Every finding on record at San Jose Healthcare & Wellness Center

Based on interview and record review, the facility failed to establish and communicate which licensed nurse was responsible for providing care to one of three sampled residents (Resident 1) on the evening shift (3:00 p.m. to 11:00 p.m.) of 4/9/25. This failure resulted in Resident 1 not receiving scheduled medications in a timely manner, and had the potential to result in other care needs not being met. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including, but not limited to dementia (a progressive state of decline in mental abilities), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertensive heart disease (a heart condition that develops from chronic high blood pressure), and heart failure (a condition in which the heart does not pump blood as well as it should). Review of Resident 1's medication administration record (MAR), dated 4/2025, indicated Resident 1 was scheduled to receive the following evening medications: 1.) Lactobacillus oral capsule (a supplement that contains beneficial bacteria) at 5:00 p.m.; 2.) Metformin (a medication used to treat DM) 500 milligrams (mg, unit of dose measurement) at 5:30 p.m.; 3.) Metoprolol (a medication used to treat high blood pressure and heart failure) 25 mg at 5:00 p.m.; and 4.) Insulin Lispro injection (medication used to treat DM) 100 units per milliliter (u/ml, unit of dose measurement) per sliding scale (amount to be administered depends on blood sugar reading) at 5:00 p.m. For lactobacillus, metformin, and metoprolol, the MAR did not specify what time the medications were given on 4/9/25. However, for the insulin lispro injection, the MAR indicated the medication was administered by licensed vocational nurse A (LVN A) at 6:59 p.m. (almost two hours after the scheduled administration time) on 4/9/25. The facility's monthly nursing assignment, dated 4/2025, was reviewed. The monthly nursing assignment indicated licensed vocational nurse B (LVN B) was scheduled to provide care to Resident 1's area of the facility on 4/9/25. During an interview with LVN A on 6/19/25 at 10:44 a.m., LVN A stated there was an evening shift during which there was confusion about the licensed nurse assignment for Resident 1. LVN A stated he was the nurse supervisor on this particular evening shift. LVN A explained that LVN B was usually scheduled to provide care to Resident 1's area of the facility on the evening shift, but it had been requested that LVN B not provide care to Resident 1. LVN A further explained that since LVN B could not provide care to Resident 1, licensed vocational nurse C (LVN C) was supposed to take on that responsibility. LVN A confirmed LVN C was not informed that she was supposed to provide care to Resident 1 on this particular evening shift. LVN A stated he or LVN B should have communicated this to LVN C. LVN A confirmed that on this particular evening shift, he was the one who administered Resident 1's scheduled 5:00 - 5:30 p.m. medications at around 7:00 p.m. LVN A confirmed these medications were administered late, as they should have been administered within one hour before or after the scheduled times. The facility's undated document, titled LVN Staff Nurse Job Description, indicated the LVN was responsible for giving and receiving nursing reports upon beginning and ending of their assigned shift. It also indicated the LVN was responsible for reviewing and assisting in revision of nursing assignments. The facility's policy titled Medication - Administration, revised 1/1/2012, indicated, Medications may be administered one hour before or after the scheduled medication administration time.

Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for six of 11 residents (31, 33, 35, 37, 42, and 49) when: 1. Residents 31, 33, and 35 did not have care plan for siderails; 2. Residents 42 and 49 did not have a physician's order for the use of siderails and care plan for siderails; and 3. Resident 37 did not have a consent and a physician's order for the use of siderails, and care plan for siderails. These failures had the potential to place the residents at risk of entrapment and injury. Findings: During an observation on 3/4/25 at 11:47 a.m., Residents 31, 33, 35, 37, 42, and 49 had bilateral siderails. Review of Residents 31, 33, and 35's clinical records indicated Residents 31, 33, and 35 did not have care plan for siderails. Review of Residents 42 and 49's clinical records indicated Residents 42 and 49 did not have a physician's order for the use of siderails and care plan for siderails. Review of Resident 37's clinical record indicated Resident 37 did not have a consent and a physician's order for the use of siderails, and care plan for siderails. During an interview with the director of nursing (DON) on 3/7/25 at 11:49 a.m., she reviewed Residents 31, 33, 35, 37, 42, and 49's clinical records, and she confirmed that Residents 31, 33, and 35 did not have care plan for siderails; Residents 42 and 49 did not have a physician's order for the use of siderails and care plan for siderails; and Resident 37 did not have a consent and a physician's order for the use of siderails, and care plan for siderails. The DON stated the residents should have documented consent, physician's order, and care plan for the use of siderails. Review of the facility's policy, NP120 Bed Rails, dated 6/12/24, indicated . 1. Evaluating the Resident's Need for Bed Rails: . d. The ordering physician will obtain informed consent from the resident/resident representative prior to the use of bed rails. e. A care plan will be developed regarding the use of bed rails.

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when kitchen staff did not correctly demonstrate how to test the dish machine sanitizer. This failure had the potential to place 51 residents who consumed food from the kitchen at risk for exposure to contaminants in food that may lead to food borne illness. Findings: During a kitchen observation and interview on 3/4/25 at 1:09 p.m. with the Registered Dietician (RD), Dietary Manager (DM), and Dietary [NAME] (DC), DC tested the sanitizer of the facility dish machine. DC took a test strip and dipped it in the water that came out of the dish machine after a cycle. The test strip turned purple and DC compared it to the test strip container. The RD and DM stated this was how they test the sanitizer. During an interview on 3/5/25 at 10:41 a.m. with dish machine vendor technician specialist (TS), TS stated, the correct way to test the dish machine sanitizer was either to take a cleaned plate out of a dish machine, flip the plate upside down, and put the test strip on the bottom of the plate or let the test strip touch the inside walls of the dish machine and then compare the strip with the test strip container. TS also stated, that test strip should not be dipped directly in the water from the dish machine. TS stated that kitchen staff were trained about this technique. Dish machine procedure manual/manufacturer guidelines was requested but was not provided. Based on dish machine vendor's Proper Testing Procedure for the low temperature dish machine, When testing for sanitizer, we need to test the items that are actually being washed .a good example is coffee cups .coffee cups have a concave bottom that will hold a little bit of final rinse water .as soon as the rack comes out of the machine, take the test strip, wipe it on the bottom of the coffee cup . (https://diversey.com/en/video-hub/chlorine-sanitizer-testing) A review of facility's policy and procedure (P&P) entitled Dish Machine Operation and Cleaning revised 10/1/2014, the P&P indicated, .The dietary staff will use the dish machine according to the manufacturer's guidelines A review of facility's policy and procedure (P&P) entitled, Dietary Department-General revised 6/1/2014, the P&P indicated, .I. The primary objectives of the dietary department include: .B. Maintenance of standards for sanitation and safety

Based on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation equipment and food storage methods, according to standards of practice and facility policy when: 1. Foods were stored unlabeled and/or past used-by date; and 2. Sink drainage pipe with buildup within the inner lining. These failures had the potential for food contamination, resulting in food borne illnesses for 51 residents who consume food from the kitchen. Findings: 1. During the initial kitchen tour observation and interview on 3/3/25 at 8:51 a.m., with the Registered Dietician (RD), the sink faucet was dripping and drainage pipe with an air gap was dirty with accumulation of whitish to yellowish build up around the inner lining. The outer part of the pipe had whitish substance in drip patterns. During an observation and interview in the kitchen on 3/4/25 at 1:00 p.m. with the Dietary Manager (DM), the DM confirmed the state of the dirty sink drainage pipe and stated that the DM is the cleaner for the drainage pipe, but it was not in the schedule. DM confirmed the sink faucet cannot be turned off completely for one or two weeks and a work order was requested. During a concurrent interview and record review on 3/6/25 at 9:40 a.m. with the Regional Registered Dietician (RRD), the RRD stated, The drainage pipe could have been cleaner. The RRD also verified the facility kitchen's Food and Nutrition: Cleaning Log dated 12/30/24 to 3/6/25 did not include the sink and drainage pipe on the list of areas/equipment to be cleaned. The RRD stated that it will be recommended to add the sink on the cleaning log. A review of facility's policy and procedure (P&P) entitled, Dietary Department-General revised 6/1/2014, the P&P indicated, .I. The primary objectives of the dietary department include: .B. Maintenance of standards for sanitation and safety A review of facility's policy and procedure (P&P) entitled, Cleaning Schedule revised 10/1/2014, the P&P indicated, The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager .II. The Dietary Manager monitors the cleaning schedule to ensure compliance. 2. During the initial kitchen tour observation and interview on 3/3/25 at 9:11 a.m., with the Registered Dietician (RD), RD verified a container of sugar-free gelatin labeled with 2/6/25-2/28/25, an opened non-dairy creamer without labeled open-date and lettuce salad mix without labeled open-date were stored in the refrigerator. The RD stated that refrigerators were checked every morning. The RD stated that the non-dairy creamer must be labeled with the date it was opened and can be used within seven days. The RD verified that the lettuce salad mix was wilted and must be thrown out. During a concurrent interview and record review on 3/6/25 at 9:40 a.m. with the Regional Registered Dietician (RRD), the RRD stated ,Produce should not be necessarily labeled. According to the non-dairy creamer manufacturer's guidelines, once opened, the product can be refrigerated up to three weeks. (https://www.richsusa.com/products/toppingscreams/creamers/02209/#:~:text=KEEPS%203%20WEEKS%20IN%20REFRIGERATOR.) A review of facility document entitled Produce Storage Guidelines dated 2023 indicated, lettuce, salad greens, parsley may be refrigerated for three to five days. A review of facility's policy and procedure (P&P) entitled, Dietary Department-General revised 6/1/2014, the P&P indicated, .I. The primary objectives of the dietary department include: .B. Maintenance of standards for sanitation and safety; C. Maintenance of standards for quality of food . A review of facility's policy and procedure (P&P) entitled, P-DS52 Food Storage and Handling dated 6/4/24, the P&P indicated, .9. Fresh Vegetable Storage .f. Label and date all food items

Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection control procedures when: 1. Licensed Vocational Nurse D (LVN D) did not wash or sanitize hands before checking Resident 21's vital signs (blood pressure [BP], pulse, and oxygen saturation [SpO2], which measures the amount of oxygen in the blood); 2. Certified nursing assistant C (CNA C) did not wash or sanitize her hands before feeding Resident 40; licensed vocational nurse A (LVN A) and registered nurse F (RN F) did not wash or sanitize their hands before opening the plate lids to check the residents' meals on the meal tray; and 3. Licensed vocational nurse A (LVN A) did not clean the used scissors before cutting the granufoam dressing (designed to adapt to irregular wound contours) and the vacuum assisted closure tape for Resident 31's wound. These failures had the potential to increase the risk of spreading infections in the facility. Findings: 1. During an observation and concurrent with interview on 3/4/25, at 3:53 p.m., LVN D was observed pushing a portable vital signs machine into Resident 21's room. LVN D placed the BP cuff around Resident 21's left upper arm and proceeded to check the resident's other vital signs. However, LVN D did not wash or sanitize hands before entering the resident's room or before checking the vital signs. LVN D confirmed the observations and acknowledged that hand hygiene should have been performed before checking Resident 21's vital signs. Review of the Centers for Disease Control and Prevention's (CDC) guidance titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24, recommends performing hand hygiene immediately before touching a patient. 37409 2. During a dining observation, on 3/3/25 at 12:23 p.m., certified nursing assistant C (CNA C) brought the chair over, sat down, and fed Resident 40 without sanitizing her hands. During a concurrent interview with CNA C, she acknowledged that she should sanitized her hands before feeding Resident 40. During an observation, on 3/3/25 at 12:37 p.m., licensed vocational nurse A (LVN A) pushed Station 2 lunch cart over and opened the lids of residents' lunch plates to check on the meals without washing or sanitizing her hands; then registered nurse F (RN F) came over and opened the lids of residents' lunch plates to check on the meals without washing or sanitizing her hands. During a concurrent interview, LVN A and RN F acknowledged that they should wash or sanitize their hands before opening the plate lids to check on the meals on residents' meal trays. Review of the facility's policy, DD05 Dining Program, dated 2/20/25, indicated . Facility staff will perform hand hygiene prior to distribution of trays. The Centers for Disease Control and Prevention (CDC) recommends healthcare professionals practice hand hygiene before and after interacting with patients, especially before feeding them, using alcohol-based hand rubs or washing hands with soap and water. 3. During a wound treatment observation, on 3/5/25 at 2:11 p.m., licensed vocational nurse A (LVN A) cut the bag of the V.A.C. Granufoam Dressing [(VAC, vacuum assisted closure of a wound; granufoam - designed to adapt to irregular wound contours; it is a negative pressure wound therapy dressing)] with the scissors. Then without cleansing the scissors, she used it to cut the granufoam dressing and inserted it into Resident 31's sacral wound; and cut the vacuum assisted closure tape and applied the tapes on Resident 31's sacral wound. During an interview with LVN A, on 3/5/25 at 3:20 p.m., LVN A acknowledged that she should cleaned the scissors before cutting the granufoam dressing and the vacuum assisted closure tape to apply them to Resident 31's wound. For infection control during wound care, the Centers for Disease Control and Prevention (CDC) recommends standard precautions, proper use of personal protective equipment (PPE), hand hygiene, and meticulous cleaning and disinfection of equipment and surfaces.

Based on observation, interview, and record review, the facility failed to treat the residents with dignity for one of 14 residents (31) when licensed vocational nurse A (LVN A) opened Resident 31's room door without covering her while her back and buttocks were exposed. This failure had the potential to cause embarrassment and feelings of low self-esteem (unhappy and thinking negatively about yourself) for the resident. Findings: Review of Resident 31's Admission Record indicated she was admitted to the facility on [DATE]. During a wound treatment observation, on 3/5/25 at 2:11 p.m., Resident 1 was lying in her bed, the first bed from her room door; the curtain was opened all the way, and the door was closed. LVN A turned Resident 1 to the side. Resident 1's back and buttocks were exposed and facing the room door. LVN A found that Resident 1 had bowel movement. Without covering Resident 1's body, LVN A opened the door and called the certified nursing assistant (CNA) to come to clean Resident 1. During the wound treatment, LVN A needed assistance. Again, without covering Resident 1's body, LVN A opened the door and called for help. During an interview with LVN A, on 3/5/25 at 3:20 p.m., she acknowledged that she should have covered Resident 31's body before she opened the room door to call for assistance. Review of the facility's policy, Resident Rights, dated 1/1/12, indicated Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.

Based on interview and record review, the facility failed to properly obtain informed consent (permission granted in the knowledge of the possible consequences) for psychotropic medications (medications capable of affecting the mind, emotions and behavior) for three (Resident 20, Resident 4, and Resident 28) out of 14 residents. This failure had the potential to compromise the right of the residents or responsible parties (persons designated to make decisions of behalf of the residents) to be fully informed regarding care and treatment in order to make health care decisions. Findings: 1. A review of Resident 20's clinical record indicated he had a physician's order for Risperidone (medication used to treat mental illness that causes disturbed or unusual thinking, loss interest in life, and strong or inappropriate emotions) 0.25 milligrams (mg, unit of dose measurement) to be administered at bedtime for one week started on 3/1/25 until 3/8/25. A review of Resident 20's diagnoses included but not limited to unspecified psychosis [refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality] not due to a substance or known physiological condition During a concurrent interview and record review of Resident 20's clinical record with The Director of Nursing (DON) on 3/6/25 at 1:58 p.m., the DON verified the document entitled Informed Consent Documentation dated 12/10/24, signed by Resident 20 and the physician, did not indicate medication name, dose, frequency, indications, side effects and possible adverse reactions. The DON also verified Resident 20's Verification of Informed Consent for Risperidone which did not indicate a date and a nurse's signature. A review of facility's Policy and Procedure (P&P) entitled NP67 Informed Consent dated 1/3/24, the P&P indicated, Except in emergencies, informed consent must be obtained prior to the proposed treatment or procedure. A review of facility's undated Policy and Procedure (P&P) entitled, Behavior/Psychoactive Drug Management, the P&P indicated, .J. When processing a new order or an increase in psychoactive drugs, the Attending Physician/Prescriber must do and as follows: i. Obtain informed consent from resident or responsible party .K. When an order for psychotropic drug is obtained, the Licensed Nurse verifies with the Attending Physician/Prescriber that informed consent has been obtained . 42819 2. A review of Resident 4's clinical record shows diagnoses including Parkinson's Disease (disorder of the nervous system that causes tremors, stiffness, and slow movements), Schizoaffective disorder (a mental health condition including schizophrenia, which affects thinking, emotions, and behavior), mood disorders and, Dementia (a group of thinking and social symptoms that interferes with daily functioning) with agitation. A review of Resident 4's physician's order for Valproic Acid (medication used to treat seizures, mood disorders) 250 milligrams/5 milliliter (mg/ml, measurement of solution's concentration) to be given two times a day to manage mood disorder, including angry outburst, throwing things towards patients and aggressive behavior. The medication was started on 6/24/24. During a concurrent interview and record review with the director of nursing (DON) on 3/7/25, at 10:47 a.m., the DON confirmed that Resident 4's clinical record did not contain an Informed Consent for Valproic acid. After further review, the DON found an informed consent for Seroquel (a medication used to treat schizophrenia, bipolar disorder, and severe depression), but acknowledged that an informed consent should also have been obtained for Resident 4's Valproic Acid. 3. A review of Resident 28's clinical record with diagnoses including Encephalopathy (a condition that affects brain function, leading to confusion, memory problems, and difficulty thinking); schizoaffective disorder, bipolar disorder (mood swings between depression and mania). A review of Resident 28's physician's order for Risperidone 0.25 mg, twice a day, to manage Schizoaffective Disorder, Bipolar type manifested by paranoid thoughts, physical aggression. The medication was ordered on 12/4/24. During a concurrent interview and record review with the DON on 3/7/25, at 2:40 p.m., the DON confirmed that the Informed Consent Documentation dated 12/5/24, and signed by Resident 28 and the physician, was incomplete. The document did not include the medication name, dose, frequency, indications, side effects, or possible adverse reactions. The DON also confirmed that Resident 28's Verification of Informed Consent for Risperidone was missing a date and a nurse's signature.

Based on observation, interview, and record review, the facility failed to ensure medications were not left unattended at the bedside for one of 14 sampled residents (Resident 4). Resident 4 was not approved to self-administer medications. This deficient practice placed Resident 4 and other residents at risk for harm. Findings: A review of Resident 4's clinical record with diagnoses including Parkinson's Disease (disorder of the nervous system that causes tremors, stiffness, and slow movements), schizoaffective disorder (a mental health condition including schizophrenia [mental health illness affects thinking, emotions, and behavior), mood disorders, Dementia (a group of thinking and social symptoms that interferes with daily functioning) with agitation. A review of Resident 4's Self-Administration of Medication Assessment form, dated 1/16/25, indicated that Resident 4 was not a candidate for self-administration of medications. During an observation of Resident 4 in her room on 3/3/25 at 9:01 a.m., the resident was sitting in her wheelchair, and a medication cup with five pills was left on her breakfast tray. In a concurrent interview, Resident 4 stated that staff routinely leave her medications, and she takes them on her own. No licensed staff member was present in the room. During an interview with Registered Nurse E (RN E) on 3/3/25, at 3:19 p.m., RN E confirmed that she gave the pills to Resident 4. However, the resident indicated she would take the medication later. RN E stated she left the medication in the room and did not stay to observe whether Resident 4 took all of the prescribed medications. During an interview with the Director of Nursing (DON) on 3/7/25, at 2:37 p.m., the DON confirmed that Resident 4 is not approved for self-administration of medications. Review of facility's policy, titled, Medication Administration, dated 1/1/12, indicated, Medication will be administered directed by a license nurse and upon the order of a physician or licensed independent practitioner.

Based on observation, interview and record review, the facility failed to ensure one (Resident 14) out of 14 sampled residents was free from abuse when staff shouted at and did not acknowledge Resident 14's statement for hunger. This failure had the potential to impact the physical and mental well-being of the resident. Findings: A review of Resident 14's clinical record indicated admitted [DATE] with diagnoses including Unspecified Dementia [decline in mental abilities, like memory, thinking, and reasoning], Type 2 Diabetes Mellitus [a condition where the body either does not make enough insulin or cannot use insulin properly, leading to high blood sugar levels] with diabetic chronic kidney disease [occurs when high blood sugar levels from diabetes damage the kidneys' ability to filter waste and excess fluid] and, Major Depressive Disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest]. A review of Resident 14's Minimum Data Set (MDS, an assessment tool), dated 2/4/25, indicated a brief interview for mental status score of 12 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. The MDS indicated, Resident 14 had poor appetite or overeating. A review of Resident 14's Psychiatric Evaluation dated 2/28/25 indicated a psychiatric follow up visit dated 12/19/24 indicated, Symptom #1: mood lability .Symptom triggers: current social, medical condition Symptom #2: anxiety . Symptom triggers: current social, medical condition .Associated signs and symptoms: behavioral outbursts, verbal aggression, mood lability, and interpersonal conflicts . A review of Resident 14's Nutrition/Dietary notes dated 12/2/24 indicated, significant weight loss of 11.3% within x 180 days . A review of Resident 14's physician order indicated, Snacks twice daily at 2 pm and 8 pm two times a day. During an interview on 3/6/25 at 10:58 a.m. with Licensed Vocational Nurse (LVN) G, LVN G stated, Resident 14 eats by herself and was independent. During a kitchen observation and interview on 3/6/25 at 3:10 p.m., a State Surveyor (SS, California Department of Public Health, CDPH nurse surveyor) was walking down the hallway towards the kitchen, this SS observed Resident 14 in a wheelchair, holding the kitchen door slightly opened and was saying Hello, I'm hungry. The SS heard a shouting voice coming from inside the kitchen said Go to your room! Go to your room! Then, a hand was seen trying to close the door and the staff still shouting at Resident 14, Go to your room! The SS then showed herself at the kitchen door and witnessed the Dietary Manager (DM) holding the door from inside the kitchen as she was shouting, Go to your room! to Resident 14. The DM stopped when she noticed the SS. DM then told Resident 14 that her tray will be brought to her room. Resident 14 let go of the kitchen door and left. The HFEN entered the kitchen and observed DM was not wearing a hair covering. DM stated she removed it because she was about to leave the kitchen. The SS informed DM that emergency food supplies were to be checked, and DM led the SS into the kitchen pantry. The Registered Dietician (RD) came in the middle of checking the emergency supplies. The HFEN asked the DM for appropriate ways on how to address a resident stating hunger, DM did not provide an answer. During an interview on 3/6/25 at 4:12 p.m. with the Regional Registered Dietician (RRD), the RRD was asked what is the appropriate response to a resident who is stating she was hungry, the RRD stated, We let them know what we can do for them. During an interview on 3/7/25 at 2:04 p.m. with the Dietary [NAME] (DC), the DC stated, she will not shout at a resident if they were asking for food and instead will say, How can I help you? What can I do for you? During an interview on 3/7/25 at 2:22 p.m. with the Director of Nursing (DON), the DON stated, kitchen staff must speak respectfully to the residents. The DON also stated, kitchen staff must let the nurse or nurse aide get the food from the kitchen. A review of facility's Job Description for Dietary Services Supervisor/Certified Dietary Manager indicated, .Ensures that all consumer/resident rights are protected. A facility document entitled, Employee Relations Conduct January 2024 edition indicated, .the following are examples of conduct that are prohibited and will not be tolerated .Rude, discourteous condescending, unprofessional or otherwise socially unacceptable behavior toward a customer, or anyone in contact with the Company .Any employee/resident abuse . A review of facility's policy and procedure (P&P) entitled, Resident Rights revised 1/1/2012, the P&P indicated, Purpose to promote and protect the rights of all residents at the facility Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights .III. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: A. Sleeping, eating .

Based on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for three of 14 residents (3, 21, and 23) when: 1. Resident 3 was not served yogurt, tofu, orange, tangerine with his meals as ordered by the physician; 2. For Resident 21, rolled towels to his bilateral (right and left sides of the body) hands and offloading boots to his bilateral lower extremities were not applied as ordered by the physician; and 3. Certified nursing assistant C (CNA C) did not know about her resident, Resident 23. These failures had the potential to affect the residents' care and could jeopardize their health and well-being. Findings: 1. Review of Resident 3's Admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 3's physician order, dated 1/31/25, indicated he had an order for the facility to provide yogurt, tofu, orange, tangerine with his meals. During an observation, on 3/4/25 at 12:45 p.m., Resident 3 did not have yogurt, tofu, orange, tangerine with his lunch. During an observation and interview with the registered dietician (RD), on 3/5/25 at 12:35 p.m., Resident 3 did not have yogurt, tofu, orange, tangerine with his lunch. The RD reviewed Resident 3's physician order and confirmed Resident 3 had an order for the facility to provide yogurt, tofu, orange, tangerine with his meals. During an interview with Resident 3, on 3/5/25 at 1:25 p.m., he stated he would like to have yogurt, orange, tangerine with his meals. During an interview with the director of nursing (DON), on 3/5/25 at 1:35 p.m., she stated that the physician order should be followed. Review of the facility's policy, Dietary Profile and Resident Preference Interview, dated 4/21/22, indicated Resident preferences will be reflected in the medical record and tray-card and updated in a timely manner. 2. Review of Resident 21's Admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 21's physician orders indicated he had orders for the licensed nurse to apply roll towel to his bilateral hand every shift for it helps fingers from rubbing due to closed hand fist, started on 12/10/24; and to apply offloading boot to his bilateral lower extremities every shift for pressure release, started on 11/17/24. During the observations, on 3/4/25 at 11:20 a.m. and on 3/4/25 at 3:40 p.m., Resident 21 did not have rolled towels in his hands and offloading boots on his lower extremities. During an observation and interview with licensed vocational nurse B (LVN B), on 3/5/25 at 11:10 a.m., Resident 21 did not have rolled towels in his hands and offloading boots on his lower extremities. LVN B reviewed Resident 21's clinical record and stated that she would apply rolled towels in Resident 21's hands and offloading boots on Resident 21's lower extremities as ordered by the physician. Review of the facility's undated job description, LVN Staff Nurse, indicated . General Duties and Responsibilities: General: Provides nursing care as prescribed by physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures . 3. Review of Resident 23's Admission Record indicated he was admitted to the facility on [DATE] with dependence on renal dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) diagnosis. Review of Resident 23' s clinical record indicated he had an arteriovenous (AV) shunt (a surgical connection between an artery and a vein) on his right lower arm. During an interview with certified nursing assistant C (CNA C), on 3/5/25 at 1:05 p.m., she stated that she worked with Resident 23. Resident 23 was a dialysis resident. CNA C stated Resident 23's dialysis site was on his chest, and she could take his blood pressure on either his left arm or right arm. Review of the facility's policy, NP37 Dialysis Management, dated 3/27/24, indicated . No blood pressure, phlebotomy (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing), or other pressure inducing procedures on the arm with an AV shunt.

Based on observation, interview, and record review, the facility failed to ensure that medications were fully administered as prescribed for one of 4 residents (Resident 21) observed during medication pass administration. This failure placed Resident 21 at risk for ineffective treatment and potential health complications. Findings: During a medication pass administration observation on 3/4/25, at 4:10 p.m., Licensed Vocational Nurse D (LVN D) prepared Resident 21's medications for administration via gastrostomy tube (GT, tube inserted through the abdomen to deliver nutrition and medications directly to the stomach). LVN D crushed each medication separately, placed them into individual medicine cups, and added approximately 10 milliliters (ml, unit of measurement) of water per cup. After confirming that Resident 21 had 12 medications, LVN D administered each medication separately, flushing the GT with 10 ml of water between doses. However, medication residue remained in 6 of the 12 medication cups after administration. During a concurrent interview, LVN D confirmed that residue remained in the six medication cups and acknowledged that more water should have been added to ensure all medication was administered. During an interview with the Director of Nursing (DON) on 3/7/25, at 2:35 p.m., the DON acknowledged that Resident 21 did not receive the full prescribed dose because medications remained in the medication cups. Review of Resident 21's physician's order, ordered date 11/16/24, indicated, crush and dilute medications with water prior to administering via TF (tube feeding) as appropriate Review of facility's policy, titled, Medication Administration, dated 1/1/2012, indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.

Based on observation, interview and record review, the facility failed to store and label medications and biologicals according to manufacturer instructions and facility policy. These failures had the potential for residents to receive incorrect or unsafe medications. Findings: During an observation on 3/4/25, at 3:50 p.m., in Station 2, while inspecting the medication cart with Registered Nurse E (RN E), the following issues were identified: 1. One unopened bottle of Latanoprost eye drops (a medication used to treat glaucoma, which is increased pressure inside the eye) for Resident 3 was found in the top drawer of the medication cart. The pharmacy label indicated that it should be refrigerated until opened, it was not stored in the refrigerator. 2. An inhaler Breo Ellipta (an inhaled medication to treat breathing problems) for Resident 15 was opened but did not have an open date indicated on the label. 3. One unopened Humalog (a fast-acting insulin used to control blood sugar) insulin vial (a small glass or plastic bottles used to store liquids, or powder medication) for Resident 16 was stored in the medication cart. The pharmacy label on the insulin vial indicated that it should be kept in the refrigerator until opened. During a concurrent interview, RN E confirmed that the Latanoprost eye drops, and Humalog insulin vial should have been stored in the refrigerator until opened and that the Breo Ellipta inhaler should have been labeled with an open date upon first use. A review of the facility's policy and procedure titled, Medication Storage in the Facility, dated 4/2008, indicated: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations.

Based on interview and record review, the facility failed to explain the arbitration agreement (a contract requires that person who signed it resolve disputes by a neutral third party, rather than in court before a judge and/or jury) which Resident 23 and Resident 31 signed during their admission to the facility. This failure resulted in Resident 23 and Resident 31 signing the facility's arbitration agreement without their full understanding of the same. Findings: Review of Resident 23's clinical record indicated he was admitted to the facility on [DATE], and he signed the facility's arbitration agreement on 1/20/25. Review of Resident 23's Minimum Data Set (MDS, a clinical assessment tool), dated 1/9/25, indicated his cognition was intact. Review of Resident 31's clinical record indicated she was admitted to the facility on [DATE], and she signed the facility's arbitration agreement on 1/22/25. Review of Resident 31's MDS, dated [DATE], indicated her cognition was intact. During an interview with Resident 23, on 3/5/25 at 12:15 p.m., he stated that he did not know about arbitration agreement; no one explained about it to him. Resident 23 stated that the facility gave him document to sign, and he signed it. During an interview with Resident 31, on 3/5/25 at 12:30 p.m., she stated that she did not know about arbitration agreement; no one explained about it to her. Resident 31 stated that the facility gave her document to sign, and she signed it. During an interview with the admission director (AD), on 3/7/25 at 10:55 a.m., she stated that she oversaw the facility's arbitration agreement, and she would make sure to explain the arbitration agreement to the residents. Review of the facility's policy, AD 17 Arbitration Agreements, dated 5/26/23, indicated . 3. If the facility presents an arbitration agreement to the resident, the person presenting the arbitration agreement will: a. Explain the agreement to the resident in a form and manner that they understand, including in a language the resident understand; and b. Confirm that the resident understands the agreement.

Based on observation, interview, and record review, the facility failed to ensure 10 bedrooms measured at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive. Findings: The residents' bedroom measurements were as follows: Room Number Bed Capacity Square Feet per Resident 1 2 78 9 3 69 10 3 69 11 2 66 12 3 76 14 3 76 17 3 69 18 3 69 21 3 77 23 3 77 During the survey, residents were observed in their rooms. Nursing care and services were not negatively impacted by the shortage of space. During the survey, residents and staff were interviewed to determine if there were any concerns or issues with the lack of space. The residents and staff verbalized no complaints or concerns regarding space. Recommend continuance of room waiver.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received medications as ordered by the physician. This failure had the potential to compromise the resident's health and well-being. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including cellulitis (a type of skin infection) and other disorders of the skin and subcutaneous tissue (the deepest layer of skin). Review of Resident 1's Order Summary Report indicated she had physician orders, dated 8/3/24, for the following medications: 1. Cleocin-T External Lotion (antibiotic lotion used to treat infection) 1% (unit of dose measurement) apply to affected areas topically (to the skin) two times a day for infection; 2. Mupirocin External Ointment (medication used to treat infection) 2% apply to affected area topically three times a day for infected skin; 3. Diclofenac Sodium External Gel (medication used to treat pain) 1% apply to affected area topically four times a day for pain; and 4. Nyamyc External Powder (medication used to treat skin infections caused by fungus) 100,000 units per gram (unit of dose measurement) apply to abdominal fold/groin area topically four times a day for MASD (moisture-associated skin damage). Resident 1's medication administration record (MAR) and treatment administration record (TAR), dated 8/2024, were reviewed. On 8/3/24 and 8/4/24, there were multiple scheduled times for which the above medications were not documented as administered. Instead, the nurses who were supposed to administer the medications documented, 9. Further review of the MAR and TAR indicated a documentation of 9 meant, See Progress Notes. Review of Resident 1's Progress Notes, dated 8/3/24 and 8/4/24, indicated licensed nurse A (LN A) and LN B documented the above medications were on order. During an interview and concurrent record review with LN A on 9/11/24, at 4:11 p.m., LN A reviewed Resident 1's medical record and acknowledged the documentations of 9 and on order regarding the medications mentioned above. LN A stated that on order meant the pharmacy had not yet delivered the medications to the facility. LN A stated she looked for Resident 1's medications but could not find them. During an interview and concurrent record review with LN B on 9/13/24, at 11:09 a.m., LN B reviewed Resident 1's medical record and acknowledged the documentations of 9 and on order regarding the medications mentioned above. LN B stated he looked in the medication cart, treatment cart, and medication room and could not find Resident 1's medications. LN B confirmed that on the days and times he documented 9 and on order in Resident 1's medical record, he did not administer the medications because he could not find them in the facility. The facility's Consolidated Delivery Sheets (documentation of medications delivered from the pharmacy) were reviewed. The delivery sheets indicated the facility did, in fact, receive all of Resident 1's above-mentioned medications on 8/3/24 at 2:31 a.m. (before the first doses were due to be administered). The facility's policy titled Medication - Administration, revised 1/1/12, indicated medications and treatments will be administered as prescribed.

Based on interview and record review, the facility failed to ensure the medical record was complete and accurate for one of three sampled residents (Resident 1) when there was no documentation that the nurse notified Resident 1's physician of multiple medications that were not administered. This failure had the potential to compromise the facility's ability to track and communicate care relevant to Resident 1. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including cellulitis (a type of skin infection) and other disorders of the skin and subcutaneous tissue (the deepest layer of skin). Review of Resident 1's Order Summary Report indicated she had physician orders, dated 8/3/24, for the following medications: 1. Cleocin-T External Lotion (antibiotic lotion used to treat infection) 1% (unit of dose measurement) apply to affected areas topically (to the skin) two times a day for infection; 2. Mupirocin External Ointment (medication used to treat infection) 2% apply to affected area topically three times a day for infected skin; 3. Diclofenac Sodium External Gel (medication used to treat pain) 1% apply to affected area topically four times a day for pain; and 4. Nyamyc External Powder (medication used to treat skin infections caused by fungus) 100,000 units per gram (unit of dose measurement) apply to abdominal fold/groin area topically four times a day for MASD (moisture-associated skin damage). Resident 1's medication administration record (MAR) and treatment administration record (TAR), dated 8/2024, were reviewed. On 8/3/24 and 8/4/24, there were multiple scheduled times for which the above medications were not documented as administered. During an interview with licensed nurse B (LN B) on 9/13/24, at 11:09 a.m., LN B confirmed he did not administer the above medications to Resident 1 because he was not able to find the medications in the facility. Further review of Resident 1's medical record indicated there was no documentation that LN B notified Resident 1's physician of the medications that were not administered. During a follow-up interview and concurrent record review with LN B on 9/13/24, at 11:54 a.m., LN B reviewed Resident 1's medical record and confirmed there was no documentation that he notified Resident 1's physician of the medications that were not administered. LN B stated he did notify the physician, but he did not document. LN B confirmed he was supposed to document this and stated, If it is not documented, it didn't happen. The facility's policy titled Completion & Correction, revised 1/1/12, indicated the facility will work to complete medical records in a standardized manner to provide the highest quality and accuracy in documentation. The policy indicated, Entries will be recorded promptly as the events or observations occur. Entries will be complete, legible, descriptive and accurate. The policy further indicated to document each time a physician is notified by phone or in person regarding a resident's condition.

Based on interview and record review, the facility failed to provide care in accordance with professional standards of practice for two of three sampled residents (Resident 1 and 2) when: 1. Staff did not complete an SBAR (situation, background, assessment, recommendation, a communication tool) and did not notify the physician and the responsible party (RP, person designated to make decisions on behalf of a resident) when an altercation occurred between Resident 1 and Resident 2; 2. Licensed nurse did not do a skin assessment for Resident 1 when Resident 2 threw coffee on Resident 1; 3. Licensed nurses did not put Resident 1 and Resident 2 on alert charting (nurses on each shift closely monitor and document in the medical record for 72 hours about a specific condition) when an altercation between Resident 1 and Resident 2 occurred; 4. Staff did not follow up with Resident 2 following a room change. These failures had the potential to result in inadequate monitoring of the resident's conditions, and the potential to negatively affect the residents' health, safety and well-being. Findings: Review of facility's document titled SOC 341 (Document for reporting suspected dependent Adult/Elder Abuse), dated 1/11/24, indicated at approximately 8:17 a.m., it was reported that Resident 2 threw cold coffee on roommate, Resident 1. A facility's untitled document, dated 1/15/24, contained a summary of the findings regarding the SOC. The summary indicated on 1/11/24 the certified nursing assistant (CNA) noticed that coffee had been spilled on Resident 1. The document further indicated Resident 1 informed the CNA that her roommate Resident 2 had thrown cold coffee on her. Upon interview with Resident 2, Resident 2 admitted to throwing coffee at Resident 1 1. During an interview with the director of nursing (DON) on 7/11/24 at 2:45 p.m., she reviewed the clinical records of Resident 1 and Resident 2 and confirmed there was no SBAR done on 1/11/24 when the incident occurred between Resident 1 and Resident 2. The DON acknowledged an SBAR should have been completed and stated in addition the facility must notify a resident's physician and responsible party if there is an altercation between 2 residents. The DON reviewed Resident 1 and Resident 2's clinical records and confirmed there was no documentation that the physicians and RPs of the residents had been notified. The DON acknowledged the facility should have notified the physicians and the RPs about the altercation between Resident 1 and Resident 2. Review of the facility's policy titled Change of Condition. Revised 11/18/21, indicated The licensed nurse will document the following: Date, time, and pertinent details of the incident and subsequent assessment in the Resident's chart. In addition, the policy indicated the licensed nurse will notify the resident's physician, legal representative or appropriate family member when there is an incident or accident involving the resident. 2. During an interview with licensed vocational nurse A (LVN A) on 7/11/24 at 1:00 p.m., she stated when there is a physical altercation between two resident the licensed nurse must complete a skin assessment and document any findings in the resident's clinical record. LVN A reviewed Resident 1's clinical record and confirmed there was no documentation that a skin assessment had been performed on Resident 1 on 1/11/24 after Resident 2 had thrown coffee on Resident 1. LVN A stated Resident 1 should have a full skin assessment performed to assess for any injury. Review of the facility's policy titled Abuse Prevention and Management, dated 2022, indicated .6. Immediate Actions . b. The resident will be assessed by the licensed nurse for any physical or emotional distress. Notify the physician and provide treatment as ordered, if applicable. Notify the responsible party of the incident and result of assessment findings. 3. During an interview with the DON on 7/11/24 at 2:45 p.m., she reviewed the clinical records of Resident 1 and Resident 2 and confirmed licensed nurses did not document in the days following the incident between Resident 1 and Resident 2 on 1/11/24. The DON stated the licensed nurse should document every shift for 3 days after the incident to assess and record any adverse effects from the altercation. The DON acknowledged there was no follow-up documentation by the licensed nurses and stated there should be. Review of the facility's policy titled Change of Condition. Revised 11/18/21, indicated when there is an incident or accident involving the resident the Licensed nurse will document each shift for at least 72 hours on Resident. 4. Review of Resident 2's clinical record indicated that on 1/11/24 she had a room change and was no longer roommates with Resident 1. There was no documentation in Resident 2's record to indicate any follow up was done to assess the transition to the new room. There was no documentation to indicate if Resident 2 was getting along with her new roommate or was having any adverse effects to the room change. During an interview with the DON on 7/11/24 at 2:45 p.m., she reviewed the clinical record of Resident 2 and confirmed there was no documentation to indicate any follow up was conducted to assess Resident 2's adjustment to the new room location. The DON stated staff should document for 3 days after a room change to monitor any adverse effects. Review of the facility's policy titled Room or Roommate Change, revised March 2018, indicated Social Service or designee will make a follow up visit to assess the resident's adjustment to the change.

Based on interview and record review, the facility failed to ensure the Ombudsman (resident advocate) was notified of discharges for three of three residents (Residents 1, 2, and 3). This failure had the potential to result in the residents not having someone to advocate for their admission, transfer, and discharge rights. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE]. Review of Resident 1's Progress Notes, dated 4/22/24, indicated the facility informed Resident 1 that her insurance issued a last covered date of 4/25/24 (this indicated the insurance would not pay for Resident 1's stay in the facility after 4/25/24). Review of Resident 1's Progress Notes, dated 4/26/24, indicated Resident 1 was discharged from the facility at 10:50 a.m. There was no documentation in the Progress Notes that indicated the facility notified the Ombudsman of Resident 1's discharge. During an interview with the director of nursing (DON) on 5/31/24 at 12:39 p.m., the DON stated the nurses were responsible for notifying the Ombudsman via fax when residents are discharged or transferred from the facility. When asked how to determine whether or not the information was actually faxed to the Ombudsman, the DON explained that the fax machine would print out a fax confirmation. The DON stated she would try to find documentation that indicated the facility notified the Ombudsman of Resident 1's discharge on 4/26/24. During an interview and concurrent record review with the DON on 5/31/24, at 1:27 p.m., the DON presented two documents. One of the documents was Resident 1's Notice of Proposed Transfer and Discharge, dated 4/26/24. The other document was a fax cover sheet, dated 4/26/24 and addressed to the Ombudsman. The subject line on the fax cover sheet was left blank, and there was no documentation that indicated the intended fax was regarding a discharge from the facility. Also, the fax cover sheet did not have a fax confirmation. The DON confirmed there was no indication that the Notice of Proposed Transfer and Discharge was actually faxed to the Ombudsman. On 5/31/24, at 2:30 p.m., the administrator (ADM) presented a different fax cover sheet, dated 4/26/24 and addressed to the Ombudsman. This fax cover sheet did have a fax confirmation printed on the top. However, the subject line on the fax cover sheet was still blank, and there was no documentation that indicated the intended fax was regarding a discharge from the facility. During an interview with Ombudsman office representative B (OOR B) on 6/3/24, at 8:50 a.m., OOR B confirmed the Ombudsman office did not receive notification that Resident 1 was discharged from the facility on 4/26/24. OOR B added that the Ombudsman office actually had not received notifications of transfers and discharges from the facility since July of 2023. Review of Resident 2's medical record indicated she was admitted to the facility on [DATE]. Review of Resident 2's progress notes, dated 2/23/24, indicated Resident 2 was transferred to the acute hospital. There was no documentation in the medical record that indicated the facility notified the Ombudsman of Resident 2's hospital transfer. Review of Resident 3's medical record indicated he was admitted to the facility on [DATE]. Review of Resident 3's Progress Notes, dated 4/7/24, indicated Resident 3 was transferred to the acute hospital. There was no documentation in the medical record that indicated the facility notified the Ombudsman of Resident 3's hospital transfer. During an interview and concurrent record review with the DON on 6/11/24, at 12:11 p.m., the DON reviewed the medical records of Resident 2 and Resident 3. The DON confirmed these residents were transferred to the acute hospital on 2/23/24 and 4/1/24, respectively. The DON confirmed there was no documentation in the medical records that indicated the facility notified the Ombudsman of these residents' hospital transfers. The facility's policy titled Notice of Transfer/Discharge, revised 10/2017, indicated when a transfer or discharge is initiated by the facility, the facility will provide a Notice of Transfer and Discharge to the resident, responsible party, and Ombudsman 30 days prior to the transfer or discharge. The policy indicated if the resident requires immediate transfer due to medical needs, the Notice of Transfer and Discharge will be given as soon as practicable. The policy further indicated, A facility representative will retrieve the completed Notice of Proposed Transfer and Discharge form from the clinical record and mail/fax it to the resident, responsible party and Ombudsman, and document in the clinical record that the notice was mailed/fax[ed], to whom it was mailed/fax[ed] and the date of the mailing/fax. All Facilities Letter (AFL) 17-27, dated 12/26/17 and addressed to long-term care facilities, indicated, Effective January 1, 2018, AB 940 requires a LTC facility to notify the local LTC Ombudsman at the same time notice is provided to the resident or the resident's representatives when a facility-initiated transfer or discharge occurs. The facility must send notice to the local LTC Ombudsman for any transfer or discharge that is initiated by the facility, whether or not the resident agrees with the facility's decision. AFL 17-27 further indicated, The facility is required to provide a copy of the notice to the LTC Ombudsman as soon as practicable if a resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis.

Based on observation, interview, and record review, the facility failed to follow its Oxygen Therapy policy for two of three sampled residents (Residents 4 and 5) who used oxygen when: 1. Resident 4's nasal cannula (flexible tubing inserted into the nostrils and attached to an oxygen source) was unlabeled and undated; and 2. There was no No Smoking sign posted for Resident 5's room. These failures had the potential to compromise the residents' health and safety. Findings: 1. Review of Resident 4's medical record indicated she was admitted on [DATE] and had the diagnosis of chronic respiratory failure (a condition in which the respiratory system does not exchange oxygen and carbon dioxide properly). Review of Resident 4's Order Summary Report indicated she had a physician's order, dated 2/6/24, for oxygen to by administered via nasal cannula as needed. During observations on 5/31/24, at 11:52 a.m. and 1:23 a.m., Resident 4 was in her room receiving oxygen via nasal cannula. The nasal cannula was not labeled with a date. During an observation and concurrent interview with licensed nurse A (LN A) on 5/31/24, at 1:39 p.m., LN A entered Resident 4's room and confirmed Resident 4's nasal cannula was not labeled with a date. LN A stated nasal cannulas should be changed weekly and should be labeled with the date they were changed. The facility's policy titled Oxygen Therapy, revised 11/2017 indicated, Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed. 2. Review of Resident 5's medical record indicated she was admitted on [DATE] and had the diagnosis of chronic respiratory failure. Review of Resident 5's Order Summary Report indicated she had a physician's order, dated 11/10/23, for oxygen to be administered via nasal cannula as needed. During an observation on 5/31/24, at 11:55 a.m., Resident 5 was in her room receiving oxygen via nasal cannula. There was no No Smoking sign posted at the entrance to, or anywhere inside Resident 5's room. During an observation on 5/31/24, at 1:20 p.m., Resident 5 was in her room sitting on her wheelchair. There was an oxygen concentrator (machine used to deliver oxygen) next to Resident 5's bed, and a portable oxygen tank attached to her wheelchair. There was still no No Smoking sign posted at the entrance to, or anywhere inside Resident 5's room. During an observation and concurrent interview with LN A on 5/31/24, at 1:39 p.m., LN A stated for residents who use oxygen, there should be a No Smoking sign posted at the entrance to their room. LN A went to Resident 5's room and confirmed there was no No Smoking sign posted. The facility's policy titled Oxygen Therapy, revised 11/2017 indicated, 'No Smoking' signs will be prominently displayed wherever oxygen is being stored or administered.

Based on interview and record review, the facility failed to ensure complete records for controlled medications (those with high potential for abuse and addiction) when controlled medication use audit for three of six residents (Residents 13, 43, and 153) were not reconciled. The medications were signed out of the Individual Narcotic Record count sheet (an inventory sheet that keeps record of the usage of controlled medications); however, they were not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications. Findings: On 10/17/23, six random Individual Narcotic Records count sheets for six residents were requested for review. Review of Resident 13's clinical record indicated he had a physician's order, dated 6/7/23 for tramadol (a potent narcotic for pain) 50 mg one tablet every six hours as needed (PRN) for pain. Review of the count sheet for Resident 13's tramadol indicated the medication was signed out on 10/4/23 at 5 p.m., 10/9/23 at 5 p.m., 10/10/23 at 5 p.m. and 10/10/23 at 11:05 p.m. with no documentation of administration on Resident 13's MAR. Review of Resident 43's clinical record indicated he had a physician's order, dated 9/22/23 for hydrocodone-acetaminophen oral tablet 5-325 mg (a potent narcotic for pain) one tablet every four hours as needed (PRN) for pain. Review of the count sheet for Resident 43's hydrocodone-acetaminophen indicated the medication was signed out on 10/14/23 at 9 a.m. and 10/15/23 at 9 a.m. with no documentation of administration on Resident 43's MAR. Review of Resident 153's clinical record indicated he had a physician's order, dated 9/29/23, for hydrocodone-acetaminophen oral tablet 5-325 mg one tablet every eight hours as needed (PRN) for severe pain. Review of the count sheet for Resident 153's hydrocodone-acetaminophen indicated the medication was signed out on 10/10/23 at 6:30 a.m. and 10/12/23 at 9 a.m. with no documentation of administration on Resident 153's MAR. During concurrent record review and interview on 10/19/23 at 1:15 p.m., the director of nursing (DON) confirmed there was a discrepancy between the count sheets and the MAR for Residents 13, 43, and 153. The DON stated when a nurse removed a narcotic from the locked narcotic box, signed it out on the count sheet, and administered the medication, the expectation was it would be documented in the MAR. Review of the facility's policy, Medication - Administration, revised 1/1/12, indicated, When a PRN medication is given, it will be charted on the Medication Administration Record. The Nurse will document the reason given, reason for drug, route of administration, date, and time.

Based on observation, interview, and record review the facility failed to ensure to transfer the resident's body to the referred mortuary (a funeral home, where dead bodies are kept before burial or cremation) within four hours after Resident 1 expired at the facility. This failure has caused significant emotional distress for three of three sampled residents (Resident 2, 3, and 4). Findings: Review of Resident 1's undated face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 was admitted to facility on [DATE] with diagnoses including acute and chronic respiratory failure (a condition in which the respiratory system is unable to provide an adequate supply of oxygen or to remove carbon dioxide efficiently), adult failure to thrive (a condition with weight loss, poor nutrition, and decreased activity), hepatitis c (a viral infection that affects the liver), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident 1's face sheet section for mortician (a person who arranges funerals) name and license number indicated, Funeral Home Unknown/TBD (TBD: to be to decide). Review of Resident 1's alert note dated [DATE] indicated, paramedics (a medical professional who specializes in emergency treatment) assessed the resident and pronounced the time of the death at 6:34 pm. Review of Resident 1's alert note dated [DATE] indicated, Mortuary pick up the body by mortuary representative. Left the facility at 9:12 am. Review of Resident 1's mortician (a professional involved in the business of funeral rites) receipt/record of death document indicated, Resident 1's body was released from facility by licensed vocational nurse A (LVN A), and Resident 1's body was received by mortuary representative on [DATE] at 9:00 a.m. During an interview with director of nursing (DON) on [DATE] at 4 :49 p.m., DON stated staff should have released Resident 1's body to mortuary and staff should not have kept in the facility more than 4 hours after Resident 1's death. During an interview with LVN A over the telephone on [DATE] at 3:52 p.m., LVN A confirmed Resident 1's body was released to mortuary on [DATE] at 9:00 a.m. LVN A stated there was strong odor came from the Resident 1's body into the hallway in the morning of [DATE]. LVN A further stated facility should not have kept Resident 1's body more than 4 hours and arranged for mortuary to pick up within 4 hours after Resident 1 expired at 6:34 p.m., on [DATE]. 1. During an observation and interview with Resident 2 in his room on [DATE] at 1:07 p.m., Resident 2 was up in a wheelchair. Resident 2 stated he (Resident 2) felt sad, and repeatedly asked staff when the mortuary will be coming to pick up the body. Resident 2 also stated he (Resident 2) was bothered by the smell seemed like came from the body. Resident 2 further stated he (Resident 2) does not want to deal with that smell again in the facility. Resident 2's minimum data set (MDS: clinical and functional assessment tool) assessment dated [DATE] indicated, Resident 2's brief interview for mental status (BIMS) score of 13 of 15 (,d+[DATE]: Intact cognition). Resident 2's assigned room was located opposite to Resident 1's room. 2. During an observation and interview with Resident 3 in his room on [DATE] at 1:20 p.m., Resident 3 was observed sitting in a wheelchair next to his bed. Resident 3 stated felt sorry for the resident who died in facility and staff unable to send the body to mortuary till next day. Resident 3 also stated he (Resident 3) was sad worried and hoped facility would not keep his body in the facility long time when he dies. Resident 3 stated he kept on asking staff when the mortuary would be coming to pick up the body. Resident 3 further stated he could smell in his room most likely that smell came from the body, and he (Resident 3) wished no one could have to smell that kind of smell in their life. Review of Resident 3's face sheet indicated Resident 3 was admitted to facility on [DATE] with current diagnoses including depressive, adjustment disorder (an emotional or behavioral reaction to a stressful event or change in resident's life), and transient cerebral ischemic attack (a temporary blockage of blood flow to the brain). Review of Resident 3's MDS assessment dated [DATE] indicated, Resident 3's BIMS score of 15 of 15, intact cognition. Resident 3's assigned room was located opposite to Resident 1's room. 3. During an observation and interview with Resident 4 in her room on [DATE] at 1:40 p.m., Resident 4 was observed sitting in a chair in her room. Resident 4 stated she (Resident 4) felt sad and emotionally heartbroken when she (Resident 4) heard about facility was not able to release the body till next day. Resident 4 further stated she (Resident 4) remembered the smell from the body and not able to forget. Review of Resident 4's face sheet indicated Resident 4 was admitted to facility on [DATE], with current diagnoses including psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (a mood disorder is a mental health condition that primarily affects person's emotional state), and anxiety (a disorder involves more than temporary worry or fear). Review of Resident 4's MDS assessment dated [DATE] indicated Resident 4's BIMS score of 15 of 15, intact cognition. Resident 4's assigned room was located opposite to Resident 1's room. During an interview with certified nursing assistant B (CNA B) on [DATE] at 2:15 p.m., CNA B said she (CNA B) could smell strong odor from Resident 1's dead body. CNA B said she (CNA B) observed some kind of fluid came out of Resident 1's mouth when mortuary staff came to pick up the body on [DATE]. CNA B also stated Resident 2, and Resident 3 were looked sad, worried and did not eat breakfast on [DATE]. CNA B stated both Resident 2 and 3 were kept on asking CNA B when the Resident 1's body would be removed from the facility. CNA B further stated Resident 4 was quiet, appeared sad, and did not speak much on [DATE]. During an interview with facility's administrator (ADMN) on [DATE] at 3:30 p.m., the ADMN confirmed Resident 1's body was released to mortuary on [DATE] at 9 a.m. The ADMN stated miscommunication between nursing staff and previous DON in handling the mortuary situation for Resident 1 has potentially caused in delay to release the body. ADMN stated nursing staff should have released Resident 1's body to mortuary within 4 hours after Resident 1's death. During a telephone interview with LVN C on [DATE] at 3:38 p.m., LVN C stated she spent time to find a mortuary to release the Resident 1's body affected her work that night. LVN C stated she was told by public administrator (PA: this office gets involved when there is no one else with higher authority to act when resident has no next of kin)'s office staff, they cannot send mortician to pick up the body. LVN C stated she made telephone calls during that night to several mortuaries in the area with no success and no help from DON, or ADMN till the next morning. LVN C also stated Resident 2, and Resident 3 did not sleep during night on [DATE]. LVN C stated Resident 2 and Resident 3 seemed worried and kept on asking LVN C for when Resident 1's body would be removed from facility. LVN C further stated Resident 2, Resident 3, and Resident 4 had verbalized feeling sad about facility not able to release the body to mortuary. During an interview with Resident 2 on [DATE] at 7:44 a.m., Resident 2 stated he (Resident 2) did not sleep during the night on [DATE]. Resident 2 also stated he missed the sleep and felt sad that night. Resident 2 further stated he lost interest in food due to the smell from the body, he stated he ate very little breakfast on [DATE]. During an interview with Resident 3 on [DATE] at 7:50 a.m., Resident 3 stated did not sleep whole night on [DATE]. Resident 3 stated he could not sleep by knowing a body was near to his room. Resident 3 also stated he lost his appetite and did not eat breakfast on [DATE]. Resident 3 stated he was scared and worried about what would happen to his body when he dies in facility. Resident 3 further stated he desperately waited that night for Resident 1's body to be removed from the facility. During an interview with Resident 4 on [DATE] at 8:00 a.m., Resident 4 stated she felt emotionally sad and did not want to talk to anyone. Resident 4 also stated she was emotionally scarred from the fact that the facility kept the body until it started smelling bad. During a telephone interview with the DON on [DATE] at 2:20 p.m., the DON stated, definitely could have caused emotional distress for other residents in the facility when body was kept more than 12 hours. Review of facility's policy and procedure (P&P) titled, Identifying a Mortuary, revied, dated [DATE], the P&P indicated, The facility will obtain information regarding the resident's preferred mortuary to ensure a timely transfer of the body following a resident's death. If the resident/resident representative has not informed the facility of their choice of mortuary, and the resident expires, efforts will be made to contact the representative. If the resident representative cannot be contacted within 4 hours, the body will be released to a mortuary on the facility referral list.

Based on interview and record review, the facility failed to ensure one of three sampled residents (1) had adequate supervision to prevent an accident and injuries when the facility failed to assist the resident to the bathroom and failed to implement fall interventions. These deficiencies resulted in a fall and a subarachnoid hemorrhage (a bleeding in the area between the brain and thin tissue which cover the brain). Findings: Resident 1's clinical record was reviewed and indicated she was admitted with [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS, an assessment tool), dated 4/6/16, indicated she had severely impaired decision making skills and required assistance from the nursing staff with activities of daily living (ADLs, bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing). Resident 1's Fall Risk Assessment, dated 7/7/15, indicated she had a score of 17 (a score of 10 or above represents a high risk for falls). Resident 1's Physical Therapy (PT) Note, dated 7/18/15, indicated she could safely ambulate on a level surface for an unlimited distance using a front-wheeled walker with assistance. Her Occupational Therapy (OT) Note, dated 7/18/15, indicated she could safely perform toileting with an assistive device and assistance. Resident 1's physician order, dated 7/20/15, indicated a toileting schedule before meals and before sleeping. Resident 1's physician progress notes [REDACTED]. Her Minimum Data Set (MDS, an assessment tool), dated 4/6/16, indicated she required assistance (staff providing weight-bearing support) with one person assistance during ADLs. Her decision-making skills were severely impaired. Resident 1's care plan for falls, dated 4/12/16, indicated she had a previous fall on 4/11/16 and wanted to go to the bathroom. Her care plan intervention was to continue the toileting schedule before meals and before sleeping and recommended the staff follow the toileting schedule. Resident 1's Situation Background Assessment Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication), dated 4/23/16, indicated the certified nurse assistant (CNA) informed a licensed nurse she heard the sound of a walker falling and when he checked Resident 1's room, he found the resident on the floor. Resident 1 had a bump on the back of her head and was bleeding. Resident 1 stated she went to the bathroom and lost her balance. She complained of pain after the incident and was given Norco (narcotic pain medication). Resident 1's Neurological Flow Sheet, dated 4/23/16, indicated her blood pressure (pressure of blood in the circulatory system) was 183/90 (normal is 120/80) at 11:45 p.m., 183/79 at 12 a.m., and 163/76 at 12:15 a.m. Resident 1's Ambulance Transfer Record indicated she was transferred to the acute care hospital on [DATE], at 8:38 a.m. The record from the acute care hospital, dated 5/23/16, indicated she had a suspected post traumatic left sided subarachnoid and parenchymal intracranial hemorrhage (bleeding in the space between the brain and the tissue covering the brain). During an interview with licensed vocational nurse B (LVN B) on 5/5/16, at 10:30 a.m., she stated Resident 1 was by herself when she went to the bathroom and fell . During an interview with LVN A on 5/5/16, at 2:10 p.m., she stated Resident 1 should have had a toileting schedule on the Medication Administration Record (MAR) but she was unable to find any documentation. During an interview with certified nurse assistant D (CNA D) on 5/6/16, at 8:10 a.m., he stated Resident 1 did not have a toileting schedule. During an interview with the director of nurses (DON) on 5/23/16, at 12 p.m., she stated Resident 1's toileting schedule should have been documented on the MAR and the licensed nurse should have instructed the nursing staff to take Resident 1 to the bathroom. The DON stated Resident 1 should have been accompanied to the bathroom and the care plan should have been implemented. The facility's 3/2016 policy, Fall Management Program, indicated the facility will implement a fall management program supporting an environment free of hazards and provide a safe environment to minimize complications associated with falls. The plan of care will also be reviewed and implemented to prevent further falls.