Every finding on record at Riverside Heights Healthcare Center, LLC

Based on observation, interview, and record review, the facility failed to identify adverse effects of psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for one of six residents reviewed (Resident 44), when Resident 44 was administered Risperdal (an antispychotic medication) and was observed with a facial chewing motion. This failure had the potential for Resident 44 to have irreversible adverse effects such as extrapyramidal symptoms (EPS, movement disorders caused by certain medications, particulary antipsychotics). Findings: On June 16, 2025, at 12:04 p.m., Resident 44 was observed having a facial chewing motion while sitting at a table in the dining room. On June 18, 2025, at 1:50 p.m., a second observation of Resident 44 was conducted. Resident 44 was observed having a facial chewing motion while sitting in the dining room awaiting the start of an activity. A review of Resident 44's medical record was conducted on June 18, 2025. The medical record indicated Resident 44 was admitted to the facility on [DATE], with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and depression. Resident 44's medication administration record indicated Risperdal 2mg (mg-milligram a unit of measurement) by mouth at bedtime was started on June 23, 2023. Resident 44's medical record indicated EPS monitoring (an assessment for drug induced movements caused by psychotropic medication) every shift. The following dates for the month of June 2025, indicated zero (0-means no drug induced movements were observed) for every shift June 1, 2025, through June 18, 2025. Resident 44's AIMS (Abnormal Involuntary Movement Scale) dated June 3, 2025, indicated Resident 44 had none of the following AIMS, .Facial and Oral Movement .Lips puckering .smacking .Jaw Movement .chewing . Resident 44's Care Plan indicated .Focus .will be/remain free of psychotropic drug related complications .movement disorder . On June 18, 2025, at 2:16 p.m., a concurrent observation and interview was conducted with the assigned CNA (Certified Nurse Assistant). The CNA verified Resident 44 had facial chewing with no evidence of food or gum in the resident's mouth. The CNA further stated she did not know this was a sign of EPS. On June 18, 2025, at 2:21 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 verified Resident 44 had facial chewing with no evidence of food or gum in the resident's mouth. LVN 1 further stated she did not know this was a symptom of EPS. On June 18, 2025, at 2:30 p.m., a concurrent observation was conducted with the Director of Nursing (DON). The DON verified Resident 44 had facial chewing with no evidence of food or gum in the resident's mouth. The DON stated Resident 44 was demonstrating EPS. The DON further stated nursing should have been able to assess the signs and symptoms of EPS. A review of the facility's policy and procedure titled, Psychotropic Drugs, revised April 28, 2025, indicated When the interdisciplinary team and the physician agree that a psychotropic drug is indicated, the following documentation shall be included .The resident's care plan with duration and circumstances under which the drug is to be used, appropriateness of the clinical objectives and care plan interventions .data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions .

Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 20), when the physician's order for oxygen administration was not followed. This failure had the potential to result in respiratory distress and decline in the resident's health condition. Findings: On June 16, 2025, at 10:45 a.m., Resident 20 was observed in his room, in bed, with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 20 was unable to communicate. Resident 20's oxygen administration was observed at 2.5 liters per minute (LPM - a unit of measurement). On June 18, 2025, at 9:12 a.m., Resident 20's record was reviewed. Resident 20 was re-admitted to the facility on [DATE], with diagnoses which included seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), Huntington's disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), chronic respiratory failure (low oxygen in the blood), and dementia (a progressive state of decline in mental abilities). The physician's order dated October 14, 2024, indicated, .May use oxygen @ (at) 2-3L/min (LPM) via nasal cannula or face mask for oxygen saturation (a measure of the percentage of oxygen in the blood, normal range for healthy individuals between 95-100%) below 92% . On June 18, 2025, at 9:20 a.m., Resident 20 was observed in the activity room, without oxygen. Resident 20 was observed restless. Licensed Vocational Nurse (LVN) 1 was asked to check Resident 20's O2 saturation. Resident 20's O2 saturation was 80%. No portable O2 tank was observed available by Resident 20. LVN 1 stated Resident 20's O2 saturation is too low, and he needs O2. LVN 1 took Resident 20 back to his room to administer O2. On June 18, 2025, at 9:30 a.m., a concurrent interview and record review was conducted with LVN 1. LVN 1 reviewed the physician's order for Resident 20 and stated Resident 20 should have been on oxygen if his O2 saturation was below 92%. LVN 1 stated the physician's order was not followed for Resident 20. On June 18, 2025, at 10:20 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 20 should have been on O2 in the activities room, to maintain his O2 saturation above 92%, as per physician's order. The facility policy and procedure titled, Oxygen Therapy, revised November 2017, was reviewed. The policy indicated, .To deliver supplemental oxygen to aid the relief of tissue hypoxia (low levels of oxygen in the body tissues) or hypoxemia (abnormally low levels of oxygen in the blood) .It is the policy of this facility that oxygen therapy is administered as ordered by the physician or as an emergency measure until a physician order can be obtained .Read physician's orders .Obtain liter flow and mode of administering oxygen .Monitor oxygen usage frequently .Monitor resident for signs of shortness of breath, restlessness or other symptoms of oxygen deprivation .

Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 18) was free from unnecessary medications when Resident 18 received an antihypertensive medication (used to manage high blood pressure) outside of the prescribed blood pressure (BP) parameter four times in April 2025. This failure increased the potential for Resident 18 to experience side effects such as low BP, leading to further heart related complications. Finding: A review of Resident 18's admission Record, dated June 19, 2025 indicated the resident was initially admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses including hypertension (high blood pressure), heart failure (serious condition when heart does not pump blood to the body efficiently), and cardiomyopathy (disease of the heart muscle), and atrial fibrillation (abnormal heart beat). A review of Resident 18's Care Plan Report, dated May 8, 2025, indicated the resident was at risk for hypotension (low BP) and indicated interventions including, Administer anti-hypertensive medications as ordered -metoprolol .Follow blood pressure parameters as ordered prior to administering medications. The BP is measured in millimeters of mercury (mmHg, unit of measurement) and in two numbers. The upper number is the systolic BP, or SBP, indicating the pressure in the arteries when the heart beats and pumps blood through the body; the lower number is the diastolic BP, or DBP, is the pressure in the arteries when the heart rests between beats. A review of Resident 18's clinical record indicated a physician's order, dated March 19, 2025, for metoprolol succinate ER (extended release, designed to release medication slowly) tablet 25 mg (milligram, unit of measurement), give one tablet one time a day for hypertension hold if SBP is below 110 [mmHg] . A review of Resident 18's Medication Administration Record (MAR), dated April 2025, indicated Resident 18 received metoprolol succinate ER when it should have been held (SBP, upper number, was below 110), on the following dates and times: - On April 3, 2025, at 7:30 a.m. with BP of 101/66; - On April 4, 2025, at 7:30 a.m. with BP of 106/65; - On April 19, 2025, at 7:30 a.m. with BP of 102/62; and - On April 20, 2025, at 7:30 a.m. with BP of 108/63. During a concurrent interview and record review on June 18, 2025, at 3:50 p.m., Resident 18's clinical record, including the MAR dated April 2025 was reviewed with the Director of Nursing (DON). The DON confirmed the above findings and acknowledged nursing staff should not have administered metoprolol succinate ER to Resident 18 when SBP was below 110 on the above dates and times. The DON stated the expectation was for nursing staff to have followed hold parameters as ordered by the physician. During a follow-up interview on June 19, 2025, with the DON, the DON stated it was important to follow the BP medication hold parameters to prevent dropping the resident's BP too low. A review of the Prescribing Information (PI, manufacturer's instructions) for metoprolol succinate extended release tablet, dated January 2025, retrieved from DailyMed (a public website maintained by the U.S. Food and Drug Administration), indicated, Most common adverse reactions: tiredness, dizziness, depression, shortness of breath (difficulty breathing), bradycardia (abnormally slow heart rate), hypotension (abnormally low blood pressure) . During a review of the facility's policy and procedure (P&P) titled, Procedure: Preparation of Doses - General Instructions, dated January 16, 2025, indicated, The nurse shall read and follow precautionary or additional instructions available on the prescription label (i.e. [example] .Parameters).

Based on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during the medication administration for two of four residents (Residents 28 and 52). The facility did not administer the residents' prefilled insulin (medication for diabetes) pen injection according to the manufacturer's instructions. This failure had the potential to result in Residents 28 and 52 not receiving the full therapeutic benefit of their medications. Findings: 1a. During a medication pass observation on June 18, 2025, at 11:35 a.m., Licensed Vocational Nurse (LVN) 2 was observed preparing a prefilled Humalog (insulin lispro, brand name: Humalog KwikPen, medication for diabetes) 100 units/milliliter (ml, unit of measurement) pen for Resident 28. On June 18, 2025, at 11:39 a.m., LVN 2 was observed administering 4 units from the prefilled Humalog pen as a subcutaneous (under the skin) injection in Resident 28's lower right abdomen. LVN 2 pressed and immediately released the prefilled Humalog pen's dose knob without holding it in place for at least 5 seconds. A review of Resident 28's medical record indicated a physician's order, dated April 29, 2025, for Humalog Injection Solution 100 units/ml (Insulin Lispro), inject 4 units subcutaneously before meals. 1b. During another medication pass observation on June 18, 2025, at 11:51 a.m., LVN 2 was observed preparing a prefilled Lispro (insulin lispro, brand name: Lispro Kwikpen, medication for diabetes) 100 units/ml pen for Resident 52. On June 18, 2025, at 11:56 a.m., LVN 2 was observed administering 6 units from the prefilled Lispro pen as a subcutaneous injection in Resident 52's back of the right upper arm. LVN 2 pressed and immediately released the prefilled Lispro pen's dose knob without holding it in place for at least 5 seconds. A review of Resident 52's medical record indicated a physician's order, dated April 30, 2025, for Insulin Lispro Injection Solution 100 units/ml (Insulin Lispro), inject 6 units subcutaneously before meals. During an interview on June 18, 2025, at 12 p.m., LVN 2 acknowledged she did not hold the prefilled Humalog and Lispro pens' dose knob down for at least 5 seconds when administering the medication to Residents 28 and 52. LVN 2 stated she did not know she was supposed to hold the pens' dose knob down for at least 5 seconds. During a concurrent interview and record review on June 18, 2025, at 12:30 p.m. with the Director of Nursing (DON), the DON reviewed the prefilled Humalog and Lispro pens manufacturer's instructions from the manufacturer's website. The prefilled Humalog and Lispro pens manufacturer's instructions indicated, Continue to hold the dose knob in and slowly count to 5 before removing the needle. The DON stated nursing staff should have followed the manufacturer's instructions during the administration of prefilled Humalog pen for Resident 28 and prefilled Lispro pen for Resident 52. During a follow-up interview on June 19, 2025, at 1:06 p.m., the DON stated it was important for nursing staff to administer the prefilled insulin pens according to the manufacturer's instructions to ensure the full dose was administered to the residents. A review of Humalog (Insulin Lispro) KwikPen manufacturer's Instructions for Use, dated May 2025 provided by the facility, indicated, Step 11 .Insert the Needle into your skin .Push the Dose Knob all the way in .Continue to hold the Dose Knob in and slowly count to 5 before removing the Needle. During a review of the facility's policy and procedure (P&P) titled, Subcutaneous medication administration procedures, dated January 16, 2025, indicated, Procedure .inject medication slowly .

Based on observation, interview, and record review the facility failed to ensure refrigerated medications and biologicals were stored at temperatures in accordance with facility policy and manufacturer's specifications when one of two medication refrigerators was identified with documented temperature readings below the normal range on multiple days between January to June 2025. This failure had the potential for residents to receive ineffective medications which could result in the residents not receiving the full benefit of the medications, leading to further health complications. Findings: During a concurrent observation and interview at nursing station 1 on June 16, 2025, at 2:15 p.m. with Registered Nurse (RN) 1, a medication refrigerator was identified. The refrigerator was observed to contain the following medications: - Afluria (flu vaccine) injectable suspension; - Latanoprost (used to lower pressure in the eye) eye drops; - Ozempic (used for diabetes and weight loss) prefilled pen; - Retacrit (used to produce more red blood cells) vial; - various types of insulin (used to treat diabetes) including Semglee (insulin glargine) prefilled pen; and - Tubersol PPD (test agent used in the diagnosis of tuberculosis) vial. During the same concurrent interview and observation on June 16, 2025, at 2:15 p.m., RN 1 stated the medications in the refrigerator should have been stored at 36 degree Fahrenheit (F, a temperature measurement) to 46 degree F. During this interview, the product labeling from the Ozempic carton (dated September 2023), reviewed with RN 1 indicated, .Storage Conditions for the Ozempic Pen .Refrigerated 36 degree F to 46 degree F. Additionally, RN 1 reviewed the medication refrigerator temperature logs dated January to June 2025 and acknowledged the medication refrigerator temperatures were below 36 degree F (out of range) against the manufacturer's instructions, on multiple days. RN 1 stated when the medication refrigerator was out of range, nursing staff needed to adjust the thermostat inside the refrigerator and should have reported to maintenance if temperature had not returned to normal range. RN 1 stated if medications were not stored according to the required temperature they could have been ineffective. During an interview on June 16, 2025, at 3:09 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated nursing staff needed to document the medication refrigerator temperature on the log at every shift (morning and evening). LVN 3 stated the normal range for the medication refrigerator was between 36 degree F to 46 degree F. LVN 3 stated if the medication refrigerator temperature was out of range, nursing staff should have tried to adjust, rechecked temperature in one to two hours, then should have notified maintenance staff if the temperature was not back in range. A review of the Prescribing Information (PI, manufacturer's instructions) for Afluria (flu vaccine) injectable suspension, dated July 2024, retrieved from DailyMed (a public website maintained by the U.S. Food and Drug Administration), indicated, Store refrigerated at 2-8 degree Celsius [C, a temperature measurement] (36-46 degree F). A review of the PI for Latanoprost eye drops, dated June 2024, retrieved from DailyMed, indicated, Store unopened bottle(s) under refrigeration at 2 degree C to 8 degree C (36 degree F to 46 degree F). A review of the PI for Retacrit, dated September 2024, retrieved from DailyMed, indicated, Store refrigerated at 2 degree C to 8 degree C (36 degree F to 46 degree F). A review of the PI for Semglee (insulin glargine) prefilled pen, dated March 2025, retrieved from DailyMed, indicated, Not in-use (unopened) Refrigerated (2 degree to 8 degree C [36 degree to 46 degree F]). A review of the PI for Tubersol PPD, dated October 2021, retrieved from DailyMed, indicated, Store at 2 to 8 degree C (35 to 46 degree F). During a concurrent interview and record review on June 17, 2025, at 9:45 a.m. the facility's nursing station 1 medication refrigerator temperature logs dated January to June 2025 were reviewed with the Director of Nursing (DON). The DON stated nursing staff were expected to document the medication refrigerator temperature on the log twice a day at the beginning of each shift (morning and night) and the normal temperature range was between 36 degree F to 46 degree F according to the facility's policy. The DON confirmed the nursing station 1 medication refrigerator temperatures were below the normal range as follows: - In January 2025: 34 degree F on 14 days during morning shift; - In February 2025: 34 degree F on 15 days during morning shift, 25 degree F on one day (reported to maintenance by nursing staff) during morning shift, and 34 degree F on 6 days during night shift; - In March 2025: 34 degrees F on 15 days during morning shift, 35 degree F on one day during morning shift, and 34 degrees F on 10 days during night shift; - In April 2025: 34 degree F on 9 days during morning shift; - In May 2025: 34 degree F on 21 days during morning shift, 35 degree F on one day during morning shift, 34 degree F on two days during night shift, and 35 degree F on 5 days during night shift; and - In June 2025: 35 degrees F on one day during morning shift and one day during night shift. During the same concurrent interview and record review on June 17, 2025, at 9:45 a.m., the DON acknowledged in April 2025, three days were missing a temperature recording during night shift and stated it should have been documented. The DON stated when temperatures were out of range, nursing staff were expected to adjust the thermostat inside the refrigerator and recheck in 15 minutes, then if the temperature was not back in range, they should have called maintenance and notify the DON. The DON stated it was important to ensure refrigerated medications were stored at the appropriate temperatures according to the manufacturer's instructions and facility policy because the effectiveness of the medication could have been altered and might not work as intended when administered to residents. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated January 16, 2025, the P&P indicated, Medications requiring 'refrigeration' or 'temperature between 2 degree C (36 degree F) and 8 degree C (46 degree F)' are kept in a refrigerator with a thermostat to allow temperature monitoring.

Based on observation, interview, and record review, the facility failed to provide safe storage, preparation, and distribution of food when the kitchen staff performed the chlorine (a sanitizing solution) testing of the dishwashing machine with expired test strips. This failure had the potential to result in foodborne illness to a vulnerable facility population. Findings: On June 18, 2025, at 11:26 a.m., a concurrent observation and interview was conducted with the dietary aide (DA). The DA was observed to run the dishwasher and performed the chlorine test strip. The vial containing the test strips was observed with an expiration date of May 1, 2025. The DA stated the chlorine test strips were expired and should not have been used to test the level of the sanitizing solution from the dishwasher. On June 18, 2025, at 11:35 a.m., an interview was conducted with the Dietary Supervisor (DS). The DS stated the chlorine test strips were expired and should not have been used to test the level of the sanitizing solution from the dishwasher. On June 20, 2025, at 11:21 a.m., an interview was conducted with the Registered Dietician (RD). The RD stated if the chlorine test strips were expired, the kitchen staff was unable to tell if the dishwasher sanitizing solution was in the right concentration. The RD stated the kitchen staff should not have used expired test strips. The facility policy and procedure, titled, Dishwashing Machine Use, dated January 16, 2025, was reviewed. The policy and procedure indicated, .Test the sanitizing solution using the manufacturer's suggested test strips to assure appropriate .

2. On June 16, 2025, at 9:35 a.m., Resident 18 was observed lying in bed, awake, alert, and able to make his needs known. Resident 18 was receiving oxygen (O2) at 3 LPM (liters per minute - a unit of measurement) via the nasal cannula attached to an O2 concentrator (a machine that supplies oxygen). The nasal cannula was labeled with Resident 1's name, room number and date of 6/6/25. A wheelchair was observed at the foot of Resident 18's bed. Resident 18 stated he was using the wheelchair when he was up. An O2 cannula with no date was observed attached to a portable O2 tank. The O2 cannula was observed hanging on the back of the wheelchair, exposed to the environment. On June 16, 2025, at 9:46 a.m. Registered Nurse (RN) 2 was observed assisting Resident 18 in the room. In a concurrent interview with RN 2, she stated Resident 18's nasal cannula was dated 6/6/25. RN 2 stated she was not sure when the O2 cannula should have been changed. She stated Resident 18 was using the wheelchair located at the foot of the bed. She stated the O2 cannula in the wheelchair attached to the portable O2 tank did not have a date and was not stored in a plastic bag. RN 2 stated the O2 tubing should have been labeled and stored in a plastic bag for infection control. On June 18, 2025, at 11:01 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 18 had an order for O2 at 3 LPM via NC or face mask continuously. She stated the licensed nurses on the night shift were responsible for changing the NC. She stated the facility practice was to change the respiratory equipment every Sunday night. She also stated the respiratory equipment should be changed at least every seven days, labeled, dated, and stored in a plastic bag when not in use for infection control. On June 18, 2025, at 11:25 a.m., the DON was interviewed. She stated the facility practice was to change the O2 cannula every Sunday night by the charge nurses. She also stated when not in use, the O2 cannula should be stored in a plastic bag, labeled and dated, for infection control. Resident 18's record was reviewed. Resident 18 was admitted to the facility on [DATE], with diagnoses which included pulmonary edema (a condition with excess fluid in the lungs) and pleural effusion (a build up of fluid between the lungs and the chest). Resident 18's Brief Interview of Mental Status (BIMS - an assessment tool), dated May 28, 2025, indicated a score of 14 (cognitively intact). The Physician's Order, dated June 16, 2025, indicated, .Change nasal cannula or face mask and tubing q (every) week on Sundays. Date nasal canula or face mask and tubing when changed. Every night shift every Sunday . The facility policy and procedure titled Oxygen Therapy, reviewed January 6, 2025, indicated, .The cannula should be dated with date set-up and/or changed .A clean bag will be placed at the patient's bedside for cannula storage when not in use. The bag will be labeled with the patient's name and date of set-up/change . Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for 3 out of 65 sampled residents when: 1. For Residents 28 and 52, nursing staff failed to properly clean a shared glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms); and 2. For Resident 18, the nasal cannula tubing (NC - a tube used to deliver oxygen through the nose) was not changed every seven days and stored in a sanitary plastic bag as per facility policy and procedure. These failures had the potential for Residents 18, 28, and 52 to be exposed to bacterial cross contamination and the development of infection. Findings: 1. During an observation on June 18, 2025, at 11:25 a.m., Licensed Vocational Nurse (LVN) 2 was observed using a shared glucometer to measure Resident 28's concentration of blood glucose. LVN 2 was observed wiping the glucometer with a Sani-Cloth disposable wipe and did not disinfect the glucometer according to the manufacturer specified contact time. During another observation on June 18, 2025, at 11:44 a.m., LVN 2 was observed using the same shared glucometer to measure Resident 52's concentration of blood glucose. LVN 2 was observed wiping the glucometer with a Sani-Cloth disposable wipe and did not disinfect the glucometer according to the manufacturer specified contact time. During an interview on June 18, 2025, at 12 p.m., LVN 2 stated nursing staff needed to wipe all shared resident care equipment, such as glucometers, with Sani-Cloth disposable wipe to disinfect after each use and let the glucometer air dry for two (2) minutes. Additionally, LVN 2 stated she did knot know what contact time meant. LVN read the manufacturer's instructions on the disposable wipe label and acknowledged the instructions indicated, Allow surface to remain wet for two (2) minutes. During an interview on June 18, 2025, at 12:08 p.m. with the Infection Preventionist (IP), the IP stated nursing staff were expected to clean and disinfect all shared resident care equipment after use and before the next resident using Sani-Cloth disposable wipes. The IP stated nursing staff needed to wipe the equipment, put it down, and wait to air dry for two (2) minutes before using on the next resident. The IP stated contact time meant the time required for the equipment become disinfected according to the manufacturer's instructions. The IP read the manufacturer's instructions on the disposable wipe label and acknowledged the instructions indicated, Allow surface to remain wet for two (2) minutes. The IP acknowledged nursing staff should have been instructed to keep the surface wet for two (2) minutes to achieve contact time when disinfecting shared resident care equipment, such as glucometers, according to the manufacturer's instructions. During a concurrent interview and record review on June 18, 2025, at 12:30 p.m. with the Director of Nursing (DON), the DON stated nursing staff were expected to clean and disinfect all shared resident care equipment between every resident after each use and to follow the Sani-Cloth manufacturer's instructions for contact time to achieve proper kill time of organisms. The DON read the manufacturer's instructions on the disposable wipe label and acknowledged the instructions indicated, Allow surface to remain wet for two (2) minutes. The DON acknowledged nursing staff should have been instructed to keep the surface wet for two (2) minutes to achieve contact time when disinfecting shared resident care equipment, such as glucometers, according to the manufacturer's instructions. During a follow-up interview on June 19, 2025, at 1:06 p.m., the DON stated it was important to follow the disposable wipe manufacturer's instructions for contact time when disinfecting shared resident care equipment to ensure the wipe effectively killed organisms to prevent cross contamination. During a review of the facility's policy and procedure (P&P) titled, Blood glucose monitoring with insulin coverage, dated January 16, 2025, the P&P indicated, Procedure .sanitize and disinfect the glucometers machine following manufacturer's recommendations. During a review of the manufacturer's instructions for contact time for the Sani-Wipes provided by the facility, the manufacturer's instructions indicated, Contact time .thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry.

Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment in accordance with the facilities policy and procedures for two of five residents (Resident 1 and Resident 4) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents ' health condition. Findings: On May 22, 2024, at 7:40 am, an unannounced abbreviated survey was conducted for the investigation of one complaint. A review of Resident 1 ' s History and Physical, dated May 25, 2022, indicated Resident 1 was admitted with a medical history which included chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow or breathing problems), anxiety disorder (a disorder caused by excessive anxiety), and paranoid schizophrenia (a serious mental disorder that affects how people interpret reality). A review of Resident 1 ' s Physician ' s Orders, dated January 7, 2024, indicated May use Continuous oxygen @ (at) 2-3 L/min (liters per minute) via nasal cannula or face mask for oxygen saturation below 92%. Every shift related to chronic obstructive pulmonary disease with (acute) exacerbation if oxygen is delivered at 3L/min or above, humidifier must be applied. A review of Resident 1 ' s Vital Signs, for oxygen saturation trends indicated, for the dates of January 10, 2024, January 11, 2024, January 12, 2024, and January 13, 2024, was only documented one time per day, instead of every shift as ordered. During a concurrent observation and interview on May 23, 2024, at 7:55 am, with Resident 4, Resident 4 stated he has lived in the facility for one year and uses oxygen on and off throughout the day and while he sleeps every night because of COPD. The oxygen was set at 3.5 liters per minute with humidifier (a device for increasing the humidity of the air) attached. A review of Resident 4 ' s History and Physical, dated December 20, 2023, indicated Resident 4 was admitted with medical diagnoses which include COPD exacerbation (an increase in the severity of the disease), status asthmaticus (a prolonged and severe asthma attack that does not respond to standard treatment), depression, anxiety, and periodic psychosis (loss of contact with reality). A review of Resident 4 ' s Physician Orders, dated March 21, 2024, indicated May use oxygen @ 2-3 L/min via nasal cannula or face mask for oxygen saturation below 88%. Monitor use q shift. As needed if oxygen is delivered at 3 L/min or above, humidifier must be applied. A review of Resident 4 ' s Vital Signs, for oxygen saturation trends, dated March 28, 2024, April 14, 2024, May 1, 2024, May 7, 2024, May 12, 2024, and May 16, 2024, were the only days oxygen saturations were documented. During an interview on May 23, 2024, at 11:00 am, with Administrator, Administrator stated the staff should be documenting oxygen levels per physician orders. A review of the facility ' s policy and procedure titled, Oxygen Therapy, revised November 2017, indicated, .Document administration in the medication administration record .Document oxygen saturation levels per physician order . Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment in accordance with the facilities policy and procedures for two of five residents (Resident 1 and Resident 4) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents' health condition. Findings: On May 22, 2024, at 7:40 am, an unannounced abbreviated survey was conducted for the investigation of one complaint. A review of Resident 1's History and Physical, dated May 25, 2022, indicated Resident 1 was admitted with a medical history which included chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow or breathing problems), anxiety disorder (a disorder caused by excessive anxiety), and paranoid schizophrenia (a serious mental disorder that affects how people interpret reality). A review of Resident 1's Physician's Orders, dated January 7, 2024, indicated May use Continuous oxygen @ (at) 2-3 L/min (liters per minute) via nasal cannula or face mask for oxygen saturation below 92%. Every shift related to chronic obstructive pulmonary disease with (acute) exacerbation if oxygen is delivered at 3L/min or above, humidifier must be applied. A review of Resident 1's Vital Signs, for oxygen saturation trends indicated, for the dates of January 10, 2024, January 11, 2024, January 12, 2024, and January 13, 2024, was only documented one time per day, instead of every shift as ordered. During a concurrent observation and interview on May 23, 2024, at 7:55 am, with Resident 4, Resident 4 stated he has lived in the facility for one year and uses oxygen on and off throughout the day and while he sleeps every night because of COPD. The oxygen was set at 3.5 liters per minute with humidifier (a device for increasing the humidity of the air) attached. A review of Resident 4's History and Physical, dated December 20, 2023, indicated Resident 4 was admitted with medical diagnoses which include COPD exacerbation (an increase in the severity of the disease), status asthmaticus (a prolonged and severe asthma attack that does not respond to standard treatment), depression, anxiety, and periodic psychosis (loss of contact with reality). A review of Resident 4's Physician Orders, dated March 21, 2024, indicated May use oxygen @ 2-3 L/min via nasal cannula or face mask for oxygen saturation below 88%. Monitor use q shift. As needed if oxygen is delivered at 3 L/min or above, humidifier must be applied. A review of Resident 4's Vital Signs, for oxygen saturation trends, dated March 28, 2024, April 14, 2024, May 1, 2024, May 7, 2024, May 12, 2024, and May 16, 2024, were the only days oxygen saturations were documented. During an interview on May 23, 2024, at 11:00 am, with Administrator, Administrator stated the staff should be documenting oxygen levels per physician orders. A review of the facility's policy and procedure titled, Oxygen Therapy , revised November 2017, indicated, .Document administration in the medication administration record .Document oxygen saturation levels per physician order .

Based on observation, interviews, document review, and record review, the facility failed to ensure they did not place a fitted sheet on the low air loss mattress for 1 (Resident #42) of 1 sampled resident reviewed for pressure ulcer/injury. Findings included: A review of Resident #42's Admission Record revealed the facility admitted the resident on 04/08/2020. Per the Admission Record, the resident had diagnoses to include pressure-induced deep tissue damage of the left heel and pressure ulcer of the right heel, left heel, right ankle, and left ankle. A record review of Resident #42's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2024, revealed the resident had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making. The MDS revealed the resident was at risk for pressure ulcer development and had four Stage I pressure ulcers and three unstageable pressure ulcers. A record review of Resident #42's care plan, revised on 10/16/2023, revealed the resident was at risk for pressure ulcers secondary to impaired mobility and incontinence status. There was intervention added on 2/16/2024, that directed staff to provide a low air loss mattress as ordered. A review of Resident #42's Order Summary Report revealed an order dated 02/16/2024, for may use low air loss mattress at air pressure range of 180 to 200 pounds. On 04/02/2024 at 10:56 AM, Resident #42 was observed in bed with a tightly fitted sheet over their low air loss mattress. In an interview on 04/03/2024 at 2:53 PM, the Medical Director stated he preferred to use non-fitted sheets on beds with a low air loss mattress. In an interview on 04/04/2024 at 9:48 AM, Registered Nurse #1 stated it was best practice to not have fitted sheets on beds with a low air loss mattress. In an interview on 04/04/2024 at 1:45 PM, the Administrator stated her opinion was irrelevant. In an interview on 04/04/2024 at 4:21 PM, the Director of Staff Development (DSD) stated fitted sheets were not supposed to be placed on beds with a low air loss mattress. The DSD stated the staff were trained that way, and if sheets were on those beds, it was done by mistake. In an interview on 04/04/2024 at 4:23 PM, the Director of Nursing stated normally beds with a low air loss mattress did not have sheets on them and she was not sure what happened. A review of a document titled, In-Service Sign in Sheet, dated 08/01/2023, revealed Air loss mattress use draw sheet and chux ONLY.

Based on interviews, record review, document reviews, and facility policy reviews, the facility failed to conduct outbreak testing as directed by the Centers for Disease Control and Prevention when 1 (Resident #119) of 15 sampled residents tested positive for COVID-19. Findings included: A review of the facility policy titled, Infection Prevention and Control Program, revised in June 2021, revealed It is the policy of the facility to establish and maintain and Infection Prevention and Control Program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. A review of the undated facility policy titled, Resident COVID Testing, revealed It is the policy of this facility to provide testing for the Covid-19 virus to our residents as directed by the Centers for Disease Control and the California Department of Public Health. A review of the undated facility policy titled, Employee Covid Testing, revealed It is the policy of this facility to provide testing for the Covid-19 virus to our employees as directed by the Centers for Disease Control and the California Department of Public Health. A review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 03/18/2024, revealed a section titled Responding to a newly identified SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] infected HCP [healthcare personnel] or resident that specified, Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. A review of Resident #119's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/10/2023, revealed the facility readmitted the resident on 11/03/2023. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Per the MDS, the resident had active diagnoses to include coronary artery disease, hypertension, peripheral vascular disease, renal insufficiency, dementia, and osteoporosis. A review of a document titled, COVID-19 Log, revealed Resident #119 had no symptoms. Per the COVID-19 Log, the date of the test for Resident #119 was listed on 01/09/2024. During an interview on 04/03/2024 at 11:52 AM, the Infection Preventionist (IP) stated the facility's last COVID-19 outbreak occurred on 01/09/2024. According to the IP, a resident (Resident #119) was sent to the hospital on 01/09/2024, and the hospital staff notified the facility that the resident tested positive for COVID-19. The IP acknowledged all residents and staff were then tested weekly, on 01/09/2024 and again on 01/16/2024. A review of documents titled Testing Record, revealed facility staff and residents were tested for COVID-19 on 01/09/2024, 01/16/2024, and 01/23/2024. During an interview on 04/04/2024 at 10:58 AM, the Director of Nursing stated when the facility had a resident who was positive for COVID-19, the facility tested other residents and staff on the same day as to when the resident was found to be positive for COVID-19 and then weekly thereafter. In an interview on 04/04/24 at 1:37 PM, the Administrator stated she expected the staff to follow the regulations.

Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Several various size of metal sheet pans were stacked and stored wet; and 2. The ice machine was not cleaned and sanitized properly per manufacturer's guidance. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. The facility census was 58. Findings: 1. During the initial tour in the kitchen, an observation and concurrent interview with the Dietary Services Supervisor (DSS) on May 17, 2021, at 9:10 a.m. was conducted. Two of two-third (2/3) size metal pans, two of one-quarter (1/4) size metal pans, four of full sheet metal pans were observed stacked wet and stored in the clean storage area. The DSS confirmed the mental pans were wet and stacked on top of each other. She stated that all dishes, pots, and pans should be air-dried and completely dried before stored away in the storage area. During an interview on May 19, 2021, at 2:50 p.m., the Registered Dietitian (RD) stated all dishes, pots, pans, and utensils needed to be air-dried before stored away. She stated the moisture environment could induce bacteria or mold growth. During a review of facility policy and procedure titled, Cleaning Dishes - Dishwashing, dated 2008, it indicated after washed, rinsed and sanitized, all dishes should be air-dried, and staff should check all dishes to be sure they are clean and dry prior to storing. During a review of facility document titled, Dietary In-Service Record, Topic: Kitchen Sanitation, completed on January 9, 2020 and February 4, 2021, it showed .To provide safe food, dietary still will follow sanitation guidelines which include .Dishes should be air dried .Inspect for .dryness before putting away . According to FDA Federal Food Code 2017, Section 4-901.11 Equipment and Utensils, Air-Drying Required, after cleaning and sanitizing, equipment, and utensils .shall be air-dried .before contact with food. 2. During an observation on May 17, 2021, at 10:24 a.m., the ice machine had several visible dark brown and black residues on the ice baffle (a panel uses to direct the flow of the ice stored in the ice storage bin) when the Maintenance Supervisor (MS) took it apart from the ice machine. The residues were easily removed with a white paper towel. In addition, there was significant amount of yellow and orange slimy residue around the ice chute (area where the ice is dispensed) and was easily removed with a white paper towel. A concurrent interview with the MS, he confirmed the residues on the ice baffle and ice chute. The MS stated he was responsible for the deep cleaning of the ice machine monthly and the last deep clean was on April 20, 2021. The MS explained the steps of the cleaning of the ice machine. He stated he would empty the ice from the ice storage bin, took off the parts apart, and washed and rinsed the tubing and water reservoir at the top machinery part of the ice machine. Then he would use manufacturer's brand cleaning solution add in the water reservoir per manufacturer's instruction. The MS also stated the next step was to run the cycle with adding the manufacturer's brand sanitizer solution without mixing any water per manufacturer's instruction to the water reservoir. After those cycles were done, he would run two cycles with clean water and drain. The MS explained the step of cleaning and sanitizing the ice storage bin. He stated he would clean and scrub the interior the ice storage bin with the same manufacturer's cleaning solution and then rinse with water. Then he would use the same sanitize solution mix with water in a bucket to sanitize the ice storage bin. He stated he would rinse with water again after sanitizing the ice storage bin. During a review of the manufacturer's brand cleaning solution bottle on May 17, 2021, at 11:40 a.m., the instruction indicated to use of three to six ounces (oz.) of cleaning solution per gallon of circulating water of the ice machine. A concurrent interview with the MS, he stated he did not know the amount of circulating water for the ice-machine. During a review of the manufacturer's brand sanitizing solution bottle on May 17, 2021, at 11:40 a.m., the instruction for the sanitizing solution indicated to use of eight ounces of the sanitizing solution per five gallons of water for food contact sanitizing performance. The other instruction for sanitizing the ice machine indicated that to allow all surface to air dried after sanitizing and do not rinse after sanitized. A concurrent interview with the MS, he stated he was not sure the amount of sanitizing solution put in the circulating water and did not know the amount of gallon of the circulating water for the ice-machine. The MS also acknowledged that he should not rinse with water after sanitizing the ice storage bin after he read the manufacturer's instruction on the sanitizer solution bottle.

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from storage and not readily available for use, when: 1. One unopened bottle of milk of magnesia (MOM - medication to treat constipation) expired on April 2021, and one unopened bottle of an iron supplement syrup (medication to treat low iron) expired on February 2021; and 2. One open bottle of multivitamins expired on February 2021, and the multivitamins from the expired bottle were administered to Residents 1, 9, 475, 476, and 477. These failures increased the possibility for the residents to receive expired medications with decreased efficacy, and for Residents 1, 9, 475, 476, and 477 to receive medications unsafely. Findings: 1. During the medication storage inspection conducted with Licensed Vocational Nurse (LVN) 1 on May 19, 2021, beginning at 11:46 a.m., at the Station 1 medication cabinet, the following medications were found readily available for use: - One unopened bottle of MOM with an expiration date of April 2021; and - One unopened bottle of iron supplement syrup with an expiration date of February 2021. On May 19, 2021, at 12:08 p.m., LVN 1 was interviewed. LVN 1 stated there should be no expired medications readily available for use in the medication cabinet at Station 1. 2. During the medication storage inspection conducted with Licensed Vocational Nurse (LVN) 3 on May 19, 2021, beginning at 1:43 p.m., one open bottle of multivitamins with an expiration date of February 2021, was found in the Station 2 medication cart, readily available for use. On May 19, 2021, at 1:58 p.m., LVN 3 was interviewed. LVN 3 stated there should be no expired medications readily available for use in the medication cart. LVN 3 was asked how many residents had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the residents records indicated the following physician orders: - For Resident 1, Multivitamins give one tablet by mouth one time a day for supplement, order date January 27, 2021; - For Resident 9, Multivitamins give one tablet by mouth one time a day for supplement, order date January 28, 2021; - For Resident 475, Multivitamins give one tablet by mouth one time a day for supplement, order date April 24, 2020; - For Resident 476, Multivitamins give one tablet by mouth one time a day for supplement, order date January 28, 2021; and - For Resident 477, Multivitamins give one tablet by mouth one time a day for supplement, order date February 27, 2021. On May 19, 2021, at 1:58 p.m., the Director of Nursing (DON) was interviewed. The DON stated there should be no expired medications readily available for use in the medication cabinet or the medication cart. The DON stated the licensed nurses should check medication expiration dates before administering any medication. The undated facility policy and procedure titled, STORAGE OF MEDICATIONS, was reviewed. The policy indicated, .Outdated .are immediately removed from inventory, disposed of according to procedures for medication disposal .The nurse will check the expiration date of each medication before administering it .No expired medication will be administered to a resident .All expired medications will be removed from the active supply .

Based on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when one Cook and one Dietary Aide (DA) were unable to demonstrate and verbalize the process of manual dishwashing by using a two-compartment sink. This failure had the potential to place 51 out of 58 highly susceptible residents who received food from the kitchen at risk for food-borne illness. Findings: During an interview on May 17, 2021, at 9:30 a.m., the DA verbalized and demonstrated the process of manual dishwashing with the two-compartment sink. The DA stated usually they used the two-compartment sink for wash and rinse pots and pans only and then would use the dishwashing machine for sanitizing process. The DA stated she was not sure the wash and rinse water temperature for manual dishwashing. She also stated she could not completely demonstrate and verbalized the whole process of manual dishwashing. During an interview on May 17, 2021, at 9:32 a.m., the Cook verbalized the process of manual dishwashing with the two-compartment sink. The Cook stated the process was washing and rinsing would use the same sink and she would clean and sanitize the sink between washing and rinsing. She stated the water temperature for the wash and rinse would be at least 110 degrees Fahrenheit (F). She stated the sanitizing solution was premixed and load in the sanitizing sink and the sanitizer solution concentration should be 200 parts per million (ppm) by using the quaternary [MEDICATION(S)] (quat) test strip. The Cook stated she then put the dishes, pots, or pans into the quat solution fully immerse for 10 seconds, and last step was to air dried. During an interview on May 17, 2021, at 9:38 a.m., the Dietary Services Supervisor (DSS) acknowledged the DA did not know the process of manual dishwashing and the Cook verbalized the incorrect immersion time of pots, pans, and dishes in the quat solution, and the correct immersion time was at least 60 seconds. She stated her expectation for the dietary aide staff and the Cooks should have the knowledge of manual dishwashing in case the dishwashing machine was not functioning. During an interview on May 19, 2021, at 2:50 p.m., the Registered Dietitian (RD) stated her expectation for the Cooks and dietary aide staff should know the process of manual dishwashing. The RD stated they should know the dishes, pans, and pots needed to be fully immerse into the sanitizing solution for at least one minute (60 seconds) for the sanitation procedure for the manual dishwashing. A review of competency audits of the DA and the Cook and a concurrent interview were conducted on May 19, 2021, at 1:48 p.m. The facility documents titled, Food and Nutrition Services Competency Check List, completed on November 10, 2020 for the Cook, and completed on March 11, 2021 for the DA, and both showed that the DA and the Cook were competent to demonstrate two- or three-compartment sink dishwashing method and evaluated by the DSS. The DSS stated all dietary aide staff were cross-trained and worked as dishwashers when scheduled. She stated they should know the process of manual and machine dishwashing. The DSS also stated the Cook must have the knowledge of everything in the kitchen from food safety, sanitation, and dishwashing because she would be responsible for the kitchen when the DSS was not available. A review of facility policy and procedure titled, Cleaning Dishes - Manual Dishwashing, dated 2008, it indicated wash and rinse water temperature should be a minimum of 110 degrees F, and sanitize dishes by immersion in quaternary ammonium solution for 60 seconds.

Based on observation, interview, and record review, the facility failed to ensure that the menu was being following for the therapeutic diet for lunch on May 18, 2021 when: 1. Two residents (Resident 76 and 564) on regular puree (regular diet modifies in texture of a smooth and moist consistency and able to hold its shape. Foods usually in soft and smooth state such as pudding or mashed potatoes) diet did not receive sauce on the puree chicken as indicated on the menu; 2. Two residents (Resident 475 and 469) on regular CCHO (consistent carbohydrate) diet (a diet used in the treatment for diabetes) did not receive diet gelatin dessert as indicated on the menu; and 3. One resident (Resident 53) on CCHO Large portion received extra one and half ounces of regular barbeque (BBQ) chicken. These failures had the potential to result in compromising the medical and nutrition status of those five residents. Findings: 1. During an observation of lunch meal service on May 18, 2021, beginning at 12:00 p.m., it was noted Resident 76 and 564 were on regular puree diet did not receive sauce on the puree chicken. A concurrent review of the undated facility document titled, Spring Cycle Menus: Week 3 Tuesday, showed that puree diet should receive puree BBQ chicken with sauce. During an interview on May 18, 2021, at 1:16 p.m., the Dietary Services Supervisor (DSS) acknowledged both residents with puree diet which not fortified did not receive sauce for the puree chicken. The DSS stated that the puree BBQ chicken should be with sauce per menu and it helped moisturizing the meat and swallowing. 2. During an observation of lunch service on May 18, 2021, beginning at 12:00 p.m., it was noted Resident 475 and 469 were on regular CCHO diet on the meal tickets (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, and likes) received regular strawberry gelatin whip as dessert. A concurrent review of undated facility document titled, Spring Cycle Menus: Week 3 Tuesday, indicated regular CCHO diet should receive diet strawberry gelatin whip. During an interview on May 18, 2021, at 1:16 p.m., the DSS stated she was aware that the dietary aide did not provide the diet strawberry gelatin whip dessert to Resident 475 and 469. 3. During an observation of lunch service on May 18, 2021, beginning at 12:00 p.m., it was noted Resident 53 was on CCHO large portion on the meal ticket received one and a half piece (four and a half ounces) of regular BBQ chicken. A concurrent review of undated facility document titled, Spring Cycle Menus: Week 3 Tuesday, indicated CCHO large portion should receive three ounces of BBQ chicken with lite BBQ sauce. During an interview on May 18, 2021, at 1:16 p.m., the DSS acknowledged Resident 53 on CCHO large portion diet received extra portion (one and half ounces) of chicken and the chicken should be with lite BBQ sauce for CCHO. During an interview on May 18, 2021, at 1:25 p.m., the DSS stated her expectation was the Cooks and dietary aide staff should follow the menu to provide adequate nutrition and the right modified and therapeutic diets to the residents. During an interview on May 19, 2021, at 2:50 p.m., the Registered Dietitian (RD) stated the Cooks and the dietary staff should follow the menu during the meal service. The RD stated the puree diet should have received sauce as indicated to moisturize and give better taste of the puree chicken. She stated residents with CCHO diet should have received diet strawberry gelatin whip for dessert to prevent increasing the glucose (blood sugar) level. She also stated the resident with CCHO large portion diet should have received the portion of the chicken as indicated on the menu which it was calculated to help with glucose control and the lite BBQ sauce was less in sugar. A review of facility policy and procedure titled, Standardized Recipes, dated 2008, indicated that Cooks are expected to use and follow the recipes provided. A review of undated facility document titled, Job Description: Cook, showed .the Cook should prepare and serve food as directed by the menu .prepare food for meals, including modified foods for restricted and therapeutic diets, in proper quantity and serve in proper portion sizes . A review of undated facility document titled, Job Description: Dietary Aide, showed .prepare hot and cold foods .following recipes and posted menus, for regular, modified and therapeutic diets .serve food for meal delivery by reading tray card .check carefully .correct type of food and texture as ordered by the diet .

Based on observation, interview, and record review, the facility failed to ensure two of 21 residents reviewed for care and treatment (Residents 4 and 470) maintained their highest practicable physical well-being when: 1. Resident 4's skin injuries on his face and chin areas were not identified, assessed, and referred to the physician. This failure had the potential to delay care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. For Resident 470, the facility did not identify and assess a dark bluish discoloration on the left neck and a yellow-greenish fading discoloration on the right jaw timely. This failure had the potential for Resident 470 to not receive care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. On May 17, 2021, at 3:18 p.m., Resident 4 was observed lying in bed, awake, and able to respond to simple questions. Four dry and dark brown scabs were observed on the right side of Resident 4's face. During a concurrent interview with Resident 4, Resident 4 was asked if the scabs on his face were skin injuries from shaving. Resident 4 nodded his head (yes). On May 18, 2021, at 9:30 a.m., Resident 4 was observed awake and sitting in a wheelchair. Four dry and dark brown scabs were observed on the right side of Resident 4's face. On May 19, 2021, at 8:15 a.m., Resident 4 was observed to have four linear cuts on the right side of his face, approximately 0.3 centimeters (cm - a unit of measurement). The four dry and dark brown scabs were no longer present. On May 19, 2021, at 8:20 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated the linear cuts on Resident 4's face were skin injuries from shaving. On May 19, 2021, at 8:50 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated the linear cuts on Resident 4's face were skin injuries from shaving. On May 19, 2021, at 9:05 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 reviewed Resident 4's record and stated there was no documentation regarding the resident's skin injuries from shaving. On May 19, 2021, at 10:34 a.m., a concurrent interview and record review was conducted with the Director of Nurses (DON). The DON stated the skin injuries for Resident 4 should have been identified and reported. Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool), dated April 28, 2021, indicated Resident 4 required one person assistance for his personal hygiene including shaving. A review of the facility policy and procedure titled, CHANGE IN RESIDENT CONDITION, dated November 2017, indicated, .changes in physical .during the care or observation of a resident .All symptoms and unusual signs will be communicated to the physician .promptly . A review of the facility policy and procedure titled, Skin Tears - Abrasions and Minor Breaks, Care of, dated on September 2013, indicated, .Complete in-house investigation of causation . 2. On May 18, 2021, at 10:21 a.m., Resident 470 was observed lying in bed awake and nonverbal. A large dark bluish discoloration on the left neck approximately four by three centimeters and a yellow-greenish fading bruise on the right side of Resident 470's jaw were observed. On May 18, 2021, at 10:26 a.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 was asked about Resident 470's discoloration on the left neck and right jaw area. CNA 2 stated he noticed Resident 470 had the bruise since last Saturday (May 15, 2021). He stated, I think the charge nurse was aware, regarding Resident 470's bruise. On May 18, 2021, at 10:39 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 reviewed Resident 470's record from April 2021 to May 2021. LVN 2 stated there was no incident report or change in condition documentation for Resident 470 regarding the bruise on the left neck and right jaw. LVN 2 stated she did not receive reports regarding Resident 470's bruising on the left neck and right jaw. On May 18, 2021, at 10:51 a.m., the Director of Nursing (DON) was interviewed. The DON stated the facility's process when a resident had a bruise or change of condition was as follows: The nurse would report to the charge nurse, assess the resident, and then initiate an incident report. The DON stated the charge nurse would notify the physician, responsible party and also the DON or the Administrator after an incident report had been created. The DON stated there should have been an incident report completed for Resident 470's bruises. On May 18, 2020, Resident 470's record was reviewed. Resident 470 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool), dated March 16, 2021, indicated Resident 470 had a BIMS (Brief Interview for Mental Status - an assessment for cognitive status) of never understood (severely impaired). The physician order dated March 10, 2021, indicated, [MEDICATION(S)] Tablet (blood thinner medication) 2.5 MG (milligram - unit of measurement) Give 1 tablet via PEG-Tube (percutaneous endoscopic gastrostomy - tube directly inserted through the skin into the stomach for nutrition, hydration, and medication administration purposes) two times a day. The Care Plan dated May 11, 2020, indicated, .at risk for bleeding, bruising, skin tears, and discoloration related to daily use of [MEDICATION(S)] .Interventions .Assess/document/report PRN (as needed) adverse reactions of [MEDICATION(S)] therapy: .bruising . The facility policy and procedure titled, CHANGE IN RESIDENT CONDITION, dated November 2017, was reviewed. The policy indicated, It is the policy of this facility that changes in resident condition will be communicated to the physician, resident, and/or resident representative, appropriate nursing measures and physician orders implemented and documentation requirements completed

Based on observation, interview, and record review, the facility failed for one of one resident reviewed for oxygen therapy (Resident 50), to ensure the oxygen nasal cannula tubing (a two-pronged tubing connected to the nose) was labeled indicating the date the nasal cannula tubing was changed. This failure had the potential to result in the nasal cannula tubing to not be changed timely, which could allow infectious organisms to grow causing an infection to Resident 50. Findings: On May 18, 2021, at 11:32 a.m., Resident 50 was observed inside her room, lying in bed, asleep, with a nasal cannula in place, receiving oxygen at 2 LPM (liters per minute- a unit of measurement). The nasal cannula tubing did not have a label indicating the date when the nasal cannula tubing was changed. On May 18, 2021, at 11:35 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident 50's oxygen nasal cannula tubing did not have a label indicating the date when the nasal cannula tubing was changed. LVN 1 stated the licensed nurse on Sunday should have changed the nasal cannula tubing and should have labeled and dated it. On May 18, 2021, at 11:59 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated oxygen nasal cannula tubings were changed by the licensed nurses every Sunday and should have a label indicating the date when it was changed. On April 19, 2021, Resident 50's record was reviewed. Resident 50 was admitted under hospice care (care for the sick or terminally ill), on August 29, 2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The History and Physical, dated February 8, 2021, indicated Resident 50 did not have the capacity to understand and make decisions. The Order Summary Report dated April 14, 2021, was reviewed. The document indicated .Change and date nasal cannula or face mask and tubing once a week or prn (as needed) when oxygen in use, every night shift every Sun (Sunday) . Resident 50's care plan titled, Chronic Respiratory failure and [CONDITION(S)] (chronic obstructive pulmonary disease- a chronic [CONDITION(S)] lung disease), dated April 14, 2021, indicated, .Change and date nasal cannula or face mask and tubing once a week or prn when oxygen in use . On April 19, 2021, at 9:59 a.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated Resident 50's oxygen nasal cannula tubing should have been dated when it was changed. The facility policy and procedure titled, OXYGEN THERAPY, dated November 2017, was reviewed. The policy indicated, .The cannula should be dated with date set-up and/or changed .

Based on observation, interview, and record review, the facility failed to implement infection control precautions to prevent cross-contamination (transfer of bacteria or other contaminants from one surface to another) when: 1. One facility staff was observed wearing artificial fingernails while assisting in feeding Resident 31 ; and 2. One facility staff did not perform hand hygiene and did not disinfect the blood pressure cuff in between uses for Residents 29 and 39. These failures had the potential to increase the risk of cross-contamination which could result in the development and transmission of infection to a vulnerable population of 58 residents in the facility. Findings: 1. On April 17, 2021, at 12:25 p.m., during dining observation in the main dining room, Certified Nursing Assistant (CNA) 3 was observed wearing artificial fingernails while assisting in feeding Resident 31. On April 17, 2021, at 12:28 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated CNA 3 was wearing artificial fingernails. The DSD stated artificial fingernails were not allowed in the facility. On April 17, 2021, at 12:30 p.m., CNA 3 was interviewed. CNA 3 stated she was wearing artificial fingernails. CNA 3 stated she was aware artificial fingernails were not allowed in the facility. On April 17, 2021, at 12:35 p.m., the Director of Nursing (DON) was interviewed. The DON stated artificial fingernails were not allowed in the facility. The DON stated the DSD and the Infection Preventionist (IP) should have monitored the staff wearing artificial fingernails. On April 20, 2021, Resident 31's record was reviewed. Resident 31 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The History and Physical, dated September 16, 2020, indicated Resident 31 did not have the capacity to understand and make decisions. Resident 31's Minimum Data Set (MDS- an assessment tool) dated April 24, 2021, was reviewed. Resident 31's functional status required one person assistance with eating. According to the Centers for Disease Control and Prevention (CDC - a leading national public health institute in the United States) website, .Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and hand washing. It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients . The facility policy and procedure titled, DRESS CODE AND APPEARANCE, dated January 2019, was reviewed. The policy indicated, .(Name of facility) does not allow it's employees to have artificial fingernails . 2. On May 17, 2021, at 12:05 p.m., during an observation of the dining room, while residents were playing bingo, Certified Nursing Assistant (CNA) 4 was observed taking Resident 39's blood pressure. CNA 4 was observed using a blood pressure wrist cuff (machine use to measure the resident's blood pressure via the wrist) on the resident, then CNA 4 proceeded to obtain Resident 29's blood pressure. CNA 4 did not perform hand hygiene and did not disinfect the blood pressure cuff, before, in between, and after using the blood pressure cuff on Residents 39 and 29. On May 20, 2021, at 1:53 p.m., a telephone interview was conducted with CNA 4. CNA 4 stated he did not follow the facility's policy regarding the disinfection of blood pressure wrist cuffs when taking residents blood pressures. CNA 4 stated he should have followed the facility policy. On May 20, 2021, at 2:10 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated CNA 4 should have disinfected the blood pressure cuff before and after use and between Residents 39 and 29. On May 20, 2021, at 2:30 p.m., the Infection Preventionist (IP) was interviewed. The IP stated the facility policy was to use disinfecting wipes before and after use of the blood pressure cuff. The IP stated CNA 4 should have performed hand hygiene before and after each contact with the residents. The facility policy and procedure titled, POLICY FOR CLEANING & DISINFECTING BLOOD PRESSURE MACHINE AND BLOOD PRESSURE CUFF, dated November 2017, was reviewed. The policy indicated, .The blood pressure cuff and gauge will be cleaned after each use with a disinfectant wipe . The facility policy and procedure titled, HAND HYGIENE PROGRAM, dated November 2017, was reviewed. The policy indicated, .Indications for performing hand hygiene .Before and after contact with resident or the their (sic) environment .After touching items that are likely to be contaminated .

Based on observation, interview, and record review, the facility failed to implement infection control practice in preventing the transmission of COVID-19 ([MEDICAL CONDITION]- an illness caused by [MEDICAL CONDITION] that can be transmitted from person to person) infection when: 1. The facility staff, required to wear a tight-fitting N95 respirator mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles),when working with residents with positive and suspected COVID-19 infection, were not fit-tested in accordance to the Center for Disease Control and Prevention (CDC) guidance and OSHA (Occupational Safety Health Administration - a regulatory agency that inspect and examine workplaces to assure healthy and safe work environment); and 2. The facility staff were wearing a non-NIOSH (National Institute for Occupational Safety and Health - federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness) approved respirator when providing care to residents with an unknown COVID-19 status. These failures had the potential to result in serious harm due to an increase in COVID-19 transmission risk to staff and the vulnerable residents, which could lead to complications and death. On January 21, 2021, at 1:40 p.m., the Director of Nursing (DON) and the Infection Preventionist (IP) were verbally notified that an immediate jeopardy situation existed regarding the failure to ensure the facility staff were fit-tested for the appropriate respirator, to use as a personal protective equipment in accordance to Centers for Disease Control and Prevention (CDC) guidance and Occupational Safety and Health Administration (OSHA) requirements. The facility, on January 21, 2021, had a total of 14 residents and 18 staff members with confirmed COVID-19 infection and 15 residents with unknown/suspected COVID-19 status. On January 21, 2021, at 5:20 p.m., the facility presented to the California Department of Public Health (CDPH) with an acceptable plan of action that indicated the following: The facility will immediately begin fit testing staff working in the Red and Yellow units as soon as the hood is received tomorrow (January 22, 2021). Medical Health Operational Area Coordinator (MHOAC) will review our fit test procedures on Sunday (January 24, 2021) to confirm our appropriate use the fit test procedure. The DON and the IP will provide an in-service and education for the staff on N95 respirator seal check before fit testing on January 22, 2021. On January 26, 2021, at 12:05 p.m., the immediate jeopardy was removed, in the presence of the DON and the IP, after the facility implemented the immediate plan of action of conducting N95 respirator fit testing to the staff, training and educating the staff on proper N95 respirator fitting. Findings: 1. On January 21, 2021, at 9:50 a.m., during an interview with the Infection Preventionist (IP) and the Director of Nursing (DON), they stated staff were required to wear N95 respirators when providing care to residents in the COVID-19 positive zone. The IP and the DON stated facility did not conduct N95 respirator fit-testing prior to staff using the N95 respiratory in the COVID-19 positive zone. In addition, the DON stated she was not aware of the OSHA requirement to conduct fit testing prior to use of a N95 respirator. A review of the facility COVID-19 tracking sheets for staff from January 2, 2021 to January 18, 2021, and facility census dated January 20, 2021, indicated the facility had 18 staff members and 15 residents who tested positive for the COVID-19 infection and 15 residents with unknown and/or suspected COVID-19 status. The facility had a total of 54 residents. On January 21, 2021, at 12:10 p.m., Licensed Vocational Nurse (LVN) 1 was observed wearing a NIOSH approved N95 respirator. In a concurrent interview with LVN 1, she stated that she provided direct care to the residents in the COVID-19 red zone (designated unit for residents with positive COVID-19). LVN 1 stated she did not fit test on the N95 she was using. On January 21, 2021, at 12:15 p.m., Certified Nurse Assistant (CNA) 1 was observed wearing a NIOSH approved N95 respirator. In a concurrent interview with CNA 1, she stated that she provided direct care to the residents in the COVID-19 red zone. CNA 1 stated she did not fit test on the N95 she was using. On January 21, 2021, at 12:20 p.m., CNA 2 was observed wearing a NIOSH approved N95 respirator. In a concurrent interview with CNA 2, she stated that she provided direct care to residents in the COVID-19 red zone. CNA 2 stated she did not fit test on the N95 she was using. On January 21, 2021, at 1:00 p.m., during a phone interview with the Administrator, she stated the facility placed an order for [REDACTED]. The administrator did not respond if the facility had tried reaching out to other agency to assist them in obtaining the hood for fit-testing. A review of the CDC guideline titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated December 14, 2020, indicated, .Personal Protective Equipment HCP (health care personnel) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator. Information about Respirators: A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer's risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by the CDC/NIOSH, including those intended for use in healthcare. Respirator use must be in the context of a complete respiratory protection program in accordance with OSHA Respiratory Protection standard (29 CFR 1910.134external icon). HCP should be medically cleared and fit tested if using respirators with tight-fitting face pieces (e.g., a NIOSH-approved N95 respirator) and trained in the proper use of respirators, safe removal and disposal, and medical contraindications to respirator use . A review of OSHA requirement titled, Standard Number 1910.134 - Respiratory Protection indicated, .1910.134(f)(2) The employer shall ensure that an employee using a tight-fitting face piece respirator is fit tested prior to initial use of the respirator, whenever a different respirator face piece (size, style, model or make) is used . 2. On January 21, 2021, at 9:50 a.m., during an interview with the DON, she stated staff were required to wear KN95 mask when providing care to residents with unknown and/or suspected COVID-19 infection. The DON stated there was no need for fit testing if staff used KN95 mask. On January 21, 2021, at 10:00 a.m., during a concurrent interview and record review of the N95 respirator inventory log with the DON, she stated there were more than two weeks of N95 respirator supply in the facility. The inventory log, dated January 4, 2021, indicated 1000 pieces of N95 respirators available for use. On January 21, 2021, at 10:30 a.m., during an interview with the IP, she was unable to state the reason why the staff were wearing KN95, a non-NIOSH approved respirator, in providing care to residents with unknown COVID-19 status and residents with suspected COVID-19 infection. On January 21, 2021, at 11:50 a.m. The RN (Registered Nurse) was observed wearing a non-NIOSH approved KN95 mask. In a concurrent interview with the RN, she stated she provided direct care to resident with unknown and/or suspected COVID-19 infection. The RN stated she did not know the difference between N95 respirator and KN95. On January 21, 2021, at 11:55 a.m., CNA 3 was observed wearing a non-NIOSH approved KN95 mask. In a concurrent interview, CNA 3 stated she provided direct care to residents with unknown and/or suspected COVID-19 infection. She stated she did not know the difference between N95 respirator and KN95. On January 21, 2021, at 12:30 p.m., the Housekeeper was observed wearing a non-NIOSH approved KN95 in COVID-19 red zone. In a concurrent interview, she stated she was assigned to conduct environmental cleaning in the rooms designated for the residents in yellow zone (for residents with unknown and/or suspected COVID-19 infection) first then to the red zone. The Housekeeper stated she was provided a KN95 at the beginning of the shift and she was not aware she needed to use a N95. A review of the CDC (Centers for Disease Control and Prevention) guideline titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated December 14, 2020, indicated, .Personal Protective Equipment HCP (health care personnel) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator . A review of the NIOSH-Approved N95 Particulate Filtering Face piece Respirators list updated on January 11, 2021, indicated that KN95 was not included in the list of the approved N95 respirator by NIOSH. A review of the CDC guideline titled, Strategies for Optimizing the Supply of N95 Respirators, dated November 23, 2020, indicated, .Non-NIOSH-approved products developed by manufacturers who are not NIOSH approval holders .should only be used in crisis situations when no other NIOSH-approved N95 respirator .is available .Once availability of NIOSH-approved respirators returns to normal, healthcare facilities should promptly resume conventional practices .

Based on interview and record review, the facility failed to ensure an allegation of physical abuse involving Resident A was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made, for one of three sampled residents (Resident A). This failure had the potential to place Resident A at risk for harm from further abuse. Findings: On March 27, 2020, at 2:01 p.m., CDPH received a facsimile (fax - telephonic transmission) report of an allegation of abuse involving Resident A. The report indicated the allegation of abuse was reported to the facility on [DATE], at around 7 a.m., when the Registered Nurse Supervisor (RNS) heard Resident A calling 911 (emergency call) and telling them someone attempted to kill her at around 1 a.m. The report indicated the RNS interviewed Resident A who stated two staff tried to suffocate her with a pillow. The report indicated the Director of Nurses (DON) notified CDPH about the allegation of abuse involving Resident A on March 23, 2020, at about 11:20 a.m. On October 6, 2020, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident. Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility document titled, HISTORY AND PHYSICAL, dated September 26, 2019, indicated Resident A did not have the capacity to understand and/ or make decisions. The untitled document, dated September 26, 2019, indicated, .(name of Resident A) has history of fabricating stories . Investigate all accusations made by Resident to ensure that it is indeed a false accusation . The Progress Notes, indicated the following: a. On March 22, 2020, at 1:43 p.m., .Around 7:00 am (a.m.) resident was calling 911, asking for sheriff department and telling them that somebody tried to kill her early in this morning around 1 AM (a.m.) . stated (name of staff) and .CNA tried to suffocate her with (a) pillow . DON made aware . b. On March 23, 2020, at 2:06 p.m., . round 11:20 (a.m.) called CDPH .about resident accusation of someone tried to suffocate her with pillow on 3/22/20 (March 22, 2020) around 1 AM (a.m.) . On October 6, 2020, at 10:00 a.m., the DON was interviewed. She stated Resident A called 911 on March 22, 2020, at approximately 7:00 a.m., and told them the CNA and (name of staff) tried to suffocate her with a pillow. She stated she was notified by the RNS of Resident A's allegation of abuse against the staff on March 22, 2020, at around 8 a.m. The DON stated she reported the incident to CDPH on March 23, 2020, at 11:20 a.m. (28 hours after the allegation of abuse was made by Resident A). The DON stated an allegation of abuse should have been reported to CDPH within two hours from the time the facility was made aware of the allegation. She stated the facility reported the allegation of abuse late and should have been reported to CDPH within two hours from the time the allegation was reported to the facility staff. On October 6, 2020, at 12:15 p.m., the RNS was interviewed. She stated on March 22, 2020, at 7:00 a.m., while she was doing her morning rounds, she heard Resident A calling 911 about someone trying to kill her by suffocating her with a pillow. She stated she did not report the allegation of abuse to CDPH. She stated she reported the allegation of abuse to the DON on March 22, 2020, at around 8 a.m. She stated the allegation of abuse should have been reported to CDPH within two hours from the time the facility was made aware of the allegation. The facility's policy and procedure titled, Abuse Allegation Investigation and Prohibitive Abuse, dated November 2017, was reviewed. The policy indicated, .It is the policy of this facility to ensure that all alleged violation by anyone in the facility which involves mistreatment, exploitation, neglect, or abuse . are reported immediately to the facility Administrator and to the State agencies including local law enforcement and the Department of Public Health, Licensing and Certification .

Based on observation, interview, and record review, the facility failed to maintain an environment free from abuse for one resident (Resident 2) when the facility failed to re-assess Resident 1's risk for aggressive behavior before removing Resident 1 from 1:1 observation. This failure resulted in Resident 2 being hit by Resident 1. Findings: On (MONTH) 19, 2019, Resident 2's record was reviewed. Resident 2 was admitted on (MONTH) 25, 2019. Resident 2's history and physical dated (MONTH) 26, 2019 indicated that Resident 2 did not have the capacity to understand and make decisions. On (MONTH) 19 2019, at 11:30 a.m., Resident 2 was interviewed. Resident 2 stated Resident 1 came into the dining room and punch her on the right side of her back. Resident 2 stated she felt afraid and anxious because she could not take care of herself. Resident 2 further stated her back hurt for a week. On (MONTH) 19, 2019, at 9:30 a.m., the Activity Assistant (AA) was interviewed. The AA stated that on (MONTH) 21, 2019, at about 2 p.m., Resident 2 was in the dining room playing bingo. The AA stated Resident 1 entered the dining room and made his way to Resident 2. Resident 1 immediately hit Resident 2 on the right side of her back. On (MONTH) 19, 2019, at 9:45 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 1 was having severe anger and agitation toward Resident 2 starting on (MONTH) 20, 2019. The DON stated Resident 1 was placed on a 1:1 Certified Nursing Assistant (CNA) care on (MONTH) 20, 2019, at 1:09 p.m., but was taken off the 1:1 during the night shift of (MONTH) 21, 2019 and remained off the 1:1 during the day shift of (MONTH) 21, 2019. The DON also stated Resident 1 was placed on every 15-minute monitoring on 10/21/2019 starting at 6:30 a.m., per nursing protocol. However, that afternoon Resident 1 hit Resident 2. On (MONTH) 19, 2019, at 12:15, the DON was interviewed. The DON stated the facility did not have a policy or procedure to re-assess residents before removing residents from 1:1 observation. The DON stated Resident 1 hit Resident 2 in the dining room on (MONTH) 21, 2019, at 2 p.m., despite every 15-minute monitoring from the CNA staff. The DON further stated Resident 1 should have remained on 1:1 observation. The facility policy and procedure titled Abuse Allegation Investigation & Prohibitive Abuse Policy and Procedure, revised (YEAR), was reviewed. The policy indicated .Instances of abuse of all residents, irrespective any mental or physical condition, cause physical harm, pain or mental anguish .abuse means the individual must have acted deliberately not that the individual must have intended to inflect injury or harm .

Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident A was free from sexual abuse, when Resident A was left in the dining room on (MONTH) 18, (YEAR), without staff supervision with other residents, including Resident B, who had a known behavior of sexual inappropriateness; and 2. Ensure Resident A does not experience another sexual abuse, when Resident A was left in the dining room without staff supervision for the second time on (MONTH) 29, (YEAR), with other residents, including Resident C, who had a known behavior of sexual inappropriatess. These failures resulted in Resident A to be sexually abused twice while at the facility. Findings: 1. On (MONTH) 20, (YEAR), at 9:30 a.m., an unannounced visit was conducted to investigate a facility reported incident related to sexual abuse. On (MONTH) 20, (YEAR), at 10:23 a.m., Resident A was observed in the dining room sitting in a wheelchair, leaning forward, with her head resting on the table. Resident A did not wake up when her name was called. On (MONTH) 20, (YEAR), at 10:25 a.m., the facility Administrator was interviewed. The facility Administrator stated he was informed by the Restorative Nursing Assistant (RNA) 1 on (MONTH) 18, (YEAR), of an incident of sexual abuse involving Residents A and B. The facility Administrator stated RNA 1 had witnessed the incident. On (MONTH) 20, (YEAR) at 1:27 p.m., RNA 1 was interviewed. RNA 1 stated on (MONTH) 18, (YEAR), at around 10 a.m., she walked into the dining room and saw Resident B in a sitting position facing the wall and was hunched over Resident A. RNA 1 saw Resident A's shirt was pulled up over her breasts and Resident B's left hand was squeezing the right breast of Resident A while his mouth was sucking on Resident A's left breast. RNA 1 also stated there were a lot of residents in the dining room at that time but did not see any staff. RNA 1 also stated she immediately separated Residents A and B and called for help. RNA 1 further stated Activity Assistant (AA) 1 came into the dining room when she called for help. On (MONTH) 20, (YEAR), Resident A's clinical record was reviewed. Resident A was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Resident A's History and Physical, dated (MONTH) 10, (YEAR), indicated Resident A did not have the capacity to understand and make decisions. Resident A's Minimum Data Set (MDS- a comprehensive assessment and care-planning tool), dated (MONTH) 18, (YEAR), indicated Resident A had severe cognitive impairment (condition when a person has trouble remembering, learning new things, concentrating or making daily decisions affecting daily life), required limited assistance with one-person assist with ambulation, and was totally dependent on staff with eating, toileting, personal hygiene, and bathing. On (MONTH) 20, (YEAR), Resident B's clinical record was reviewed. Resident B was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. Resident B's MDS, dated (MONTH) 27, (YEAR), indicated resident B had clear speech, made self understood, and had the ability to understand others, had moderately impaired cognition, required limited assistance with one-person assist with ambulation, toileting, and personal hygiene, and able to move to and return from off-unit locations (including dining and activities) with supervision using a wheelchair. Resident B's care plan titled, Impaired Behavior Status, indicated the following: a. On (MONTH) 22, (YEAR), .sexually inappropriate behavior m/b (manifested by) attempting to place his hand into a female resident's pants . The goal for this problem indicated, .will have no episode of inappropriate behavior . The care plan was re-evaluated on (MONTH) (YEAR) and (MONTH) (YEAR). One of the approaches/plan included was to attempt to redirect resident; b. On (MONTH) 5, (YEAR), Inappropriate behavior m/b trying to touch a female resident, was documented. There were no approaches/plans developed to address this behavior; and c. On (MONTH) 22, (YEAR), Inappropriate behavior of touching another female resident, was documented. The approaches/plan included to monitor Resident B's behavior closely and remind resident not to go near the other resident. Resident B's nurse's notes, dated (MONTH) 23, (YEAR), indicated Resident B was observed behind another resident in the dining room, with Resident B's hands under the resident's left sleeves, grabbing her chest. Nurse's notes further indicated Resident B was put on 72 hours monitoring for inappropriate behavior and frequent visual check. Resident B's nurse's notes, dated (MONTH) 18, (YEAR), indicated, At approximately 1000 am staff notified this writer of resident having a sexual inappropriate BX (behavior) in dinning (sic) area. Staff member observed male resident leaning forward a female resident, while having her shirt pulled over breasts. He was holding her R (right) breast in his mouth .Resident (Resident B) had New order to send resident out to (name of psych hospital) for further Eval (evaluation) . On (MONTH) 29, (YEAR), at 10:18 a.m., AA 1 was interviewed. AA 1 stated he was the one assigned to provide supervision in the dining room on (MONTH) 18, (YEAR), for residents who attend activities. AA 1 stated Residents A and B were present in the dining room during the activity. AA 1 also stated he was aware of Resident B's previous episodes of inappropriate sexual behavior towards other female residents. He stated facility staff provided closer monitoring to residents who had previous inappropriate behavior to make sure they were not too close to female residents. AA 1 also stated he stepped out of the dining room three times and went to Nursing Station 1 to remind nursing staff to pass snacks to residents. AA 1 also stated when he came back to the dining room after the third time, RNA 1 already separated Resident B from Resident A. AA 1 further stated he should not have left the dining room. On (MONTH) 29, (YEAR), at 11:10 a.m., the facility Administrator was interviewed. The facility Administrator stated AA 1 was assigned to the dining room when the incident happened between Residents A and B. The facility Administrator also stated there should always be a staff present in the dining room when residents are present. On (MONTH) 29, (YEAR), at 3:40 p.m., the Director of Nursing (DON) was interviewed. The DON stated, Staff should be present in the dining area if there are residents who were identified before with behavior of sexual inappropriateness. On (MONTH) 18, (YEAR), the (Name of county) County Sheriff's incident report dated (MONTH) 18, (YEAR), was reviewed. The sheriff's incident report indicated, on (MONTH) 18, (YEAR), the sheriff reviewed the surveillance video of the incident with the Administrator. The incident report indicated, .In the surveillance video you can see several clients and two staff members in the dining room. As the staff members walked out of the dining room, you can see (Resident B's name) wheel himself to where Doe (an injunction used for someone whose identity was not known at the time it was issued/Resident A) was sitting. The incident report indicated Resident B leaned over onto Resident A's torso and stayed in the same position for approximately 10-15 minutes without interruption, until RNA 1 approached Resident B and separated him from Resident A. 2. On (MONTH) 29, (YEAR), at 8:10 a.m., another visit was conducted at the facility to investigate a second incident of sexual abuse involving Resident A by another male resident (Resident C). On (MONTH) 29, (YEAR), at 1:08 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated there was an incident of sexual abuse that happened involving Residents A and C Right before change of shift this morning. CNA 1 also stated Resident D was the witness. CNA 1 further stated Resident D was interviewable. On (MONTH) 29, (YEAR), at 1:12 p.m., Resident A was observed up in a wheelchair in the small activity room. Resident A did not make any eye contact, and did not respond verbally when asked how she was doing. On (MONTH) 29, (YEAR), at 1:14 p.m., CNA 2 was interviewed. CNA 2 stated when there was a resident in the TV room or dining room, a staff should always be there. On (MONTH) 29, (YEAR), at 1:16 p.m., Resident D was interviewed with CNA 2 present. Resident D stated she was in the dining room on (MONTH) 29, (YEAR), at around 5:30 a.m. Resident D also stated she saw Resident C sucking on Resident A's breast one at a time, with Resident C's hand touching Resident A's crotch area and masturbated her. Resident D also stated there was no staff present in the dining room when the incident happened. Resident D also stated she yelled, He's (Resident C) sucking her (Resident A) tities (breast), and help, help. Resident D further stated Resident C ran away from Resident A when she yelled for help. On (MONTH) 29, (YEAR), at 2:45 p.m., CNA 3 was interviewed regarding the incident involving Resident A and C. CNA 3 stated she got Resident A up in a wheelchair and to the dining room on (MONTH) 29, (YEAR), at around 5:40 a.m. CNA 3 also stated there were about six or seven residents in the dining room, including Residents C and D. CNA 3 also stated she stepped out of the dining room and was in the hallway near Nursing Station 1 when she heard somebody yelled from the dining room. CNA 3 also stated she ran into the dining room and saw Resident C looking frightened and was walking very fast away from Resident A. CNA 3 also stated Resident D was yelling, He's (Resident C) sucking on (Resident A's) tities. CNA 3 also stated she thought it would be safer for Resident A to stay in the dining room because there were more people in there. CNA 3 also stated she was aware of Resident C's history of inappropriate gestures of touching other female residents and she would always remind Resident C not to do it. CNA 3 also stated Resident A was an easy target because she was non-verbal and could not defend herself. CNA 3 further stated she could not recall if there was a staff present in the dining room. On (MONTH) 29, (YEAR), at 3:11 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, on (MONTH) 29, (YEAR), at around 5:40 to 5:50 a.m., while he was inside Nursing Station 1, he heard somebody yelling from the dining room. LVN 1 also stated he rushed into the dining room behind CNA 3. LVN 1 also stated by the time he went into the dining room, he saw Resident D by the exit door near the front lobby. LVN 1 also stated there was no staff present in the dining room when the incident happened. LVN 1 further stated a sheriff came within 20 minutes and interviewed Resident D. On (MONTH) 29, (YEAR), at 3:30 p.m., a follow-up interview was conducted with Resident D. Resident D stated, there was no staff present this morning at around 5:30 in the dining room when Resident C, sucked Resident A's tities. Resident D also stated, (Resident C's name) grabbed (Resident A's name) crotch and masturbated her. Resident D stated staff came to the dining room after she yelled for help. On (MONTH) 20, (YEAR), Resident A's clinical record was reviewed. Resident A was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Resident A's History and Physical, dated (MONTH) 10, (YEAR), indicated Resident A did not have the capacity to understand and make decisions. Resident A's MDS, dated (MONTH) 18, (YEAR), indicated Resident A had severe cognitive impairment, required limited assistance with one-person assist with ambulation, and was totally dependent on staff with eating, toileting, personal hygiene, and bathing. Resident A's Departmental Notes, dated (MONTH) 18, (YEAR), indicated, .resident was sitting in dining room with male resident sitting facing her leaning forward .female's shirt was pulled over her breasts .male resident had his left hand on right breast as he squeezed it .he had his mouth on her left breast .female resident placed on 72 hour monitoring for emotional distress . Resident A's Short Term Care Plan, dated (MONTH) 18, (YEAR), indicated Resident A was at risk for emotional distress due to recent events with male resident. The interventions included: - Encourage resident to participate in activities; - Report to MD (Medical Doctor) any change of condition; - Assess for pain and discomfort; and - Frequent visual check to ensure comfort. Resident A's Psychology Consult, dated (MONTH) 19, (YEAR), indicated, .Patient was referred to be evaluated as a result of an incident related to inappropriate touching by a male resident towards patient .patient presented calm and mostly unresponsive .does not show any emotion .evaluated for emotional distress .patient does not seem to be aware of the incident . On (MONTH) 29, (YEAR), Resident C's clinical record was reviewed with the DON (Director of Nursing). Resident C was admitted to the facility on (MONTH) 8, (YEAR). Resident C's Annual Physician Assessment, dated (MONTH) 1, (YEAR), indicated Resident C did not have the capacity to understand and make decisions. Resident C had [DIAGNOSES REDACTED]. Resident C's Behavior Care Plan, dated (MONTH) 20, (YEAR), indicated, .Problems/Needs .needs behavior management r/t (related to) touching the female residents and staff .goals .will have less episode of behavior to touch the female .behavior will be redirected daily x (times)3 months .approaches/plan .monitor episodes of behavior every shift for inappropriateness .educated the resident to stop that behavior because this inappropriate .redirect the resident to other activities .Re-eval (Re-evaluation) dates .5/17 (May (YEAR)) .8/17 (August (YEAR)) .11/17 (November (YEAR)) .2/18 (February (YEAR)) . Resident C's Departmental Notes, dated (MONTH) 21, (YEAR), indicated, .IDT (Interdisciplinary Team) for 2/20/2017 .Resident grabbed/touched a female resident's left breast then he walked away .IDT recommendation .monitor resident's behavior closely .move other resident away when he is walking in the hallway .remind staff to step away when resident walks in his way . Resident C's Behavior Care Plan, dated (MONTH) 7, (YEAR), indicated, .Problem/Needs .touching inappropriately other female resident . There were no approaches/plans developed to address this behavior. Resident C's Departmental Notes, dated (MONTH) 8, (YEAR), indicated, .IDT review for 3/07/2017 .a female resident was heard screaming for assistance when this resident grabbed her hand and place it inside his pants .IDT recommends to do frequent visual check and to monitor . Resident C's Behavior Care Plan, dated (MONTH) 16, (YEAR), indicated, .Problem/Needs .touching female resident unnecessarily . There were no approaches/plans developed to address this behavior. Resident C's Departmental Notes, dated (MONTH) 17,2016, indicated .IDT review for 4/16/2017 .Resident was found grabbing another female resident by her hips .IDT recommends to redirect when around female residents; educate on inappropriate behavior . Resident C's Psychological Services Progress Notes, dated (MONTH) 17, (YEAR), indicated, .continued to experience difficulties with boundaries .sat with patient and talked about .inappropriate vs (versus) appropriate touching .he laughs as if he is aware he acts inappropriately, he agreed to try . Resident C's Psychological Services Progress Notes, dated (MONTH) 7, (YEAR), indicated, .continues to experience delusions (false belief) and inappropriate behavior . worked on psychoeducation about appropriate vs inappropriate touching . he listens and stops, however staff continues to report ongoing inappropriate behavior . Resident C's Psychological Services Progress Notes, dated (MONTH) 21, (YEAR), indicated, .continues to experience .difficulties interacting appropriately and inappropriate touching and gestures . Resident C's Psychological Services Progress Notes, dated (MONTH) 3, (YEAR), indicated, .continues to experience anxiety, inappropriate boundaries and inappropriate touching .engaged resident by pointing out appropriate approach . Resident C's Psychology Progress Notes, dated (MONTH) 28, (YEAR), indicated, .tends to approach people and want to touch female's buttocks and think it is funny . Resident C's MDS dated (MONTH) 17, (YEAR), indicated Resident C had severe cognitive impairment, and did not require assistance with transfers and ambulation. On (MONTH) 29, (YEAR), at 3:35 p.m., the facility Administrator was interviewed. The facility Administrator stated it was CNA 2 who got Resident A up to the dining room at around 5:40 a.m. on (MONTH) 29, (YEAR). The facility Administrator also stated the dining room was left unsupervised for a couple of minutes. The facility Administrator also stated there should always be a staff present in the dining room when residents are present. On (MONTH) 29, (YEAR), at 3:40 p.m., the DON was interviewed. The DON stated Staff should be present in the dining room if there are residents who were identified before with behavior of sexual inappropriateness. The DON also stated Resident A was placed on one-on-one sitter after the second incident of sexual abuse to Resident A. The DON further stated the facility would arrange for Resident A to be transferred to another facility. On (MONTH) 1, (YEAR), the (Name of county) County Sheriff's incident report dated (MONTH) 29, (YEAR), was reviewed. The Sheriff's incident report indicated, .I responded to a reported call of sexual battery .The surveillance video showed on 12/29/17, about 0540 hours, (Resident C's name) grabbing (Resident A's name) breasts and vagina .The video also showed (Resident C's name) lifting (Resident A's name) shirt to expose her breasts .(Resident C's name) then bent over and placed his mouth in the area of (Resident A's name) breasts .I placed a 5150 WIC (section of Welfare and Institutions Code - authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes them a danger to themselves, a danger to others, or gravely disabled) hold on (Resident C's name) for being a danger to others and gravely disabled . The facility policy and procedure (P/P) titled, Abuse Prevention Program, dated (MONTH) 2006, was reviewed. The P/P indicated, . residents have the right to be free from abuse .Our abuse prevention program provides policies and procedures that govern, as a minimum .Identification of occurrences and patterns of potential mistreatment/abuse .An ongoing review and analysis of abuse incidents .The implementation of changes to prevent future occurrences of abuse.

Based on observation, interview, and record review, the facility failed to provide supervision and necessary care for one of three sampled residents (Resident A) when Resident A, who was NPO (nothing by mouth) and known to steal food from other residents' meal trays, was found unresponsive and blue in a resident room. These deficient practices caused Resident A to choke on a meatball. The facility performed the [MEDICATION NAME] maneuver (a technique using abdominal thrusts in an attempt to remove a foreign body from the throat or windpipe of a choking person) for ten minutes before Resident A was checked for breathing which delayed initiation of CPR (Cardio-Pulmonary Resuscitation), resulting in irreversible brain damage and death of Resident A. Findings: On (MONTH) 27, (YEAR), at 10:50 a.m., an unannounced complaint visit was conducted at the facility regarding a quality of care concern. On (MONTH) 27, (YEAR), at 11:33 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated Resident A was non-compliant with his NPO diet because he could not eat due to swallowing difficulties. The RNS stated Resident A required bolus feedings (a one time feeding as opposed to continuous feeding) through a gastrostomy tube (a tube placed directly into the stomach surgically to provide nourishment and medications). The RNS stated Resident A would pace from room to room and grab food from other residents' food trays. The RNS stated Resident A knew where the feeders (residents fed by staff) were. He said Resident A could walk independently and further stated the resident was supposed to be monitored frequently by visual checks. The RNS stated there were a couple of times the resident managed to get food in his mouth, but staff were able to remove the food before he choked. The RNS stated he heard an overhead page for Code Blue (a page used to signal staff of a respiratory and/or [MEDICAL CONDITION]) on (MONTH) 12, (YEAR), around late morning. When he entered Room X, Resident A was unresponsive. He said LVN 1 was performing the [MEDICATION NAME] maneuver on Resident A. RNS stated LVN 1 was standing behind the resident, lifting him up while doing abdominal thrusts. He stated Resident A had chunks of food around his mouth. RNS said they failed to clear the resident's airway with the [MEDICATION NAME] maneuver so he called 911 (Emergency Medical Services paramedics). The RNS stated that after he called 911, he and LVN 1 laid the resident on the floor and performed CPR He said when the paramedics arrived, they took over CPR, intubated (a tube placed into the windpipe to provide ventilation) the resident and transported Resident A to the acute hospital. The RNS stated later he received report from the acute care hospital that Resident A had choked on a meatball. On (MONTH) 27, (YEAR), at 11:50 a.m., Licensed Vocational Nurse 1 (LVN 1) was interviewed. She stated Resident A was, Nice and pleasant, but could not understand why he could not have anything to eat by mouth. She said facility staff needed to be behind him continuously and re-direct him all the time when he grabbed food from other residents' trays. LVN 1 stated Resident A was everywhere around the facility and the staff caught him snatching food from other residents. She said the facility's Speech Therapist did an evaluation for Resident A's swallowing ability, and the resident failed it twice. LVN 1 further stated she heard a stat (immediate) page for Room X while she was in the dining room during lunch time on (MONTH) 12, (YEAR). She said when she walked into the room, Resident A was leaning over the foot of the bed and was not responding. The room was not Resident A's. She stated she did a finger sweep of the resident's mouth and found nothing. LVN 1 said after the finger sweep was done, she managed to get the resident up on his feet and performed the [MEDICATION NAME] maneuver. When asked how long she performed abdominal thrusts, LVN 1 stated she was not sure, but it Seemed like forever. Maybe ten minutes. She said Resident A was too heavy to carry so RNS helped her carry him while she performed the [MEDICATION NAME] maneuver. LVN 1 stated she was in a panic mode, and that ([MEDICATION NAME] maneuver) was the first thing that came into her mind after finding him on the bed. She said the RNS called 911. She said she laid the resident on the floor and started CPR. The RNS returned and helped with the chest compressions. LVN 1 stated, EMS then arrived at the scene and helped with the CPR, and then took the resident to the hospital. On (MONTH) 27, (YEAR), at 1:48 p.m., Certified Nurse Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned to Resident A on the day shift (MONTH) 12, (YEAR). CNA 1 stated Resident A was not on frequent visual checks. She stated she changed Resident A's diaper before lunchtime and then around 1:30 p.m., after lunch, she heard the Code Blue page. When CNA 1 entered the room she saw LVN 1 doing the [MEDICATION NAME] maneuver. CNA 1 continued by saying the resident had been walking around the facility's hallways before the incident occurred. CNA 1 stated he Always takes food. CNA 1 stated he should have been closely watched. She further stated the resident should have been assigned a one to one caregiver for close supervision. On (MONTH) 27, (YEAR), at 2:10 p.m., the Director of Nursing (DON) was interviewed. The DON stated staffing was not an issue and the facility could have easily had a one to one care giver to increase supervision. The DON stated the Activities Assistant (AA) was the one who found Resident A first. The DON stated Resident A was found unresponsive and slumped over by the foot of the bed. The DON stated LVN 1 performed the [MEDICATION NAME] maneuver and RNS performed CPR. On (MONTH) 27, (YEAR), Resident A's facility record was reviewed. Resident A was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the record titled HISTORY AND PHYSICAL, dated (MONTH) 22, (YEAR), indicated Resident A did not have the capacity to understand and make decisions. On (MONTH) 27,2017, a form titled, Physician order [REDACTED]. The physician orders, for the month of (MONTH) (YEAR), were reviewed and indicated, .DIET: NPO; [MEDICATION NAME] (a tube feeding formula) 1.2 CAL (calories) BOLUS FEEDINGS . [DATE] .ST (speech therapy) .order for TX (treatment) of Dysphagia (difficulty swallowing) .3/wk (three times a week) x 30 days . Resident A's care plans were reviewed and located care plans for .Aspiration (breathing a foreign substance into the lungs) and Dysphagia, (difficulty swallowing) both dated in (MONTH) (no date ) (YEAR). The care plan for aspiration indicated potential for injury and aspiration related to impaired swallow ability. The care plan indicated Resident A was non-compliant with his NPO diet order, picked up food from other resident's trays, and put the food items in his mouth. The care plan's goal indicated that Resident A would not have any incidents of aspiration for 90 days and lung sounds would remain clear. The facility interventions were to re-direct the resident to be away from the dining area at meal times, monitor the resident's whereabouts, and frequent reminders to not take food from others and not put the food in his mouth. The care plan for aspiration was revised on (MONTH) 16, (YEAR), and indicated Resident A was a high risk for aspiration due to grabbing food from other trays. A speech evaluation was done on (MONTH) 15, (YEAR) and indicated Resident A had difficulty managing his own saliva, had poor safety awareness and significant impaired cognition. The facility staffs' interventions were to have frequent reminders not to grab food from other residents' trays and to re-direct his attention during meal times. In addition, the staff were to provide different activities during mealtime and monitor his whereabouts/coughing and aspiration. A review of Resident A's care plan for dysphagia initiated on (MONTH) 20, (YEAR), indicated Resident A had a swallowing impairment due to Alzheimer's or dementia manifested by difficulty swallowing. The care plan indicated Resident A would grab food and put the food in his mouth. The care plan also indicated Resident A picked up food on other residents' trays and hid food in his clothes. The facility's interventions were to have a ST evaluation and treatment as ordered and to remind the resident not to have food in his mouth. On (MONTH) 12, (YEAR), the care plan was revised after the first swallow evaluation was completed by a speech therapist. The plan indicated Resident A was a high risk for aspiration due to non-compliance of nothing by mouth diet. The care plan further indicated Resident A failed the swallowing evaluation and was to continue the NPO diet. The care plan further indicated Resident A had increased mouth opening and was unable to have labial (lip) seal during swallowing, had a consistent cough, immediate cough during food trials, and was unable to follow simple swallow instructions. The care plan further indicated for facility staff to encourage Resident A to refrain from putting food into his mouth, and to re-direct the resident to step out from the dining area. A second swallowing screen was conducted on (MONTH) 15, (YEAR). The report, ST (Speech Therapist) Swallow Screen indicated, Pt (patient - Resident A) was referred to ST screen for possible po (oral) feeding. ST recommend to continue NPO with peg (Percutaneous Endoscopic Gastrostomy) feeding at this time to prevent aspiration and meet nutritional hydration needs. Pt is not a candidate for ST services, communicated to nursing for screen result. On (MONTH) 16, (YEAR) an Interdisciplinary Team (IDT) meeting was conducted due to Resident A's behavior of grabbing food on tray (sic) and other places. There was no documented evidence of any new recommendations made by the IDT. On (MONTH) 27, (YEAR), facility records titled Departmental Notes, were reviewed for (MONTH) 12, (YEAR), and indicated: -AT 1:45 PM. RESIDENT WAS FOUND BY HOUSE KEEPING SLUMPED OVER FOOT OF BED. FOOD WAS FOUND ON BED, SWEEP OF MOUTH WAS DONE NO FOOD WAS FOUND. [MEDICATION NAME] MANEUVER (sic) WAS STARTED. 911 WAS CALLED. RESIDENT WAS NOT BREATHING, CPR WAS THEN STARTED. 1:55 PM, CONTINUED WITH CPR. NO VITALS NOTED. 2 PM PARAMEDICS ARRIVED. CONTINED (sic) WITH CPR. 2:10 PM RESIDENT WAS TAKEN TO (hospital name) VIA GURNEY. VITALS WERE OBTAINED PRIOR TO LEAVING . An additional note written by the DON on (MONTH) 12, (YEAR), read: -[DATE] .3:27 PM .Resident was found by staff slumped over the bed and appeared to have difficulty breathing around 1355 (1:55 p.m.). Code Blue was called, license nurses proceeded to resident room. Swept resident mouth, unable to obtain any food. Suction resident using [MEDICATION NAME] (the name of a suction tip), no secretion noted. Staff provided [MEDICATION NAME] (sic) maneuver to no avail. Pulse thread (sic) and weak. Resident turned cyanotic (blue color to the skin), breathing ceased. Placed resident on the floor, CPR initiated while other staff member called 911 . arrived around 1400 (2 pm) with paramedics and took over patient care. IV (intravenous line) start to right knee via intra osseous (a needle that is injected directly into the bone marrow to allow fluids to get into circulation when a vein cannot be accessed), Hydration provided, Resident was intubated (placement of a tube down the windpipe so that artificial respirations can be provided) without difficulty. Able to obtain vitals sign (blood pressure and pulse) prior to transfer. Resident was placed in gurney and transfer to (hospital name omitted) per EMT (emergency medical technicians) @ 1415 (2:15 p.m.). Review of the record titled Patient Care Report, dated (MONTH) 12, (YEAR), indicated the time of the [MEDICAL CONDITION] was at 1:40 p.m. and the call from the facility was received at 1:45 p.m. The paramedics were at the scene at 1:51 p.m. The primary impression was airway obstruction and respiratory arrest. Further review of the paramedics records indicated at 1:51 p.m., the paramedics arrived at the scene of a [AGE] year old male in [MEDICAL CONDITION] and pulseless electrical activity on the EKG (electrocardiogram) machine. The record also indicated no blood pressure, pulse, or respirations on the paramedics' arrival. The paramedics administered Oxygen, [MEDICATION NAME] (a medication used during resuscitation of [MEDICAL CONDITION]), and intubated Resident A. The resident's pulse returned, and he was transported to the acute care hospital. On (MONTH) 29, (YEAR), at 2:47 p.m., the AA (Activity Assistant) was interviewed. The AA stated before the activities started, he walked down the hallways to see if any residents wanted to join the activities the day of (MONTH) 12, (YEAR). When the AA walked by Room X, he said he saw Resident A lying long ways on the bed, looking down. The AA stated Resident A's face was blue, and was unable to talk or respond when talked to. The AA stated Resident A eyes were white and rolled. The AA stated he pressed the call light and yelled for help. The AA grabbed the resident from the back and started to do the [MEDICATION NAME] maneuver. The AA stated Resident A was not breathing and was blue. The AA stated he had never seen anybody with that kind of blue color before during his career as an activities assistant. The AA stated he saw an empty carton of milk by the bed. The AA stated LVN 1 took over, and while Resident A was already blue, she performed the [MEDICATION NAME] maneuver. The AA said the nurses laid Resident A onto the floor and performed CPR. He said they (staff) were pumping for a while. The AA stated the paramedics took a while to get to the facility. On (MONTH) 30, (YEAR), at 2:41 p.m., Resident A was observed in his hospital room. He was non-verbal and non-responsive when spoken to. Resident A's acute hospital records were reviewed. The acute hospital record titled INTERNAL MEDICINE HISTORY AND PHYSICAL, dated (MONTH) 12, (YEAR), indicated Resident A was brought in by EMS for choking. The acute care hospital documented that the resident had a [DEVICE] and was not supposed to eat, but apparently was eating cookies and started to choke. [MEDICATION NAME] was performed and Resident A went apneic (stopped breathing), downtime about 8 minutes, CPR performed, 2 rounds of epi ([MEDICATION NAME] - a medication use in cardio-pulmonary arrest) given and(NAME)airway (a sterile tube inserted in the mouth used to provide artificial oxygenation) placed by EMS. A document written by the Emergency Department Physician (EDP) indicated that she (EDP) had removed a piece of meatball that measured four centimeters from Resident A's throat. A review of the facility's production menus, from (MONTH) 12, (YEAR), until (MONTH) 18, (YEAR), indicated on (MONTH) 12, (YEAR), the facility served Swedish meatballs to the residents at lunch. A review of the acute hospital record titled CRITICAL ARE PROGRESS NOTE, dated (MONTH) 12, (YEAR), indicated Resident A had a [DIAGNOSES REDACTED]. Paperwork was submitted to the Bioethics Team (a group who review moral issues regarding life extension) for cessation of life support. Further review of the acute hospital record titled BIOETHICS RECORD OF CASE REVIEW, dated (MONTH) 15, (YEAR), indicated, .Reason for Referral: Assistance with end of life and code status decisions for patient (Patient A) with Conservator . The record went on to read EXPECTED OUTCOMES: Poor prognosis for functional recovery. Anticipate hospital-based death . On (MONTH) 3, (YEAR), at 11:22 a.m., the hospital LCSW was interviewed over the telephone. She stated Resident A had passed away on (MONTH) 1, (YEAR). The LCSW said the Bioethics Team had removed life support from the resident so that he could pass peacefully. On (MONTH) 1, (YEAR), EDP was interviewed over the telephone. The EDP stated Resident A was not supposed to eat. She said the facility nurses tried to perform the [MEDICATION NAME] maneuver. She said the resident was not intubated at the facility but had a(NAME)airway in place on arrival at the emergency room . The EDP stated she intubated (placement of a tube into the trachea (windpipe) to provide artificial ventilation) Resident A and found food that resembled a meatball on the back of the patient's throat by the vocal chords. She said it was round and had consistency of ground up meat. The EDP stated she was not able to talk to nursing at the facility but received a report from the paramedics that Resident A was on peg tube feedings and choked on food he had attempted to eat. On (MONTH) 10, (YEAR), Resident A's record titled Coroner Investigation, dated (MONTH) 1, (YEAR), indicated Resident A had died on (MONTH) 1, (YEAR), at 6:48 p.m. at the acute care hospital. The record further indicated, .While en route (from the facility to the acute care hospital), Resident A was resuscitated and while in the Emergency Department, physicians were able to remove a piece of meatball from his airway. Resident A remained in a comatose state since his admission and his condition never improved. Due to his poor prognosis, his physicians placed a do not resuscitate order on [DATE] at 1123 (11:23 a.m.) hours due to Resident A having no known family to make healthcare decisions for him. He was then extubated (the tube in his windpipe was removed) at 1300 (1 p.m.) hours as part of a terminal wean (removal of all life support medications and devices) and continued to experience [MEDICAL CONDITION] until he was pronounced dead at 1848 (6:48 p.m.) hours by (doctor's name) . Further review of the Coroner Investigation, dated (MONTH) 2, (YEAR), indicated the causes of death were hypoxic [MEDICAL CONDITION] ([MEDICAL CONDITION] caused by oxygen deprivation to the brain) due to asphyxia (suffocation) and choking on food. Other significant conditions contributing to his death were dysphagia. On (MONTH) 7, (YEAR), Resident A's death certificate, dated (MONTH) 14, (YEAR), indicated the resident's causes of death on (MONTH) 1, (YEAR), 19 days after choking on a meatball, were hypoxic [MEDICAL CONDITION], asphyxia, and choking on food.

Based on interview, and record review, the facility failed to provide adequate supervision for one resident (Resident A) in a sample of three residents who was known to be an aspiration risk and compulsive food seeker. This failure caused Resident A to choke on another resident's food, become unresponsive, require CPR (cardio- pulmonary resuscitation) with transportation to the acute care hospital via paramedic ambulance where the resident died 19 days later due to anoxic brain injury (no oxygen supplied to the brain). Findings: On (MONTH) 27, (YEAR), at 10:50 a.m., an unannounced complaint visit was conducted at the facility regarding a quality of care concern. The complaint intake indicated Resident A had choked on a meatball and was sent to an acute care hospital. On (MONTH) 27, (YEAR), at 11:33 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated Resident A was non-compliant with his diet because he could not eat due to swallowing difficulties. The RNS stated Resident A required bolus feedings (a one time feeding as opposed to continuous feeding) via gastrostomy tube (a tube placed directly into the stomach by surgery to provide nourishment, liquids, and medications). The RNS stated Resident A would pace from room to room and grab food from other residents' food trays. The RNS stated the resident knew where the feeders (residents fed by staff) were He stated Resident A could walk independently. The RNS further stated the resident was supposed to be monitored frequently by visual checks, but he managed to get food into his mouth a couple of times. The RNS said staff were able to remove the food on those occasions before he choked. Around late morning on (MONTH) 12, (YEAR), the RNS stated he heard an overhead page for Code Blue (a page used to signal a respiratory and/or cardiac arrest) to alert staff at the facility, around late morning. He said when he entered Room X (not resident's room), Resident A was unresponsive. He said Licensed Vocational Nurse 1 (LVN ) was performing the Heimlich maneuver (a technique using abdominal thrusts to remove a foreign body such as food from the throat or windpipe of a choking person) on Resident A. The RNS stated LVN 1 was standing behind the resident, lifting him up while doing abdominal thrusts. He stated Resident A had chunks of food around his mouth when they tried to suction his mouth. RNS said they failed to clear the resident's airway with the Heimlich maneuver so he called 911 (Emergency Medical Services). The RNS stated that after he called 911, he and LVN 1 laid the resident on the floor and performed CPR (Cardio-Pulmonary Resuscitation). He said when the paramedics arrived, they took over CPR. The RNS said the paramedics intubated (a tube placed into the windpipe to provide artificial ventilation) the resident and transported (Resident A's name) to the acute care hospital. The RNS stated later he received report from the acute care hospital that Resident A choked on meatball. On (MONTH) 27, (YEAR), at 11:50 a.m., LVN 1 was interviewed. LVN 1 stated Resident A was nice and pleasant, but could not understand that he could not have anything to eat by mouth. She stated facility staff needed to be continuously behind him and re-direct him all the time when he grabbed food from other residents' food trays. LVN 1 stated Resident A was everywhere around the facility. Staff caught him snatching food from other residents. LVN 1 stated the facility had a swallow evaluation done by a speech therapist, and he failed it twice. LVN 1 stated she heard a Stat (immediately) page while she was in the dining room on (MONTH) 12, (YEAR). She stated when she walked into the room, (Resident A's name) was leaning over the foot of the bed and was not responding. She said the room belonged to one of his friends where he knew he could get food. LVN 1 stated (Resident A's name) had a girlfriend and that resident thought the resident was her husband. LVN 1 stated the staff told the resident that he cannot eat, but the staff needed to constantly watch her room and the dining room and always be behind him. LVN 1 stated when she found the resident, she did a finger sweep in (Resident A's name) mouth and found nothing. Then, she said she managed to get Resident A up on his feet and performed the Heimlich maneuver, but that did not clear his airway (Resident A). On (MONTH) 27, (YEAR), at 1:48 p.m., the Certified Nurse Assistant 1 (CNA) was interviewed. CNA 1 stated she was assigned to Resident A on the day shift of (MONTH) 12, (YEAR). She stated Resident A was not on frequent visual checks. CNA 1 stated she changed his diaper before lunchtime and then around 1 p.m., after lunch, she heard the Code Blue page. When CNA 1 entered Room X, LVN 1 was doing the Heimlich maneuver. CNA 1 stated Resident A had been walking around the facility's hallways before the incident occurred. CNA 1 stated Resident A Always takes food. She said he should have been closely watched. CNA 1 stated Resident A name should have been assigned a one to one caregiver for close supervision. On (MONTH) 29, (YEAR), at 2:47 p.m., the Activity Assistant (AA) was interviewed. The AA stated before the activities started, he walked down the hallways to see if any residents wanted to join the activities the day of (MONTH) 12, (YEAR), around after lunch. When the AA walked by Room X which was not the resident's room, he noticed the Housekeeping staff (IHS) staring outside the room. When the AA entered Room 1, he observed Resident A lying long ways on the bed, looking down. The AA stated Resident A's face was blue, and he was unable to talk and respond when talked to. The AA stated Resident A's eyes were white and rolled. The AA stated he pressed the call light and yelled for help. The AA grabbed Resident A from the back and started to do the Heimlich maneuver. The AA stated Resident A was not breathing and was blue. The AA stated he had, Never seen anybody with that kind of color blue before during his career as an activities assistant. The AA stated he saw an empty carton of milk by the bed. Resident A's facility record was reviewed. Resident A was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's facility record titled HISTORY AND PHYSICAL, dated (MONTH) 22, (YEAR), indicated Resident A did not have the capacity to understand and make decisions. Resident A's facility record titled Physician order [REDACTED]. A review of Resident A's care plan titled .DYSPHAGIA, initiated on (MONTH) 20, (YEAR), indicated Resident A had a swallowing impairment due to Alzheimer's or Dementia manifested by difficulty swallowing. The care plan indicated Resident A would grab food and put food in his mouth. The care plan also indicated Resident A picked up food from other residents' trays and hid the food in his clothes. The facility's interventions were to have a Speech Therapy (ST) evaluation and treatment as ordered and to remind the resident not to have food in his mouth . On (MONTH) 12, (YEAR), a note written by a speech therapist was reviewed. The note indicated that the therapist had assessed the resident's swallow functions for his ability to take food by mouth since he consistently rummaged for po (oral) foods. Per ST Resident A had physical impairments (such as inability to control his saliva and/or close his lips around an object). The Speech Therapist determined the resident was at risk for aspiration, further decline in functions, and decreased participation. A review of the facility's records titled Departmental Notes, dated (MONTH) 1, (YEAR), at 9:48 a.m.,documented an IDT (Interdisciplinary Team - consisting of member from optional services provided in the facility) Review [DATE] at 5:35 Pm (sic) indicated, CNA notified CN (Charge Nurse) that resident was struck on the right side of his neck while attempting to take another residents food in the dining area. residnet (sic) is noted to take or pick at food. will cont (continue) to monitor . The On (MONTH) 9, (YEAR), the Departmental Notes written by nursing indicated that at 2:30 AM .Resident was pacing up and down hallway and bathroom; he was redirected several times but another resident became agitated and smacked him on his shoulder; no injury noted; IDT recommends: Monitor whereabouts; psych (psychiatrist) consult r/t (related to) pacing; inability to sleep . On (MONTH) 12, (YEAR), at 2:28 p.m., the Departmental Notes, indicated, AT 1:45 PM. RESIDENT WAS FOUND BY HOUSE KEEPING SLUMPED OVER FOOT OF BED. FOOD WAS FOUND ON BED, SWEEP OF MOUTH WAS DONE NO FOOD WAS FOUND. HEIMLACH MANEUVAR (sic) WAS STARTED. 911 WAS CALLED. RESIDENT WAS NOT BREATHING, CPR WAS THEN STARTED. 1:55 PM, CONTINUED WITH CPR. NO VITALS NOTED. 2 PM PARAMEDICS ARRIVED. CONTINED (sic) WITH CPR. 2:10 PM RESIDENT WAS TAKEN TO (hospital name) VIA GURNEY. VITALS WERE OBTAINED PRIOR TO LEAVING . On (MONTH) 27, (YEAR), a review of the facility's production menus, from (MONTH) 12, (YEAR), until (MONTH) 18, (YEAR), had been completed. The menus indicated the facility served Swedish meatballs to the residents for lunch on (MONTH) 12, (YEAR). On (MONTH) 30, (YEAR), Resident A's records from the general acute care hospital were reviewed. A review of the acute hospital record titled INTERNAL MEDICINE HISTORY AND PHYSICAL, dated (MONTH) 12, (YEAR), indicated Resident A was brought in by EMS (emergency medical services) for choking. Resident A had a [DEVICE] and was not supposed to eat, but apparently was eating cookies and started to choke. Heimlich was performed and went apneic (stopped breathing), downtime about 8 minutes, CPR performed, 2 rounds of epi (epinephrine) given and(NAME)airway (artificial airway) placed by EMS. In the emergency department, the doctor removed a piece of meatball. On (MONTH) 3, (YEAR), at 11:28 a.m., LVN 2 was interviewed. LVN 2 stated, A couple of months before Resident A aspirated on food and was sent to the hospital for pneumonia caused by the aspiration. LVN 2 said the resident was not on frequent visual checks. She stated Resident A had an altercation with another resident for entering his room and the other resident hit him on the shoulder. She further stated Resident A should have been on every 15 minute visual checks. The facility's policy titled Safety and Supervision of Residents, revised (MONTH) 2007, indicated: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Facility-Oriented Approach to Safety . Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A reviews of safety and incident/accident reports; and a facility wide commitment to safety and incident/accident reports, and a facility-wide commitment to safety at all levels of the organization . When accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible . Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents . Resident-Oriented Approach to Safety . Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS (Minimum Data Set) . The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents . Implementing interventions to reduce accident risks and hazards shall include the following . Communicating specific interventions to all relevant staff . Assigning responsibility for carrying out interventions . Providing training, as necessary . Ensuring that interventions are implemented . Documenting interventions . Monitoring the effectiveness of interventions shall include the following . Ensuring that interventions are implemented correctly and consistently . Evaluating the effectiveness of interventions . Modifying or replacing interventions as needed; and . Evaluating the effectiveness of new or revised interventions . Systems Approach to Safety . The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment . The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment .or if there is a change in the resident's condition . A review of the record titled Coroner Investigation, dated (MONTH) 1, (YEAR), indicated Resident A had died on (MONTH) 1, (YEAR), at 6:48 p.m. at the acute care hospital. The record further indicated, .While en route, Resident A was resuscitated and while in the Emergency Department, physicians were able to remove a piece of meatball from his airway. Resident A remained in a comatose state since his admission and his condition never improved. Due to his poor prognosis, his physicians placed a do not resuscitate order on [DATE] at 1123 (11:23 a.m.) hours due to Resident A having no known family to make healthcare decisions for him. He was then extubated (the artificial airway tube was removed) at 1300 (1 p.m.) hours as part of a terminal wean and continued to experience respiratory failure until he was pronounced dead at 1848 (6:48 p.m.) hours by (doctor's name omitted) . Resident A died 19 days after he had choked on the meatball. Further review of the Coroner Investigation, dated (MONTH) 2, (YEAR), indicated the causes of death were hypoxic [DIAGNOSES REDACTED] (brain injury caused by lack oxygen to the brain) due to asphyxia (suffocation) and choking on food. Other significant conditions contributing to his death were dysphagia. Resident A's death certificate, dated (MONTH) 14, (YEAR), indicated the causes of Resident A's death were hypoxic [DIAGNOSES REDACTED], asphyxia, and choking on food.

Based on observation, interview, and record review, the facility failed for two of 15 sampled residents (Residents 52 and 55) to: 1. Ensure Resident 55 received adequate supervision to prevent an accident.This failure resulted in Resident 55 having a fall, and suffered a left shin and left ankle fracture (break in the continuity of the bone) that required three surgical treatments to repair the left shin and left ankle fracture; and 2. Ensure Resident 52 was assessed for safety and appropriate use of siderails. This failure had the potential to put the resident at risk for injuries from accidents and entrapment. Findings: 1. On October 4, 2016, Resident 55's medical record was reviewed. Resident 55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (minimum date set- an assessment tool), dated August 18, 2016, indicated Resident 55 had moderate cognitive impairment (inability to think and/or decide with reasoning) and disorganized thinking. The MDS also indicated Resident 55 needed supervision with no physical help from staff with her bed mobility, transfer, walking, locomotion on and off unit, dressing, toilet use and personal hygiene. The care plan, dated May 5, 2016, identified Resident 55 was at risk for elopement (act or instance of running away) and had the behavior of running outside during the night shift stating I'm getting out of here. The facility's intervention for the elopement problem included, One on One (one facility staff to monitor and/or observe one resident at all times). The licensed nurse progress notes dated June 17, 2016, at 5:07 p.m., indicated Resident 55 was seen by another resident climbing out of the window in Room 9. The notes further indicated Resident 55 was found laying in the bushes in front of the building. After the incident on June 17, 2016, a care plan dated June 18, 2016, was developed. The care plan indicated Resident 55 had attempted to leave the facility and the facility's intervention was to continue monitoring Resident 1 on strict 1:1 (one on one) with CNA (Certified Nursing Assistant). The licensed nurse progress notes dated September 27, 2016, at 9:28 a.m., indicated Resident 55 was found outside the fence by the kitchen at around 12 midnight. The notes further indicated Resident 55 stated she hurt her foot and Resident 55 had swelling and pain on her left ankle and foot. On September 27, 2016, at 1:40 p.m., Resident 55 was transferred to the general acute care hospital emergency room for further evaluation due to an injury on her left ankle with possible fracture. On October 4, 2016, at 8:42 a.m., an observation of the outside fence was conducted with the facility Acting Director of Nursing (ADON). The ADON stated on September 27, 2016, sometime during the night shift, Resident 55 climbed over the fence which was approximately nine feet above the ground level, and fell to the ground on the other side of the fence. The ADON further stated, Resident 55 was supposed to be monitored 1:1 due to previous attempts of elopement in the facility. The ADON stated CNA 1 was supposed to provide 1:1 monitoring on Resident 55, however, CNA 1 was actually assigned to monitor both Resident 55 and her roommate before the incident happened. The ADON acknowledged facility did not follow Resident 55's care plan for one on one monitoring. On October 10, 2016, at 3:54 p.m., an interview was conducted with CNA 1. CNA 1 stated on the night shift of September 27, 2016, she was assigned to provide 1:1 monitoring for both Resident 55 and her roommate. CNA 1 stated both Resident 55 and her roommate had behavioral problems and had to be monitored 1:1 all the time. CNA 1 stated she had to clean Resident 55's roommate and was not able to stop Resident 55 when she left the room. CNA 1 stated by the time she had the chance to look for Resident 55, the resident had already climbed over the fence and fell to the ground. CNA 1 stated she did not provide 1:1 monitoring on Resident 55 because she had to watch the roommate at the same time. On November 23, 2016, at 10:15 a.m., the facility Administrator was interviewed. The Administrator stated 1:1 monitoring on a resident would mean one CNA will be assigned to monitor only one resident. The Administrator stated the CNA assigned to provide 1:1 should be with the resident at all times. The facility's undated policy and procedure titled, One-On-One Observation Policy and Procedure, was reviewed. The policy indicated, .When a resident's condition changes .IE: behavioral natures .elopements .a One-On-One Observation will be implemented . On January 9, 2017, Resident 55's hospital record was reviewed. Resident 55 was admitted to the general acute care hospital on September 27, 2016, with [DIAGNOSES REDACTED]. During Resident 55's acute care hospital stay, she underwent three major surgeries: - On September 29, 2016, an [DEVICE] (the method of applying pins and screws into the bone of both sides of the fracture to allow to heal) was applied on the left ankle. A posterior splint (strip of rigid material used to support and immobilize a broken bone) was applied to the left leg as well. According to the operative report it was determined Resident 55 was not ready for an open reduction and internal fixation (ORIF- surgical procedure to fix a severe bone fracture) due to significant blistering and swelling on the left ankle. -On October 6, 2016, the [DEVICE] on the left ankle was removed and an ORIF was conducted on the left distal tibia , and left ankle malleolus. A coaptation/stirrup splint (type of splint) with posterior splint was applied on the left leg as well. According to the operative report, the surgery was a medical necessity for the resident's continued proper orthopedic care (treatment involving muscles and bones); and - On October 17, 2016, a wound debridement (removal of damaged tissue or foreign object from a wound) was done on the left ankle surgical wound, then a left distal fibula (smaller of the two bones between the knee and ankle) ORIF was conducted. After the procedure a posterior splint with coaptation/stirrup splint was again applied. On October 16, 2016, the physical therapy evaluation notes indicated Resident 55 had impaired mobility and cannot bear weight on her left lower extremity. Resident 55 needed total assistance with her mobility such as walking, transferring self from bed to chair and climbing the stairs. Resident 55 had to wear a CAM (controlled ankle motion) boot on her left lower extremity during ambulation. On January 9, 2017, at 9:55 a.m., a visit was made to the acute care hospital. Resident 55 was observed in bed with a sheet over her head, covering half of her upper body. The licensed nurse stated Resident 55 did not want to take her morning medications and had refused care from the staff. Resident 55 continued to have the the sheet over her head and refused to be interviewed during the visit. As of January 9, 2017, Resident 55 remained in the general acute care hospital medical-surgical ward and was awaiting for placement to a nursing facility. Resident 55 continued with the physical therapy treatments to her left lower extremity. The physical therapy progress notes, dated January 6, 2017, indicated Resident 55 had a [DIAGNOSES REDACTED]. 2. On January 23, 2017, at 8:36 a.m., during the initial tour conducted with Registered Nurse (RN) 1, Resident 52 was observed asleep in bed lying on her left side with head of the bed elevated at 30 degree angle. The resident was on alternating air mattress, with two full bed rails up on both sides. Resident 52 was receiving a gastrostomy tube ([DEVICE], a tube inserted directly to the stomach used for nutrition, medications and fluids administration) feeding through a pump. On January 23, 2017, Resident 52's record was reviewed. Resident 52 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On January 23, 2017, at 1:55 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated Resident 52 needed the side rails due to falls. LVN 2 further stated the resident needed two persons assist for repositioning. On January 23, 2017, at 1:57 p.m., Resident 52 was observed in her room with the Assistant Director of Nursing (ADON). The two full side rails remained up in both sides of the bed. A concurrent interview was conducted with the ADON. She stated the two full side rails were for mobility. A record review was conducted with the ADON. The ADON was unable to locate documented evidence of the following: - The resident's assessment prior to the use of bed rails; - Appropriate alternatives prior to installing the bed rails; - Involvement of the resident's responsible party to review the risks, benefits of bed rails; - Consent obtained from the responsible party; and - Physician notification and order. On January 23, 2017, at 4:23 p.m., the Administrator was interviewed. The Administrator stated Resident 52 should not have the two full bed rails. She further stated the use of two full bed rails for Resident 52 was inappropriate. The facility's policy and procedure titled, Proper Use of Side Rails, dated October 2010, was reviewed. The policy indicated, .An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include .ability to change position, transfer to and from bed or chair . Consent for side rails use will be obtained from the resident or legal representative, after presenting potential benefits and risks .The resident will be checked periodically for safety to side rails use .

Based on observation, interview, and record review, the facility failed to ensure, for eight of eight sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, and 8), laboratory tests ordered by the physician were carried out in a timely manner. The facility failed to: * Have a system in place to ensure all laboratory tests were completed in accordance with the physician's orders [REDACTED]. * Have supervision and monitoring of the processes of carrying out and obtaining the results of the ordered laboratory tests; and * Have a system in place to ensure the physician was notified if a laboratory test was not carried out as ordered. On September 7, 2016, at 6:35 p.m., the facility Administrator and the Director of Nursing (DON) were informed of the system failure which resulted in Immediate Jeopardy. This system failure placed the residents at risk for delay of necessary treatments and/or medications for the residents and undetected side effects and toxic (harmful) blood levels of medications. The Immediate Jeopardy was removed on September 12, 2016, at 4 p.m., in the presence of the facility Administrator and the DON, after the facility's acceptable written plan of action was reviewed and it was verified that the plan of action was implemented. Findings: 1. On September 1, 2016, at 9:20 a.m., Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].>a. Atorvastatin (medication to lower cholesterol) 40 mg taken by mouth at bedtime, order dated July 29, 2016; b. Order dated August 1, 2016, to be done on the morning of August 2, 2016: Complete blood count (CBC, a blood test); Complete metabolic panel (CMP, blood tests); Lipid panel (test to check abnormal cholesterol level in the blood); HGBA1C (hemoglobin b A1c- test to check the average three months blood glucose level); Vitamin D level; Vitamin B12 level; and Folate (a vitamin) level; and c. Order dated August 19, 2016, to be done on August 22, 2016: [MEDICATION NAME] ([MEDICATION NAME], a female hormone) 5 mg by mouth two times a day for sexually inappropriate behavior; and Testosterone level (level of male hormone in the blood). Atorvastatin may lower cholesterol and increase blood glucose. Blood glucose, which was included in CMP, HGBA1C, and lipid panel, should be monitored. Resident 1's lipid panel was also necessary to be monitored related to his [DIAGNOSES REDACTED]. Testosterone level should be monitored since [MEDICATION NAME] may decrease the testosterone level. Also, testosterone level should be monitored in relation to the [DIAGNOSES REDACTED]. There was no documented evidence the CBC, CMP, fasting lipid panel, HGBA1C, Vitamin D, Vitamin B12, and folate levels were performed on August 2, 2016, as ordered by the physician. There was no documented evidence the testosterone level was performed on August 22, 2016, as ordered by the physician. On September 1, 2016, at 3:54 p.m., Register Nurse Supervisor (RNS) was observed going through the laboratory log binder. The requisition forms (used to request for laboratory test) in the laboratory log binder were reviewed with RNS. In a concurrent interview, RNS stated there were no requisition forms for the laboratory tests ordered on August 1 and 19, 2016. RNS stated if there was no requisition form for a laboratory test, the laboratory test was not done. On September 1, 2016, at 4:59 p.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated laboratory tests should have been carried out as ordered. On September 3, 2016, after it was brought to the facility's attention, the facility conducted the laboratory tests that were ordered to be done on August 2, 2016 for Resident 1. The laboratory test results, dated September 3, 2016, indicated the HGBA1C was high at 7.1% (normal range was 4.0 to 6.0%). The fasting glucose (blood sugar) was high at 116 mg/dl (normal range was 70 to 99 mg/dl). On September 7, 2016, at 9:45 a.m., the DON was interviewed and stated the Medical Records Director (MRD) was responsible for following up the laboratory tests ordered for residents. On September 7, 2016, at 1:24 p.m., the MRD was interviewed. The MRD stated she did not know how the laboratory tests ordered for Resident 1 on August 1 and 19, 2016 were missed. 2. On September 1, 2016, at 11:55 a.m., Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].>a. [MEDICATION NAME] ([MEDICATION NAME] acid, medication used for [MEDICAL CONDITION] and/or [MEDICAL CONDITION] disorder) level every 3 months, order dated November 13, 2015; b. Order dated November 14, 2015: [MEDICATION NAME] ([MEDICATION NAME] acid) 750 mg/15 ml (per 15 milliliters) by mouth three times a day; Prolactin (a hormone) on the second Tuesday in August; CBC with differential (a blood test); CMP; Lipid panel; and VPA ([MEDICATION NAME] acid) level on the second Tuesday of February and August; c. Order dated February 16, 2016: [MEDICATION NAME] (a diuretic) 40 mg tablet by mouth every morning; and [MEDICATION NAME] (potassium) 20 meq (milliequivalent) by mouth daily; and d. [MEDICATION NAME] (medication to treat high cholesterol level) 20 mg tablet, order dated April 21, 2016. The side effects of [MEDICATION NAME] acid use included liver problems and lowered white blood cells (WBC) and platelet counts. It was important to monitor the CBC (which included tests for WBC and platelet) and CMP (which included tests for liver function). It was also important to monitor if the VPA was in the therapeutic level (VPA level in the blood which conditions may improve) or the toxic levels (level in which VPA may damage or cause side effects to the body). The side effects of [MEDICATION NAME] included a decrease in potassium and sodium (minerals). The side effects of [MEDICATION NAME] included an increase in the potassium level in the blood which may cause paralysis. Low sodium level in the blood may cause swelling of the body and brain, [MEDICAL CONDITION], and coma. Both high and low potassium levels may cause abnormal heart beats. It was necessary to monitor the potassium and sodium levels (which were included in the CMP) while Resident 2 was on [MEDICATION NAME] and [MEDICATION NAME], especially since Resident 2 had a [DIAGNOSES REDACTED]. [MEDICATION NAME] decreased cholesterol in the blood. Lipid panel was necessary to determine if [MEDICATION NAME] was effective or not. Resident 2's lipid panel should also be monitored related to his [DIAGNOSES REDACTED]. There was no documented evidence the CBC, CMP, lipid panel, VPA, Prolactin, and [MEDICATION NAME] levels, were done in February and August 2016. 3. On September 1, 2016, the record of Resident 3 was reviewed. Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].>a. [MEDICATION NAME] (medication used to treat mental disorder) 10 mg by mouth three times a day order dated August 24, 2015; and b. CMP and Lipid panel to be obtained on the second Tuesday of June and December, order dated May 16, 2016. One of the side effects of [MEDICATION NAME] included an increase in blood glucose level and undesirable changes in the level of cholesterol in the blood (according to the NIH). Therefore, the blood glucose level and lipid panel were needed to be monitored for Resident 3. The lipid panel test should also be monitored related to the [DIAGNOSES REDACTED]. There was no documented evidence CMP and lipid panel were done in June 2016. 4. On September 1, 2016, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].>a. [MEDICATION NAME] DR (delayed release) 250 mg tablet by mouth every 12 hours, order dated May 30, 2015; and b. HGBA1C to be done every three months, order dated November 19, 2015. There was no documented evidence the facility requested for a clarification for the lack of a physician's orders [REDACTED]. The monitoring of [MEDICATION NAME] level, especially if the resident was on [MEDICATION NAME] for a long time, was necessary to determine if the level was therapeutic or toxic to the resident. The HGBA1C test was necessary to monitor the blood glucose levels in the blood related to Resident 4's [DIAGNOSES REDACTED]. There was no documented evidence the HGBA1C test was done every three months from November 2015 to July 2016. 5. On September 7, 2016, Resident 5' record was reviewed. Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].>a. [MEDICATION NAME] 15 mg tablet by mouth two times a day; [MEDICATION NAME] (medication used to stabilize mood) 300 mg by mouth daily; and [MEDICATION NAME] level every month, order dated July 5, 2016; b. [MEDICATION NAME] 20 mg by mouth daily; Potassium Chloride ER (extended release) 8 meq (millequivalent) by mouth daily, order dated July 8, 2016; and c. CBC, CMP, lipid panel, and HGBAIC, to be done August 4, 2016, order dated August 3, 2016. The [MEDICATION NAME] level test was necessary to monitor the amount of [MEDICATION NAME] in the blood so the physician may be able to determine if the medication was helpful or harmful to the resident. The use of [MEDICATION NAME] may also affect the minerals (such as sodium, potassium, and calcium), and blood cells in the body. The side effects of [MEDICATION NAME] may include a decrease in sodium and potassium in the body. The side effect for potassium chloride may include an increase in the potassium level in the blood. It was necessary to monitor the potassium and sodium level while the resident was on [MEDICATION NAME] and potassium chloride. Abnormal (high or low) levels of sodium and potassium in the blood may cause serious or harmful effects to the body. The HGBA1C test was necessary to monitor the blood sugar level in the blood related to Resident 5's [DIAGNOSES REDACTED]. It was necessary to obtain CBC and CMP baseline levels to monitor Resident 5 for the potential side effects of potassium chloride, [MEDICATION NAME], and [MEDICATION NAME] (according to Lexicomp). There was no documented evidence the [MEDICATION NAME] level test was ever performed. There was no documented evidence the CBC, CMP, Lipid panel, and HGBA1C were ever done. 6. On September 7, 2016, Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].>a. HGBA1C every three months on the second Tuesday of January, April, July, and October, order dated October 2, 2013; b. Lipid panel every six months on the second Tuesday of April and October, order dated April 24, 2014; c. Prolactin on the second Tuesday of January, order dated June 6, 2014; d. CBC with differential (a lab test) every six months on the second of January and July, order dated January 7, 2015; e. [MEDICATION NAME] 10 mg by mouth every morning, order dated April 22, 2015; f. [MEDICATION NAME] (medication used to decrease the fat in the blood) 10 mg tablet by mouth daily, order dated October 14, 2015; and g. [MEDICATION NAME] (medication used to lower blood glucose) 10 mg tablet by mouth two times a day, order dated June 6, 2016. The medication [MEDICATION NAME] and [MEDICATION NAME] may cause abnormal (high or low) levels of blood glucose in the body. It was necessary to monitor Resident 6's blood sugar levels through the HGBA1C test to monitor the effects of these medications. A CBC test was also necessary to monitor abnormal changes in the blood related to [MEDICATION NAME] use (according to Lexicomp). The medication [MEDICATION NAME] affects the production of prolactin and may impair sexual function. It was necessary to monitor the prolactin level while Resident 6 was on [MEDICATION NAME]. The medication [MEDICATION NAME] requires monitoring of the lipid panel to determine the effectiveness and necessity of the medication for Resident 6. There was no documented evidence the HGBAIC test was done in October 2015, and January and April 2016. There was no documented evidence the lipid panel was done in April 2016. There was no documented evidence the Prolactin was done in January 2016. There was no documented evidence CBC with differential was done in July 2016. 7. On September 7, 2016, Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. a. [MEDICATION NAME] ([MEDICATION NAME], medication for [MEDICAL CONDITION]) 200 mg by mouth three times a day; b. CBC with differential every two weeks for [MEDICATION NAME] use; and c. [MEDICATION NAME] level every month. The use of [MEDICATION NAME] may cause serious blood disorder and required monitoring of the WBC count through the CBC test. The [MEDICATION NAME] blood level had to be monitored to determine if the level was therapeutic or not to the resident. At a certain level, the resident's mental condition may worsen and the WBC may be severely affected, especially since Resident 7 had a [DIAGNOSES REDACTED]. There was no documented evidence CBC was done in August 2016. There was no documented evidence the [MEDICATION NAME] level was done in March and August 2016. 8. On September 7, 2016, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].>a. CBC with differential, CMP, lipid panel, and Prolactin every second Tuesday of February and August, with the order dated February 27, 2015; b. [MEDICATION NAME] acid level every second Tuesday of February and August, with the order dated March 15, 2015; c. [MEDICATION NAME] 15 mg by mouth twice a day, and [MEDICATION NAME] DR 500 mg by mouth two times a day, order dated May 27, 2015; and d. [MEDICATION NAME] level every three months, with the order dated December 11, 2015. The medication [MEDICATION NAME] may put the resident at risk for developing blood disorders and may also cause an increase in the blood glucose and cholesterol level in the blood. This medication may also affect the production of prolactin that may cause sexual dysfunction. The monitoring of the CBC, CMP, lipid panel and Prolactin level were necessary to monitor for the side effects of [MEDICATION NAME] for Resident 8. The medication [MEDICATION NAME] may put the resident at risk for developing liver damage and blood disorders. A part of the CMP was to test how well the liver was working. CBC and CMP were necessary to monitor the side effects of [MEDICATION NAME] use for Resident 8. The monitoring of [MEDICATION NAME] level, especially if the resident was on [MEDICATION NAME] for a long time, was necessary to determine if the level was therapeutic or toxic to the resident. There was no documented evidence CBC with differential, CMP, and lipid panel were done in August 2016. There was no documented evidence [MEDICATION NAME] acid level was done in February and August 2016. There was no documented evidence [MEDICATION NAME] level was done every 3 months in 2016. There was no documented evidence the facility clarified the orders for [MEDICATION NAME] acid and [MEDICATION NAME] levels, both referring to the same lab test but were scheduled to be done for different months. On September 7, 2016, at 9:45 a.m., the DON was interviewed. The DON stated the laboratory tests should be done as ordered by the physician. The DON stated the physician should be notified if the laboratory test was not done. The DON stated night shift nurses checked the physician orders [REDACTED]. On September 7, 2016, at 4:30 p.m., the MRD was interviewed. The MRD stated there was no system in place yet to prevent laboratory tests from being missed. On September 7, 2016, at 5:05 p.m., the DON was interviewed. The DON stated the physician was not notified of missing laboratory test results. The DON stated the physician should have been notified if an ordered laboratory test was not done. On September 7, 2016, at 5:05 p.m., the RNS was observed to go through the laboratory log binder. In a concurrent interview, the RNS stated there were three different forms the licensed nurses used for routine laboratory test orders. The RNS stated the licensed nurse use any of the three forms, depending on which form the licensed nurse wanted to use. The RNS stated the laboratory requisition forms were used for stat (tests which needed to be done right away) and one-time lab orders only. On September 7, 2016, at 5:10 pm, LVN 1 was interviewed. LVN 1 stated she did not know how the physician's orders [REDACTED]. On September 7, 2016, at 5:30 p.m., LVN 2 was interviewed. LVN 2 stated the physician's orders [REDACTED]. The three licensed nurses interviewed were not able to state consistently the facility's process in carrying out orders for laboratory tests. On September 7, 2016, at 6:30 p.m., the Administrator and DON were interviewed. The Administrator stated the MRD did daily audit and the ADON did weekly audit of laboratory test orders. The Administrator stated he and the DON spot checked the laboratory test orders. The Administrator stated the system had been set up but fell through. The DON was unable to state why there were inconsistencies in the processing of laboratory tests among facility staff. The facility policy and procedure titled, Diagnostic Tests, dated December 2014, was reviewed. The policy indicated, .Physician ordered labs will be handled in a proficient manner to ensure timeliness, accuracy, and proper follow up . .Procedure: 1. When receiving an order for [REDACTED]. 2. When receiving an order for [REDACTED]. 3. There is a notebook located at each nurses' station for communication of lab to be done on the identified resident . 5. The physician will be notified of all lab results . 6. MD must be notified of the resident's refusal of laboratory to be done for further intervention. Upon review of the facility compliance history for the past 12 months, from September 2015 to August 2016, deficiencies related to laboratory test not carried out in a timely manner were identified and cited in four different surveys: - During two abbreviated standard surveys on November 9 and 12, 2015; - During the facility's recertification survey on January 14, 2016; and - During an abbreviated standard survey on May 12, 2016. As of September 7, 2016, the same deficient practice that were identified and cited during those four surveys remained uncorrected. On September 7, 2016, at 6:35 p.m., the Administrator and the DON were verbally notified of the Immediate Jeopardy. On September 8, 2016, at 11:29 a.m., the facility provided the immediate plan of actions: - Chart review of all residents will be completed to identify potential missing laboratory tests. All missing laboratory tests identified will be corrected; - In services regarding facility policy and procedure for all laboratory tests will be conducted by the DON/ ADON for all licensed nurses and medical records staff; and - Systemic measures will be put in place. These systemic measures included procedures for carrying out and processing of laboratory test orders and results, forms to be used, what to do in case of resident refusal of the blood test, notification of the physician. Included also were the process for monitoring, review, and evaluation of the procedures including involvement of the quality assurance improvement committee. On September 12, 2016, at 4 p.m., an onsite visit was conducted in the facility. After the immediate plan of correction was verified to have been implemented, the facility Administrator, DON, and ADON were verbally notified that the Immediate Jeopardy was removed.

Based on interview and record review the facility failed to provide services necessary to prevent serious physical harm to one resident (Resident 9) in a universe of 69 residents when the resident sustained [REDACTED]. This failure caused the resident to be transported to the emergency department of an acute hospital via paramedic ambulance where the resident underwent [REDACTED]. Findings: On August 22, 2016, at 10:40 a.m., an unannounced visit was made to the facility for the investigation of two complaints. A review of Resident 9's medical record was conducted. Resident 9 was [AGE] years old and was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. that interferes with daily functioning) anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear), and [MEDICAL CONDITION] (brain disorder which causes one to interpret reality abnormally). Resident 9's document titled, History and Physical, (H&P) dated August 1, 2016, failed to indicated whether the resident had capacity to understand and make decisions. This section of the H&P was left blank. Review of Resident 9's document titled, Physician order [REDACTED]. The POLST further indicated that medical interventions were to include, Full Treatment- primary goal of prolonging life by all medically effective means. A review of Resident 9's document titled, FALL RISK ASSESSMENT, indicated an assessment date of August 1, 2016. Resident 9's fall risk score was documented as a total score of 22. The document further indicated, IF the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. After further record review, no prevention protocol was found on Resident 9's care plan. The document titled, physician's orders [REDACTED]. The document indicated on August 1, 2016, an order for [REDACTED]. The U.S Food and Drug Administration (FDA) January 2014, Summary View, for Xeralto indicated, WARNINGS AND PRECAUTIONS .Risk of Bleeding: Promptly evaluate any signs or symptoms of bleeding . The December 2014, Summary View, indicated, .addition of [MEDICAL CONDITION] (bleeding into the tissues, bruising, and slow blood clotting after injury) as an adverse reaction .) A review of Resident 9's nursing documentation found an entry on August 8, 2016, at 4:19 p.m., that indicated, .PATIENT fell IN HALL ON STATION 2 NO VISIBLE INJURIES NOTED, THIS NURSE WITNESS (sic) FALL, AMBULATING WITH WALKER PATIENT APPEARED TO HAVE TRIPPED ON HIS OWN FEET .NEURO CHECK (neurological checks- used to assess level of consciousness in order to determine functionality and or injury. The purpose of a neuro check is to make sure neurological functions were not impaired after a head injury) IN PROGRESS, PLACE ON Q15 (every 15 minute) MONITORING FOR SAFETY . Review of Resident 9's document titled, INVESTIGATION FOR ALL INCIDENTS, with a date of incident documented as August 10, 2016, indicated, Resident was in dinning (sic) room and fell from chair and hit his head resident assessed already had previous bruising from previous fall . The document titled, RESIDENT TRANSFER RECORD, dated August 11, 2016, was reviewed. It was indicated by documentation in the section, Skin and Body Assessment, a bruise to the right side of Resident 9's head. Review of a nursing note dated August 11, 2016, at 10:18 a.m., for Resident 9 indicated, PATIENT SENT OUT TO HOSPITAL, PER (physician's name) VIA (name of ambulance company) FOR CHANGE OF LOC (level of consciousness) . Review of a nursing note dated August 11, 2016, at 3:39 p.m., for Resident 9 indicated, RELATED TO PATIENT status [REDACTED]. A review of the form titled, INCIDENT REPORT, completed for Resident 9 on August 12, 2016, had a handwritten note that indicated, Incident report completed 8/12/16 By (sic) (license vocational nurse - LVN 7's name). The incident report indicated, Resident was in dinning (sic) room and fell from chair and hit head. Assessed Resident and injury noted to R (right) middle forehead in same spot as previous injury d/t (due to) previous fall Bruising and hematoma . The handwritten note was signed by the Director of Nursing (DON) with his title next to his signature. Thus indicating the DON was aware of the August 10, 2016, fall on August 12, 2016. On August 22, 2016, at 12:03 p.m., an interview was conducted with the DON. The DON was asked if Resident 9 had had a witnessed fall. The DON stated, Yes. The DON was asked where the fall had occurred. The DON stated in the hall. The DON was asked if the resident had had any visible signs of bruising after the fall. The DON stated, No. The DON was then asked why a resident who was on a blood thinner would not have been sent out to the hospital if there was possibility of a head injury that occurred during the fall. The DON stated that just because a resident was taking a blood thinner was not a reason to send the resident out for evaluation. The DON further stated it was up to the physician to send the resident out to the hospital for evaluation. The DON stated again, just because a resident was on a blood thinner and hit his head was not necessarily a reason to send a resident out for evaluation. The DON was asked if the physician had been notified of the Resident 9's fall, the DON stated, Yes, and stated that 72 hour neuro checks had been ordered. Review of Resident 9's document titled, 72 HOURS NEURO-CHECK LIST, indicated a section for, Q SHIFT (every shift) X (for) 8 (8 shifts). The last four boxes were blank on this document. The last neuro check had been documented on Wednesday August 10, 2016 at 5:30 a.m., approximately 39 hours after it had been ordered. If the last four boxes had been filed out, the neuro checks would have ended at 1:30 p.m., on Thursday August 11, 2016, the day the resident was sent to the emergency room of the acute hospital for CHANGE OF LOC as was documented in the nursing notes dated August 11, 2016, at 10:18 a.m. The lack of documentation indicated that the neuro checks had not been done for the last 28 hours Resident 9 had been in the facility and which was verified in interview with the DON. On August 22, 2016, at 1:28 p.m., a phone interview was conducted with a LVN 6 who had observed Resident 9's fall on August 8, 2016. LVN 6 was asked about Resident 9's fall on August 8, 2016. LVN 6 stated she observed the resident place his walker against the wall, then proceed to trip over his own feet and fall. LVN 6 was asked if she observed Resident 9 hit his head. LVN 6 stated, No, she had not seen him hit his head. LVN 6 was asked if she had observed any bruising on Resident 9's head. LVN 6 stated she had been off work August 9th and 10th and had not seen the bruising until she had returned to the facility on [DATE]. LVN 6 was asked if she had been aware of any other falls Resident 9 had sustained after she had observed him fall on August 8th. LVN 6 stated she had not been made aware of any falls after the August 8, 2016, fall. On August 22, 2016, at 1:39 p.m., a second interview was conducted with the DON. The DON was asked if there was any documentation or if he had received any notification of a fall after the August 8, 2016, fall that would have occurred prior to Resident 9 being transported to the emergency department of the acute hospital via paramedic ambulance on the morning of August 11, 2016. The DON stated there was no documentation of a fall witnessed or unwitnessed after the August 8th fall. The DON further stated he had not been notified of any falls after Resident 9 had fallen on August 8, 2016. On August 25, 2016, at 9:41 a.m., a second interview was conducted with LVN 6. LVN 6 was asked when the last time she had seen Resident 9. LVN 6 stated before she had left for the day on August 8, 2016, at approximately 2:30 p.m. When asked if she had identified any injury to the residents head, LVN 6 stated it was a little red. LVN 6 stated when she returned to work on August 11, 2016, after being off for two days that was when she had observed the bruising to Resident 9's head. LVN 6 stated no one had reported to her the bruise on the resident's head. LVN 6 stated that on August 11, 2016, the resident could not move or talk. LVN 6 further stated after the resident had been sent out to the hospital via 911 she had called other staff members at the facility to find out what had happened to the resident. LVN 6 stated no one could tell her what had happened to the resident in her absence. LVN 6 stated something had to have happened to the resident between August 10th and the 11th. On August 25, 2016, at 5:12 p.m., a phone interview was conducted with a paramedic who had transported Resident 9 from the facility to the acute hospital after the facility had called 911 on August 11, 2016. The paramedic stated the resident had an altered mentation (confused) and had incomprehensible (unable to understand) and garbled (unclear) speech. The paramedic further stated two staff members had assisted him in the resident's room but neither of the staff members were able to state what had caused the bruise on the resident's head. The paramedic stated the bruise on Resident 9's forehead had a yellow aura around it which indicated it had begun healing. The paramedic stated the bruise on the resident's head was, difficult to miss. Resident 9's ambulance report titled, PATIENT CARE REPORT, dated August 11, 2016, was reviewed. The report indicated, .PT (patient) NOTED TO BE IN UNKEPT ROOM. STAFF REPORTS FINDING PT. TO BE MORE ALTERED THAN BASELINE AS WELL AS FEBRILE (with a fever) EMS (emergency medical services-paramedic) NOTES MULTIPLE BRUISES TO BOTH PT. KNEES, ELBOWS AND FOREHEAD ABOVE RIGHT EYE. COLOR INDICATES BRUISES ARE FROM A FALL THAT OCCURRED YESTERDAY, HOWEVER PT. WAS NOT TRANSPORTED TO ED (emergency room ) FOR EVAL (evaluation) PT. FOUND TO BE ALTERED .BASE CONSULTED DUE TO NATURE OF PT. INJURIES, ADVISED TO CONTINUE TO CLOSEST ED .REPORTS GIVEN TO ED RN (registered nurse) AND MD (physician) AT BEDSIDE DUE TO CONCERNS WITH PT. CARE AT FACILITY . Further review of the report indicated under heading, PHYSICAL ASSESSMENT, the forehead was, POSITIVE: CONTUSION (region of injured tissue or skin in which blood capillaries have been ruptured) ECCHYMOSIS (discoloration of the skin resulting from bleeding underneath) AND [MEDICAL CONDITION]/SWELLING- TRAUMATIC . On August 26, 2016, at 3:10 p.m., a phone interview with the DON and facility Administrator indicated a certified nurse's assistant (CNA 1) had observed Resident 9 fall from a wheelchair in the dining room on August 10, 2016, and that an LVN charge nurse (LVN 7) had been notified of the fall. The DON stated LVN 7 had not documented the incident. On August 26, 2016, at 4:00 p.m., a phone interview was conducted with LVN 7. LVN 7 stated Resident 9 had been sitting in an oversized wheelchair that had belonged to another resident and was moved to a different wheelchair that was tilting. LVN 7 stated Resident 9 was leaning forward in the wheelchair so she and another nurse went to find Resident 9 a more suitable wheelchair. LVN 7 stated when she had returned to the dining room with another wheelchair a CNA (CNA 1) had informed her that Resident 9 had fallen, again. LVN 7 stated CNA 1 had stated that Resident 9 had hit his head again on the same side as the day before. LVN 7 was asked what side of Resident 9's head had been injured. LVN 7 hesitated briefly and then stated the right side-Yes, right side. LVN 7 stated there was no observed cut or bleeding on the resident's forehead. LVN 7 was asked if she had documented the incident. LVN 7 stated she had completed an Incident Report, but stated she had not documented the fall. LVN 7 stated she had informed other staff members about Resident 9's fall. On August 29, 2016, at 1:57 p.m., a phone interview was conducted with CNA 1. CNA 1 was asked if he had witnessed Resident 9 fall. CNA 1 stated he had observed Resident 9 fall from his wheelchair in the dining room but was unable to remember the date of the fall. CNA 1 stated Resident 9 had leaned forward in his wheelchair and had fallen completely out of the wheelchair and had hit his head. CNA 1 stated he had informed the charge nurse (LVN 7). CNA 1 stated Resident 9 had landed on the right side of his head. CNA 1 stated that he had assisted the resident back into his wheelchair and had observed a red bruise, on Resident 9's head and stated it appeared more like, internal bleeding because he fell a little bit too hard. CNA 1 stated he was the only staff member that had observed the fall, but stated again that he had informed the charge nurse (LVN 7) of the fall. On August 29, 2016, at 4:40 p.m., a phone interview was conducted with CNA 2. CNA 2 was asked about Resident 9. CNA 2 stated she had seen the resident on August 10, 2016, the day before he had been sent out to the hospital. CNA 2 stated she had assisted a charge nurse (LVN 7) move Resident 9 from one wheelchair to another wheelchair in the dining room after LVN 7 had informed her and another CNA that the resident had fallen. CNA 2 stated LVN 7 had asked her to assist the resident back to his room. CNA 2 was asked if she had observed any bruising on Resident 9's head. CNA 2 stated she had observed a circular bruise above his left eye. CNA 2 stated she believed it was the left eye. CNA 2 was then asked if she had seen Resident 9 again that day. CNA 2 stated, No, she further stated, I thought she (LVN 7) was going to take care of everything. On September 14, 2016, at 2:16 p.m., a phone interview was conducted with the Director of Staff Development/Assistant Director of Nursing (DSD/ADON) while Resident 9 had been in the facility. When asked about Resident 9's falls the DSD/ADON stated the fall on August 10, 2016, had not been reported to her or the DON. The DSD/ADON stated it had not been reported to them until two days later when LVN 7 returned to the facility and completed the incident report. The DSD/ADON stated, You can't neglect a patient like that. The DSD/ADON further stated LVN 7 had not reported the fall, She did nothing. The DSD/ADON stated LVN 7 had not even documented the fall in the 24 hour log. The DSD/ADON repeated again, She did nothing, the DSD/ADON stated it was, Ultimately neglect. Review of the facility's policy and procedure titled, POLICY AND PROCEDURE ON FALL PREVENTION AND REDUCTION, undated indicated, If and when fall (sic) occurs, facility shall implement corrective measures to reduce incidence of fall. The policy further indicated, .6. Residents with fall incident shall be referred to appropriate healthcare professionals. 7. Licensed nurse shall immediately complete an incident report and incident investigation report relating to the fall incident. The policy indicated under heading, COMPONENTS OF A FALL REDUCTION PROGRAM, section I, Monitoring & Reporting of Fall Incidences- each staff must report all incidents he or she is involved in or witnesses to, to (sic) his or her immediate supervisor .Residents identified to be at greater risk for falls or further falls should be monitored closely to prevent further occurrence of fall incident. Review of Resident 9's acute hospital record title, HISTORY AND PHYSICAL-STANDARD HOSPITAL ADMIT, (H&P) dated August 11, 2016, indicated, .Patient (Resident 9) presents with: ALTERED LEVEL OF CONSCIOUSNESS (ALOC) .Called (facility phone number) busy signal. Noted with head bruise and per nurse, facility states he had fallen there. Further review of this document indicated, EMERGENCY DEPARTMENT COURSE/INTERM INTERVENTIONS: had CT (CAT scan- computed tomography -radiologic imaging that uses computer processing to generate an image) with Impression as follows: Acute left subdural hematoma (a clot of blood that develops between the surface of the brain and the brain's outer covering, due to stretching and tearing of veins on the brain's surface. These veins rupture when a head injury suddenly jolts or shakes the brain) measuring up to 2.4 cm (centimeter or approximately 1 inch) overlying the left parietal lobe (one of four major lobes of the brain). The H&P further indicated, Patient Active Problem List: SUSPECTED ADULT NEGLECT. Section titled, ASSESSMENT AND PLAN-PROBLEM LIST, indicated, Active Problems: .ALOC---unclear source, possibly due to Subdural hematoma from fall .Due to bleed no LP (lumbar puncture-- procedure of taking fluid from the spine in the lower back through a hollow needle) .TRAUMATIC SUBDURAL HEMATOMA--patient on Xarelto per nursing facility notes. Give Kcintra (a medication given to stop bleeding) for helping with bleed .on Xarelto, hold medication due to bleed . Review of Resident 9's hospital form titled, MEDICAL SOCIAL WORKER INITIAL ASSESSMENT, dated August 11, 2016, indicated, SUMMARY: Patient is a [AGE] year old male who was BIB (brought in by) ambulance .for ALOC and significant bruising. Called facility and spoke to (LNV 6's name) who gave the following contact person (contact's name) .Spoke to (contact's name) who states that there is no family, next of kin. The form further indicated, Reason For Consult: abuse. The document further indicated, Legal/Protective Issues: Abuse/Violence/Neglect issues: yes. The hospital operating room surgeon note dated August 12, 2016, for Resident 9 indicated, .bruises found all over his body . Review of a hospital consult note for Resident 9 dated August 15, 2016, indicated, Patient Active Problem List: SUSPECTED ADULT NEGLECT . A neurological consultation note for Resident 9 dated August 17, 2016, indicated, (name of resident) is a [AGE] year old male .whom we are being asked to consult on regarding persistent altered mentation . Further review of this documented indicated, Patient Active Problem List: SUSPECTED ADULT NEGLECT . Resident 9's hospital progress note dated August 18, 2016, at 5:30 a.m., indicated, PHYSICAL EXAM: GENERAL: disheveled, unkept, ill appearing .SKIN: multiple bruises . Review of a hospital progress note for Resident 9 dated August 18, 2016, also at 5:30 a.m., by a different physician indicated in section, HPI (history of present illness) .On Neurosurgery examination patient .was taken to the OR (operating room) emergently for Left Craniotomy (neurosurgical procedure that involves removing a portion of the skull in order to relieve pressure on the underlying brain. The procedure is typically done in cases where a patient has experienced a very severe [MEDICAL CONDITION] that involves significant amounts of bleeding around the brain or excessive swelling of the brain, typically performed as a life saving measure) for evacuation of subdural hematoma by (name of physician) on 8/12/2016. Further review of the progress note indicated that on August 18, 2016, a CT scan of Resident 9's head was performed and showed, large R (right) MCA (middle cerebral artery in brain) stroke . A review of a hospital critical care progress note for Resident 9 dated August 18, 2016, indicated, HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: .(Resident 9's name) .who was admitted for fall with multiple trauma including head trauma resulting in subdural hematoma. Patient was taken emergently for evacuation of hematoma . The note further indicated, .Given poor prognosis (outcome) for meaningful neurological recovery per neurology and neurosurgery, requested Bioethic (committee which supports hospitals in providing clinical ethics discussions such as withholding and withdrawing life-sustaining for a patient) consult regarding guidance on goals of care, since patient has no family member or decision maker. Review of a progress note by Bioethics, dated August 18, 2016, indicated, An Ethics consult was requested by (physician's name) on Thursday, August 18th. He expressed concern regarding whether it is ethically justifiable for the patient's friend (contact's name), to serve as surrogate decision-maker (if patient is unable to make decisions for themselves someone else must provide direction in decision-making) for this patient .(contact's name) is currently the only available potential surrogate for this patient .It is ethically justifiable for (contact's name) to serve as this patient's surrogate decision-maker . A hospital progress note dated August 18, 2016, at 8:47 a.m., indicated, Persistent ALOC .-MRI (magnetic resonance imaging- scan that uses magnetism, radio waves, and a computer to produce images of body structures) brain showed large right MCA stroke, which may explain patient's ALOC . The note further indicated, Patient remains in critical condition requiring constant attention . Review of a hospital progress note dated August 19, 2016, indicated, ICU Note: .telephone conference with patient's friend, (contact's name) .during the telephone conference with (contact's name), .provided medical updates regarding (Resident 9's name) current condition, pointing out the massive right hemispheric stroke (stroke on the right side of the brain), persistent coma, and on-going multiple medical issues .offered (contact's name) .recommendation of comfort measures (medical care at the end of life to help a person who is dying. The goals are to relieve suffering as much as possible) and [MEDICATION NAME] extubation (withdrawal of mechanical ventilation at end of life ensuring a comfortable and peaceful experience for the patient) .(contact's name) completely agreed with the recommendation of comfort measures and DNR (do not resuscitate) status. A hospital progress note dated August 20, 2016, indicated, Patient is on comfort care only status. This is due to poor prognosis following left craniotomy for evacuation of subdural hematoma 8/12/16 . Further review of the note indicated, Care conference (sic) had with (contact's name) regarding the patient's poor clinical status and prognosis. Decision was made to proceed with comfort measures only. Pt (patient) extubated (removal of the breathing tube connected to the ventilator) and placed on [MEDICATION NAME] (medication to treat severe pain) gtt (drip). Review of a hospital progress note dated August 20, 2016, at 12:11 p.m., indicated, Called by RN (registered nurse) to bedside to assess the patient. Patient's rhythm on telemetry (machine used to monitor changes in blood pressure and the rate and rhythm of the heart) noted to be asystole (flatline). The patient was then examined. Pupils were fixed and dilated (pupils that are unequal in size can be a sign of serious conditions affecting the brain, fixed and dilated pupils indicate no chance of survival). No spontaneous respirations (breathing) observed. No heart sounds were auscultated (heard) .Patient pronounced dead at 8/20/2016 (sic) 1200.

Based on interview and record review, the facility failed to ensure necessary care and services were provided for one of 70 residents (Resident 10), who had [DIAGNOSES REDACTED]. Resident 10's highest practicable psychological level and physical functioning could not be met when the facility discharged the resident to a room and board that was unfamiliar to her. Resident 10 was moved to an location where staff were strangers to her. This move resulted in the resident's elopement (ran away) into an environment where she had no money or means to obtain food and shelter. She was picked up by the local police and taken to an acute care hospital for evaluation, treatment, and care. Findings: On May 26, 2016, a complaint was received from an acute care hospital's (Hospital 1) licensed clinical social worker (LCSW). The hospital reported that Resident 10 had been brought to the hospital's emergency room by the local police who had found the resident wandering the streets. The resident was unable to provide adequate information to Hospital 1 about where she lived. A telephone interview was conducted with Hospital 1's LCSW at 2 p.m. on May 26, 2016. The LCSW stated that through investigation, Hospital 1's staff had located the facility where Resident 10 had been living. The LCSW said she had made several attempts to contact the facility. In the LCSW's written complaint to California Department of Public she wanted to know how the facility was able to determine, why this Pt (patient - Resident 10) was discharged to a room and board knowing that she (Resident 10) needed a higher level of care. The LCSW said in her telephone interview that she had not received a return call from the facility. The LCSW stated that the patient had been at (Hospital 1's name) for three days, and when she was offered food, the resident refused it and told the hospital staff that she had no money to pay for it. Resident 10 would not accept a hospital bed for the same reason. On May 26, 2016, at 3:15 p.m., an unannounced visit was conducted at the facility to investigate a complaint related to an inappropriate discharge. Resident 10's facility medical record was reviewed on May 26, 2016. The record indicated that the resident had an original admitted [DATE], with a readmitted [DATE]. Resident 10's [DIAGNOSES REDACTED]. Resident 10's Minimum Data Set (MDS - an assessment tool), dated March 14, 2016, was reviewed and indicated the resident's BIMS (Brief Interview for Mental Status - a test used to detect cognitive impairment) score was seven. A score of 0-7 reflects severe cognitive impairment per the 3.0 Resident Assessment Instrument (RAI). The MDS further indicated Resident 10 needed supervision and some oversight to perform her activities of daily living such as walking in and around the facility, dressing, eating, and personal hygiene. During continued review of Resident 10's facility record, three physician telephone orders were located regarding Resident 10's first admission's discharge. On December 14, 2015, a hand written order indicated, Clear to D/C (discharge) when Arrangements made for Discharge. There was no location indicated in the order where the resident would be discharged to. A second order hand written on December 14, 2015, read, Home Health c (with) (Name of agency and phone number). The order failed to name any facility or place where resident would go upon discharge. A facility nurse's note dated December 14, 2015, indicated that Resident 10's physician had been in to see the resident, assessed her, and gave an order to discharge the resident. No additional documents with discharge location could be located in the medical record provided that indicated Resident 10 had been discharged on or around the December date. On February 2, 2016, a hand written order on the facility record indicated, D/C to (Name of facility), a sister facility. The order had not been signed by the physician. No documents or discharge forms were located in the resident's medical record to indicate that the February 2, 2016, discharge to the sister facility had been carried out. Further review of Resident 10's facility record on May 26, 2016, located copies of records sent to the facility from an acute care hospital in northern California (Hospital 2). The hospital records indicated that Resident 10 had been admitted to Hospital 2 on February 23, 2016, after she was found wandering around. Hospital 2's LCSW documented, Patient (Resident 10) states she is from LA (Los Angeles) and was put on a bus to San Francisco, but cannot report why she was sent there. She states that she was on a bus back to LA, but that she got out at a stop to use the bathroom and that the bus had left when she returned. The social worker further wrote that she, keeps repeating that she wants to go back home and that her family will come and get her. Hospital 2 located a son who stated that the resident had a history of [REDACTED]. He said he no longer wanted to be involved in the resident's life. The resident was discharged back to the facility from Hospital 2 on March 2, 2016, eight days after admission. In Hospital 2's Social Worker note, the LCSW wrote that he had spoken to the facility's Case Manager who told him the facility will take pt (patient) back. There was no indication in Hospital 2's record how the hospital staff knew Resident 10 had been a resident in the current SNF (skilled nursing facility) facility. Hospital 2's case manager wrote, Requires custodial SNF secured unit. Transportation back to the facility was arranged by Hospital 2. Further review of the facility record indicated Resident 10 was readmitted to the facility on [DATE]. A care plan written on that date indicated that the resident was at risk for AWOL (absent without leave or elopement). Interventions for the concern were Q (every) 15 (minutes) monitoring, and Encourage pt (patient) to verbalize needs & (and) concerns. The form, History and Physical completed by Resident 10's Physician and dated 3/17 (March 17, 2016), indicated a [DIAGNOSES REDACTED]. There was no record of a surrogate decision maker listed on the history and physical form. The line was left blank. On April 20, 2016, the physician wrote on the facility record that Resident 10 was confused and wandering about in the facility hallway. The physician's assessment was dementia. On May 10, 2016, the physician wrote that Resident 10 had dementia and needed supportive care. On May 3, 2016, the physician wrote that the resident was delusional. On May 18, 2016, the psychiatrist wrote that Resident 10 had dementia. The psychiatrist's plan was for supportive care. Continued review of Resident 10's facility record on May 26, 2016, located a hand written physician order [REDACTED]. On May 21, 2016, a second hand written note signed by a nurse order indicated, Resident may D/C to (same name, address, and phone number of facility). The facility form titled, Social Services Discharge Planning, dated and signed by the Social Services Designee (SSD) on May 20, 2016, indicated Resident 10, Has a (sic) order to discharge to (Name of facility) to a lower level of care. No orders for Home Health or DME (durable medical equipment) at this time none needed. Resident will discharge with all her belongings and medications. Resident is self responsible .Resident needs to schedule a follow up appointment with her primary MD (medical doctor) in 1 or 2 weeks from discharge date . The form further indicated that Resident 10 would be transported by owner's (room and board's owner) private van. A room and board is defined in Webster's New World College Dictionary as Sleeping accommodations and meals. No other services are provided in the rental agreement. The facility form, Notice of Proposed Transfer/Discharge, indicated the notification date given to Resident 10 was May 19, 2016, with an effective date of May 20, 2016. The reason for discharge indicated it was appropriate because, Your (Resident 10) health has improved sufficiently so that you no longer require services provided by this facility . The form was signed and dated by the facility's SSD on May 21, 2016. The resident, who was named as self responsible, did not sign the form. A person from the accepting facility (room and board) signed it She did not indicate any relationship to Resident 10 on the space provided. On May 26, 2016, at 3:30 p.m., a concurrent interview was conducted with two admission coordinators (AC 1 and AC 2). AC 1 was asked if she thought a room and board was proper placement for Resident 10. She said that the facility's SSD checked out these facilities (room and board facilities). The SSD thought it was appropriate placement for Resident 10. AC 2 was asked if the owner of the room and board had met Resident 10 before the resident was accepted to live in her room and board. She said the owner told them she could take the resident and thought the owner was told about Resident 10's behaviors. AC 2 could not say what the behaviors were. Both ACs were asked if they knew where Resident 10 was at the present time. AC 1 said she was told earlier that Resident 10 had run away from the room and board facility. An interview was conducted with the Director of Nursing on May 26, 2016, at 4 p.m. He agreed that Resident 10's discharge to a room and board was an inappropriate discharge. He stated that the SSD made the arrangements for placement of residents who were not discharged to family. On June 6, 2016, at 10:50 a.m., an interview was conducted with the SSD. She stated that the resident looked so sad all the time and wanted to leave. She said that she thought the resident would be happier at the room and board, and the room and board owner said she could take care of the resident. The SSD stated she was not aware that Resident 10 had not been taken to the room and board listed on the facility discharge form, but she knew the owner had a second home in another city and was trying to fill it (populate the home). The SSD said that Resident 10 was her first admission to the new home. When asked if she thought a room and board was appropriate placement for Resident 10, the SSD did not answer. The facility's undated policy and procedure titled, Policy and Procedure on Discharge Planning, was reviewed on June 7, 2016. It indicated, It is the policy of this facility to provide ongoing evaluation and discharge planning for all appropriate residents while in the facility .3. Upon admission, Social Services shall determine potential for resident to be discharge (sic) to a lower level of care or home care 9. Social Services shall also be responsible for coordination with the resident and/or family or surrogate decision maker and appropriate disciplines regarding any home equipment, environmental set-up, supervision .that are needed once the resident has been discharged . Using the reasonable person concept, the facility caused psychological harm to Resident 10 by removing her from surroundings that were known to her. This move caused her to run away from the board and care home to the city streets where Resident 10 could have sustained serious injury or harm inflicted on her by others until she was taken to a safe place, (Hospital 1) where her needs were met.

Based on interview and record review, the facility failed to ensure one Resident (Resident 9) in a universe of 69 residents was free from harm and had received adequate supervision when the resident sustained [REDACTED]. This failure caused Resident 9 to suffer a severe head injury and required him to be transported to the emergency department of an acute hospital via paramedic ambulance where he underwent emergent brain surgery and ultimately died nine days later. Findings: On [DATE], at 10:40 a.m., an unannounced visit was made to the facility for the investigation of two complaints. A review of Resident 9's facility medical record was conducted. Resident 9 was [AGE] years old and was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. that interferes with daily functioning) anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear), and schizophrenia (brain disorder which causes one to interpret reality abnormally). Resident 9's facility document titled, History and Physical, (H&P) dated [DATE], failed to indicated whether the resident had capacity to understand and make decisions. This section of the H&P was left blank. Review of Resident 9's facility document titled, Physician order [REDACTED]. The POLST further indicated that medical interventions were to include, Full Treatment- primary goal of prolonging life by all medically effective means. A review of Resident 9's facility document titled, FALL RISK ASSESSMENT, indicated an assessment date of [DATE]. Resident 9's fall risk score was documented as a total score of 22. The document further indicated, IF the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. After further record review, no prevention protocol was found on Resident 9's care plan. The facility document titled, physician's orders [REDACTED]. The document indicated on [DATE], an order for [REDACTED]. The U.S Food and Drug Administration (FDA) [DATE], Summary View, for Xeralto indicated, WARNINGS AND PRECAUTIONS .Risk of Bleeding: Promptly evaluate any signs or symptoms of bleeding . The [DATE], Summary View, indicated, .addition of [DIAGNOSES REDACTED] (bleeding into the tissues, bruising, and slow blood clotting after injury) as an adverse reaction . A review of Resident 9's facility nursing documentation found an entry on [DATE], at 4:19 p.m., that indicated, .PATIENT fell IN HALL ON STATION 2 NO VISIBLE INJURIES NOTED, THIS NURSE WITNESS (sic) FALL, AMBULATING WITH WALKER PATIENT APPEARED TO HAVE TRIPPED ON HIS OWN FEET .NEURO CHECK (neurological checks- used to assess level of consciousness in order to determine functionality and or injury. The purpose of a neuro check is to make sure neurological functions were not impaired after a head injury) IN PROGRESS, PLACE ON Q15 (every minute) MONITORING FOR SAFETY . Review of Resident 9's facility document titled, INVESTIGATION FOR ALL INCIDENTS, with a date of the incident documented as [DATE], indicated, Resident was in dinning (sic) room and fell from chair and hit his head resident assessed already had previous bruising from previous fall . A review of the facility form titled, INCIDENT REPORT, completed for Resident 9 on [DATE], had a handwritten note that indicated, Incident report completed [DATE] By (sic) (license vocational nurse-LVN 7's name). The incident report indicated, Resident was in dinning (sic) room and fell from chair and hit head. Assessed Resident and injury noted to R (right) middle forehead in same spot as previous injury d/t (due to) previous fall Bruising and hematoma . The handwritten note was signed by the Director of Nursing (DON) with his title next to his signature. Thus indicating the DON was aware of the second fall that occurred [DATE], on [DATE]. The facility document titled, RESIDENT TRANSFER RECORD, dated [DATE], was reviewed. It was indicated by documentation in the section, Skin and Body Assessment, a bruise to the right side of Resident 9's head. Review of a facility nursing note dated [DATE], at 10:18 a.m., for Resident 9 indicated, PATIENT SENT OUT TO HOSPITAL, PER(physician's name) VIA (name of ambulance company) FOR CHANGE OF LOC (level of consciousness) . Review of a facility nursing note dated [DATE], at 3:39 p.m., for Resident 9 indicated, RELATED TO PATIENT status [REDACTED]. On [DATE], at 12:03 p.m., an interview was conducted with the DON. The DON was asked if Resident 9 had had a witnessed fall. The DON stated, Yes. The DON was asked where the fall had occurred. The DON stated in the hall. The DON was asked if the resident had had any visible signs of bruising after the fall. The DON stated, No. The DON was then asked why a resident who was on a blood thinner would not have been sent out to the hospital if there was possibility of a head injury that occurred during the fall. The DON stated that just because a resident was taking a blood thinner was not a reason to send the resident out for evaluation. The DON further stated it was up to the physician to send the resident out to the hospital for evaluation. The DON stated again, just because a resident was on a blood thinner and hit his head was not necessarily a reason to send a resident out for evaluation. The DON was asked if the physician had been notified of the Resident 9's fall, the DON stated, Yes, and stated that 72 hour neuro checks had been ordered. On [DATE], at 1:28 p.m., a phone interview was conducted with a LVN 6 who had observed Resident 9's fall on [DATE]. LVN 6 was asked about Resident 9's fall on [DATE]. LVN 6 stated she observed the resident place his walker against the wall, then proceed to trip over his own feet and fall. LVN 6 was asked if she observed Resident 9 hit his head. LVN 6 stated, No, she had not seen him hit his head. LVN 6 was asked if she had observed any bruising on Resident 9's head. LVN 6 stated she had been off work [DATE]th and 10th and had not seen the bruising until she had returned to the facility on [DATE]. LVN 6 stated she had not been made aware of any falls after the [DATE], fall. On [DATE], at 1:39 p.m., a second interview was conducted with the DON. The DON was asked if there was any documentation or if he had received any notification of a fall after the [DATE], fall that would have occurred prior to Resident 9 being sent out 911 (paramedic ambulance) on the morning of [DATE]. The DON stated there was no documentation of a fall witnessed or unwitnessed after the [DATE]th fall. The DON further stated he had not been notified of any falls after Resident 9 had fallen on [DATE]. On [DATE], at 9:41 a.m., a second interview was conducted with LVN 6. LVN 6 was asked when the last time she had seen Resident 9. LVN 6 stated before she had left for the day on [DATE], at approximately 2:30 p.m. When asked if she had identified any injury to the residents head, LVN 6 stated it was a little red. LVN 6 stated when she returned to work on [DATE], after being off for two days that was when she had observed the bruising to Resident 9's head. LVN 6 stated no one had reported to her the bruise on the resident's head. LVN 6 stated that on [DATE], the resident could not move or talk. LVN 6 further stated after the resident had been sent out to the hospital via 911 she had called other staff members at the facility to find out what had happened to the resident. LVN 6 stated no one could tell her what had happened to the resident in her absence. LVN 6 stated that something had to have happened to the resident between [DATE]th and the 11th. On [DATE], at 5:12 p.m., a phone interview was conducted with a paramedic who had transported Resident 9 from the facility to the acute hospital after the facility had called 911(emergency phone number to call for paramedic staff) on [DATE]. The paramedic stated the resident had an altered mentation (confused) and had incomprehensible (unable to understand) and garbled (unclear) speech. The paramedic further stated two staff members had assisted him in the resident's room but neither of the staff members was able to state what had caused the bruise on the resident's head. The paramedic stated the bruise on Resident 9's forehead had a yellow aura around it which indicated it had begun healing. The paramedic stated the bruise on the resident's head was, difficult to miss. Resident 9's paramedic ambulance report titled, PATIENT CARE REPORT, dated [DATE], was reviewed. The report indicated, .PT. (patient) NOTED TO BE IN UNKEPT ROOM. STAFF REPORTS FINDING PT. TO BE MORE ALTERED THAN BASELINE AS WELL AS FEBRILE (with a fever) EMS (emergency medical services-paramedic) NOTES MULTIPLE BRUISES TO BOTH PT. KNEES, ELBOWS AND FOREHEAD ABOVE RIGHT EYE. COLOR INDICATES BRUISES ARE FROM A FALL THAT OCCURRED YESTERDAY, HOWEVER PT. WAS NOT TRANSPORTED TO ED (emergency room ) FOR EVAL (evaluation) PT. FOUND TO BE ALTERED .BASE CONSULTED DUE TO NATURE OF PT. INJURIES, ADVISED TO CONTINUE TO CLOSEST ED .REPORTS GIVEN TO ED RN (registered nurse) AND MD (physician) AT BEDSIDE DUE TO CONCERNS WITH PT. CARE AT FACILITY . Further review of the report indicated under heading, PHYSICAL ASSESSMENT, the forehead was, POSITIVE: CONTUSION (region of injured tissue or skin in which blood capillaries have been ruptured) ECCHYMOSIS (discoloration of the skin resulting from bleeding underneath) AND EDEMA/SWELLING- TRAUMATIC . On [DATE], at 3:10 p.m., a phone interview with the DON and facility Administrator indicated a certified nurse's assistant (CNA 1) had observed Resident 9 fall from a wheelchair in the dining room on [DATE], and that an LVN charge nurse (LVN 7) had been notified of the fall. The DON stated LVN 7 had not documented the incident. On [DATE], at 4:00 p.m., a phone interview was conducted with LVN 7. LVN 7 stated Resident 9 had been sitting in an oversized wheelchair that had belonged to another resident and was moved to a different wheelchair that was tilting. LVN 7 stated Resident 9 was leaning forward in the wheelchair so she and another nurse went to find Resident 9 a more suitable wheelchair. LVN 7 stated when she had returned to the dining room with another wheelchair a CNA (CNA 1) had informed her that Resident 9 had fallen, again. LVN 7 stated CNA 1 had stated that Resident 9 had hit his head again on the same side as the day before. LVN 7 was asked what side of Resident 9's head had been injured. LVN 7 hesitated briefly and then stated the right side-Yes, right side. LVN 7 stated there was no observed cut or bleeding on the resident's forehead. LVN 7 was asked if she had documented the incident. LVN 7 stated she had completed an Incident Report, but stated she had not documented the fall. LVN 7 stated she had informed other staff members about Resident 9's fall. On [DATE], at 1:57 p.m., a phone interview was conducted with CNA 1. CNA 1 was asked if he had witnessed Resident 9 fall. CNA 1 stated he had observed Resident 9 fall from his wheelchair in the dining room but was unable to remember the date of the fall. CNA 1 stated Resident 9 had leaned forward in his wheelchair and had fallen completely out of the wheelchair and had hit his head. CNA 1 stated he had informed the charge nurse (LVN 7). CNA 1 stated Resident 9 had landed on the right side of his head. CNA 1 stated that he had assisted the resident back into his wheelchair and had observed a red bruise, on Resident 9's head and stated it appeared more like, internal bleeding because he fell a little bit too hard. CNA 1 stated he was the only staff member that had observed the fall, but stated again that he had informed the charge nurse (LVN 7) of the fall. On [DATE], at 4:40 p.m., a phone interview was conducted with CNA 2. CNA 2 was asked about Resident 9. CNA 2 stated she had seen the resident on [DATE], the day before he had been sent out to the hospital. CNA 2 stated she had assisted a charge nurse (LVN 7) move Resident 9 from one wheelchair to another wheelchair in the dining room after LVN 7 had informed her and another CNA that the resident had fallen. CNA 2 stated LVN 7 had asked her to assist the resident back to his room. CNA 2 was asked if she had observed any bruising on Resident 9's head. CNA 2 stated she had observed a circular bruise above his left eye. CNA 2 stated she believed it was the left eye. CNA 2 was then asked if she had seen Resident 9 again that day. CNA 2 stated, No, she further stated, I thought she (LVN 7) was going to take care of everything. Review of the facility's policy and procedure titled, POLICY AND PROCEDURE ON FALL PREVENTION AND REDUCTION, undated indicated, If and when fall (sic) occurs, facility shall implement corrective measures to reduce incidence of fall. The policy further indicated, .6. Residents with fall incident shall be referred to appropriate healthcare professionals. 7. Licensed nurse shall immediately complete an incident report and incident investigation report relating to the fall incident. The policy indicated under heading, COMPONENTS OF A FALL REDUCTION PROGRAM, section I, Monitoring & Reporting of Fall Incidences- each staff must report all incidents he or she is involved in or witnesses to, to (sic) his or her immediate supervisor .Residents identified to be at greater risk for falls or further falls should be monitored closely to prevent further occurrence of fall incident. Review of Resident 9's acute hospital record title, HISTORY AND PHYSICAL-STANDARD HOSPITAL ADMIT, (H&P) dated [DATE], indicated, .Patient (Resident 9) presents with: ALTERED LEVEL OF CONSCIOUSNESS (ALOC) .Called (facility phone number) busy signal. Noted with head bruise and per nurse, facility states he had fallen there. Further review of this document indicated, EMERGENCY DEPARTMENT COURSE/INTERM INTERVENTIONS: had CT (CAT scan- computed tomography-radiologic imaging that uses computer processing to generate an image) with Impression as follows: Acute left subdural hematoma (a clot of blood that develops between the surface of the brain and the brain's outer covering, due to stretching and tearing of veins on the brain's surface. These veins rupture when a head injury suddenly jolts or shakes the brain) measuring up to 2.4 cm (centimeter or approximately 1 inch) overlying the left parietal lobe (one of four major lobes of the brain). The H&P indicated, Patient Active Problem List: SUSPECTED ADULT NEGLECT. Section titled, ASSESSMENT AND PLAN-PROBLEM LIST, indicated, Active Problems: .ALOC---unclear source, possibly due to Subdural hematoma from fall .Due to bleed no LP (lumbar puncture--procedure of taking fluid from the spine in the lower back through a hollow needle) .TRAUMATIC SUBDURAL HEMATOMA--patient on Xarelto per nursing facility notes. Give Kcintra (a medication given to stop bleeding) for helping with bleed .on Xarelto, hold medication due to bleed . The hospital's operating room surgeon note dated [DATE], for Resident 9 indicated, .bruises found all over his body . Resident 9's progress note dated [DATE], at 5:30 a.m., indicated, PHYSICAL EXAM: GENERAL: disheveled, unkept, ill appearing .SKIN: multiple bruises . Review of progress note for Resident 9 dated [DATE], also at 5:30 a.m., by a different physician indicated in section, HPI (history of present illness) .On Neurosurgery examination patient .was taken to the OR (operating room) emergently for Left Craniotomy (neurosurgical procedure that involves removing a portion of the skull in order to relieve pressure on the underlying brain. The procedure is typically done in cases where a patient has experienced a very severe brain injury that involves significant amounts of bleeding around the brain or excessive swelling of the brain, typically performed as a life saving measure) for evacuation of subdural hematoma by (name of physician) on [DATE]. A review of a hospital critical care progress note for Resident 9, dated [DATE], indicated, HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: .(Resident 9's name) .who was admitted for fall with multiple trauma including head trauma resulting in subdural hematoma. Patient was taken emergently for evacuation of hematoma . The note further indicated, .Given poor prognosis (outcome) for meaningful neurological recovery per neurology and neurosurgery, requested Bioethic (committee which supports hospitals in providing clinical ethics discussions such as withholding and withdrawing life-sustaining treatments for a patient) consult regarding guidance on goals of care, since patient has no family member or decision maker. A hospital progress note dated [DATE], at 8:47 a.m., indicated, Persistent ALOC .-MRI (magnetic resonance imaging- scan that uses magnetism, radio waves, and a computer to produce images of body structures) brain showed large right MCA stroke, which may explain patient's ALOC . The note further indicated, Patient remains in critical condition requiring constant attention . A hospital progress note dated [DATE], indicated, Patient is on comfort care only status. This is due to poor prognosis following left craniotomy for evacuation of subdural hematoma [DATE] . Further review of the note indicated, Care conference (sic) had with (contact's name) regarding the patient's poor clinical status and prognosis. Decision was made to proceed with comfort measures only. Pt (patient) extubated (removal of a tube used to help with breathing) and placed on morphine (medication to treat severe pain) gtt (drip). Review of a hospital progress note dated [DATE], at 12:11 p.m., indicated, Called by RN (registered nurse) to bedside to assess the patient. Patient's rhythm on telemetry (machine used to monitor changes in blood pressure and the rate and rhythm of the heart) noted to be asystole (flatline). The patient was then examined. Pupils were fixed and dilated (pupils that are unequal in size can be a sign of serious conditions affecting the brain, fixed and dilated pupils indicate no chance of survival). No spontaneous respirations (breathing) observed. No heart sounds were auscultated (heard) .Patient pronounced dead at [DATE] (sic) 1200.