Every finding on record at San Luis Post Acute Center

Based on observation, record review, and interview, the facility failed to securely lock medications cart, discard expired medication, and discard open single use over the counter medication. This failure had the potential to result in a residents or unauthorized personnel accessing and ingesting medication that could cause signigicant adverse effects, the use of expired medications on residents and improper administation. During a concurrent observation and interview on 7/14/2026 at 8:10 a.m. with Licensed Nurse (LVN 2), in Resident 13 and 33's room, the medication cart was left unlocked for two of two residents. LVN2 stated per policy the cart does not have to be locked when in the doorway of residents room. During a review of facilities policy and procedure (P&P) titled, Medication Administration, the P&P indicated, section m. During administration of medications , the cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the residents room , with open drawers facing inward and all other sides closed.The cart must be clearly visible to the personnel administering medications and all outward sides must be inaccessible to residents or others passing by. During a review of Clinical Competency Evaluation Medication Administration dated 5/20/26 for LVN2. Competency indicated LVN2 meets competency for Med Cart: clean, no missing supplies, locked if out of site. During an interview on 7/14/26 at 10:39 a.m. with the Director of Nursing (DON). The DON read from policy medication cart may be kept in the room with the drawers facing inwards clearly visible. Should be closed and locked if out of sight. The DON stated the mediation cart can be kept in the hallway with open drawers facing inward. No meds on top of cart and cart must be clearly visible to the person administering medications. During a concurrent observation and interview on 7/14/26 at 6:17 a.m. with Licensed Nurse (LVN3), at medication cart 3, One single use tube of Sterile Lubricating Jelly, in the drawer with suppositories, was opened undated and not labeled for a resident. LVN3 removed Jelly from medication cart and LVN3 stated should not have been put back in medication cart During a concurrent observation and interview on 7/15/26 at 11:42 a.m. with Licensed Nurse (LVN1) , at medication cart 2 . One bottle of Systane Gel Drops, for Resident #4, Labeled opened on 5/2/26 expired on 7/1/26. LVN1 stated yes it is expired and removed the medication from use. LVN1 stated if expired medications are found they are removed from medication cart replaced from medication supply room or reordered and let supervisor know. During a review of facilities Policy and Procedure P&P titled Storage of Medications dated 3/2026. P&P indicated .N. Outdated, contaminated ,or deteriorated mediations and those in containers that are cracked soiled or without secure closures are immediately removed from stock . During an interview 7/15/26 at 11:51 a.m. with the DON, the DON confirmed that medication was opened, expired and stated nurses check medication before giving and as needed.

Based on interview and record review, the facility failed to develop a care plan with resident-specific interventions for 1 of 3 sampled residents (Resident 1) related to non-compliance with care and refusal to wear protective foam boots (designed to protect patient's feet-heels, ankles).This failure resulted in the development of maggots in the dorsal (upper side) wound of Resident 1's left foot and was transferred to the hospital for further evaluation and treatment. During a concurrent interview and record review, on 9/24/25, at 11:24 a.m. with the Director of Nursing (DON), the DON stated, The resident (Resident 1) was admitted on [DATE] with 10 plus wounds. All were pre-existing wounds upon admission. Resident 1's History and Physical dated 9/3/25, revealed Resident 1 was admitted to the facility on [DATE]. Diagnoses included PAD (Peripheral Artery Disease [a condition where arteries that carry blood to the arms, legs, and feet become narrow or blocked]) with associated chronic venous stasis (condition where blood pools in the veins, primarily the legs, due to impaired blood flow back to the heart) and chronic BLE (both lower extremities) wounds. During a review of the Treatment Administration Record (TAR), for the month of September 2025, treatment order indicated, Notes: To left dorsal foot dark necrotic area: Cleanse area, pat dry, paint on betadine, cover with non-adherent pad and cover with kerlix, change daily and as needed if soiled or dislodged.During a review of the Clinical Notes Report, dated 9/2/25, it indicated that Resident has refused to wear foam boots to BLE for heel protection at this time. MD aware and order is discontinued. During a review of the Clinical Notes Report, History and Physical Exam by the doctor, dated 9/3/25, indicated, Of note, boots ordered/recommended but he is refusing them. Further record review revealed that no care plan was developed for the refusal of foam boots, and when the physician discontinued the order, there was no evidence that showed the facility attempted to find alternative ways to protect Resident 1's foot wound and dressing.During a review of the Clinical Notes dated 9/22/25, it indicated, MD (name) made aware of wound and new verbal orders to send resident to (name of hospital) where resident originally was seen for BLE wounds for further evaluation.During a record review of hospital records titled ED Physician Notes, dated 9/22/25, it indicated, States they have noticed maggots on his left foot and The left foot has a 5 cm. x 7 cm. area of dry necrosis with maggots in the wound.During a telephone interview, on 9/24/25, at 12:29 p.m., with the Charge Nurse (CN), CN stated she performed treatments for Resident 1's wounds on the left dorsal foot for 2 consecutive days on 9/21/25 and 9/22/25; there was nothing out of the ordinary observed on 9/21/25. CN further stated that on 9/22/25, when cleansing solution was applied to the wound bed, there was bubbling and a single grain like object crawled out of the wound. CN also stated the DON and the physician were notified of her findings and observation. During an interview on 9/24/25, at 1:50 p.m., with the Administrator (ADM) and the DON, when asked how maggots developed in Resident 1's wound, DON stated Resident 1 was non-compliant with care and often left his room's sliding door open, sitting either inside or outside his room. The ADM stated, because of this non-compliance, flies might have crawled past the kerlix gauze wrapped around the wound as it loosens/gets dislodged with movement. The DON concurred with the Administrator.During a record review of an article by the National Institute for Health, (undated), titled The Stages of Maggot Development , indicated, Maggots hatch from eggs in a wound within hours to a day and begin feeding, progressing through three larval stages over several days, during which they grow significantly and liquefy dead tissue for consumption.

Based on observation, interview, and record review, the facility's interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to conduct an assessment of self-administration of medications, obtain a doctor's order, and ensure a care plan was developed for one of 5 sampled residents (Resident 30). This failure had the potential to increase the risk for medication errors which could compromise the safety and well-being of Resident 30. Findings: Resident 30 is a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included unspecified asthma with acute exacerbation (a sudden worsening of asthma symptoms, where the specific type of asthma is not specified, requiring immediate medical attention). On 3/10/25 at 10:15 a.m., in room [ROOM NUMBER], Resident 30 was observed holding in her hand, an inhaler medication. Resident 30 stated that she was a retired physician and aware of how to self-administer her own inhaler medications. On 03/10/2025 at 10:25 a.m., a concurrent interview and record review was conducted for Resident 30 with licensed nurse (LN) 4. LN4 confirmed there were no physician orders for Resident 30 to keep inhaler medication at the bedside. LN4 confirmed there were no IDT notes which included documentation of an assessment of self-administration of medication for Resident 30. On 3/11/2025 at 4:10 p.m., a record review was performed for Resident 30. No care plan for self-administration of bedside medication was found in the electronic medical record (EMR) or in patient's paper chart. On 3/11/2025 at 4:20 p.m., a concurrent interview and record review was performed for Resident 30 with LN5. LN5 confirmed there was no care plan for Resident 30 for self-administration of bedside medication. LN5 confirmed there should have been a care plan and interventions for self-administration of bedside medication. During a review of the facility's policy and procedure titled, Medication Storage: Medication Bedside Storage (March 2024), indicated in part, .bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and is deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team (IDT). During a review of the facility's policy and procedure titled, Care Plans Procedures and Development / Implement Comprehensive Care Plan, (undated), indicated in part, .staff initiates care plans for identified needs and / or problems of the resident ., and .facilities will develop and implement a comprehensive person-centered care plan for each resident using the results of the comprehensive assessment . On 03/12/25 at 9 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated and confirmed the facility's policy regarding residents self-medicating with medications at bedside was not followed. DON also stated there was no care plan with interventions for Resident 30 to self-administer bedside medication.

Based on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety when: 1. The nourishment refrigerator that contained multiple food items had a temperature of 46 degrees 2. A boxed food item that was stored in the freezer had an expired date. This failure had the potential to result in the growth of microorganisms that can cause foodborne illness to 66 residents admitted to the facility. Findings: 1. During an observation of the Station 1 nourishment room refrigerator on [DATE] at 1:59 p.m., there were two thermometers located inside the refrigerator that showed the temperature was 42 degrees Fahrenheit (F). The refrigerator contained sandwiches, yogurts and milk. The yogurt dated [DATE], temperature was 46 degrees F. The low-fat milk was 46.2 degrees F. At 2:00 p.m. a concurrent observation and interview was conducted with the Social Services Director (SSD), confirmed and validated the temperature of the milk. During a concurrent observation and interview on [DATE] at 2:01 p.m., with the Dietary Manager (DM), the DM stated both kitchen staff or nursing staff were responsible for checking the refrigerator temperatures. During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 2022, the P&P indicated, .Refrigerators should maintain food temperature at or below 41 degrees Fahrenheit and all foods should be labeled and dated . 2. During an observation on [DATE] at 11:43 a.m. in the kitchen freezer, a boxed food item in freezer with labeled freeze by [DATE]. During a concurrent observation and interview on [DATE] at 2:36 p.m., with the DM in the kitchen freezer, when asked what the date and item in a boxed food stored in the freezer, the DM stated the frozen foods are good for 3 months and stated the date of the boxed food item stated labeled freeze by [DATE] and contained Canadian bacon. DM removed the boxed item to throw away. During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated 2022, the P&P indicated, .All foods will be consumed by their safe use dates or discarded .all foods should be labeled and dated. All foods will be consumed by their safe use by dates or discarded. During a review of the facility's P&P titles Food Storage Chart-Food Storage Guidelines, undated, the P&P indicated, Bacon freezer storage are good for 1 month.

Based on observation, interview, and record review the facility failed to ensure staff followed proper hand hygiene during direct resident contact for one of 18 sampled residents. This failure had the potential to result in the spread of infectious disease throughout the facility. Findings: During an observation on 3/12/25 at 10:05 a.m., in resident room, Licensed Nurse (LN) 2 was observed performing a brief change for Resident 18. LN2 cleaned stool from Resident 18's buttocks and rolled Resident 18 onto the right side while wearing the same soiled gloves. LN2 did not perform hand hygiene or change gloves prior to touching resident. During an interview on 3/12/25 at 10:40 a.m., with LN2, LN2 stated, I know I should have changed my gloves. I wiped her poop. During an interview on 3/13/25 at 9:45 a.m., with Director of Staff Development (DSD), Assistant Director of Nursing (ADON), both were informed that during an interview with LN2, LN2 stated she was aware that she should have changed her soiled glove after she completed the brief change but she did not. DSD stated LN2 will complete a one on one coaching. During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated 2001, indicated, Hand hygiene is indicated .before moving from work on a solid body site to a clean body site on the same resident.

Based on observation, interview, nd record review the facility failed to ensure the walk-in freezer was maintained in a safe operating condition. There was excessive ice buildup in the freezer. This failure had the potential to result in reduced efficiency and temperature fluctuations that can lead to improper food preservation. The facility census was 66. Findings: During an initial kitchen tour that started on 3/10/25 at 10:17 a.m., the following were observed: ice buildup on different areas and surfaces including the freezer pipes (approximately 6 inches by 3 inches and 2-inch-deep of ice), the plastic air curtains hanging in the doorway contained ice buildup approximately half to three quarters of the way down the curtain flaps. On the shelf under the fans, two different areas with ice on the shelf below approximately two inches in length. The second area was approximately eight inches in length. Around the door and gasket, there was ice buildup with the width of the doorway. The freezer door on the outside at bottom there was also ice buildup. During an interview on 3/11/25 at 2:42p.m.,with the Registered Dietitian (RD), RD stated she conducted monthly sanitation audits in the kitchen and those audits she has noted issues with the ice in the walk-in freezer. RD stated she would submit her audits to administration for ice buildup in the freezer monthly and administration was aware since last year. During a concurrent observation and interview on 3/11/25 at 3:29 p.m., with the Maintenance Director (MDIR) in the kitchen and walk-in freezer, the MDIR stated he has had no recent notifications regarding ice buildup in the kitchen freezer and the last preventative maintenance to the freezer was February 13th, 2025, and there was no ice buildup. Upon entering the freezer, the MDIR stated he had not seen it with this much ice buildup. During a review of the RD's Comprehensive Safety and Sanitation Audits dated September 2024 through February 26, 2025, the audits indicated the walk-in freezer had continuing ice buildup and frozen around freezer door and handle. During a review of the facility's policy and procedure (P&P) titled, Preventative maintenance, undated, the P&P indicated, .It is the policy of this facility to maintain all refrigeration units: Freezers. All major problems with equipment are to be reported immediately .

Based on interviews, facility policy review, and review of facility documents, the facility failed to ensure all potential sources of water-borne illness were identified and monitored. This deficient practice affected all 65 residents who currently reside in the facility. Findings included: A review of the facility's undated policy titled, Legionella Water Management and Risk Reduction and Prevention Program, revealed, Our facility is committed to the prevention, detections and control of water-borne contaminants, including Legionella. The policy specified, 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risks of Legionnaire's disease [a type of pneumonia caused by Legionella bacteria]. A review of the facility Legionella Prevention Program Maintenance Log, revealed no evidence to indicate the facility monitored the bathtubs in the facility, the water fountains, the laundry area, or the kitchen dishwasher. During an interview on 01/18/2024 at 11:01 AM, the Maintenance Consultant stated the facility did not have a water flow map. On 01/18/2024 at 12:40 PM, the Acting Administrator and Chief Nursing Officer provided the surveyor with a copy of the facility diagram which illustrated the flow of water throughout the building and the location of the facility's water heaters. A review of the diagram revealed no evidence to indicate the facility monitored the flow of water in the water fountains, showerheads, bathtubs, two ice machines, the laundry room, and the saltwater fish tank. During an interview on 01/18/2024 at 2:23 PM, the Director of Nursing stated the areas in the facility that were at an elevated risk of creating water-borne illness included the facility's water supply, water fountains, and the drinking fountains. During an interview on 01/18/2024 at 2:29 PM, the Acting Administrator stated she expected the facility to maintain a water system consistent with the facility's policies and procedures. The Acting Administrator stated she expected maintenance to follow all protocols and check and maintain all the various aspects of mitigation strategies for water-borne illness. According to the Acting Administrator, the facility diagram used to illustrate the flow of water throughout the building was not updated until 01/18/2024. The Acting Administrator acknowledged the importance of ensuring the facility diagram was updated as part of the facility's overall water management program.

Based on interviews, record review, and document review, the facility failed to notify the state designated authority when a significant change in status assessment was completed for 1 (Resident #7) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: A review of Resident #7's Face Sheet, revealed the facility admitted the resident on 06/01/2009, with diagnoses of malignant neoplasm of colon, anxiety, psychotic disorder with hallucinations, and major depressive disorder. A review of a document addressed to Resident #7 from the State of California - Health and Human Services Agency Department of Health Care Services, dated 01/28/2019, revealed Resident #7's Level II PASARR evaluation suggested the resident was best served in a skilled nursing facility bed with access to services. A review of Resident #7's medical record revealed a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2023, was signed as being completed on 12/26/2023. A review of Resident #7's medical record revealed no evidence to the state designated authority was notified when the resident had a significant change in status assessment completed. During an interview on 01/18/2024 at 1:40 PM, the Director of Nursing stated she would expect a rescreen to be completed if a resident who received Level II services had a significant change in status assessment completed. During an interview on 01/18/2024 at 1:54 PM, the Acting Administrator stated she would expect Resident #7 to have a rescreen PASARR submitted when the significant change in status assessment was completed.

Based on observation, interview, and record review the facility failed to ensure infection control practices were implemented when: 1) Glucometers (machine used to measure blood sugar) were cleaned and disinfected per manufacturer's instructions for use. 2) Dirty PPE (personal protective equipment) was reused by staff while doing laundry. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for patients in an already compromised condition. Findings: 1) Review of the manufacturer's instructions for use titled, Evencare G3, dated 12/18 indicated in part . The Evencare G3 Meter should be cleaned and disinfected between each patient . Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas . Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes . allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Review of the label for wipes, Clorox Healthcare Bleach Germicidal Wipes, undated indicated in part . Bactericidal, Virucidal, Fungicidal, Tuberculocidal, Sporicidal . Disinfects in 3 minutes . 3 minute wet time. During an interview with licensed nurse (LN 1) on 11/15/22, at 10:54 am, LN 1 stated I use the bleach wipes before and after use. I wipe the glucometer down and wait 3 minutes then I put it away and it is clean. During an interview with LN 2 on 11/15/22, at 11:00 am, LN 2 stated I clean the glucometer with a bleach wipe for 3 minutes and let it stay wet for 3 minutes, then it needs to dry before using again. During an interview and concurrent record review on 11/15/22, at 11:08 am, with the assistant director of nursing (ADON) and the administrator (ADM), the ADON and ADM confirmed staff need to clean and disinfect the glucometer per MFU's. that staff are not following MFUs for cleaning and disinfecting glucometer between residents. 2) Review of the facility policy and procedure titled, Personal Protective Equipment - Gowns, Aprons, Lab Coats revised 7/2009, indicated in part . When gowns are used, they must be used only once and discarded into appropriate receptacles . During an observation and concurrent interview with laundry staff (LS) and plant maintenance (PM) on 11/15/22 at 11:27 am, LS explained that LS uses one gown for the day. Additionally LS stated the gown is worn when sorting dirty laundry hung up and then put back on. LS stated understanding that dirty gown should not be reused. PM confirmed gown should be used once and then a new gown should be used.

Based on observation, interview, and record review the facility failed to ensure infection control practices were implemented when the : 1) Glucometers (machine used to measure blood sugar) were cleaned and disinfected per manufacturer's instructions for use. 2) N95 respirators were disposed after use per infection control guidelines. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for patients in an already compromised condition. Findings: 1) Review of the manufacturer's instructions for use titled, Evencare G3, dated 12/18 indicated in part . The Evencare G3 Meter should be cleaned and disinfected between each patient . Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas . Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes . allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Review of the label for wipes, Sani-Cloth Bleach Germicidal, Disposable Wipe, undated indicated in part . Bactericidal, Fungicidal, Tuberculocidal, and Virucidal in 4 minutes . Disinfects in 4 minutes . 4 minute wet time. During an interview with licensed nurse (LN 1) on 11/24/21, at 10:12 am, LN 1 stated I use mild soap and water to clean to clean glucometer then let it dry on a paper towel. During an interview with LN 2 on 11/24/21, at 10:15 am, LN 2 stated I clean the glucometer with a bleach wipe for 3-5 minutes and let it stay wet for 3 minutes, then it has to dry before using again. During an interview and concurrent record review on 11/24/21, at 11:26 am, with the director of nursing (DON), the DON confirmed staff need to clean and disinfect the glucometer per MFU's. that staff are not following MFUs for cleaning and disinfecting glucometer between residents. 2) According to the centers for disease control (CDC), updated 9/21, considerations are intended for use by federal, state, and local public health officials, respiratory protection program managers, leaders in infection prevention and control programs, and other leaders in healthcare settings who are responsible for developing and implementing policies and procedures for preventing pathogen transmission in healthcare settings. CDC indicated N95 respirators (face mask filtering 95% of particles, virus .) are the personal protective equipment (PPE) most often used to control exposures to infectious pathogens transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use. N95 respirators are intended to be used once and then properly disposed of and replaced with a new N95 respirator. During an observation and concurrent interview with licensed nurse LN 2 on 11/22/21 at 4:30 pm, LN 2 explained that part of the PPE doffing (removing) included to remove the N-95 respirator, store the used N-95 respirator inside a paper bag with a used face shield that had been wiped down until the next time the PPE needed to be used. LN 2 stated we use the N95 for the whole day which means we could be using it 10-15 times that day and then throw it away. During an interview with the director of nursing (DON) on 11/22/21 at 5:10 pm, DON confirmed that the paper bags contain face shields that staff have cleaned after each use and their N95 that they have worn. DON acknowledged staff should be throwing out their N95s after each use.

Based on record review, and interview, the facility failed to ensure one in three sampled residents (Resident 1) bed mobility support was coded according to the Resident Assessment Instrument guidelines (comprehensive assessment instruction manual) to reflect the resident's actual bed mobility status. This failure had the potential to place Resident 1 at risk for increased impairment on the already compromised ,limited mobility condition. Findings: Review of the clinical record for Resident 1 indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's minimum data set (MDS- a comprehensive resident assessment) dated 10/19/21,the bed mobility task of Resident 1 was coded as requiring a one-person physical assist. During a review of the activities of daily living worksheet (ADL- form used by direct care staff to document amount of assistance provided to residents) dated 10/13/21, 10/14/21, 10/15/21 and 10/16/21 indicated Resident 1 received a two-person physical assist during the bed mobility task ( side to side,up and down movement while on bed). The ADL worksheet further indicated the highest support Resident 1 received from 10/13/21 to 10/16/21 is by two person assist. During an interview and concurrent record review of Resident 1's MDS dated [DATE], the ADLs dated 10/13/21, 10/14/21, 10/15/21,10/16/21, and the RAI on 11/16/21 at 10:12 a.m., with the MDS coordinator (MDSC), the MDSC verbally acknowledged coding Resident 1's bed mobility as a one person physical assist instead of two person assist. The MDSC indicated according to the RAI manual it should have been coded as a two person physical assist per instructions of Code for the most support provided over all shifts; code regardless of residents self-performance classification and in Resident 1's case the highest support received per ADLs dated 10/13/21 to 10/16/21 is a two person assist. . During a review of the facility's policy and procedure titled Activities of Daily Living (ADL's)/Maintain Abilities, dated 3/1/18, indicated in part Compass Health facilities provide care based on each resident's comprehensive assessment.

Based on record review, and interview, the facility failed to develop and implement a comprehensive care plan for one of 24 sampled residents (Resident 32). This facility failure had the potential for Resident 32's dental care needs to not be met. Findings: During a review of Resident 32's dental consult titled Onsite Skilled Dental Care dated 3/2/20, indicated Pt (Resident 32) refuses Tx (treatment) .multiple missing teeth. The document further indicated Resident 32's cooperation and motivation for dental services was Poor/Negative. During a review of Resident 32's Onsite Dental Visit Summary dated 4/8/21, indicated that Resident 32 Refused X-Ray. During a review of Resident 32's Dietary Progress Notes dated 4/21/21, indicated the registered dietician (RD 1) spoke with Resident 32. The progress notes indicated RD 1 Spoke with resident (Resident 32) regarding request to change diet due to oral pain. During a review of Resident 32's dental consult titled Onsite Skilled Dental Care dated 5/3/21, indicated Resident 32's cooperation and motivation for dental services was Poor/Negative. The document further indicated Pt (Resident 32) refuses dental tx. During an interview on 5/14/21, at 8:42 a.m., with the director of social services (DSS 1), DSS 1 was asked if the facility had developed a care plan pertaining to Resident 32's missing and painful teeth and if the facility had developed care planned interventions in response to Resident 32's repeated refusals for dental care services. DSS 1 stated I don't see it and further stated Right now its generic pertaining to care, nothing in the care plan specific to oral care. During a review of the facility's policy and procedure titled Develop/Implement Comprehensive Care Plan dated 3/1/18, indicated in part The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being. Residents' right to refuse care and treatment shall also be included in the comprehensive care plan.

Based on observation, interview, and record review the facility failed to obtain an order prior to the administration of oxygen for one of 24 sampled residents (Resident 31). This failure had the potential for Resident 31 to suffer complications from incorrect dosage of oxygen administration. Findings: According to Potter and Perry's Fundamentals of Nursing, Eighth Edition, page 336, Nurses follow physicians orders unless they believe the orders are in error or harm clients. During an initial tour on 5/11/2021 at 2:43 p.m., Resident 31 was observed lying in bed with a nasal cannula (a device placed in the nose to deliver oxygen), connected to an oxygen concentrator administering 2 liters per minute of oxygen. During a review of Resident 31's clinical record on 5/13/2021 at 2:20 p.m., no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/13/2021 at 2:25 p.m. with a licensed nurse (LN2), LN2 indicated Resident 31 is on 2 liters of oxygen via nasal cannula. LN2 agreed there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy and procedure titled Oxygen Procedure undated, indicates Patients that require oxygen as ordered by the physician will be placed on an oxygen concentrator or oxygen tank. The oxygen therapy will be administered as ordered.

Based on observation, interview, and record review, the facility failed to ensure a nasal cannula and tubing (a device used to deliver supplemental oxygen or increased airflow to a patient) was secured in the designated storage bag for one sampled resident, (Resident 25). This failure had the potential for increased risk of infection due to improper storage of the nasal canula and tubing. Findings: During a concurrent observation and interview on 5/11/21, at 3:03 P.M with a Certified Nursing Assistant (CNA 1), in Resident 25's room, the nasal cannula tubing was hanging over the side rail of the bed. CNA 1 stated, This (pointing to the nasal cannula and tubing) should be in this bag (pointing to the storage bag hanging on the oxygen concentrator). During a concurrent observation and interview on 5/14/21, at 9:06 A.M., with a Student Nursing Assistant (SNA 1), in Resident 25's room, observed nasal cannula and tubing wrapped over the side rail of the bed. SNA 1 confirmed this stating, Yes, it is. Would you like me to put it in the bag? During a review of the facility's policy and procedure titled. F 695- Oxygen Procedure, (undated), indicated, The equipment will be maintained in a manner to ensure the best possible outcome for the patient.

Based on observation, interview, and record review, the facility failed to ensure : 1. A medication cart and medication storage closet were free from expired medications. This failure had the potential to result in residents receiving expired medications (drugs which are past their shelf life can decompose and either be ineffective or even harmful). 2. Tube feeding formula and tubing were labeled when open for use on resident .This failure had the potential for formulas and tubings to be used over shell life . Findings: 1. During a concurrent observation and interview on 5/12/2021, at 12:07 P.M., with the Assistant Director of Nursing (ADON), observed in Station 2 medication storage closet, one bottle of Senna Syrup, natural vegetable [MEDICATION(S)] had expired 02/2021. ADON confirmed this and stated, Yes, it's expired. During a concurrent observation and interview on 5/13/2021, at 9:59 A.M., with licensed nurse (LN 1), the following expired medications were found inside Station 1 medication cart: -[MEDICATION(S)] expired 11/2020. -[MEDICATION(S)] 10 milligram (mg) tablets expired 04/2021. -ASA (aspirin) 325 mg tablets expired 11/2020. -Multi Vitamin expired 12/2020. -[MEDICATION(S)] [MEDICATION(S)] expired 02/2021. -[MEDICATION(S)] 0.125 mg expired 3/05/2020. LN 1 confirmed these medications were expired and stated, They are expired. I went through these last week. Where did they come from? 2. During initial tour at 5/11/2021 at 10:36 a.m., Resident 22 was in bed with an ongoing feeding formula via gastronomy (GT- opening in the stomach ).The GT tubing and formula were noted to be unlabelled . During an interview at 5/11/2021 at 10:52 a.m., LN 3 indicated tube feedings are labeled with the time and date when hanged for use . LN3 agreed there were no label on the tubing and the formula bottle. During an interview on 5/12/2021 at 10:58 a.m., the registered dietician (RD1) indicated tube feedings are considered as medication when it is administered to a resident and should be labeled accordingly. During an interview on 5/13/2021 at 10 a.m., the director of nursing (DON) indicated tube feedings are considered as medication and should be labeled. The facility policy and procedure titled Label/Store Drugs & Biological dated 3/1/2018 indicated in part . drugs and biologicals used in the facility will be labeled in accordance with currently accepted professional principles as well as the expiration date when applicable .in part

Based on observation, interview, and record review, the facility failed to ensure the necessary adaptive equipment was provided for one of 24 sampled residents (Resident 17), when spouted cups with handles were not provided on the lunch tray. This failure resulted in Resident 17 not having the appropriate assistive devices to consume drinks with increased risk for aspiration of liquids. Findings: During an observation on 5/11/21, at 12:55 p.m., in the dining room, Resident 17 was eating lunch. The lunch tray had a plate of meat, noodles, vegetables, and a fruit cup. The tray had a glass of tomato juice, two glasses of water, a glass of milk, and a glass of apple juice with a straw. During a concurrent interview and record review of Resident 17's meal tray ticket, on 5/11/21, at 1:05 p.m., with the nursing assistant (CNA 2), the meal tray ticket indicated Resident 17 was to have a two-handled spouted cup for each drink. There were no two handled spouted cups observed on Resident 17's tray. CNA 2 acknowledged Resident 17's lunch tray should have a two-handled spouted cup for each drink. During an interview with the registered dietician (RD 1), and dietary manager (DM 1), on 5/12/21, at 10:50 a.m., RD 1 indicated orders for assistive devices for eating and drinking come from occupational, physical, and speech therapy. RD 1 further indicated the order is put into the computer system. DM 1 indicated once the order is in the system, kitchen staff print out the meal tray ticket and if a resident is on a therapeutic diet, and/or requires adaptive equipment, it will show up on the meal tray ticket. DM 1 further indicated all the meal trays get checked before they leave the kitchen and get checked a second time, by the CNA's, before the resident starts eating. When informed Resident 17's lunch tray was missing the two-handled spouted cups, RD 1 and DM 1 agreed Resident 17 should have the proper equipment on the tray. During a review Resident 17's Physician Order Sheet dated 5/21, the orders indicated to use a spouted cup during all meals to increase safety during oral intake and decrease risk for aspiration of liquids. During a review of the facility's policy and procedure titled, Assistive Devices-Eating Equipment/Utensils dated 3/18, indicated in part . Compass Health Facilities will provide special eating equipment and utensils for residents who need them .the food and nutrition services department will provide residents with assistive eating devices to maintain or improve their ability to eat independently.

Based on observation, and interview, the facility failed to maintain a sanitary environment in the kitchen. This facility failure had the potential for residents meals to be contaminated with dust and debris. Findings: During an observation on 5/12/21, at 12:23 p.m., in the facility kitchen, three fans were observed covered in dust and debris. One fan was in operation and angled toward kitchen staff plating food for residents. During an interview, on 5/12/21, at 12:45 p.m., with dietary manager (DM 1), DM 1 agreed the three kitchen fans needed cleaning and indicated he would inform the maintenance supervisor to clean the kitchen fans.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care) was accurate for two of 24 sampled residents (Resident 14 and Resident 17) when: 1. The dental assessment of Resident 14's broken and missing teeth was not reflected on the MDS. 2. Resident 17's neurological status of [CONDITION(S)] (TBI) was left blank. These failures had the potential to result in Resident 14's and 17's identified care needs to go unmet. Findings: 1. During a concurrent observation and interview on 5/11/21, at 11:55 a.m., with Resident 14, Resident 14 indicated having right upper tooth pain. The tooth was observed to be yellow/brown in color and also noted were several missing teeth. Resident 14 further indicated x-rays of teeth was performed ,the tooth needed to be extracted and causes pain when eating. During a review of Resident 14's Dental Care evaluation form dated 3/2/20, the evaluation indicated, Resident 14 had multiple missing teeth and many cavities that are not restorable. During a review of Resident 14's Dental Care evaluation form dated 5/3/21, the evaluation indicated, Resident 14 had poor teeth condition and does not want full mouth extractions or dentures. During a review of Resident 14's MDS Assessment Section L dated 9/1/20, 11/24/20, and 2/16/21, was blank, indicating Resident 14 did not have any dental concerns. During concurrent interview and record review on 5/14/21, at 11:00 a.m., with the MDS nurse (MDS 1), Resident 14's Dental Care evaluations and MDS Assessments for Section L were reviewed. MDS 1 agreed Resident 14 had dental concerns and section D (obvious or likely cavity or broken natural teeth) should have been checked. MDS 1 further agreed assessments should be accurate. 2. During concurrent interview and record review on 5/14/21, at 8:43 a.m., with the director of nursing (DON), Resident 17's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes indicated Resident 17 had dementia with cognitive impairment, history of [CONDITION(S)] (TBI) and history of subarachnoid hemorrhage (brain bleed). Resident 17's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes indicated Resident 17 had a subarachnoid hemorrhage, [CONDITION(S)] secondary to an aneurysm (a ballooning and weakened area of an artery that can rupture and cause internal bleeding) in 2001, and memory impairment. During a review of Resident 17's MDS Assessment Section I dated 9/1/20, 12/1/20, and 2/24/21, the box under neurological diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 5/14/21, at 10:45 a.m., with the MDS 1, Resident 17's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS 1 agreed Resident 17 had a TBI and and this should have been checked off under neurological diagnoses. MDS 1 stated, I missed it and indicated MDS assessments was filled out according to the physician diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility's policy and procedure titled, Accuracy of Assessments dated 3/18, indicated in part . Compass Health facilities will ensure that each resident receives an accurate assessment by qualified staff that is reflective of resident's status at the time of the assessment.

Based record review and interview, the facility failed to obtain informed consent for an increased dose of a [CONDITION(S)] medication ([MEDICATION(S)]) prior to administration for one out of 24 sampled residents, (Resident 31). This failure had the potential for the responsible party to be uninformed of the risks and benefits of the medication. Findings: Review of the facility policy and procedure titled Right To Be Informed/Make Treatment Decisions dated 3/18/2018 indicated the right to be informed in advance, by the physician or other practitioner or professional of the risk and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative or options he or she prefers. During a concurrent record review and interview on 5/14/2021 at 10:45 a.m., with the assistant director of nursing (ADON), the document titled Physician Orders dated 5/7/21, indicated in part . [MEDICATION(S)] (an antipsychotic medication) increased to 75mg . for Resident 31. Further review of Resident 31's electronic health record (EHR) did not contain a signed informed consent for this medication change. The ADON indicated a signed, informed consent is needed and was not located.

Based on interview and record review the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) matched the electronic medical record (EMR) in one of 24 sampled residents (Resident 16), This facility failure had the potential to cause a delay in receiving or incorrectly administering life-sustaining treatments. Findings: During a concurrent interview and record review on 5/12/21, at 12:11 p.m., with the director of nursing (DON), Resident 16's POLST was reviewed. The POLST indicated do not attempt resuscitation (DNR), selective treatment IV (in the vein) fluids, IV antibiotics, do not intubate and a trial period of artificial nutrition including feeding tubes. Resident 16's Physician Orders in the EMR were reviewed. The physician orders indicated DNR and comfort measures only. The physician orders did not indicate a trial period of artificial nutrition. The DON agreed the records did not match. The DON indicated the physician order in the EMR was changed on 11/11/19 discontinuing the trial period of artificial nutrition and was changed to no artificial means of nutrition. The DON further indicated the POLST needed to be updated to reflect the current orders in the EMR. During a review of the facility's policy and procedure titled, Request/Refuse/Discontinue Treatment; Formulate Advanced Directive dated 3/2018, indicated in part . Compass Health Inc. facilities maintain guidelines regarding advanced directives .residents or resident's representatives are given written information on their right to accept or refuse medical treatment and formulate an advanced directive if the resident so wishes.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from verbal, physical, mental, and any form of abuse. A Certified Nursing Assistant (CNA 1) was rough to Resident 1 during incontinent care (personal care and changing and of soiled-wet disposable briefs), got upset, and deprived the resident the service of another incontinent care on a second request by crumpling and jamming a rolled towel into the residents' private area between the legs, on top of a wet brief. This failure resulted in Resident 1 experiencing pain, emotional distress and being scared of getting hurt by CNA 1. Findings: During an interview on 6/3/19 at 3 p.m., the Facility Operations Manager/ acting administrator (FOM-ADM 1) indicated on 5/31/19 at 9 p.m., a CNA 6 informed him, Resident 1 reported an incident that happened on the night shift (11 p.m. to 7 a.m.) of 5/30/19 to 5/31/19. On 5/31/19 the FOM-ADM1 went to the facility to interview the Resident 1. On the interview, Resident 1 indicated asking CNA 2 for a urinal (urine container) on 5/31/19 at 2:30 a.m., but CNA 2 left the room without providing the urinal. Resident 1 had an incontinence of urine (wet self on disposable briefs), and called for assistance and CNA 1 (assigned to care for the Resident 1) responded (came to the room). CNA 1 got upset at the resident for being wet, changed the soiled disposable briefs but was rough during turning and repositioning. On the resident's second call for assistance, CNA1 placed a rolled towel in between the resident's leg on top of a wet disposable brief and was rough during turning and repositioning which caused pain to the resident's right leg. Resident 1 indicated hearing a crackling noise from the bones during the turning and repositioning by CNA1. During an observation and interview on 6/3/19 at 4 p.m., inside the resident's room, Resident 1 was in bed, and awake. Resident 1 indicated on 5/31/19 at 2:30 a.m., Resident 1 requested a urinal from CNA 2 who was inside the resident's room watching TV, but CNA 2 left without providing the resident with the urinal. Resident 1 then had a urine incontinence and called for assistance . CNA 1 responded and got upset because the resident was wet, and was rough during the changing of the resident's wet disposable briefs. Resident 1 stated, She was intentionally rough with me, I told her to stop pushing my right leg, it was fractured in April, 2019. Resident 1 further indicated on 5/31/19 at 3:30 a.m. to 4:00 a.m., after calling for assistance for a urinal, CNA 2 responded and provided the resident with a urinal and left the room. Resident 1 rang the call light again for assistance after accidentally wetting the disposable briefs changed by CNA 1 at 2:30 a.m. CNA 1 responded but when informed of the resident's wet brief, CNA 1 got upset and replied, No, it didn't, and I'm not going to do anything more. (referring to changing the resident's brief again). Resident 1 stated, She crumpled up a towel and jammed it into my private parts on top of the wet brief. It hurt when she did that. Resident 1 further indicated at 5:40 a.m., CNA 1 returned and changed his disposable brief without providing a cleaning wash. Resident 1 stated, I know she (CNA 1) was intentionally rough with me because she was angry. I felt a SNAP in my leg when she (CNA 1) turned me and it hurt. I wouldn't' say I'm afraid of her (CNA 1), just scared she's (CNA 1) going to hurt me. Review of the clinical record for Resident 1 on 6/3/19, indicated [DIAGNOSES REDACTED]. Review of the minimum (MDS) data set [DATE] (MDS -assessment) indicated Resident 1 had a cognition level of 15 (fully alert and oriented), required extensive assistance of 2+ people for bed mobility and toilet use. Resident 1 was assessed as always continent of bowel and bladder function. Review of the careplan dated 5/7/19 included care interventions for ADL (activities of daily living) self-care performance deficit related to [MEDICATION NAME] femur and potential for psychosocial well-being problem/at risk for emotional distress related to complaint regarding incontinent care received at night 5/31/19 and occasional bladder incontinence related to impaired mobility and poor bladder control. Reveiw of the document titled CNA (certified nursing assistant) care plan dated 5/7/19 included interventions under toileting of: brief use- uses disposable briefs, change at least twice every shift and PRN (as needed) for episodes of incontinence . Review of the Progress Notes, dated 6/1/19 at 00:00 (12 a.m.) documented by a registered nurse (RN 1) indicated, Resident 1 was assessed related to a complaint of right hip pain during a brief change by N[NAME] (night) CN[NAME] Resident reported feeling a joint-bone cracked. Assessment of resident reveals no signs of acute injury, denies tenderness, and pain upon palpation, other than usual aches and pains with turning and repositioning. No skin discoloration observed. Resident stated, I don't think I have a fracture or anything. It just hurt me when she (CNA1) grabbed my right hip. Resident claimed that a towel was used as an insert when it was placed between the resident's legs, rubbing against the resident's private area. No skin discoloration or breakdown observed to the peri area. During an interview on 6/20/19 from 5:35 a.m., CNA 3 indicated the day shift nurses frequently complains CNA 1's residents are all left soaked in urine. During an interview on 6/20/19 at 6:05 a.m.,CNA 2 confirmed working with CNA 1 on the night of the incident on 5/31/19. CNA 2 indicated upon checking on Resident 1, she found the resident with a rolled towel between the legs. During an interview on 6/20/19 at 6:20 a.m., Registered Nurse (RN 1) indicated interviewing Resident 1 after the incident on 6/1/19 and the resident told RN 1, CNA 1 was rough during turning and repositioning and it hurt and a towel was placed in between the resident's legs. During an interview and concurrent record review with the Director of Staff Development (DSD) on 6/20/19 at 8:00 a.m., the DSD reviewed CNA1's employee file and was unable to locate a performance evaluation. DSD acknowledged the completion of the performance evaluations is behind and CNA 1 had no performance evaluation since hire on 6/23/17. The facility policy and procedure titled, Abuse: Prevention and Prohibition Against, dated 3/30/19, states, in part, The Facility will take action to protect and prevent abuse and neglect from occurring within the Facility by supervising staff to identify and correct any inappropriate or unprofessional behaviors.

Based on interview and record review, the facility failed to ensure: 1. Staff checked the blood sugar of one of two residents (Resident 1's) as ordered. Resident 1's order for blood sugar check was daily at 6:30 a.m. On [DATE] staff checked the resident's blood sugar at 5:35 a.m. an hour early. 2. Staff re-checked Resident 1's blood sugar an hour after as ordered by the physician after doses of regular insulin (fast acting injection -to treat high blood sugar) were administered for a high blood sugar level of 550 mg. dl on [DATE] at 5:40 a.m. and 7:00 a.m. Resident 1's blood sugar was re-checked at 6:06 a.m. 26 minutes after the regular insulin was administered at 5:40 a.m., and was not re-checked after administration at 7:00 a.m. As a result of these failures on [DATE] from 6:06 a.m. to 9:40 a.m Resident 1's blood sugar level after a succession of insulin administrations dropped to an unmonitored level of LO ( from 550 mg. dl to critically low unable to read- blood sugar level below 20 mg. dl). Resident 1 died on [DATE] at 9:42 a.m. Findings: According to Potter and Perry, 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order [REDACTED]. According to Diabetes Education Online, Insulin Basics, Types of Insulin, insulins are categorized by difference in onset (how quickly it acts), peak (how long it takes to achieve maximum impact), duration (how long it lasts), concentration (100 units per milliliter), and route of delivery ( given under the skin or intravenous). >Regular Insulin -fast acting -onset (½-1 hour), peak (,[DATE] hours), duration (,[DATE] hours). >[MEDICATION NAME] (Insulin [MEDICATION NAME]) long acting-onset (1.5 hours), peak (5 hours), duration (24 hours). According to WebMD ,Normal Blood Sugar levels for Adults With Diabetes, the target blood sugars before meals is ,[DATE] mg./dl, after meals less than 180 mg./dl. Normally the pancreas releases insulin when your blood sugar or blood glucose gets high after a meal. That signals your body to absorb glucose until levels get back to normal. But if you have diabetes the body does not make insulin (type 1 diabetes) or does not respond to it normally (type 2 diabetes). Review of the clinical record for Resident 1 on [DATE] to [DATE], indicated [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. > [DATE] -Blood sugar check every morning at 6:30 a.m. > [DATE] - [MEDICATION NAME] (injection - long acting insulin ) 20 units in the morning.(6:30 a.m.) > [DATE] - [MEDICATION NAME] (oral tablet for blood sugar) 500 mg. 2 tablets (=1,000 mg) two times a day (morning and afternoon). On [DATE] the progress notes by licensed nurse (LN1) indicated Resident 1's morning blood sugar was checked and the result was 550 mg/dl. The physician was informed with an order to administer regular insulin 10 units one time and to re-check the blood sugar within an hour. The progress notes indicated regular insulin was administered and the blood sugar was re-checked within an hour, and the result was 450 mg/dl. The physician was informed and ordered a second dose of regular insulin 10 units one time and for the blood sugar to be re-checked again within an hour. Review of the electronic Medication Administration Record [REDACTED]./dl as stated in the [DATE] progress notes of LN 1. Review of the physician orders [REDACTED]. -5:40 a.m. -10 units subcutaneous (SC- injection under the skin) one time and to re-check the blood sugar after an hour and, -7:00 a.m. -10 units SC one time and to re-check the blood sugar after an hour. Review of the electronic medication administration for Resident 1 indicated the following : >[DATE] -5:35 a.m., LN 1 checked Resident 1's blood sugar and the result was 550 mg. dl.(the blood sugar was checked an hour early, order is every day at 6:30 a.m.) > [DATE]- 5:40 a.m.- Physician ordered regular insulin 10 units SC and to re-check the blood sugar after an hour. LN 1 injected 10 units of regular insulin to Resident 1's left lower quadrant abdomen). > [DATE]- 6:06 a.m.- LN 1 re-checked Resident 1's blood sugar (26 minutes after regular insulin was administered- order was to re-check after an hour ) and the result was still 550 mg.dl. > [DATE] - 6:06 a.m.- LN 1 administered [MEDICATION NAME] (long acting insulin) 20 units to Resident 1's left lower quadrant abdomen. ([MEDICATION NAME] was injected to Resident 1, 24 minutes early, the order was daily at 6:30 a.m. daily. The [MEDICATION NAME] was also injected 26 minutes after regular insulin 10 units was administered to the resident at 5:40 a.m.) > [DATE] - 7:00 a.m.- Resident 1's attending physician (AP) ordered a second dose of regular insulin 10 units and to re-check the blood sugar after an hour (8:00 a.m.). Insulin was injected to Resident 1's right lower quadrant abdomen. (Injected less than 2 hours after the Ist dose of regular insulin was administered at 5:40 a.m. and 54 minutes after [MEDICATION NAME] was administered at 6:06 a.m.). > [DATE] - 8:00 a.m. - LN 2 administered to Resident 1 [MEDICATION NAME] (tablet by mouth -medication to lower blood glucose level) 1,000 mg. Resident 1's blood sugar was not re-checked. No other documentations in the resident's clinical record were located indicating the blood sugar level was re-checked on [DATE], an hour after regular insulin was administered to Resident 1 at 5:40 a.m.,and 7:00 a.m. According to Medical- Surgical Nursing: Assessment and Management of Clinical Problems, 6th edition, copyright 2004, Mosby Inc. defines [DIAGNOSES REDACTED] or low blood glucose, occurs when there is too much insulin in proportion to available glucose in the blood. This causes the blood glucose level to drop to less than 70 mg/dl. Because the brain requires a constant supply of glucose in sufficient quantities to function properly, [DIAGNOSES REDACTED] can affect mental functioning. Common manifestation of [DIAGNOSES REDACTED] includes confusion, irritability, diaphoresis, tremors, hunger, weakness, [DIAGNOSES REDACTED] includes confusion, irritability, diaphoresis, tremors, hunger, weakness, and visual disturbances. Untreated [DIAGNOSES REDACTED] can progress to loss of consciousness, [MEDICAL CONDITION], coma, and death. Causes of [DIAGNOSES REDACTED] are often related to a mismatch in the timing of food intake and the peak action of insulin or oral hypoglycemic agents that increase endogenous insulin secretion. The progress notes dated [DATE] at 9:40 a.m., indicated, a nurse stat (emergency) call to the resident's room. Resident 1 was found with emesis (vomitus) and was not breathing. Vital signs were: Blood pressure (,[DATE]), heart rate (77), and the blood sugar read LO. At 9:42 a.m., the resident had no respirations, no vitals signs (blood pressure,heart rate), and no pupillary (eye) reaction. Second nurse to confirm the resident is dead was the treatment nurse. Physician (MD) was notified, son was notified . During an interview with LN 1 on [DATE], at 4:54 p.m., LN 1 stated, I obtained the blood sugar of the resident at 5:35 a.m., the result was 550. I notified the physician about the blood sugar result. Spoke to the doctor on the phone and the doctor ordered [MEDICATION NAME] (regular) 10 units subcutaneous times one and recheck the blood sugar in fifteen minutes. Took the medication from the emergency kit, prepared and administered it to the resident. Waited for fifteen minutes and re-checked the blood sugar. It was 550 at 06:06 a.m Called the doctor again and she ordered [MEDICATION NAME] 10 units subcutaneous and to recheck blood sugar in 15 minutes. LN 1 indicated at that time Resident 1's care was endorsed to LN 2. During an interview with LN 2 on [DATE], at 5:23 p.m., LN 2 stated, I did not take (Resident 1's) blood sugar, not remember to take (resident's)blood sugar. I took the (resident's) vital signs, gave all the morning medications like [MEDICATION NAME] at 8 :00 a.m. During an interview with the resident's attending physician (AP) on [DATE], at 9:05 a.m.,the AP stated, I myself would never re-check the blood sugar after 15 minutes of administering the insulin. I have never ordered such order. My order was to re-check the blood sugar after an hour. I don't understand why it was not done. It is a nursing call.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance for one of three sampled residents (Resident 1). Resident 1, who was identified by the facility as a high risk for falls, was left unattended while on the toilet. As a result, Resident 1 fell and sustained a right lower leg fracture. Findings: Observation on 10/29/14 at 3:10 p.m., revealed, Resident 1 was up in her wheelchair, wearing a boot on the right foot up to the knee level. Resident 1 was unable to hear and has a whiteboard at bedside to read what was being said. Resident 1 was unable to acknowledge what was written on the whiteboard when asked how she broke her leg. Record review on 10/29/14 indicated, Resident 1's [DIAGNOSES REDACTED]. Review of comprehensive assessment dated [DATE], revealed, Resident 1's cognition (mental abilities and processes of acquiring knowledge and understanding) as moderately impaired and needed extensive assistance with transfers and toileting. Review of Fall Risk Evaluation dated 6/12/14 and 8/10/14, revealed, Resident 1 was a high risk for falls. Review of care plan for fall prevention, initiated on 7/9/13, revealed, Resident 1 is at risk for falls due to poor safety awareness and requests for bathroom door to be closed when toileting for privacy reasons. Facility's intervention included, Staff will stay near the resident while in BR (bathroom) while maintaining resident rights for privacy (keeping the bathroom door close). Review of nurses' Progress Notes, dated, 6/12/14 at 12:31 p.m., revealed, Resident 1 fell while in the bathroom by herself. Interdisciplinary team (IDT) investigation of the fall incident, dated 6/12/14, revealed, Resident 1 was taken to the bathroom by a certified nursing assistant (CNA), put a tab alarm (an alarming monitoring device) on, reminded resident to call for assistance, then left resident to attend to another resident. However, Resident 1 disabled the tab alarm, transferred herself and fell . IDT were in agreement to ensure staff compliance of not leaving resident in the BR unattended. Review of nurses' Progress Notes, dated, 10/16/14 at 5:42 p.m., revealed, Resident 1 fell again in the bathroom, was found sitting on the floor, with water or urine' on the floor, tab alarm in place but not sounding, and complained of pain on the right leg. IDT review of the fall incident, dated 10/17/14, revealed, CNA 1 assisted resident to the BR, applied tab alarm, and closed the bathroom door per resident's request for privacy. Just after CNA 1 assisted Resident 1 to the BR, he got a call to assist another resident. During an interview on 10/29/14 at 4 p.m., CNA 1 recalled, on 10/16/14, before dinner, he assisted Resident 1 to the bathroom. CNA 1 heard someone yell help and he left to assist the coworker. CNA 1 explained, I asked the med nurse (licensed nurse) by (Resident's 1) room to watch her so I could help. When interviewed on 10/29/14 at 4:30 p.m., the licensed nurse (LN 1) stated, she was passing medications during Resident 1's fall incident on 10/16/14, was positioned right outside (Resident 1's) room door. LN 1 stated, she heard a thud, then help coming from the bathroom door. She went into the room and saw Resident 1 sitting on the bathroom floor, legs out to the side with arms forward supporting her. Resident 1 was not able to explain why she got up and asked CNA 1 Where were you?. When LN 1 was asked if she went next to the bathroom door when CNA 1 left Resident 1, LN 1 stated, No, she was at the resident's room door, not at the bathroom door. Review of Resident 1's right lower leg X-ray result, dated, 10/17/2014, revealed, nondisplaced (bone crack but maintains in proper alignment) fracture of the distal fibula (lower leg bone).

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance for one of three sampled residents (Resident 1). Resident 1, who was identified by the facility as a high risk for falls, was left unattended while on the toilet. As a result, Resident 1 fell and sustained a right lower leg fracture. Findings: Observation on 10/29/14 at 3:10 p.m., revealed, Resident 1 was up in her wheelchair, wearing a boot on the right foot up to the knee level. Resident 1 was unable to hear and has a whiteboard at bedside to read what was being said. Resident 1 was unable to acknowledge what was written on the whiteboard when asked how she broke her leg. Record review on 10/29/14 indicated, Resident 1's [DIAGNOSES REDACTED]. Review of comprehensive assessment dated [DATE], revealed, Resident 1's cognition (mental abilities and processes of acquiring knowledge and understanding) as moderately impaired and needed extensive assistance with transfers and toileting. Review of "Fall Risk Evaluation" dated 6/12/14 and 8/10/14, revealed, Resident 1 was a high risk for falls. Review of care plan for fall prevention, initiated on 7/9/13, revealed, Resident 1 is at risk for falls due to poor safety awareness and requests for bathroom door to be closed when toileting for privacy reasons. Facility's intervention included, "Staff will stay near the resident while in BR (bathroom) while maintaining resident rights for privacy (keeping the bathroom door close)." Review of nurses' "Progress Notes", dated, 6/12/14 at 12:31 p.m., revealed, Resident 1 fell while in the bathroom by herself. Interdisciplinary team (IDT) investigation of the fall incident, dated 6/12/14, revealed, Resident 1 was taken to the bathroom by a certified nursing assistant (CNA), put a tab alarm (an alarming monitoring device) on, reminded resident to call for assistance, then left resident to attend to another resident. However, Resident 1 disabled the tab alarm, transferred herself and fell . IDT were in agreement to "ensure staff compliance of not leaving resident in the BR unattended". Review of nurses' "Progress Notes", dated, 10/16/14 at 5:42 p.m., revealed, Resident 1 fell again in the bathroom, was found sitting on the floor, with "water or urine' on the floor, tab alarm in place but not sounding, and complained of pain on the right leg. IDT review of the fall incident, dated 10/17/14, revealed, CNA 1 assisted resident to the BR, applied tab alarm, and closed the bathroom door per resident's request for privacy. Just after CNA 1 assisted Resident 1 to the BR, he got a call to assist another resident. During an interview on 10/29/14 at 4 p.m., CNA 1 recalled, on 10/16/14, before dinner, he assisted Resident 1 to the bathroom. CNA 1 heard someone yell help and he left to assist the coworker. CNA 1 explained, "I asked the med nurse (licensed nurse) by (Resident's 1) room to watch her so I could help." When interviewed on 10/29/14 at 4:30 p.m., the licensed nurse (LN 1) stated, she was passing medications during Resident 1's fall incident on 10/16/14, was positioned "right outside (Resident 1's) room door". LN 1 stated, she heard a "thud", then "help" coming from the bathroom door. She went into the room and saw Resident 1 sitting on the bathroom floor, legs out to the side with arms forward supporting her. Resident 1 was not able to explain why she got up and asked CNA 1 "Where were you?". When LN 1 was asked if she went next to the bathroom door when CNA 1 left Resident 1, LN 1 stated, "No", she was at the resident's room door, not at the bathroom door. Review of Resident 1's right lower leg X-ray result, dated, 10/17/2014, revealed, "nondisplaced (bone crack but maintains in proper alignment) fracture of the distal fibula (lower leg bone).