admitted to facility on 5/12/2026. Resident 1's FS also indicated diagnoses including anxiety disorder (a mental disorder with excessive, persistent worry and fear of everyday situations) dated 5/27/2026, and depression (a serious mood disorder with persistent sadness, lack of energy, and loss of interest in daily activities), dated 5/27/2026.Review of Resident 1's order summary report indicated an order for psychiatry/psychologic evaluation and treatment as needed, dated 5/12/2026 and escitalopram (medication used to treat depression) 5 mg (milligram, a unit of mass and weight equal to one thousandth of a gram) by mouth one time a day for 14 days for depression dated 5/29/2026 and 10 mg one time day for depression, start on 6/13/2026, dated 5/29/2026.Review of Resident 1's nursing progress notes dated 5/15/2026 indicated Resident 1 verbalized suicidal ideation with no suicidal plan.Review of Resident 1's psychological evaluation dated 5/27/2026 indicated Resident 1 reported of history of depression, anxiety and recommended for treatment plan with escitalopram for depression.Review of Resident 1's documented Level 1PASRR screening completed and submitted by acute hospital (AH, a medical facility that provides short-term active treatment for severe injuries, illnesses, or urgent medical conditions) dated 5/11/2026 indicated no serious mental illness for Resident 1 and this PASRR Level 1 screening was completed before Resident 1 was diagnosed with mental illnesses.Review of Resident 1's clinical chart indicated there was no documented evidence of Level 1 PASRR screening completed and submitted to health care services after diagnosed with depression with treatment plan and anxiety for Resident 1 on 5/27/2026.During an interview with facility's minimum data set (MDS, resident assessment tool) assistant (MDSA) on 6/8/2026 at 1:25 p.m., MDSA confirmed above both new diagnoses for Resident 1 received on 5/27/2026 while Resident 1 was in the facility, considered a significant change in mental condition. MDSA stated MDS staff were responsible for Level 1 screening and submission of PASRR for residents as needed. MDSA also stated MDS staff should have screened and submitted a new Level 1 PASRR when Resident 1 received mental illness diagnoses on 5/27/2026 for possible Level 11 PASRR evaluation and determination to receive specialized mental healthcare and services.During an interview with facility's director of nursing (DON) on 6/8/2026 at 1:43 p.m., DON stated facility's MDS staff were responsible for Level 1 PASRR screening and submission to authorities for residents in facility. DON also stated MDS staff should have screened and submitted a new Level 1 PASRR when Resident 1 was diagnosed with depression and anxiety on 5/27/2026.Facility unable to provide policy and procedure (P&P) for PASRR.Review of California Department of Health Care Services (DHCS, a state agency responsible for providing healthcare services for qualified people with physical, mental health and substance use disorders) for indications for PASRR for residents in facility indicated, Once an individual is admitted to a NF (nursing facility), if there is a significant change in condition, the NF would initiate the RR (resident review) process by submitting a Level I Screening. (refer to www. dhcs.ca.gov)

Based on interview and record review, the facility failed to ensure one of four residents (Resident 1) was treated with respect and dignity, when the occupational therapy assistant (OTA) made inappropriate gestures towards Resident 1. This failure had the potential to negatively affect Resident 1's psychosocial well-being.Findings:Resident 1 was admitted with diagnoses including abnormal gait and mobility, need for assistance with personal care, generalized muscle weakness, dependence on supplemental oxygen, hearing loss, difficulty in walking, and abnormal posture.During an interview with the director of nursing (DON) on 4/9/26 at 2 p.m., the DON stated Resident 1 was in the therapy gym during the therapists' lunch time and the OTA asked Resident 1 what he wanted. The DON further stated, Resident 1 had difficulty hearing, and could not speak well. Resident 1 waved his hands to the OTA, then the OTA asked Resident 1 why he waved his hands with the middle finger up.During an interview with the director of rehab (DOR) on 4/9/26 at 2:23 p.m., she stated when she entered the therapy gym, Resident 1 was already in the therapy gym, and the therapists were having lunch. The DOR stated she was wheeling Resident 1 out of the therapy gym when Resident 1 started pointing at the OTA. The DOR further stated the OTA came around in front of Resident 1 and tried to explain what happened, the situation escalated and the OTA gave Resident 1 the middle finger.During an interview with Resident 1 on 4/9/26 at 3:08 p.m., he stated that the OTA was eating a lot of pizza, went in front of his face eating pizza, and he did not like it. Resident 1 further stated he cussed at the OTA and the OTA stated, come get me, while still eating pizza and waved at him. Resident 1 did not like it, so he took off his oxygen and got up from the wheelchair and walked toward him, and the other therapists stopped him. Resident 1 stated the OTA gave him the middle finger first, so he gave it back.During an interview with physical therapist A (PT A) on 6/5/26 at 8:45 a.m., she stated Resident 1 was coming to the desk, the OTA had pizza in his hand, they started to exchange words and Resident 1 said he is always eating, they gave each other the middle finger, and was not sure who gave it first.During an interview with an occupational therapist (OT) on 6/5/26 at 8:58 a.m., she stated the OTA went to the table to get a piece of pizza. Resident 1 came over and the OTA said instead of getting agitated why don't you F**ing ask then made a crying gesture. Resident 1 took off his oxygen, and the OTA asked, Do you want to fight? The OT stated the OTA did flip-off Resident 1.During an interview with physical therapist B (PT B) on 6/5/26 at 9:16 a.m., she stated Resident 1 was upset, because the OTA was eating in front of him, and the OTA said it was his lunch time, and was allowed to eat, if Resident 1 wanted something to eat, Resident 1 could have just asked. PT B stated the OTA used the crying hand gesture at Resident 1 that might have caused Resident 1 to be angry.During a review of the facility's policy and procedure (P&P), titled Resident Rights, revised 02/2021, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity.

Based on interview and record review, the facility failed to properly perform and document discharge planning for one of six residents (Resident 1), when there was no documented discharge plan on the interdisciplinary team ( IDT, a group of healthcare professionals from different fields that work together towards common goal for a patient) meeting notes. This failure resulted in Resident 1 being discharged without a definitive plan documented. Findings:A review of Resident 1's electronic record indicated that he was admitted with diagnoses which included sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage), atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta), emphysema (a progressive lung disease making breathing difficult due to decreased lung surface area and trapped air).During an interview with the case manager (CM) on 7/22/25 at 11:47 a.m., she stated she had not documented a discharge plan for Resident 1. During an interview with the director of nursing (DON) on 7/22/25 at 1:09 p.m., she stated Resident 1 was discharged to a motel for two nights.During an interview with CM on 8/21/25 at 12:30 p.m., she stated she was not care planning at that time, she was writing progress notes.During a review of Resident 1's IDT Care Conference note (IDTCC), dated 7/2/25, the IDTCC indicated a check box for a discharge plan, and failed to indicate the discharge plan.During a telephone interview with the administrator (ADM) on 9/17/25 at 4:18 p.m., when asked about the lack of a documented discharge plan on the IDTCC, he pointed out other notes which indicated the facility was attempting to connect to Resident 1 with some county resources which Resident 1 had refused.During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, revised October 2022, the P&P indicated.3. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan.4. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside;b. arrangements that have been made for follow-up care and services;c. a description of the resident's stated discharge goals;d. the degree of caregiver/support person availability, capacity and capability to perform required care;e. how the IDT will support the resident or representative in the transition to post-discharge care;f. what factors may make the resident vulnerable to preventable readmission; andg. how those factors will be addressed.5. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. 6. The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan.

Based on observation, interview, and record review, the facility failed to render care and service based on professional standards of practice for one of four residents (Resident 1) when the Licensed Vocational Nurse (LVN) incorrectly administered a medication. This failure had the potential to affect the resident's health and psychosocial wellbeing. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had a diagnosis of periprosthetic fracture (a bone fracture that occurs around or near an orthopedic implant) around internal prosthetic right hip joint. Review of Resident 1's medication administration record (MAR) indicated she had an order, dated 10/23/24, for Dulcolax suppository (used to treat constipation)10 milligrams (mg, unit of dose measurement) rectally as needed. During an interview on 1/30/25 at 2:29 p.m., with Resident 1, she stated the LVN and Certified Nursing Assistant (CNA) came to her room to give the suppository she requested. Resident 1 stated she turned to her side and then felt the fingers of the LVN in her private area. Resident 1 stated she yelled wrong hole. During an interview on 1/30/25 at 4 p.m., with the Director of Nursing (DON), the DON stated the LVN was let go and blocked from working in the facility after the incident. The DON stated the LVN knew he was in the wrong hole. The DON stated the LVN did not report the incident. During an interview on 1/30/25 at 5:16 p.m., with the CNA, the CNA stated the LVN called her to help position Resident 1 to administer the suppository. The CNA stated Resident 1 turned on her side in bed facing the CNA. The CNA stated Resident 1 screamed its the wrong hole when the LVN inserted the suppository. The CNA stated she leaned forward over the resident and confirmed the suppository was in the resident's private area but not fully inserted. The CNA stated the LVN removed the suppository from Resident 1's private area. During a review of the facility's policy and procedure (P&P), titled Administering Medications, revised 10/24, indicated 4. Medications are administered in accordance with prescriber orders .6. Medication errors are documented, reported .10. The individual administering the medication checks the label .to verify the right resident .and right method (route) of administration before giving the medication.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure a phlebotomist sanitized items between residents' rooms for 2 (Resident #325 and Resident #326) of 9 residents reviewed as part of the infection control task, failed to ensure oxygen tubing and a nasal cannula was stored in a manner to prevent potential contamination when not in use for 1 (Resident #118) of 9 residents reviewed as part of the infection control task, and failed to ensure staff implemented enhanced barrier precautions (EBP) when providing care to 1 (Resident #1) of 4 residents reviewed for transmission-based precautions. Findings included: 1. A facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022, indicated, 5. Reusable items are cleaned and disinfected or sterilized between residents. Resident #326's Admission Record revealed the facility admitted the resident on 01/24/2025. According to the Admission Record, the resident had a medical history that included diagnoses of osteomyelitis (inflammation of bone caused by infection), local infection of the skin and subcutaneous tissue, and resistance to multiple antimicrobial drugs. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/30/2025, revealed Resident #326 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. According to the MDS, the resident had active diagnoses of multidrug-resistant organism and a wound infection. Resident #326's care plan included a focus area, initiated on 01/25/2024, that indicated the resident had pseudomonas (a type of bacteria) cellulitis (bacterial skin infection) of their right foot. An intervention dated 01/25/2025 direct staff to implement contact isolation. Another focus area, initiated on 01/25/2025, indicated Resident #326 received intravenous antibiotics for osteomyelitis of their right foot. Resident #325's Admission Record revealed the facility admitted the resident on 01/28/2025. According to the Admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, orthostatic hypotension (low blood pressure due to postural changes), and atrial fibrillation (irregular heart rhythm). An admission MDS, with an ARD of 02/02/2025, revealed Resident #325 had a BIMS score of 15, which indicated the resident had intact cognition. During an observation on 02/03/2025 at 9:33 AM, Phlebotomist #23 entered Resident #326's room. While in the room, Phlebotomist #23 placed a clipboard on the resident's bed. Without cleaning or sanitizing the clipboard she placed on Resident #326's bed, Phlebotomist #23 then entered Resident #325's room and placed the clipboard on the resident's overbed table. During an interview on 02/03/2025 at 9:46 AM, Phlebotomist #23 said she should have wiped down her clipboard between residents' rooms, but she did not have any wipes to do so. During an interview on 02/06/2025 at 12:32 PM, the Administrator stated phlebotomists should disinfect items between rooms of residents on transmission-based precautions and those that were not. In addition, the Administrator said phlebotomists should save the rooms of residents on transmission-based precautions for last. 2. A facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection, revised 11/2011, revealed the section titled, Infection Control Considerations Related to Oxygen Administration specified, 8. Keep the oxygen cannulae and tubing used PRN [as needed] in a plastic bag when not in use. Resident #118's Admission Record revealed the facility admitted the resident on 01/14/2025. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2025, revealed Resident #118 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #118's 02/2025 Medication Administration Record (MAR) revealed the transcription of an order started on 01/31/2025 for supplemental oxygen at a rate of 2 liters per minute via nasal cannula as needed for shortness of breath and to keep oxygen saturation above 92 percent (%). According to the MAR, the resident did not receive supplemental oxygen during the timeframe from 02/01/2025 through 02/04/2025. During a concurrent interview and observation on 02/03/2025 at 10:10 AM, Resident #118 stated they only used oxygen on an as-needed basis. Resident #118's nasal cannula and tubing were observed wrapped under the handle of their oxygen concentrator not in a plastic bag. During an observation on 02/04/2025 at 11:26 AM, Resident #118's nasal cannula and tubing were on the floor in the resident's room. During an interview on 02/04/2025 at 11:25 AM, Registered Nurse (RN) #12 said he did not know where nasal cannulas should be stored when not in use. During an interview on 02/04/2025 at 11:28 AM, RN #13 stated that oxygen nasal cannulas should be stored in a plastic bag when not in use. During an interview on 02/06/2025 at 12:47 PM, the Administrator said oxygen tubing should be stored in a plastic bag when not in use. 45645 3. A facility policy titled, Enhanced Standard Precautions, revised 08/2022, indicated, Enhanced barrier precautions (ESPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. The policy specified, 2. ESPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply: a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). The policy indicated examples of high-contact resident care activities requiring the use of gown and gloves included c. transferring. The policy further indicated, 5. ESPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Resident #1's Admission Record revealed the facility admitted the resident on 12/31/2003. According to the Admission Record, the resident had a medical history that included diagnoses of multiple sclerosis, paraplegia, chronic kidney disease, and neuromuscular dysfunction of the bladder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #1 had an indwelling urinary catheter. Resident #1's care plan included a focus area, initiated 06/07/2024 and revised 11/10/2024, that indicated the resident required EBP related to having a suprapubic catheter. An intervention dated 06/07/2024 directed staff to instruct visitors and staff to wear proper personal protective equipment (PPE) when needed. During an observation on 02/03/2025 at 9:43 AM, Certified Nursing Assistant (CNA) #3 and Licensed Vocational Nurse (LVN) #2 entered Resident #1's room with a mechanical lift. CNA #3 and LVN #2 wore gloves but no gowns while using the mechanical lift to transfer the resident out of their bed. During an interview on 02/04/2025 at 1:02 PM, LVN #2 stated she did not wear a gown on 02/03/2025 when she assisted with Resident #1's transfer, but she should have. During an interview on 02/04/2025 at 1:34 PM, CNA #3 stated she did not wear a gown on 02/03/2025 when she and LVN #2 transferred Resident #1. CNA #3 said that because the resident had an indwelling urinary catheter, she should have worn a gown to prevent the spread of germs. During an interview on 02/06/2025 at 9:05 AM, the Director of Nursing (DON) stated the expectation was for staff to follow isolation precautions and wear proper PPE. During an interview on 02/06/2025 at 9:10 AM, the Administrator stated the expectation was for staff to apply PPE during resident care and understand its purpose, which was to prevent potential spread of infection.

Based on observation, interview, and facility document review, the facility failed to ensure multiple-resident rooms provided at least 80 square feet per resident for 10 (Rooms 101, 103, 105, 107, 109, 111, 114, 116, 118, and 119) of 70 resident rooms. Specifically, each of these 10 rooms had an approved capacity of two residents and provided a total of 143 square feet, or 71.5 square feet per resident when at full capacity. Findings included: A Client Accommodations Analysis, form, signed by the Administrator on 02/19/2025, revealed Rooms 101, 103, 105, 107, 109, 111, 114, 116, 118, and 119 each had an approved capacity of two residents. The Client Accommodations Analysis form indicated each of these rooms measured 11 feet by 13 feet and provided a total of 143 square feet, or 71.5 square feet per resident when at full capacity. During a concurrent observation and interview on 02/05/2025 at 2:50 PM, the Maintenance Supervisor measured room [ROOM NUMBER] and room [ROOM NUMBER] and confirmed they both provided a total of 143 square feet but were approved for a capacity of two residents. The Maintenance Supervisor said Rooms 101, 103, 105, 107, 109, 111, 116, and 118 were also the same size and had an approved capacity of two residents.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when the facility did not follow the physician's order for Resident 1. This failure had the potential to result in Resident 1 not receiving needed care and treatment, as ordered by the physician. Findings: Review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and essential hypertension (HTN-high blood pressure). Review of Resident 1's medical record review indicated KUB (kidney, ureter, and bladder) x-ray (a type of radiation that creates images of the inside of the body) for abdominal pain was performed on 9/16/24 with the impression: no bowel obstruction (blockage) or perforation (a hole), increased bowel distention (bloating and swelling) from prior exam. Review of Resident 1's progress notes, dated 9/17/24, indicated physician A was notified of the x-ray results and ordered repeat abdominal x-ray. Review of Resident 1's physician's orders indicated there was no order to repeat abdominal x-ray. Review of Resident 1's medical record review indicated there was no documentation indicating the repeat abdominal x-ray was performed. There was no result of the repeat abdominal x-ray. During a telephone interview on 11/21/24 at 12:01 p.m. with physician A, he stated he was informed about Resident 1's abdominal x-ray result of bowel distention and ordered to repeat an abdominal x-ray to follow up the prior x-ray finding of bowel distention. The physician verified the repeat abdominal x-ray result was not reported to him. During a telephone interview and record review on 11/22/24 at 9:07 a.m. with licensed vocational nurse (LVN) B, she confirmed she notified Resident 1's abdominal x-ray result of 9/16/24 to physician A and received an order to repeat an abdominal x-ray from physician A. LVN B verified there was no order to repeat the abdominal x-ray on Resident 1's physician's order. LVN B further stated she could not locate the repeat abdominal x-ray result. Review of the facility's policy and procedure titled Medication and Treatment Orders, revised 7/2016, the P&P indicated, Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

Based on the observation, interview, and record review, the facility failed to adequately monitor and supervise one of three sampled residents (Resident 1) to prevent him from entering other female residents' rooms. This failure resulted to Resident 1 entering Residen 2 and Resident 3's room and could compromised the residents' rights to a safe environment in the facility. Findings: Review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery (blockage or narrowing in a cerebral artery. This leads to a stroke); abnormalities of gait and mobility. Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/8/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 5 indicating severe cognition (mental process of thinking, learning, and understanding) impairment. The MDS indicated that Resident 1 needed supervision for mobility and transfers. Resident 1 uses a wheelchair, and once seated in the wheelchair, Resident was able to wheel at least 150 feet in a corridor independently. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) form, dated 8/27/23, indicated Resident 1 was found inappropriately touching himself in front of another female resident (Resident 3). Review of Resident 1's Interdisciplinary (IDT, a group of health care professionals with different areas of expertise who work together toward the goals of the patients) Risk Management Meeting Notes, dated 8/28/23 indicated Resident 1 was found by a certified nursing assistant (CNA) in female residents' room inappropriately touching himself. The CNA escorted Resident 1 from the room and Resident 1 was placed on every 1-hour monitoring following the incident, and a stop sign was placed outside female residents' room to deter Resident 1 from returning. The IDT Risk Management Meeting Notes further indicated Resident 1 had behavior of constantly cleaning hallways and doors. Review of Resident 1's SBAR, dated 9/3/24, indicated Resident 1 was inappropriately touching Resident 2 and was witnessed by CNA A (Certified nursing Assistant A). CNA A saw Resident 1 in Resident 2's room rubbing Resident 2's legs with lotion. Review of Resident 1's IDT Risk Management Meeting Notes, dated 9/3/24 indicated, Resident 1 was witnessed with his hand between Resident 2's legs rubbing lotion onto Resident 2. Resident 1 had behavior of wandering. The IDT recommended a psychiatric evaluation for Resident 1's behavior of constantly cleaning walls around facility to the point of exhaustion. Resident 1 was started on every 1-hour safety checks following the incident for 1 week. Review of Resident 1's Behavior Care Plan on inappropriately touching another resident initiated on 9/3/24. The interventions included to monitor resident going into another resident's room, safety check every 1 hour. During an observation on 9/4/24 at 12:10 p.m., Resident 1 was seen seated in a wheelchair, moving independently through the hallway, and wiping the siderails and walls along the corridor. The CNA's were observed delivering meal trays to other resident rooms. During an interview with Licensed Vocational Nurse B (LVN B) on 9/4/24 at 12:15 p.m. LVN B stated that Resident 1 was being monitored every hour for safety checks for one week. When asked how the safety checks were being implemented, LVN B showed the surveyor the Medication Administration Record (MAR) and stated that staff were required to check Resident 1's whereabouts every hour and then nursing will document it in the MAR. During an interview with Certified Nursing Assistant (CNA) A on 9/4/24 at 2:01 p.m., CNA A stated that she witnessed Resident 1 in Resident 2's room, rubbing lotion between Resident 2's legs. CNA A further stated that Resident 1 frequently enters female residents' rooms. Review of Resident 1's SBAR, dated 9/21/24 indicated Resident 1 was found in female resident's (3) room. Resident 1 allegedly started touching Resident 3 inappropriately. Review of Resident 1's IDT Risk Management Meeting Notes, dated 9/23/24, indicated that IDT discussed the claim that Resident 1 entered female residents' room (Resident 3) and licked Resident 3's thigh. Resident 1 was removed from Resident 3's room. Resident 1 was placed on every 1-hour safety checks for 30 days following the claim. Resident 1 will remain on every hour safety checks until the behavior is stable and monitor the effectivenes of the medication. During an observation on 9/24/24 at 12:05 p.m., Resident 1 was seen seated in a wheelchair, moving independently through the hallway, and wiping the siderails and walls along the corridor. At the same time, the CNA's were observed delivering meal trays to other resident rooms. During a phone interview with CNA C on 9/25/24 at 11:37 a.m., CNA C stated on 9/21/24 he heard a scream coming from Resident 3's room. CNA C further stated he saw Resident 1 near Resident 3's bed and Resident 1 was about to wheel himself out of the room. CNA C confirmed he did not see Resident 1 entering Resident 3's room. During a phone interview and concurrent record review with the Director of Nursing (DON) on 10/9/24 at 11:57 a.m., the DON reviewed the three incidents involving Resident 1's inappropriate sexual behavior, icluding entering Residents 2 and 3's rooms. Despite these incidents, the DON stated that the one-hour safety checks were appropriate for monitoring Resident 1's behavior. Review of facility's policy, titled Resident Rights, revised on 2/2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: be treated with respect, kindness, and dignity .

Based on observation, interview, and record review, three of four sampled residents (Resident 2, 3 and 4) were not free from verbal abuse when Resident 1 cursed and threathened to harm Residents 2, 3, and 4. This failure had the potential to negatively impact the physical and mental well-being of all residents in the facility. Findings: Review of Resident 1's admission record, dated 5/22/24, indicated Resident 1 had diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (a stroke has occurred because a blood vessel in the brain either became blocked or narrowed), major depressive disorder (a mental health condition where a person experiences persistent feelings of sadness, hopelessness, and a lack of interest in activities). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/10/24, indicated he had Brief Interview for Mental Status (BIMS, an assessment tool that helps determine a patient's cognitive understanding) score of 13 (BIMS score of 13-15 indicates cognitively intact). Review of Resident 1's Situation, Background, Assessment and Request (SBAR, a licensed staff communication tool) form, dated 5/19/24 at 18:53 [6:53 p.m.], indicated .resident was asked to move by another resident, as he is blocking the doorway .Resident got agitated, and threatened to shoot the other resident. Review of Resident 1's Interdisciplinary Team (IDT, staff from different departments who coordinate the resident's care) meeting notes, 5/20/24, The resident has verbal altercation with another male resident when he ask him to move from blocking the doorway . Resident got agitated, and threatened to shoot the other resident .The resident has hx (history) of verbal altercations due to behavior of having angry out bursts, uses F words towards staff when being redirected for safety of his and others . Review of Resident 2's admission record dated 5/22/24, indicated Resident 2 had diagnoses of cognitive communication deficit, major depressive disorder, cerebrovascular disease (condition that affects the blood vessels in the brain, leading to reduced or blocked blood flow). Review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 13, indicating his cognition was intact. Review of Resident 2's Care Plan indicated, Alteration in Psychosocial well being due to res. alleged threatened to be shot by another resident on 5/19/24. The facility staff's interventions included skin assessment, monitor emotional distress x 72 hours, local law enforcement was called, notified MD and RP. Review of the facility's Investigation Report dated 5/22/24, indicated .On 5/19/24 resident 1 was heard yelling at another resident (Resident 2) in the hallway and threatened to shoot Resident 2. Nursing immediately separated both residents. Resident 1 was searched, and no weapons were found . Review of Resident 3's admission record, dated 6/27/24, indicated Resident 3 had diagnoses of epilepsy (a chronic brain disorder that causes seizures, which are bursts of abnormal electrical activity in the brain), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side (has weakness or complete paralysis on one side of the body as a result of stroke or other problem with the blood vessels in the brain), anxiety disorder (a mental health condition where a person experiences excessive worry, fear, or nervousness that can interfere with their daily life). Review of Resident 3's, MDS dated [DATE], indicated his BIMS score was 00 indicating his cognition was impaired. Review of the SBAR form, dated 6/26/24, at 10:49, indicated Per activity director (AD) activity assistant was told by the resident that he was in possession of a knife and showed activity assistant. Activity director was notified and requested resident to give up the knife. Resident was in fact in possession of the knife hidden in his L [left] shoe. Knife was confiscated .Resident had anger outburst after knife was confiscated and yelled I have another one in my room! Both knives were confiscated. Administrator called sheriffs .Resident is being monitored 1 on 1 for safety. Review of Resident 1's IDT risk management meeting notes, dated 6/26/24, indicated, IDT met to discuss resident recent threat to kill another resident with a knife at the facility. Residents were not near each other during threat and staff member was placed with resident for safety following the incident . Review of Resident 1's Care Plan, initiated on 6/26/24, indicated Resident threatening to kill another resident. The facility's interventions included notification of the MD (medical doctor), local enforcement, monitoring by CNA (certified nursing assistant) 1 on 1 for 72 hours, redirect resident, collect all utensils after meals, and resident was referred to in house NP (nurse practitioner) psychiatrist on 6/26/24 and declined. During an observation on 6/27/24 at 12:40 p.m., Resident 3 was seen in the dining area with other residents, sitting in a wheelchair and able to wheel himself. Resident 3 stated he was okay but was observed trying to touch the surveyor during interaction. During an interview with the AD on 6/27/24 at 12:47 p.m., about the incident where Resident 1 allegedly threatened to kill Resident 3 with a knife, the AD stated that an assistant informed her about Resident 1's plan to harm Resident 3.The AD took a knife from Resident 1, and Resident 1 mentioned that he had another knife in his room. After searching the room, the facility staff found the second knife and gave it to the administrator. During an observation on 6/27/24 at 12:57 p.m., Resident 1's room was checked, but the resident was not there. According to the charge nurse, Resident 1 had gone out with a family member. During a follow up phone interview with the AD on 9/9/24 at 2:42 p.m., regarding the investigation report from 6/28/24, the AD confirmed that Resident 1 told her, If resident (3) comes anywhere near me, I'm going to stab him in the neck and slit his throat. Review of Resident 4's admission record, dated 9/5/24, indicated Resident 4 had diagnoses of altered mental status (a person's thinking, awareness, or behavior has changed, it can include confusion, disorientation, memory problems, or unusual behavior); difficulty in walking; dementia, unspecified severity (group of symptoms that affect memory, thinking, and reasoning abilities). Review of Resident 4's MDS, dated [DATE], indicated, Resident 4 had a BIMS score of 8 (moderate cognitive impairment). Review of Resident 1's IDT risk management meeting notes, dated 8/28/24, indicated IDT met to discuss a reported incident that occurred on 8/27/24 when this resident was heard yelling and upon the nurse's arrival witnessed that he was making verbal threats towards another male resident and was attempting to hit him in front of the nurse's station. The CNA and licensed nurse immediately separated both residents . During a phone interview with CNA A on 9/4/24, at 2:21 p.m., CNA A confirmed witnessing Resident 1 threaten Resident 2 during the incident that occurred on 5/19/24. During a phone interview with CNA B on 9/6/24, at 10:20 a.m., CNA B confirmed hearing Resident 1 yelling in the hallway on 5/19/24 and verbally threatening Resident 2, stating, If I had a gun, I would shoot up this place. CNA B also witnessed the incident involving Resident 1 and Resident 4 on 8/27/24. CNA B reported that Resident 1 was verbally abusive, cursed at Resident 4, and attempted to punch him. CNA B also observed Resident 1 throwing towels and shoving staff members who intervened. During a phone interview with the Director of Nursing (DON) on 9/6/24 at 2:05 p.m., the DON acknowledged awareness of Resident 1's multiple verbal abuse incidents, where Resident 1 cursed and threatened to harm Residents 2, 3, and 4. The DON stated that Resident 1 was being monitored for angry outbursts and safety after each altercation, with facility staff anticipating Resident 1's needs. However, the DON stated that these interventions were not effective in preventing further verbal abuse because Resident 1 was non-compliant. Resident 1 refused a psychiatric evaluation and medications. The DON also noted that the facility met with Resident 1's family, and by mid-August, Resident 1 agreed to undergo a psychiatric evaluation and start psychiatric medications. During a phone interview with the Administrator (ADM) on 9/10/24 at 10:45 a.m., the ADM stated he was unsure if Resident 1's incidents of cursing and threatening to harm Residents 2, 3, and 4 constituted abuse or if they were a result of Resident 1's angry outbursts. The ADM stated that even facility staff had difficulty having conversations with Resident 1 without provoking angry outbursts. The ADM also stated that the effectiveness of interventions to prevent further outbursts from Resident 1 were limiting. Review of facility's policy, titled, Policy and Procedure on Patient Abuse and Prevention, revised on 6/26/24, indicated, The facility shall uphold resident's right to be free from any form of verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility shall establish system to prevent patient abuse including those practices and omissions, neglect and misappropriation of property that if left unchecked, may lead to abuse. Residents shall not be subjected to abuse by anyone, including, but not limited to, facility staff; other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals .Verbal Abuse is defined 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, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he or she will never be able to see her family again .Prevention: Facility shall also institute procedures that allows for identification, correction, and intervention in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Areas of identification, correction and intervention may include but not be limited to, facility environment, staffing, monitoring & supervision of staff, identification of residents with potential for behavioral symptoms and manifestations that may lead to conflict or anger through comprehensive assessment, care planning and monitoring.

Based on interview and record review, the facility failed to follow their own policy and procedure for disposal of discontinued and/or medications left in the nursing care center for two of three residents (Resident 1 and Resident 2). This failure had the potential to result in the diversion of medications compromising resident's health and wellbeing. Findings: Review of the IDT (Interdisciplinary Team, a group of healthcare professionals from different fields that work together towards common goal for a resident) Summary, dated 5/13/24, indicated the Administrator (ADM) received an anonymous email indicating medications that appeared to be from the facility were scattered in the house of a facility staff (FS). The IDT further indicated two residents' names were identified (Resident 1 who was discharged on [DATE] and Resident 2 who was discharged from the facility on 11/29/19). During an interview on 6/4/24 at 12:09 p.m., with the ADM, the ADM stated the FS admitted that he accidentally kept the medications to be disposed in a plastic bag and placed in his car. During an interview on 8/20/24 at 3:57 p.m., with the Pharmacy Consultant (PC), the PC stated the discontinued medications should be destroyed within 90 days. During a review of the facility's policy and procedure titled, Disposal of Medications, dated 11/17, the policy and procedure indicated 6. Dispose of discontinued medications within 90 days of the date the medication was discontinued.

Based on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) when: 1. For Resident 1, staff did not report an incident of potential abuse to the state agency and other required agencies; and 2. The facility did not provide abuse training to all staff at least quarterly. These failures had the potential to delay the investigation of abuse allegations and place residents at risk for further potential abuse. Findings: 1. Review of Resident 1's clinical record indicated he was admitted on [DATE] and had the diagnoses including cerebral infarction (known as a stroke, a damage to tissues in the brain due to a loss of oxygen), difficulty in walking, muscle weakness, aphasia, type 2 diabetes (high blood sugar), hypertension (high blood pressure), and major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/22/24, indicated he had a brief interview for mental status (BIMS, a structured cognitive [relating to the mental process involved in knowing, learning, and understanding things] test) score of 9 (moderate cognitive impairment). During an interview on 4/8/24 at 11:30 a.m. with Resident 1, he stated that physical therapist A (PT A) came to his room on 4/3/24 at 7 a.m. The visit was not announced and was too early. Resident 1 did not like PT A's approach and asked him to leave the room. PT A did not leave the room and yelled at Resident 1, You got a problem. Staff came into Resident 1's room, and PT A left the room after the staff asked him to leave multiple times. During an interview on 4/8/24 at 11:45 a.m. with Resident 2, who shared the room with Resident 1, he stated that PT A came to his room on 4/3/24 around 7:15 a.m. Resident 1 and PT A started to argue and yell at each other. Resident 1 asked PT A to leave the room, but PT A kept yelling at Resident 1. The director of staff development (DSD) came into the room, and PT A left the room after the DSD asked him to leave multiple times. Review of Resident 1's clinical record indicated there was no documentation of the incident involving Resident 1 on 4/3/24. Review of the SOC 341 (a document used to report elderly abuse) filed by the facility dated 4/15/24 indicated Resident 1's family member alleged the resident was verbally and emotionally abused by a physical therapist on 4/3/24. During an interview on 4/8/24 at 11:55 a.m. with licensed vocational nurse B (LVN B), he stated that he heard yelling at the nurse station on 4/3/24 around 7 a.m. Resident 1 and PT A were yelling at each other. Resident 1 was kept yelling at PT A to leave the room. LVN B stated he reported it to the DSD. The DSD came into the room and asked PT A to leave the room, but PT A kept yelling at Resident 1. PT A left the room after the DSD asked him to leave a couple of times. LVN B stated Resident 1 looked very upset, and PT A's approach was not acceptable. LVN B further stated it was a reportable incident, but he did not report or document because the DSD said she would report and document. During an interview on 4/8/24 at 12:53 p.m. with the DSD, she stated that she was called by LVN B on 4/3/24 around 7:15 a.m. Resident 1 was still in bed and upset. Resident 1 and PT A were yelling at each other. Resident 1 yelled at PT A to get out of his room, and PT A did not leave the room. The DSD asked PT A to leave the room because Resident 1 was upset, but PT A stayed in the room. PT A left the room after the DSD asked him to leave three times. The DSD stated that she reported to the administrator (ADM) and the director of nursing (DON) because it was a reportable incident for potential verbal and/or emotional abuse. The DSD further stated that the resident had a right to refuse, PT A should have respected the resident's wish then and could revisit the resident when the resident was ready for the therapy. During an interview on 4/8/24 at 2 p.m. with the ADM, he confirmed the incident involving Resident 1 was reported to him on 4/3/24. The ADM stated that he interviewed Resident 1, and Resident 1 said he did not like PT A's approach and requested not to work with PT A. The ADM stated that he filed a grievance and removed PT A from Resident 1's therapy schedule. PT A said he was raising his voice, not yelling, to redirect Resident 1. The ADM further stated that he did not report the incident to the state agency or other agencies because Resident 1 did not mention yelling, arguing, or being abused during his interview on 4/3/24. The ADM confirmed that he did not interview staff who witnessed the incident on 4/3/24. During a telephone interview on 4/9/24 at 7:15 a.m. with certified nurse assistant C (CNA C), she stated that she heard a loud voice from the room on 4/3/24 around 7 a.m. and went into the room. Resident 1 was in bed and very upset. Resident 1 was kept screaming at PT A to get out of the room and saying that it was too early. PT A looked upset and kept saying that Resident 1 needed to get ready for exercise. PT A continued to argue with Resident 1 and left the room after the DSD asked him to leave multiple times. CNA C further stated that PT A's approach was not acceptable and should be reported. During a telephone interview on 4/9/24 at 7:39 a.m. with CNA D, he stated that he was assigned for Resident 1 and 2 on 4/3/24. Around 7 a.m., Resident 1 was agitated in bed and yelled at PT A to get out of the room. PT A looked upset and confrontational to Resident 1. CNA D stated he reported it to LVN B because PT A's confrontational approach was inappropriate, and he considered it a reportable incident for possible abuse. PT A continued to argue with Resident 1 and left the room after the DSD asked him to leave the room multiple times. During a follow-up interview on 6/3/24 at 1:15 p.m. with the DSD, she stated that she reported the incident involving Resident 1 to the DON and the ADM but did not document or file SOC 341. The DSD acknowledged that she was a mandated reporter, and all alleged violations should be reported to the ADM and all required agencies. During an interview on 6/03/24 at 1:55 p.m. with the ADM, he stated Resident 1's family member filed a grievance about PT A's approach toward Resident 1 on 4/11/24, which he reviewed on 4/15/24. The family member said Resident 1 was verbally and emotionally abused by PT A. The ADM stated the facility filed SOC 341 on 4/15/24. During a review of the facility's undated Policy and Procedure (P&P) on Patient Abuse and Prevention, the P&P indicated, Reporting: Facility shall ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation. 2. During a record review and concurrent interview on 6/3/24 at 1:04 p.m. with the DSD, she confirmed that in-service (training) sheets indicated training for abuse conducted in January 2024 (on 1/9/24, 1/15/24, 1/17/24, and 1/19/24) did not include the administrator. During a record review and concurrent interview on 6/3/24 at 2:40 p.m., she confirmed that in-service sheets indicated training for abuse conducted in January 2023 (on 1/10/23, 1/12/23, 1/13/23, and 2/07/23) and July 2023 (on 7/05/23, 7/06/23, 8/22/23) did not include the DON. The DSD acknowledged that abuse training must be provided to all employees. During a record review and concurrent interview on 6/3/24 at 2:50 p.m., in-service sheets indicated training for abuse conducted in January 2023, July 2023, and January 2024. The DSD stated that the facility provides training for abuse to all employees upon hire and twice a year. The DSD reviewed the facility's policy on abuse training and acknowledged that the facility should provide training for abuse at least quarterly. The DSD further stated she was not aware of the training frequency. During an interview on 6/3/24 at 3:30 p.m. with the ADM, he acknowledged that the facility did not implement their policy of abuse training. During a review of the facility's undated Policy and Procedure (P&P) on Patient Abuse and Prevention, the P&P indicated, Training: Facility staff and employees shall receive, through orientation and continuing education sessions, training on issues related to abuse prohibition practice . Continuing education sessions on Abuse Prevention, Monitoring, Reporting, etc. shall be conducted at least once in every quarter.

Based on interview and record review the facility failed to follow the physician's order for one of three sampled residents (Resident 1) when the licensed nurses gave three pain medications at the same time and not according to the pain scale. This failure had the potential to compromise safety and well-being. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] with diagnoses including malignant neoplasm of the breast (a cancerous tumor) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow that can cause difficulty of breathing). Review of Resident 1's physician order dated 5/20/22 indicated morphine sulfate solution (pain medication used for chronic pain) give 1 ml as needed for pain scale of 7 to 10 (severe pain). Further review of Resident 1 physician order dated 5/5/22 indicated the following: 1. Tramadol 50 milligrams (mg, unit of measurement) tablet, give one tablet every eight hours as needed for moderate pain. 2. Tylenol 325 mg two tablets every four hours as needed for pain scale of 1 to 3 (mild pain) for 90 days. During a concurrent interview and record review with Licensed Vocational Nurse C (LVN C) on 3/30/23 at 2:26 p.m., LVN C reviewed Resident 1's August 2022 medication administration record (MAR) and acknowledged on 8/2/22 and 8/13/22 she administered morphine sulfate 1 ml, tramadol 50 mg, and Tylenol 650 mg at the same time. LVN C further stated, she should follow the pain scale assessment before administering the pain medications. During a phone interview with Registered Nurse B (RN B) on 4/20/23 at 8:18 a.m., RN B acknowledged on 8/3/22 and 8/24/22, she administered morphine solution 1 ml and tramadol 50 mg at the same time to Resident 1. RN B further stated Resident 1 wanted all her pain medications at the same time. RN B verified there were no notes indicating the physician was made aware that Resident 1 wanted all her medication at the same time. Review of Resident 1's November 2022 MAR, indicated an order of Tylenol 650 mg every four hours as needed for mild pain. During a concurrent interview and record review with Registered Nurse D (RN D) on 6/29/23 at 3:02 p.m., RN D reviewed Resident 1's November 2022 MAR and acknowledged on 11/17/22 and 11/20/22 both morphine solution 1 ml and tramadol 50 mg were administered together for severe pain. RN D stated on 11/22/22 he administered morphine 1ml, tramadol 50 mg, and Tylenol 650 mg all at the same time for severe pain. RN D acknowledged he should have followed the physician's order in administering the above medications. During a concurrent interview and record review with the Director of Nursing (DON) on 6/29/23 at 4:18 p.m., the DON reviewed Resident 1's August and November 2023 MAR. The DON stated licensed nurses should follow the physician's order. The pain scale should be followed when administering pain medications. The DON further stated administering tramadol and morphine together could increase the risk of respiratory depression. A review of the facility's policy titled, Administering Medications, revised April 2019 indicated, Medications are administered in accordance with prescriber orders, including any required time frame. The policy further indicated the physician, interdisciplinary team in collaboration with the consultant pharmacist as needed should reevaluate residents who uses frequent PRN (as needed) medications.

Based on interview and record review, the facility failed to maintain dignity and respect for one of three sampled residents (Resident 1) when the administrator (ADM) did not provide Certified Nursing Assistant (CNA) A's name to Resident 1 after Resident 1 asked. This deficient practice had the potential to affect Resident 1's self-esteem and self-worth. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] with diagnoses including malignant neoplasm (a cancerous tumor) of the breast and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview on 2/22/23 at 2:17 p.m., with Resident 1, she stated she asked the ADM the name of the CNA [CNA A] and the ADM did not provide the CNA's name. During an interview with the ADM on 2/22/23 at 11:50 p.m., the ADM stated that Resident 1 asked for CNA A's information after the incident happened on 12/29/22. The ADM stated he did not provide CNA A's first name and last name to Resident 1. During an interview with the social service director (SSD)on 4/19/23 at 2:57 p.m., the SSD stated if the resident asked for the CNA's name, the staff should give the CNA's name. Residents had the right to know their care provider's name. A review of the facility's policy and procedure (P&P) titled Resident Rights, revised February 2021, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to be treated with respect, kindness, and dignity .

Based on interview and record review, the facility failed to provide showers at least two times a week for three of four sampled residents (Residents 1, 2 and 3). This failure had the potential to negatively affect the residents' physical, emotional and psychosocial well-being. Findings: 1. During an interview with Resident 1 on 4/4/23 at 11:25 a.m., she stated she had been in the facility for a few weeks and had only received one shower. Review of Resident 1's medical record indicated she was admitted on [DATE]. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/21/23, indicated she required extensive assistance (staff provide weight-bearing support) with bathing. Review or Resident 1's Documentation Survey Reports, dated 3/2023 and 4/2023, indicated Resident 1 received a shower only on 3/24/23. Further review of the Documentation Survey Reports indicated on the week of 3/26/23 to 4/1/23, Resident 1 received a bed bath on 3/30/23, but did not receive any type of bathing on any other days of that week. During an interview and concurrent record review with the director of staff development (DSD) on 4/4/23 at 3:19 p.m., she stated residents must be showered on at least two days each week. The DSD stated if a resident received a shower, staff should document this in the resident's record. The DSD further stated if a resident refused a shower, staff should still document in the record and indicate the resident refused. The DSD reviewed the facility's staff assignment sheets and stated Resident 1 was scheduled to receive showers every Monday and Thursday. She reviewed Resident 1's medical record and confirmed the documentation indicated the resident only received one shower since being admitted . The DSD also confirmed that for the week of 3/26/23 to 4/1/23, there was only one day for which there was documentation that Resident 1 either received or refused any type of bathing. 2. During an interview with Resident 2 on 4/4/23 at 11: 30 a.m., she stated she had been in the facility for over a month and did not receive showers regularly. Review of Resident 2's medical record indicated she was readmitted on [DATE]. Resident 2's MDS, dated [DATE], indicated she required extensive assistance with bathing. Review of Resident 2's Documentation Survey Reports indicated for the week of 2/26/23 to 3/4/23, Resident 2 received a shower on 2/27/23, but did not receive any type of bathing on any other days of that week. The Documentation Survey Reports also indicated for the week of 3/5/23 to 3/11/23, Resident 2 received a bed bath on 3/11/23, but did not receive any type of bathing on any other days of that week. During an interview and concurrent record review with the DSD on 4/4/23 at 3:19 a.m., she reviewed the facility's staff assignment sheets and stated Resident 2 was scheduled to receive showers every Wednesday and Saturday. The DSD reviewed Resident 2's medical record and confirmed for the weeks of 2/26/23 to 3/4/23 and 3/5/23 to 3/11/23, there was only one day in each of those weeks for which there was documentation that Resident 2 either received or refused any type of bathing. 3. Review of Resident 3's medical record indicated she was admitted on [DATE]. Resident 3's MDS, dated [DATE], indicated she required supervision for bathing. Review of Resident 3's Documentation Survey Reports indicated for the week of 12/4/22 to 12/10/22, Resident 3 received a shower on 12/5/22, but did not receive any type of bathing on any other days of that week. During an interview and concurrent record review with the DSD on 4/4/23 at 3:19 p.m., she reviewed the facility's staff assignment sheets and stated Resident 3 was scheduled to receive showers every Tuesday and Friday. The DSD reviewed Resident 3's medical record and confirmed for the week of 12/4/22 to 12/10/22, there was only one day for which there was documentation that Resident 3 either received or refused any type of bathing. Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, revised 3/2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with bathing.

Based on interview and record review, the facility failed to provide access to medical records, in the form and format requested by the resident, in a timely manner for one of three sampled residents (Resident 1). Resident 1 requested that the facility provide her medical records on a flash drive (electronic device used to transfer data to and from a computer). The facility did not give the records to Resident 1 until weeks after she requested them. This failure had the potential to cause undue stress and negatively affect Resident 1's psychosocial well-being. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE]. Inside Resident 1's paper chart (a folder containing paper records instead of electronic records), there were several hand-written documents with the titles of various medical records. Further review of these documents indicated one of them was dated 1/23/23, one of them was dated 1/27/23, two of them were dated 1/31/23, and one of them was undated. Attached to one of these hand-written documents was a small note, dated 2/23/23 that said, Done. During an interview and concurrent record review with the medical records director (MRD) on 4/3/23 at 12:54 p.m., she reviewed Resident 1's paper chart and explained that on 1/23/23, 1/27/23 and 1/31/23, the resident requested that the facility provide her with the medical records that were specified on the above hand-written documents. The MRD stated Resident 1 asked the facility to provide the requested records on her flash drive. The MRD confirmed that for the above requests, she did not provide any medical records to Resident 1 until 2/23/23 (more than four weeks after the date of the first request). The MRD stated when a resident requests medical records, the facility must provide them within seven days. The MRD confirmed the facility did not provide Resident 1's requested medical records within seven days. During a follow-up interview with the MRD on 4/3/23 at 1:46 p.m., she stated she was informed by the facility administrator (ADM) that when a resident requests medical records, the facility must provide them within 48 hours. During an interview with the ADM on 4/3/23 at 2:55 p.m., he stated when a resident requests medical records, the facility has 24 hours to provide the resident with access to the records. The ADM stated if a resident requests copies of medical records, the facility has 48 hours to provide the copies. Review of the facility's policy titled Release of Information, revised 11/2009 indicated, A resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request. The policy further indicated, A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request.

Based on interview and record review, the facility failed to follow their own policies for one of four sampled residents (Resident 1) when: 1. The facility allowed Resident 1 to go out on pass (temporarily leave the facility) without obtaining a physician's order beforehand; and 2. Staff did not discard food that was in Resident 1's room for more than two hours. These failures had the potential to compromise the resident's health, safety, and well-being. Findings: 1. Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnoses of cellulitis (a skin infection) and difficulty in walking. Review of Resident 1's Progress Notes, dated 12/25/22 indicated Residents ride to go OOP [out on pass] came to pick her up . Review of the facility's document titled Release of Responsibility for Leave of Absence indicated on 12/25/22, Resident 1 left the facility at 12:40 p.m. and returned at 4:15 p.m. Further review of Resident's 1 medical record indicated there was no physician's order permitting her to go out on pass on 12/25/22. During an interview and concurrent record review with the director of nursing (DON) on 3/6/23 at 11:19 a.m., he confirmed residents must have a physician's order before going out on pass. The DON reviewed Resident 1's medical record and confirmed she did not have a physician's order permitting her to go out on pass on 12/25/22. Review of the facility's document titled Facility Out On Pass Policy, dated 12/23/22 indicated, Resident or Resident's Representative must obtain clearance from the resident's attending physician 48 hours prior to leaving the facility for an outing. 2. Review of the facility's document titled Release of Responsibility for Leave of Absence indicated on 12/25/22, Resident 1 left the facility at 12:40 p.m. and returned at 4:15 p.m. During an interview with Resident 1's family member (FM) on 1/23/23 at 10:15 a.m., the FM stated that on 12/25/22, Resident 1 went home for a few hours for Christmas. Resident 1 returned to the facility between 3:30 p.m. and 4:30 p.m. with some left-over pasta with sauce. The FM stated Resident 1 had the pasta in her room until the evening, when she asked a staff member to heat it up for her. During an interview with the registered dietitian (RD) on 2/9/23 at 12:57 p.m., she stated pasta dishes were considered potentially hazardous foods (foods that must be kept at a particular temperature to remain safe to eat). The RD explained that if left out for more than two hours, these foods could start to grow microorganisms and cause illness if eaten. The RD stated staff should throw away these foods if they are at the resident's bedside for more than two hours. During an interview with certified nurse assistant A (CNA A) on 2/9/23 at 2:23 p.m., she confirmed Resident 1 asked her to warm up food that was brought from outside the facility. She stated she did not warm up the food because it was against the facility's policy, but she did not throw it away. She stated she left the food with Resident 1. CNA A stated Resident 1 asked her to warm up the food at around 7:00 p.m. or 8:00 p.m. (almost 3 or 4 hours after Resident 1 returned to the facility with the leftovers). CNA A stated the food was in Resident 1's room, but she did not ask how long Resident 1 had the food there. CNA A confirmed if food was in a Resident's room for more than two hours, it must be thrown away. Review of the facility's policy titled Foods Brought by Family/Visitors, revised 3/2022 indicated, Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours are discarded.

Based on observation, interview, and record review, the facility failed to follow safe food handling practices when: 1. A refrigerator used to store residents' food brought in by visitors, which included TCS foods (foods that require time/temperature control to prevent bacterial growth) had recorded temperatures above 41 degrees F that were unaddressed by staff. Formerly known as Potentially Hazardous foods); and the facility did not ensure staff followed directions to label food items with an open date, the name of the resident and room number. An Immediate Jeopardy (IJ, a situation in which recipient(s) of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health safety requirements) was called on [DATE], at 5:07 p.m. On [DATE], the facility discarded the food in the resident food refrigerator. On [DATE] it was verified the facility replaced the refrigerator with a new refrigerator in nursing station ,d+[DATE] with a lock only accessible by nursing staff. The facility provided an in-service to staff on cold storage temperatures and labeling and dating food. A plan was put in place to provide oversight to ensure refrigerated foods would be stored at 41 degrees F or less for food safety. The IJ was removed on [DATE], at 1:14 p.m. with an acceptable corrective action plan; 2. An ice machine used for residents' beverages was not maintained clean; and the Maintenance Director (MD), who was in charge of cleaning the ice machine, was not knowledgeable about how to clean the equipment per manufacturer's manual. An IJ was called on [DATE] at 1:55 p.m. On [DATE], the facility discarded all ice from the facility, and cleaned and sanitized all containers used to hold ice. On [DATE], it was verified the facility had an outside vendor thoroughly clean the ice machine. A contract was put into place to have an outside vendor clean the ice machine every 6 months or as needed. The outside vendor trained MD on preventative maintenance cleaning, using the ice machine manufacturer's manual. A monitoring plan was put into place to ensure the ice machine would remain clean. The IJ was removed on [DATE] at 4:20 p.m. with an acceptable corrective action plan; 3. The facility served unpasteurized, runny (egg white firm and the yolk not firm with a liquid consistency) eggs to 15 residents who preferred undercooked eggs out of a facility census of 89. An IJ was called on [DATE] at 8:50 a.m. It was verified that all unpasteurized eggs were removed from the facility, cooks were in-serviced by the Registered Dietitian regarding egg safety, and the facility incorporated a plan and monitoring system to ensure unpasteurized eggs were not used at the facility. The IJ was removed on [DATE] at 12:27 p.m. with an acceptable corrective action plan; 4. The facility did not ensure proper procedures were followed for washing items in the kitchen 3-compartment sink; 5. The facility did not ensure proper procedures were followed for the surface sanitizer used in the kitchen; 6. The facility did not ensure the walls and shelving in the kitchen were maintained in good repair; 7. The facility did not ensure shelving and floors in the kitchen dry-food storage room were clean; 8. The facility did not ensure floor tiles in the kitchen were clean and maintained in good condition; 9. The facility did not ensure food was stored 6 inches off the ground inside the kitchen; 10. The facility did not ensure a storage rack for food containers was maintained in good condition; 11. The facility did not ensure a plastic strip curtain inside a walk-in refrigerator was maintained in good condition; 12. The facility did not ensure cooking utensils were stored in a clean and maintained area; 13. The facility did not ensure a freezer used to store food was maintained in good condition; 14. The facility did not ensure an industrial can opener was stored clean and maintained in good condition; 15. The facility did not ensure cooking knives were stored in a clean area; 16. The facility did not ensure proper procedures were followed for drying food pans; and 17. The facility did not ensure maintenance of air-gaps for the ice machine and food preparation sink drains. These failures had the potential to result in serious and potentially life-threatening foodborne illnesses to residents in this long-term care facility for 87 residents, who ate food by mouth, out of a facility census of 89. Findings: 1. Food and Drug Administration (FDA, responsible for protecting public health) Food Code 2017, section For Consumers on Storage Basics, indicated, keep the refrigerator temperature at or below 40 degrees Fahrenheit (F) [temperature measurement]. In Chapter 3 of FDA, Food, subpart ,d+[DATE], Time/Temperature Control for Safety Food, Slacking (food preparation), the Food Code indicated to maintain the food temperature at 5 C [Celsius - temperature measurement] (41F) or less . According to the FDA Food Code 2017, prepared, refrigerated, ready-to-eat, Time/Temperature Control for Safety (TCS) Food . is to be clearly marked to indicate the date or day by which the food is to be consumed on the premises or discarded when the food is held at a temperature of 41 degrees F or less for a maximum of 7 days. The preparation or open date is counted as day 1. According to the FDA Food Code 2017, A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised (people with low resistance to illness) . older adults; and (2) Obtaining food at a facility that provides services such as custodial, health care . hospital or nursing home . According to California Department of Education website, potentially hazardous foods include, but are not limited to meat, eggs, milk and dairy products, and heat-treated plant foods (rice, beans, and vegetables). Review of the facility's Procedure for Refrigerator Storage, dated 2018, indicated the refrigerator temperature should be 41 degrees F or lower. The policy also indicated in order to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2 degrees Fahrenheit (F) lower. On [DATE] at 12:45 p.m., a full-sized refrigerator/freezer used to store food for the residents was observed in the staff breakroom. The refrigerator color was white, and the majority of the outside surface of the refrigerator was covered with an orange residue. A sign taped to the outside of the refrigerator read for patients use only. Another paper taped to the outside of the refrigerator read Attention Staff: All food needs to be label with open date, room # [number] and residents name please. Food can only be store in fridge for 72 hr [hour] MAX [maximum]. All Food that is not labeled with residents Name, Room #, and Date will be thrown away, lets avoid this please. Please remain [remind] residents about our 72Hr/3day Rule before storing food in fridge. Thank you for all you do, it is truly appreciated - [First name of Infection Preventionist (IP) and the Director of Staff Development (DSD)]. Food stored inside the refrigerator included: a. Leftover pasta with red sauce and cheese in a foil to-go container; there were two white and grey fuzzy spots the size of peas on the pasta that resembled mold. The container was labeled with a resident name, room number, but no date. b. A paper bag labeled with a room number and name. Inside the bag was a reuseable, clear plastic container of rice soup. There was no date on the paper bag or the plastic container. c. A large pizza carton had 3 slices of left-over pizza inside. A room number was written on the box. The label lacked a name and date. d. A reuseable plastic container had what appeared to be a partially eaten, bean and cheese quesadilla (tortillas with refried beans and melted cheese in between the tortillas). The container was labeled with a name and room number, but no date. e. A reuseable plastic container with pasta salad (pasta mixed with other ingredients). There was no label to indicate the date, name, or room number. f. A plastic container contained a boiled egg in sauce and carrots. The container lacked a label with a date, name, or room number. g. A large plastic bag had various items. The bag was labeled with a room number but no name. Two single serve yogurts inside the bag had a manufacturer's use-by date of [DATE]. h. A 32-ounce yogurt container contained a brown matter. A note handwritten on the lid indicated, Please give her a scoop for [NAME] [breakfast]. The container was labeled with a resident name but no date. i. A yellow gel substance in a small Styrofoam container with a lid. The yellow substance had a foul, sour smell. The container was labeled with a room number, but no name or date. j. Two cheese and lunch meat sandwiches in plastic bags with no dates, names, or room numbers. k. Four peanut butter and jelly sandwiches in plastic bags with no dates, names, or room numbers. l. an open carton of creamer, with a manufacturer's use-by date of February 9, was labeled with a name, but lacked a room number. m. A large cardboard container of sausages and cheeses was labeled with a resident name. One sausage was partially eaten and not re-wrapped in the plastic wrapper. There was no date on the container to indicate when it was opened. n. A plastic container had pickle and carrot slices in fluid. The container lacked labeling with a date, name, or room number. o. Three travel mugs with liquid inside, two of the mugs were not labeled with a date, name, or room number. One mug was labeled with a room number, but no date or name. p. A sponge cake in a plastic wrapper with a manufacturer's best-by date of [DATE] was not labeled with a name or room number. During an interview on [DATE] at 1:30 p.m. with the director of nursing (DON), he stated resident food items stored in the refrigerator had to be labeled with a date, room number, and resident's initials. He stated nurses and certified nursing assistants were responsible for labeling the items, but did not know how long items could be stored. The DON stated he did not know the proper temperature for refrigerated food and was not sure if the refrigerator temperature was monitored. He stated the IP nurse was in charge of the refrigerator, and she kept it clean and organized and was responsible for discarding items. During an interview on [DATE] at 1:56 p.m., the IP stated the temperature of the residents' food refrigerator located in the staff break room was documented on a log twice a day by herself and the DSD. She showed the refrigerator documentation sheet for the month of February and there were two temperatures by each date and a signature by each temperature. She said the signatures belonged to herself and the DSD. She stated she thought refrigerated food had to be stored at 42 degrees maximum, but the documentation form said up to 46 degrees so she said the refrigerated food could be stored up to 46 degrees. She stated she was not trained on food storage refrigerator temperatures. She stated whoever put the food in the refrigerator was responsible for labeling and dating, and it was usually a CNA or a nurse. She stated in addition to the date the label needed to include the resident name and room number. The IP said the resident name was more important than the room number because residents could change rooms. She said anyone was responsible for discarding the food including housekeeping, CNAs, and nurses. The items stored in the resident food refrigerator located in the staff breakroom were observed with the IP. She stated the fluid in the travel mugs was coffee for a resident. She confirmed it was not dated and 2 of the mugs were not labeled with the resident's name. She confirmed the 6 sandwiches in plastic bags were not dated and they should be. The IP stated the ½ and ½ creamer probably belonged to a staff and should not be stored in the resident refrigerator. She stated the sponge cake was expired and should not be in the refrigerator. She confirmed the pasta salad was not labeled with a date and resident name. She said maybe it belonged to a staff. She confirmed the leftover pizza in the large pizza carton belonged to a resident and was not dated. She stated the leftover pasta with red sauce and cheese was moldy, and confirmed it belonged to a resident and was not dated. She confirmed the reuseable plastic container with the egg and carrot in fluid was not dated and labeled to identify a resident. She also confirmed the left-over quesadilla was not dated. The IP said the 2 single-serve yogurts were expired. She confirmed the soup with rice in the reuseable plastic container belonged to a resident and was not dated. She confirmed the yellow substance in the plastic Styrofoam container was not dated and did not know what the yellow substance was. She confirmed there was no date showing how long the brown substance in the yogurt container was in the refrigerator and she did not know what the brown substance was. Review of the resident refrigerator documentation log provided by the IP, titled AM & PM Shifts Resident Refrigerator Temperature Log (36 degrees F - 46 degrees F) dated February 2022 documented a.m. and p.m. refrigerator temperatures from [DATE] - [DATE]. The temperatures had a signature next to them. On [DATE] the documentation showed the p.m. refrigerator temperature was 45 degrees F. On [DATE] the p.m. temperature was 42 degrees F. On [DATE], the a.m. temperature was 45 degrees F. On [DATE] the a.m. temperature was 42 degrees F, and the p.m. temperature was 42 degrees F. During an interview on [DATE] at 4:01 p.m., the Registered Dietitian C (RD C) and the Dietary Supervisor (DS) stated there was no training they knew of that was provided to nursing staff, including the IP, regarding proper food storage in the refrigerator and that kitchen staff did not monitor the resident food refrigerator. Review of the job description checklist for the IP, titled Infection Control Nurse dated [DATE], showed a checklist of duties and responsibilities. There were no duties and/or responsibilities listed to show the IP was responsible for anything having to do with refrigerators that stored food. On [DATE] at 5:07 p.m., an Immediate Jeopardy was called in the presence of the Administrator for not ensuring the safe storage of resident food in the resident food refrigerator. In an interview on [DATE] at 2:40 p.m., the DSD stated she was aware that refrigerator temperatures were supposed to be 41 degrees or below, but she did not report temperatures above 41 degrees in the resident refrigerator because the documentation form showed the temperature range for the refrigerator was up to 46 degrees F. The Corrective Action Plan (CAP) included the following: a. Food from the resident refrigerator was discarded b. The resident food refrigerator was replaced with a new refrigerator c. The RD provided an in-service to the IP and DSD on food safety basics d. Licensed nurses were in-serviced on labeling, dating resident food placed in the refrigerator and monitoring temperature below 41 degrees F. In-services will be completed when staff is scheduled by [DATE]. The in-service will also be provided to new hires. e. CNAs were in-serviced to give food brought by visitors for residents, directly to a licensed nurse and only the licensed nurse may place the food in the refrigerator. In-services will be completed when staff is scheduled by [DATE]. The in-service will also be provided to new hires. f. The IP or Manager of the Day (when the IP is not in the building) will monitor the refrigerator daily for labeling with resident name, room number and date. g. The IP or Manager of the Day (when IP is not in the building) will monitor twice a day (AM and PM) for refrigerator temperature below 41 degrees . h. The IP or Manager of the Day will monitor for food being discarded within 72 hours of date on the label or by the manufacture's expiration date if this date is less than 72 hours after being placed in the refrigerator. i. If monitored refrigerator temperatures are above 41 degrees F, the food will be discarded, and maintenance and the administrator will be notified. Also, residents known to have consumed food during this time period will be placed on monitoring for signs and symptoms of food borne illness. The Maintenance Supervisor will adjust the refrigerator temperature settings or service the refrigerator until the temperature is below 41 degrees F for 24 hours. j. The RD with the Interdisciplinary Team (IDT) will perform visual spot checks twice a week for 1 month for refrigerator temperatures below 41 degrees F, labeling with resident name and room number and date, until 100 percent compliance. Once 100 percent compliance is reached for 2 weeks, the RD will perform monthly spot checks. k. RD will report the visual spot-check audit findings to QAPI monthly until 100 percent compliance. In an interview with the Administrator on [DATE] at 9:17 a.m., he stated the patient food refrigerator was replaced with a new refrigerator and it was now located in station ,d+[DATE]. On [DATE] at 12:44 p.m., an observation and interview with the DSD, showed the new patient food refrigerator located in nursing station ,d+[DATE]. The temperature of the refrigerator was 33 degrees F. The DSD stated the refrigerator was to remain locked and only nurses had a key for the lock and were responsible for placing food that was labeled and dated in the refrigerator. She stated the refrigerator was monitored twice a day to ensure it was 41 degrees or below and if the refrigerator was above 41 degrees F the food was discarded. On [DATE] at 12:50 p.m., CNAs and licensed nursed were interviewed and it was determined the staff were knowledgeable about labeling and dating food as well as monitoring for safe refrigerator food storage. During a meeting on [DATE] at 1:14 p.m., with the Administrator, the IJ was lifted. 2. During a review of the FDA Federal Food Code 2017, it indicates that (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch and food-contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free from sharp internal angles, corners, and crevices, finished to have smooth welds and joints . The Food Code states that the purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. The 2017 Food Code also states that freezing does not always kill microorganisms, and freezing may preserve microorganisms, so ice that comes into contact with other foods or is used directly for consumption must be as safe as drinking water. Also, the surface of equipment contacting food that is not time/temperature control for safety food such as ice makers, must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to the accumulation of microorganisms. According to the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guideline ,d+[DATE], Legionnaires' disease is a severe form of pneumonia, which frequently requires hospitalization . Legionnaires' disease can be fatal, with approximately a 9% over-all fatality rate. Within the subgroup of health-care associated Legionnaires' fatality cases are higher at 25%. People at highest risk for this disease are smokers, those receiving [CONDITION(S)] (chemical) treatment for cancer, those with underlying diseases, such as cancer, renal (kidney) disease, diabetes, and chronic lung disease, those taking drugs that weaken the immune system, and the elderly. Infection is possible in any building environment where people can be exposed to water contaminated with Legionella. Outbreaks of Legionnaires' disease is most often associated with water systems in areas including hospitals and long-term care facilities. In the case of aerosols (a substance than can be released in a fine spray when under pressure), infection may result from inhaling Legionella carried in a fine spray of microscopic water droplets that may not be visible. Infection is also possible by aspiration (taking in foreign matter into the lungs when breathing in), where water contaminated with Legionella can unintentionally enter the lungs while drinking, eating, or vomiting. Ice machines have been implicated as the source of transmission by aspiration. Legionellae spend much of their aquatic life-cycle in association with other microorganisms, including bacteria, fungi, and protozoa in biofilm. ASHRAE defines biofilm as a group of microorganisms, imbedded in slime, that adhere to a moist surface. In biofilms, Legionella bacteria are protected from environmental stressors, such as extreme temperatures and disinfectants. Biofilms may be found on any continually moist substrate (the surface or material on or from which an organism lives, grows, or obtains nourishment). Established biofilms are extremely difficult to remove and may serve for decades as reservoirs for Legionella contamination. Characteristics of both hot and cold potable water systems influence the colonization and subsequent growth of Legionella. Aspiration of contaminated water from components such as ice machines can occur. In addition, sediment can provide a home for biofilm and can insulate Legionella from disinfectants. According to the Centers for Disease Control and infection (CDC) website, many buildings need a water management program to reduce the risk for Legionella growing and spreading within the water system and devices. The CDC refers ASHRAE Guidelines as reference. On [DATE] the S&C (Survey and Certification) ,d+[DATE] was released and revised on 6.9.2017 to include the facility types. This S&C letter required all Skilled Nursing Facilities, as well as other provider types, to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. At a minimum, the plans and documentation were to include a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system; a water management program that considered the ASHRAE industry standards and the CDC toolkit; specified testing protocols and acceptable ranges for control measures and documented results of testing and corrective actions when the control limits were not maintained. The S&C letter explained that Legionella could grow in parts of building water systems that were continually wet, and certain devices could spread contaminated water droplets via aerosolization (the act of converting a physical substance into small and light particles which can be carried on air). The S&C letter provided examples of these system components and devices which included ice machines. The S&C letter included the following CMS (Centers for Medicare and Medicaid Services) Regulatory Authority: 42 CFR (Code of Federal Regulations) §483.80 for skilled nursing facilities and nursing facilities: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. On [DATE] at 9:05 a.m., an observation and interview with the Maintenance Director (MD) led to an ice machine located in the staff breakroom. MD stated it was the only ice machine in the facility. He said he worked at the facility for 6 months and cleaned the ice machine 1 time per month. He described how he cleaned the ice machine each month and said he checked the filter located on the back of the outside of machine, to make sure it was working. He said he also checked to ensure the ice machine did not leak and that the outside surface was not dusty. He also said he cleaned the inside of the machine by wiping all of the surfaces he could reach on the inside with soap and water. He said he wiped the surfaces with a soapy rag and rinsed with water. He opened the front metal cover of the top of the machine to show where he cleaned with soap and water. He said he washed the outside of the plastic water curtain (a piece of plastic that covers the evaporator which is a metal grid and the area where water runs and ice is formed), around the plastic that framed the water curtain and evaporator plate, and the outer surface of the water trough (holds water before it is frozen in the ice making process). These parts, which were all located in what is referred to as the evaporator compartment, were easily accessible when the front metal cover for the upper part of the ice machine was removed, and that he stated he only used soap and water to clean. Directly below the evaporator compartment was the ice bin where ice was stored. There was no barrier between the water trough and the ice in the ice bin below. The MD stated he did not remove the ice from the ice bin when he cleaned the area above with the soap and water. MD stated he never removed the plastic water curtain that covered the evaporator plate. He said he was still learning how to clean the ice machine and did not know how to clean the inside yet. The front surface of the water trough and the front lower surface of the water curtain had yellow, brown, black, and pink residue along the length of these parts. Yellow and black residue was also on the inside surface of the water trough. Without removing the water trough, a portion of the inside bottom surface was visible, and majority of the visible area was covered in a layer of black residue. There was thick black residue on the underside corners of the water trough. MD removed the water curtain and more yellow, pink, and black residue was observed around the frame of the evaporator plate. There were a seam and crevices surrounding the plastic frame of the evaporator plate and black and yellow residue was imbedded in the seam. The frame of the evaporator plate was wiped with a white napkin and pinkish, brown, slimy residue easily wiped off onto the napkin. The underside of the water trough was wiped with a white napkin and thick, slimy, chunky, gel-like, black, white, and clear residue easily wiped off onto the napkin. The evaporator compartment was also moist with water on the surface of the water curtain, the plastic around the evaporator plate and the water trough. MD confirmed there was a significant amount of residue inside the ice machine and said it was not clean. During an observation and interview with MD on [DATE] at 12 p.m., he was in the staff breakroom working on the ice machine with its top opened. He stated he was cleaning the inside of the machine, including the evaporator compartment, and found the instructions on how to clean the ice machine stamped on the inner surface of the ice bin door. The instructions showed how to clean the ice bin but did not show how to clean the internal components of the upper part of the ice machine, including the evaporator compartment, where ice was made. He stated he just cleaned the top part of the machine by sanitizing it with the contents from a bottle of [Brand name] ice machine cleaner. He said he made a solution according to the instructions on the bottle and wiped down the inside surfaces. MD stated he did not use the manufacturer's manual for instruction on how to clean the internal components of the ice machine and stated he needed to find the manufacturer's manual/instructions. During an observation and interview on [DATE] at 12:21 p.m. with certified nursing assistant N (CNA N), she showed an ice water dispenser filled with ice and water at nursing station 4. CNA N stated the kitchen staff brought the ice dispensers to the nursing stations everyday around 8:30 a.m. to 9 a.m. There was a date stamp on the ice dispenser that showed Feb (February) 15 2022 AM. There was also an ice chest filled with ice at the nursing station. CNA N stated when the ice in the chest started to get low, it was refilled with ice from the ice machine by any staff. She stated the ice was used for medications and to put into resident drinks. She stated at meals, drinks were delivered from the kitchen without ice and some residents preferred ice in their drinks; so, staff used the ice from the ice chests for the resident drinks. During an observation on [DATE] at 12:25 p.m., a dispenser filled with ice water with a stamp date Feb [February 15 Tues [Tuesday] 2022 AM was observed at nursing station ,d+[DATE]. During an interview on [DATE] at 12:30 p.m., Dietary Aide H and the Dietary Supervisor (DS) stated they were responsible for filling the nursing stations' ice dispensers with ice from the ice machine about 8 a.m. to 8:30 a.m. each morning. The DS stated kitchen staff had no oversite of the ice machine. During an observation on [DATE] at 12:35 p.m., a dispenser filled with ice water was at nursing station 1 (non-covid side). On [DATE] at 1:55 p.m., and Immediate Jeopardy was called in the presence of the administrator for having ice available to residents from the ice machine that was not clean and for not having a system to provide safe and sanitary ice to residents. In an interview with the Administrator on [DATE] at 2 p.m., he stated the last time the inside of the ice machine was cleaned was in [DATE] by a maintenance staff who no longer worked at the facility. He also stated their procedure for keeping the ice machine clean included having an outside vendor clean the machine on an annual basis, but the last annual visit did not happen due to Covid. He stated the last cleaning done by an outside vendor was December or January of 2020. He stated the new maintenance supervisor would normally get a brief overview on how to clean the ice machine during the annual visit from the vendor but that was postponed. Review of the document titled Quarterly Ice Machine Service dated [DATE] showed a check-off sheet for cleaning the ice machine. Typed above the procedures with check-off boxes, it indicated, Follow Manufacturer's Manual for all Maintenance and Cleaning Tasks. The following boxes were checked off: Drain water reservoir, clean water reservoir, float, fins, and dump plate, run sanitizer solution or water with 1 ounce of bleach (follow manufacturer's manual), run a rinse cycle with clear water. Review of the invoice titled [Name of Refrigeration Company] dated [DATE], showed this vendor performed preventative maintenance cleaning for the ice machine. Review of a copy of the manufacturer's manual for the ice machine titled [brand of ice machine] Installation and Maintenance Manual with a handwritten date [DATE] written on the front, showed under the Cleaning and Sanitizing section, to clean and sanitize the ice machine every six months for efficient operation. If the ice machine required more frequent cleaning and sanitizing, consult with a qualified service company to test the water quality, and recommend appropriate water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing. Under the cleaning/sanitizing procedure, the manual stated this procedure must be performed a minimum of once every 6 months and included that the ice machine must be disassembled, cleaned and sanitized, all ice produced during the cleaning and sanitizing procedure must be discarded, remove min [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide supervision and adequate assistance to prevent an unavoidable accident for one of three sampled residents (1) when Resident 1 exited from the facility and wheeled himself into an unsafe and unsupervised area. The facility staff failed to call for immediate assistance when Resident 1 did not respond to redirection, enabling Resident 1 to be out of range for visual supervision These failures resulted in a fall with laceration to the left temple. Findings: Review of the facility's investigation report dated 2/7/17, indicated Resident 1 exited the facility to sit outside and sustained a fall on 2/4/17 at 12:55 p.m. The alarm went off and receptionist L (RC L) followed the resident in an attempt to bring him back into the facility. Resident 1 got agitated and refused to go back into the facility. RC L went back to the facility and left Resident 1 unsupervised outside. Review of Resident 1's clinical record on 2/24/17, indicated Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of minimum data set (MDS, an assessment tool) dated 1/30/17, indicated the resident had impaired cognition (mental process) but was able to understand and express his needs. It also indicated Resident 1 had impaired vision, required one person assistance for bed mobility, transfers, and required no physical assistance for locomotion on and off the unit. Resident 1 was able to propel himself around the unit with his manual wheelchair. Review of Resident 1's Fall Risk assessment dated [DATE], indicated the resident had a score of 10. A score of 10 and above indicated high risk for fall. Review of Resident 1's Elopement assessment dated [DATE], indicated the resident had moderate risk for elopement with a score of 14. Review of Resident 1's care plan for elopement risk initiated on 4/14/16, indicated frequent check for whereabouts as one of the interventions. There was no indication of a process in place as to how the resident was frequently checked. Review of Resident 1's situation background assessment recommendation (SBAR, a tool technique used to facilitate prompt and appropriate communication) dated 2/4/27, indicated the resident refused to return to the facility and became physically aggressive with staff and attempted to hit staff. The resident had a fall with injury and was sent to the hospital for evaluation. Review of the acute care emergency department notes dated 2/4/17 under History and Physical Information, indicated Per EMS (emergency medical responder), one of the wheels on his wheelchair went off the curb, causing patient to fall on to his left side. Patient had laceration to his left temple. Discharge [DIAGNOSES REDACTED]. During an observation of Resident 1 on 2/24/17 at 11 a.m., the resident was sitting in the activity room. The wheelchair had a left arm and left foot rest, and a battery operated door monitor alarm attached to the back of the wheelchair. During a concurrent interview with Resident 1, he stated he did not remember when the fall incident happened, but he stated he wanted to go home. Resident 1 stated he went to the lobby, pushed the door opener for the disabled, and wheeled himself out. He stated no one was with him at that time. Resident 1 stated he wheeled himself to the sidewalk and his wheelchair hit the gutter and it flipped over, causing him to fall and hit his head on the ground next to a parked car. Review of Resident 1's interdisciplinary team care conference (IDT, team members from different departments involved in a resident's care) Fall Investigation and Intervention dated 2/5/17, under new or revised interventions, indicated it will refer resident to rehabilitation department (rehab) for rehab screening, to determine if an evaluation was required. During an interview with the dietary aide A (DA A) on 2/24/17 at 11:55 a.m., she stated she was in the kitchen and heard staff talking about a resident's fall outside the facility. She went out to check as she was the manager of the day (MOD). She saw Resident 1 lying on the ground on his left side and several staff were attending to the resident. She stated Resident 1 fell on the sidewalk in an area visible from the dining/activity area. The area was approximately 250 feet (ft., unit of measure) from the facility entrance door. During an interview with Licensed Vocational Nurse B (LVN B) on 2/24/17 at 12:20 p.m., she stated on 2/4/17, someone from the dining area informed her of Resident 1's fall. LVN B stated she and LVN C went out to assess the resident. She found the resident on the ground next to a parked car and noted an abrasion with bleeding on his left forehead. They attended to the resident until the paramedics came and the resident was transferred to the hospital for evaluation. LVN B also stated she did not hear RC L's overhead page. She stated it was customary for a receptionist to page overhead when a resident's door monitor alarm sounds off, a signal alerting a resident was attempting to leave the facility. LVN B stated she did not observe the resident display any aggressive behavior. During an interview with RCC (Resident Care Coordinator) on 2/24/17 at 2:20 p.m., she stated the facility does not prohibit residents to go sit outside including residents who are cognitively impaired. The RCC acknowledged there was no staff assigned to visually supervise cognitively impaired residents who would like to go outside of the facility. A review of the facility's revised policy dated 12/07, Elopements, indicated if an employee observes a resident leaving the premises, he/she should: attempt to prevent the departure in a courteous manner; get help from other staff members in the vicinity , if necessary; and instruct another staff member to inform the charge nurse or the director of nursing that a resident has left the premises.

Based on interview and record review, the facility failed to ensure services provided meet professional standards of quality for one of two sampled residents (Resident 1). The facility did not administer [MEDICATION NAME] (insulin medication which treats diabetes) as ordered by the physician which resulted in Resident 1 being admitted to the hospital with [REDACTED]. Findings: Review of Resident 1's clinical record indicated the resident had a [DIAGNOSES REDACTED]. Resident 1's physician order [REDACTED]. Resident 1's Medication Administration Record [REDACTED]. LVN A stated she could not remember if she gave insulin to Resident 1 on 5/7/16. Review of the nurses notes dated 5/8/16, indicated a licensed nurse checked the blood sugar level of Resident 1 at 6 a.m. and it was high. The blood sugar was rechecked at 7:18 a.m. and the reading was still high. Resident 1 was then transferred to a hospital. There was no documentation in the nurse's notes if insulin was administered on 5/8/16 prior to Resident 1's transfer to the hospital. During an interview with the director of staff development (DSD), on 5/31/16, at 9:24 a.m., he stated the licensed nurses should follow the physician's orders [REDACTED]. A report from the hospital dated 5/8/16, indicated Resident 1 was admitted with a [DIAGNOSES REDACTED]. Resident 1 had a blood glucose level of 704 milligrams per deciliter (mg/dl, unit of measure, normal level is 70 through 99 mg/dl) upon admission to the hospital. Review of Resident 1's facility medical records, indicated there was no insulin administered during the 24 hours prior to Resident 1's admission to the hospital. Resident 1 required intensive care hospitalization and intravenous (IV, through a vein) insulin infusion. A review of the 2015 Board of Registered Nursing Business and Professions Code indicated direct and indirect care services, included, but were not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by the scope of licensure of a physician, as defined in the Health and Safety Code, Section 1316.5.

Based on observation, interview and record review, the facility failed to provide adequate supervision or maintain an assistance device in good working order for 2 of 2 sampled residents (1 and 2). The facility failed to ensure Resident 1 had half side rail (SR) maintained in good working order. The latches went off the bed frame and Resident 1 fell out of the bed with the SR to the ground, which resulted in a head injury and a forehead laceration (cut) treated with 9 sutures in the acute hospital. For Resident 2 the facility failed to adequately supervise a Hoyer Lift (a machine used to mechanically lift a resident) transfer when only one attendant was used and not the required two attendants. Resident 2 fell to the floor and hit the back of the head. Findings: 1. On 1/23/13 Resident 1's clinical record was reviewed. It indicated Resident 1 was admitted with [DIAGNOSES REDACTED]. In the 12/28/12 minimum data set (MDS, an assessment tool), it indicated for bed mobility (how to turn from side to side) Resident 1 was able to turn with extensive assist by one person. The resident was cognitively intact. Resident 1's nurses notes from 1/18/13 at 8 p.m. indicated Resident 1 returned from the acute hospital with facial laceration and 9 stitches after the fall at the facility. The interdisciplinary Team Notes from 1/21/13 indicated the following: "Siderails in place at time of fall and will continue with siderails. CNA inserviced on proper positioning technique, however fall was not due to staff". During an interview on 1/25/13 at 11:15 a.m. with Resident 1, she stated she turned herself to the right side during care, tried to hold herself on the SR, when the SR broke away from the bed frame and she fell with the SR to the ground and hitting her head face down on the SR. The SR was taken from her room after the fall. The resident stated on her return from the acute hospital, it was three days before the facility replaced the SR for her bed. Since she used the SR to help turn herself she stated she told staff she did not want to have her bed moved until it was returned and functioning properly. During a telephone interview with certified nurse assistant 1 (CNA 1) on 1/23/12, at 1:50 p.m., she stated the bed was always positioned directly at the wall on the right sight with the SR up. On 1/18/13 at 1:30 p.m. CNA 1 gave a bed bath to Resident 1. CNA 1 pulled the bed towards the room away from the wall to allow her access to the other side of the bed to do her care for the resident after she was finished on her present side. CNA 1 stood on the left side of the bed when Resident 1 turned herself to the right side by holding herself on the SR. CNA 1 stated she witnessed how the SR came off the bed frame falling down with Resident 1 holding it. Resident 1 fell to the floor with her face down on top of the SR hitting her face on the SR. CNA 1 stated it happened so fast she was not able to run to the right side of the bed to prevent Resident 1 from falling. CNA 1 saw blood on Resident 1's face and called the licensed nurse 1 (LVN 1) for help. On 1/25/13 at 10:30 a.m. an interview was conducted with LVN 1 regarding Resident 1's fall. LVN 1 confirmed the report from CNA 1 and stated Resident 1 told her she fell out of the bed when the SR came off and hit her head on it on the ground. LVN 1 stated when she assessed Resident 1 she saw a laceration bleeding heavily. The doctor was informed and Resident 1 was sent to the acute hospital for treatment. On 1/25/13 at 2:16 p.m. an interview was conducted with the maintenance supervisor (MS) regarding the SR incident on 1/18/13. He stated he was informed of the incident on 1/21/13 during the morning department head meeting. When asked how often he would check the operation of all the SR's in use in the facility, he stated he would do rounds with another staff member who checks bed alarms on a regular basis, but he had no log in place to show which SRs he checked and how often. MS was unable to provide any documentation of when or if Resident 1's SR had been inspected. During an interview on 1/25/13 at 10:30 a.m., LVN 1 stated she called a housekeeping janitor to find a new SR to be installed on the right side of the bed on the day of the accident. The janitor was not able to find a replacement. LVN 1 confirmed Resident 1 did not have a SR on the right side of her bed over the weekend since there was no maintenance coverage over the weekends. During an interview on 1/25/13 at 2:33 p.m. with the assistant director of nursing (ADON), she stated she was informed of the fall, went to the room, but did not recall seeing the SR on the floor. She stated the staff could have taken an SR from an empty bed or replaced the whole bed for Resident 1 to provide a safe environment after her return from the acute hospital. During a review on the same date of the facility's 8/08 policy "Maintenance Schedules," indicated preventive maintenance schedules shall be developed and implemented to assure that the building and equipment are maintained in a safe and operable manner. It also indicated the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The facility's 12/07 policy "Proper Use of Side Rails", indicated "The resident will be checked periodically for safety relative to side rail use." On 1/25/13 Resident 2's clinical record was reviewed. Resident 2 had [DIAGNOSES REDACTED]. His 10/1/12 MDS indicated he was cognitively alert but was totally dependent on staff for transfers to or from bed, chair or wheelchair. The MDS also indicated he required a two person assist in transfers. The Interdisciplinary Team Notes dated 12/26/12 indicated a witnessed fall while being transferred with a Hoyer lift. It indicated Resident 2 had a laceration (cut) to the back of the head but the resident had refused transfer to an acute hospital. Resident 2 stated during interview on 1/22/13 at 2:15 p.m., he fell from the Hoyer Lift on 12/24/12 and hit his "butt" and the back of his head. He stated on the night he fell , the attendant (CNA 2) did not criss-cross the straps the way they usually did. Resident 2 stated two people were always used to transfer him from his bed to wheelchair and from wheelchair to bed using the Hoyer Lift. He also stated CNA 2 whom regularly provided care for him was the only staff member lifting him in the Hoyer Lift and in the room when he fell . During an interview with DON and DSD on 1/22/13 at 2:40 p.m., DSD stated CNA 2 felt bad because he knew he was supposed to use two people to lift and transfer Resident 2 with the Hoyer Lift, but did not. During an interview with CNA 2 on 1/22/13 at 3:05 p.m., he stated Resident 2 fell through the seat portion of the Hoyer Lift when he was transferring him from his wheelchair to his bed. He stated he was trained on the Hoyer lift at least two times in the past. He stated he regularly cared for Resident 2 and knew that two staff were required to transfer Resident 2 using the Hoyer Lift since Resident 2 was not able to participate in the lifting procedure. CNA 2 stated on the night of the fall he did it alone without the second required assistant. On 1/23/13 at 9:30 a.m. during a review of the facility's 4/07 policy "Lifting Machine, Using A Portable", it indicated, "The Portable Lift can be used by one nursing assistant if the resident can participate in the Lifting Procedure. If not, Two (2) nursing assistants will be required to perform the procedure."

Based on observation, interview and record review the facility failed to ensure the WanderGuard system (a sensor alarm system attached to either side of a door entrance that is activated by a band with a small plastic tab on a resident's arm, ankle or wheelchair, and is used to keep impaired residents from leaving the facility unsupervised) at the front facility entrance consistently alarmed when a resident with a WanderGuard attempted to leave through the front entrance. The facility failed to develop an effective system to ensure the WanderGuard alarm at the facility's front entrance consistently alarmed when residents with WanderGuards attempted to leave the facility for 20 of 123 residents. The facility front entrance faced a busy street and was approximately one block from a freeway entrance. On 6/14/11 at 5:00 p.m., the facility administrator was notified of the Immediate Jeopardy situation. Findings: Resident 1's clinical record was reviewed on 6/14/11. A care plan for Elopement/Wandering dated 3/8/10 and revised 3/15/10, 8/7/10, 9/14/10, and 12/16/10 indicated Resident 1 was at risk for elopement (leaving the facility unsupervised without permission) due to his decreased cognition (mental processes that include reasoning and understanding). It indicated he wanted to leave the facility by himself to go to the store. On 9/14/10 he was found outside of the facility by the bus stop and on 12/16/10 he left the facility to go to the corner gas station without informing staff. The care plan indicated Resident 1 was to wear a WanderGuard to alert staff if he attempted to leave the facility. The care plan also indicated the WanderGuard was to be monitored by the staff every shift and it was to be replaced as needed. During an interview on 6/15/11 at 6:15 a.m., licensed nurse A stated around 11 p.m. on 6/11/11 when she went into Resident 1's room she saw that his WanderGuard was missing from his ankle. She did not replace the WanderGuard. A nurse's note dated 6/12/11 at 7:50 a.m. indicated Resident 1 had eloped from the facility to go to the store to buy soda. It indicated he was last seen in the facility at 5:30 a.m. At 6:00 a.m. staff could not find him inside or outside of the facility. At 6:15 a.m. he was found in his wheelchair on the way back to the facility with soda he had purchased at a store approximately three blocks from the facility. During an interview on 6/14/11 at 3:20 p.m., the social worker stated Resident 1's cognition "goes up and down like a roller coaster". She stated sometimes his thinking was clear and other times it was not. She stated when she spoke to him on 6/13/11 he did not remember leaving the facility on 6/12/11. He told her he was married with children which was not true. During an interview on 6/14/11 at 3:50 p.m., Resident 1 was observed in his wheelchair with a WanderGuard attached to the arm of his wheelchair. He stated he did not remember leaving the facility by himself to buy soda. Resident 1 was asked to leave the facility using the front entrance to test his WanderGuard. Accompanied by the social worker, he was observed wheeling his wheelchair out the front entrance. He then was asked to turn around and re-enter the facility. The WanderGuard system did not alarm when he went out or when he returned. During an interview on 6/14/11 at 4:00 p.m., the administrator stated she had just checked the alarm system using a WanderGuard kept at the reception desk and the door alarmed. At 4:05 p.m. on 6/14/11 the maintenance supervisor checked the plastic WanderGuard on Resident 1's wheelchair and stated it did not expire until November 2011 so it should cause the system to alarm. He moved the wheelchair through the facility entrance and it did not alarm. On 6/14/11 at 4:10 p.m. Resident 2, who was blind and used a walking stick and staff to find her way, was observed to have a WanderGuard in place on her arm. Staff escorted her through the front entrance of the facility. The WanderGuard system did not alarm. On 6/14/11 at 4:35 p.m. a computer generated list indicated twenty of 123 residents wore WanderGuards for safety. The facility's 9/2008 policy, "WanderGuard" indicated WanderGuard bracelets will be used to provide a safe environment for residents that wander. The facility's 9/2008 policy, "WanderGuard," indicated WanderGuard bracelets will be used to provide a safe environment for residents that wander. After discussion with the health facilities evaluator nurse supervisor on 6/14/11 at 4:50 p.m. the administrator was interviewed concerning the facility's WanderGuard system. The administrator stated the system was not consistently alarming and it possibly had something to do with the systems range setting. She stated the system needed to be fixed and the facility policy and procedure for checking the system needed to be reviewed and revised. Because of the facility's failure to have a system in place to ensure the WanderGuard alarm at the front entrance of the facility consistently alarmed to keep residents with cognitive and safety issues from leaving the facility unsupervised, Immediate Jeopardy was called on 6/14/11 at 5:00 p.m. with the administrator of the facility. On 6/14/11 at 5:10 p.m., the administrator presented a plan of correction action to the surveyor. The plan consisted of the following elements: Immediate Measures (1) The front door will be monitored by a staff member from 5:00 a.m. until 8:00 p.m. (2) The front door will be alarmed (using red sound alarm) from 8:00 p.m. until 11:00 p.m. (3) A staff member will be posted at the front door from 11:00 p.m. until 12:00 a.m. (during shift change) (4) The front door will be alarmed from 12:00 a.m. until 5:00 a.m. (using red sound alarm) (5) Every hour monitoring of residents at risk for elopement by certified nurse assistant. Medical records to audit this documentation daily. (6) All of the above will be in place until the wanderguard is repaired. Systemic Changes (7) Wanderguard will be repaired or replaced (8) Policy and procedure for consistent testing of wanderguard system will be reviewed and adjusted as needed. (9) Findings of testing will be reviewed by administrator for completeness and brought to the Quality Assurance committee for evaluation monthly. On 6/15/11 at 6:00 a.m., the front facility entrance was observed being monitored by a facility staff member. On 6/15/11 at 6:30 a.m., the administrator stated the front door WanderGuard sensor units were readjusted and tested . They "only stayed good for about one hour and then they did not work". She stated she would contact the company that provided the WanderGuard on 6/15/11 to get it repaired or replaced. In the mean time the facility will continue their plan of correction with staff monitoring the front entrance when the red sound alarm is not on until the WanderGuard is fixed. On 6/15/11 at 6:40 a.m., the surveyor informed the administrator the Immediate Jeopardy was abated.