Every finding on record at San Rafael Healthcare & Wellness Center, LP

Based on interviews and record reviews the facility failed to protect 3 of 9 residents (Resident 1, Resident 2, Resident 8) sampled for resident rights, right to be treated with kindness, respect, and dignity, when Certified Nursing Assistant A (CNA A) continued to provide personal care despite multiple complaints from residents and staff reporting rushed and rough care, rude behavior, not providing incontinence care, leaving residents wet, and not answering call lights.This failure made residents feel uncomfortable and treated like objects, residents avoided requesting care when CNA A was assigned to them, and residents requested not to have CNA A assigned to them anymore. This failure had the potential to put other residents assigned to CNA A at risk for violations of their rights.During an interview on 8/7/26 at 10:55 a.m. with Restorative Nursing Assistant B (RNA B), RNA B stated residents had frequently complained about CNA A's care and CNA A could only work with certain residents due to requests from residents to not be assigned to CNA A , and he always had the same assignment. RNA B further stated during an interaction with CNA A he became angry and defensive when RNA B offered help and this was reported to the Director of Nursing (DON).A review of Resident 1's admission record indicated Resident 1 was admitted in 05/25 with the diagnoses of Appendicitis (an inflammation of the appendix), morbid obesity (having a Body Mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with major health problems like type 2 diabetes or heart disease) and Major Depressive Disorder (MDD- persistent feelings of sadness, emptiness, and a loss of interest in activities lasting at least two weeks).A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 7/21/26, indicated Resident 1 had a BIMS(Brief Interview for Mental Status- score is a 0 to 15 scale used in nursing homes and long-term care facilities to check a residents memory, learning, and orientation, with 0-7 for severe cognitive impairment, 8-12 for moderate cognitive impairment, 13-15 for cognitively intact) score of 15 with no cognitive impairment.During an interview on 8/7/26 at 11;10 a.m. with Resident 1 in his room, Resident 1 stated CNA A took a long time to respond to Resident 1's need for incontinence care, CNA A was rough while cleaning him, and spoke to Resident 1 curtly or would not respond when spoken to. Resident 1 stated CNA A made him feel less of a person and felt CNA A was trying to to get it over with. Resident 1 stated CNA A left Resident 1 without pants on and with his bed in the highest position putting Resident 1 at risk for falls. Resident 1 stated he filed a grievance and requested to never be on CNA A's assignment again.A review of Resident 2's admission record indicated he was admitted in 11/25 with diagnoses of Epilepsy (a chronic brain disorder defined by a lasting tendency to have recurring, unprovoked seizures) and repeated falls.A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 13 with no cognitive impairment.During an interview on 8/7/26 at 11:20 a.m. with Resident 2 in his room, Resident 2 stated CNA A was more concerned about finishing his tasks and did not care about the person he was providing care to. Resident 2 stated CNA A was rude, and out of line, rushing and being rough with his roommate Resident 1 so CNA A could clock out. Resident 2 further stated if CNA A was assigned to Resident 2 he did not bother calling for help because the last time CNA A was assigned to Resident 2, CNA A never answered Resident 2's call light and Resident 2 had to walk out to the nurses' station and discovered CNA A had clocked out without telling anyone. Resident 2 further stated last weekend he had a seizure and CNA A was nowhere to be found and his roommate Resident 1 had to hobble out to the nurses' station to get someone.A review of Resident 8's admission record indicated he was admitted in 06/26 with diagnoses of Paraplegia (paralysis that affects the lower half of the body, including both legs and sometimes parts of the lower trunk) and osteomyelitis (a severe infection and inflammation of the bone and bone marrow, usually caused by bacteria or fungi).A review of Resident 8's MDS, dated [DATE], indicated Resident 8 had a BIMS score of 15 with no cognitive impairment.During an interview on 8/7/26 at 2:00 p.m. with Resident 8 in his room, Resident 8 stated CNA A had provided care to Resident 8 before and CNA A looked at me like he hated me, like he resented having to touch me. Resident 8 stated CNA A was rough when providing care and Resident 8 felt dehumanized and like a burden. Resident 8 further stated he told staff about his concerns and Resident 8 felt management knew but would not act until something bad happened. During an interview on 8/7/26 at 12:20 p.m. with Licensed Nurse C(LN C) in Unit 2 hallway, LN C stated when she worked in Unit 1 hallway CNA A worked evenings and nights. LN C stated she had two residents' report CNA A was rough while cleaning them. LN C stated she tried to talk to CNA A and explained residents have feelings, they are human beings not objects, but CNA A just walked away. LN C stated she reported this to the DON and wrote a statement.A review of CNA A's Human Resources (HR) File indicated his Date of Hire (DOH) was 6/30/2015. CNA A had six disciplinary actions prior to 2023 for neglecting residents and unprofessional conduct. HR files further indicated recent disciplinary actions on 4/3/26 for being rough during peri-care, on 4/20/26 for abandoning his assignment without notifying anyone, and on 4/24/26 a resident complained to the charge nurse that CNA A was rude, full of anger, and had no respect for residents. This resident reported they were afraid CNA A would have angry outbursts and hoped new staff would do something because residents were human beings too. Additional disciplinary actions were documented on 6/3/2026 for not providing incontinence care during his shift.During an interview on 8/7/26 at 3:35 p.m. with the Administrator (ADM) in his office, ADM stated he had not had time to investigate all staff hired before the ADM took over in 03/26. The ADM confirmed the facility had a responsibility to know who they had working for them and to protect residents from disrespect, rough care, and abuse despite when new management took over.A review of a facility document titled, Resident Rights, revised 01/2012, indicated Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.A review of a facility document titled, Certified Nursing Assistant, Job Description, not dated, indicated CNAs must possess a sincere desire to serve, must have patience, cheerful disposition, and enthusiasm. Perform all duties as assigned and in accordance with facility's established policies and procedures, nursing care procedures and safety rules and regulations.

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect when staff failed to follow through on requests for assistance for five of six sampled residents, Residents 1, 2, 3, 5, and 6. This failure caused the residents to feel lousy and piss[ed] off and affected the residents' psychosocial well-being.During an interview on 7/1/26 at 12:01 p.m. with Resident 3 and Resident 4, who resided in the same room, Resident 3 stated he waited 20 to 30 minutes for assistance when he pressed his call light, and one time he waited an hour and a half. Resident 3 stated when he was waiting for assistance, he had been incontinent of stool and was sitting in a soiled brief. Resident 3 stated he waited long periods of time for his soiled brief to be changed so often that, he stated, Sadly, I've gotten used to it. Resident 4, stated it made him feel lousy for Resident 3 that staff did not come to help him, and Resident 4 often would go out in the hall and find someone to help Resident 3 when he was left waiting for a long time. During an interview on 7/1/26 at 12:06 p.m. with Resident 6 and Resident 5, who resided in the same room, Resident 6 stated he waited long periods of time for assistance from staff. Resident 6 stated he waited for two hours for Tylenol for his back pain. Resident 6 also stated he sent his breakfast tray back yesterday morning (6/30/26) and requested an alternate meal. Resident 6 stated that when no food came for over an hour, he called the front desk and had to ask if someone could bring him his breakfast because no one answered the call light. Resident 6 stated that recently the staff took his water pitcher and did not return it for an hour and a half, so he had no water to drink during that time, until he asked someone to bring it back. Resident 5 stated that last night (6/30/26) he got his sheets wet while he was using his urinal and he had to wait 15 minutes before anyone responded to his call light, which he stated was unacceptable to him. Resident 5 stated that when the CNA (certified nursing assistant) responded, she was surly with him and asked him, What do you want? During a text communication on 7/1/26 at 12:35 p.m., the spouse of Resident 1's roommate, Visitor B, indicated that her husband and Resident 1 roomed together from February to May of 2026. Visitor B indicated that once during that time, Resident 1 was in the bathroom by himself and began yelling for help. Visitor B indicated Resident 1 was blind and had gotten himself stuck in the toilet bowl. Visitor B indicated she went in the hall three times to ask staff for urgent help for Resident 1. Visitor B indicated the first time, she expected the staff to go right away to the bathroom, but instead he went around the corner to call someone else. Visitor B indicated no one came and Resident 1 continued to yell for help. Visitor B indicated the second time she went back in the hallway and found another staff, who acknowledged Visitor B but continued what she was doing. Visitor B indicated she tried to reassure Resident 1 that help was on the way, but still no one came to help. Visitor B indicated the third time, she went to the desk at the entrance to explain the situation, saying it was urgent, but no one seemed alarmed and no one came to check to see what Resident 1's situation was. Visitor B indicated Resident 1 still had to wait until two male staff were ready to help him. Visitor B indicated Resident 1 felt angry and he felt a faster response from staff should have been in order. During an observation and concurrent interview on 7/1/26 at 1:06 p.m., Resident 2 stated once or twice a week he got no response at all to his call light and he had to go find staff to help him sometimes. When asked what assistance he was calling for, Resident 2 stated he needed something for his blood glucose such as Ensure (nutritional supplement shake) or insulin (a hormone that helps the body's cells absorb glucose from the bloodstream), and Resident 2 held up his blood glucose monitor that displayed his blood glucose reading on the screen. Resident 2 stated, It pisses me off when staff do not respond to his call light. During an interview on 7/1/26 at 3:56 p.m., CNA C stated that if a resident presses the call light, her goal is to go right away. CNA C stated 15 to 30 minutes was too long for the resident to wait because you don't know what happened that caused the resident to press the call light. During an interview on 7/1/26 at 4:06 p.m., Interim Director of Staff Development (DSD) stated call lights needed to be answered as soon as possible. DSD stated everyone should answer call lights because it could be as simple as picking up something that fell or the resident needed a refill. DSD stated call lights should not take 15 minutes to answer because this was not a big facility. Review of Resident 1's facesheet (demographics) indicated an admission date of 11/21/23 and multiple medical diagnoses including Parkinson's disease (a progressive neurological disorder that damages dopamine-producing neurons in the brain) and legal blindness. Resident 1's MDS (minimum data set, an assessment tool), dated 5/20/26, indicated he was cognitively intact. Review of Resident 2's facesheet indicated an admission date of 1/20/25 and multiple diagnoses including Type 1 Diabetes (a chronic autoimmune disease where the body's immune system attacks and destroys the insulin-producing beta cells in the pancreas), need for assistance with personal care, and difficulty walking. Resident 2's MDS, dated [DATE], indicated Resident 2 had a moderate cognitive impairment. Review of Resident 3's facesheet indicated an admission date of 5/23/25 and multiple diagnoses including difficulty walking and need for assistance with personal care. Resident 3's MDS dated [DATE] indicated he was cognitively intact. Review of Resident 4's facesheet indicated an admission date of 11/29/25. Review of Resident 5's facesheet indicated an admission date of 5/2/26 and multiple diagnoses including history of falls, weakness, and abnormality of gait and mobility. Resident 5's MDS dated [DATE] indicated Resident 5 was cognitively intact. Review of Resident 6's facesheet indicated an admission date of 5/1/26 and multiple diagnoses including muscle weakness and unsteadiness on feet. Resident 6's MDS dated [DATE] indicated Resident 5 was cognitively intact. Review of facility policy titled Resident Rights - Quality of Life, last revised 3/2017, indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner as those that support the resident in attaining or maintaining his/her highest practicable well-being.

Based on interview and record review, the facility failed to provide adequate supervision, accurate assessment and interventions for one of three sampled residents reviewed for elopements (Resident 1) to prevent the resident from eloping (the act of leaving the facility unsupervised and without prior authorization).These failures resulted in Resident 1 walking three blocks on a busy two lane street and being found wandering on the sidewalk and had the potential to result in serious physical harm or death. Based on interview and record review, the facility failed to provide adequate supervision, accurate assessment and interventions for one of three sampled residents reviewed for elopements (Resident 1) to prevent the resident from eloping (the act of leaving the facility unsupervised and without prior authorization).These failures resulted in Resident 1 walking three blocks on a busy two- lane street and being found wandering on the sidewalk and had the potential to result in serious physical harm or death.Findings:A review of Resident 1's admission record indicated he was admitted [DATE] with diagnoses of dementia, muscle weakness and difficulty walking.A review of Resident 1's Progress Notes, dated 5/30/26, described the resident as, Patient has chronic dementia .on monitoring for recent fall with treatment .General Alert oriented to person, place .forgetful.A review of Resident 1's Progress Notes, dated 6/5/2026, at 6:50 p.m., indicated Elopement Evaluation: History of elopement while at home: Yes. Elopement Score: 1.0 .Elopement Risk Note: At 4:45 p.m. CNA (Certified Nursing Assistant), noted that Resident 1 was sitting in the activities room, meals served in his room around 5:30, found he is not in the room, . Multiple staff members looked inside and outside. Police were called (about) missing resident at 06:10PM and arrived at 06:20 PM. At 06:30 PM a call was received from RNA (Restorative Nursing Assistant) found resident on 3rd St.A review of Resident 1's Elopement Assessment, dated 3/14/26, indicated he scored 1 (1 and above indicated a high risk for elopement).A review of Resident 1's Brief Interview for Mental Status (BIMS) (An assessment tool to determine how cognitively intact a resident was), dated 3/19/26, indicated a score of 5 (0-7 significant impairment, 7-11 Moderate problems with thinking and memory, 12-15 Normal thinking and memory with very little impairment.)A review of Resident 1's Care Plan Reports dated 3/27/26 indicated he had a plan of care for High risk for falls r/t Deconditioning. Unaware of safety needs, .Dementia, cognitive communication deficit, in need of assistance with personal care. A Care Plan for risk of elopement, dated 6/6/26 indicated Resident 1 eloped on 6/5/26 at pm shift BIMS score of 1 Elopement risk score of 1. During an interview on 6/9/26 at 10 a.m. with the Administrator he stated Resident 1 left the facility through the front door. He stated Resident #1 was assessed with a high risk for elopement when he was admitted and a care plan to prevent elopement was not initiated until after he eloped. He stated without a care plan for elopement, the staff would not know he was at high risk and would not have supervised him to keep him from walking out the front door. The Administrator stated Resident 1 did not have a wandering device on (A device that would trigger an alarm if Resident 1 got too close to an exit door). He stated if he had one, staff would have been able to prevent Resident #1 from leaving the facility. The Administrator stated the facility should have had a care plan in place for elopement for Resident #1, and it could have prevented his elopement from the facility. During an interview on 6/9/26 at 10:15 a.m., the Director of Nursing (DON) stated Resident #1 was assessed as high risk for falls and high risk for elopement on admission. She stated Resident #1 had no [brand name] wandering device (WMD- a sensory device placed on a resident that alarms if near a monitored exit). Upon reviewing the elopement risk assessment completed on 3/14/26, the DON confirmed the assessment was incomplete. The DON stated if the elopement risk assessment had been completed accurately, the resident would have scored as high risk for elopement and would have had a care plan for risk of elopement initiated. The DON stated the resident was confused and consistently walked around the building. The DON acknowledged that it was an unsafe situation that Resident 1 crossed a busy street and agreed he could have fallen or been injured.During an interview on 6/9/26 at 12:30 p.m. with the admission Nurse, she stated the care plan should have been triggered for Resident #1 elopement score of 1 which was considered high risk. She stated if a care plan for elopement had been triggered staff would have monitored Resident #1 and perhaps caught the elopement attempt. She stated she was unaware the Electronic Medical Record would have triggered a care plan if the elopement evaluation completed on admission had been completed. Review of a document titled SAN [NAME] HEALTH AND WELLNESS, dated 6/6/26, it indicated CONTRIBUTING FACTORS & ROOT CAUSE ANALYSIS, Wander Risk Assessment Triggered without Care Plan Response. The resident's wander risk assessment score was at a level that should have triggered a formal clinical response. However, no corresponding care plan interventions were initiated as a result. The assessment finding was not translated into actionable safeguards . Absence of Elopement Precautions in Care Plan. At the time of the incident, the resident's care plan did not include an elopement risk problem, goal, or intervention. Given the resident's BIMS score of 3 and documented lack of decision-making capacity, elopement risk should have been an active care plan problem with specific interventions assigned. The absence of a care plan entry meant that direct care staff had no documented protocol to guide their supervision approach for this resident's specific risk profile.During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, revised 1/31/23, the P&P stipulated, The resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission .During a review of the facility's P&P titled, Resident Safety, revised 5/15/21, it indicated Residents will be evaluated on admission . to identify circumstances that pose a risk for the safety and wellbeing of the Resident.

Based on observation, interview, and record review, the facility failed to provide supervision for one resident (Resident 1) of five sampled residents when Resident 1 left the facility unaccompanied and wandered several busy streets until he was found by a friend and driven to his Responsible Party's (RP, a person who makes health care decisions on behalf of the resident when the resident does not have the mental capacity to do so) home.This failure decreased the facility's potential to provide supervision and to prevent severe injury to the residents. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with a diagnosis of toxic encephalopathy (brain dysfunction from exposure to poisons, chemicals, drugs, or natural toxins, causing altered mental status, confusion, memory loss, personality changes, tremors, and coordination issues, with outcomes varying from reversible to permanent brain damage, depending on exposure).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/3/25, indicated Resident 1 had severe memory impairment.A Review of Physician (MD) progress notes, dated 12/9/25, indicated Patient is a. with past medical history significant for anxiety and memory impairment was found wandering the street about 1 mile away from his assisted living facility. Check placement and function of wander guard left ankle.A review of Resident 1's Wander Risk Care Plan, initiated 10/30/25, indicated Resident 1 was at risk for elopement and/or wandering related to mental confusion and memory loss, and a wander management monitor was to be worn.A review of Resident 1's Treatment Administration Record (TAR), dated 12/25, indicated the wander management monitor was in place on left ankle and was confirmed functioning on the night shift of 12/9/25 and confirmed in place on left ankle day shift of 12/10/25. A review of Resident 1's MD orders, dated 10/28/25, indicated that Resident 1 may leave facility on a pass, with supervision. A review of Resident 1's Medication Administration Record (MAR), dated 12/25, indicated Resident 1 had received medications at 5:00 p.m. on 12/10/25.A review of Resident 1's nursing notes, dated 12/11/25 at 2:32 p.m. indicated at approximately 5:15 p.m. on 12/10/25, nursing staff noted Resident 1 was no longer in the facility. When they contacted the RP, they learned the resident had left the facility and walked to 4th street where a family friend picked him up and brought him to the RP's house. During an interview on 12/23/24 at 10:40 a.m. with the Director of Nursing (DON), the DON stated Resident 1 wore a wander guard because he always wanted to go out without supervision.During an interview on 12/29/25 at 12:31 p.m. with LN 1, LN 1 stated she first realized Resident 1 was missing when she went in to check on Resident 1 to see if he was ready for dinner. She looked around, requested assistance, called the family and called her supervisor. When the family called her back was when she learned Resident 1 had left the facility, walked down to 4th street, found a friend and the friend drove him to his RP's house. LN 1 stated she never heard the wander management monitor alarm. During an interview on 12/30/25 at 8:48 a.m. with CNA 1, CNA 1 stated Resident 1 was a part of his assignment that day; he had 8 residents. He had last worked with Resident 1 around 4:30 p.m. and left him in the Lobby on the sofa, a place Resident 1 likes to sit. A short time later LN1 came to him asking where Resident 1 was. They looked within the facility and outside and could not find him. That's when we called the family and found he was there. CNA 1 stated he did not hear the wander management monitor alarm. During an interview on 12/30/25 at 10:03 a.m. with Resident 1's RP, RP stated Resident 1 was wearing his wander management monitor when he arrived at her house on 12/10/25. She watched him take it off with scissors in the kitchen the next day. During a review of a facility policy titled, Wandering and Elopement, revision date 1/31/23, the policy stipulated, the facility will identify residents at risk for elopement upon admission. [in order] to enhance the safety of residents of the facility.During a review of a facility policy titled, Out on Pass, revision date 1/11/16, the policy stipulated, resident/responsible person will verbally notify a Licensed Nurse prior to going out on a pass and will sign out and back in on Form A - Resident Out On Pass Log.

Based on observation, interview, and record review, the facility failed to protect one resident (Resident 1) of four sampled residents from abuse when Resident 1 wandered into Resident 2's room and became verbally and physically aggressive. This failure resulted in Resident 2 punching Resident 1 in the face when Resident 1 would not leave Resident 2's room after repeated requests.On 7/3/25 at 4:33 p.m., the Department received a report from the facility that indicated, On 7/3/25 at 1:40 p.m. [Resident 1] was observed in [Resident 2's] room by the housekeeper and had to be separated immediately. Upon interviewing [Resident 2], he stated that [Resident 1] came into his room and would not leave. [Resident 1] was standing at the bedside with his hands up in a fist while [Resident 2] was laying down telling him to leave. According to [Resident 2] he struck [Resident 1] in the face and chest.During an observation on 7/16/25 at 1:17 p.m., Resident 1 was walking in the hallway of Station 1. Staff were trying to encourage him to come to his room to eat some lunch, which he did.During an interview on 7/16/25 at 1:43 p.m., Resident 2 stated that on 7/3/25, he was asleep in bed when Resident 1 came in his room yelling and screaming. Resident 2 stated he asked Resident 1 to leave three times, but Resident 1 did not leave. Resident 2 stated Resident 1 came over to him yelling, You die! You die! and grabbed his (Resident 2's) shirt. Resident 2 stated that at that point he punched Resident 1 several times in the face, and staff came in and separated them. Resident 2 stated Resident 1 had come in his room before at night and taken his belongings, but had never been physically aggressive. Resident 2 stated he felt unsafe because Resident 1 had made threats against his life. Resident 2 stated there was nowhere for him to run (since he was in bed), so he hit Resident 1 because his only other alternative was to get beat up.During an interview on 7/16/25 at 1:56 p.m., the Activities Director (AD) stated that during the Resident Council meeting last month (June), Resident 1 had wandered in and out a couple of times. The AD stated he went around the facility to ask residents what topics they would like discussed at the upcoming ad hoc Resident Council meeting, and one of the issues that residents complained of the most was wandering residents. The AD stated the facility was currently experiencing a COVID outbreak, and residents were concerned that the wandering resident was spreading the infection around the building by wandering in and out of rooms. The AD stated the residents also felt the wandering resident was invading their privacy.During an interview on 7/16/25 at 2:09 p.m., Resident 3 stated Resident 1 wandered in her room occasionally. Resident 3 stated Resident 1 came in, nods at her, and then goes away.During an interview on 7/16/25 at 2:12 p.m., Resident 4 stated she lived in a room just a few doors down from where Resident 1 lived. Resident 4 stated Resident 1 went in and out of people's rooms including hers. Resident 4 stated the reason she kept her door closed was to keep Resident 1 out of her room. Resident 4 stated she preferred to keep her door open and keeping it closed made her feel isolated. Resident 4 stated she felt violated when Resident 1 wandered into her room. Resident 4 stated that when her door was open, Resident 1 would wander in several times a day.During an interview on 7/16/25 2:19 p.m., Resident 5 stated Resident 1 had come into his room on a nightly basis until two weeks ago. Resident 5 stated that when Resident 1 came into his room he would stand and babble a lot, and sometimes Resident 1 would be argumentative, combative, and irritable. Resident 5 stated that when Resident 1 wandered into his room it made him feel annoyed.During an interview on 7/16/25 at 3:22 p.m., the Social Services Director verified Resident 1 had a wandering behavior.During a phone interview on 7/17/25 at 3:15 p.m., Environmental Services Staff (ESS) stated he recalled that on 7/3/25, he was taking his bucket to the room where Resident 2 resided. ESS stated he heard Resident 1 yelling, I killing you! I killing you! and then he saw Resident 2 punched Resident 1 in the face. ESS stated he yelled for help and then told Resident 1, This is not your room. ESS stated three staff came and helped separate the residents, but ESS could not recall who came. ESS stated that when he entered Resident 2's room, Resident 1 had his hands in fists and was touching Resident 2 with his fists, but did not hit him.During an interview on 7/18/25 at 10:30 a.m., the Administrator verified that when Resident 2 punched Resident 1 in the face on 7/3/25, it was considered abuse per facility policy for abuse prevention. The Administrator stated that the abuse could have been prevented by redirecting Resident 1 away from Resident 2's room. The Administrator stated Resident 1 should not have been in Resident 2's room.Review of Resident 1's medical record revealed Resident 1's face sheet indicated an admission date of 10/18/23, and medical diagnoses including dementia (loss of the ability to think, remember, and reason to the extent that it interferes with daily life and activities) with behavioral disturbance, cognitive (related to thinking, reasoning, or remembering) communication deficit, and need for assistance with personal care, among others. Review of Resident 1's Minimum Data Set (an assessment tool), dated 6/24/25, indicated Resident 1 had a BIMS score of 6 (Brief Interview for Mental Status, a score of 0 to 7 indicates severe cognitive impairment). Resident 1's care plan indicated a focus area, initiated 4/24/24, The resident is an elopement risk/wanderer [related to] Disoriented to place, Resident wanders aimlessly, with interventions that included, Assist resident when ambulating, and, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.Review of Resident 2's medical record revealed Resident 2's face sheet indicated an admission date of 1/20/25, and medical diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), among others. Resident 2's Minimum Data Set, dated [DATE], indicated a BIMS score of 14 (a score of 13 to 15 indicates intact cognition).Review of facility policy and procedure, Abuse Prevention and Management, dated 6/12/24, indicated, 'Abuse' is defined as the willful, deliberate infliction of injury . ‘Physical abuse' is defined as, but not limited to, hitting, slapping, punching and/or kicking Further review of the policy and procedure indicated under section, Prevention: The Facility identifies, corrects, and intervenes in situations in which abuse . is more likely to occur.

Based on observation, interviews, and record reviews, the facility failed to ensure two out of five sampled residents (Resident 1 and Resident 2) were treated with respect and dignity when: 1. A call light (a signal that residents in healthcare facilities use to alert staff when they need assistance) was not answered timely by facility staff, and 2. A foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine) drainage bag (bag that collects the drained urine) did not have a privacy cover. These failures had the potential to negatively affect residents' sense of dignity and privacy.[AV3] Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in May of 2025 with diagnoses including Chronic Pain Syndrome (CPS, pain that lasts longer than three months) and Functional Quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). A review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 5/11/25, indicated Resident 1 was dependent on staff (staff does all the efforts and resident does none of the effort to complete the activity) for care with toileting and personal hygiene. A review of Resident 2's face sheet indicated Resident 2 was admitted to the facility in March of 2022 with diagnoses including Dysphagia (difficulty swallowing) and a need for assistance with personal care. A review of Resident 2's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 3/7/25, indicated a score of 15, cognition in tact and no assessed memory problems. 1.During a concurrent observation and interview on 6/3/25 at 11:21 a.m., the call light for room [ROOM NUMBER] was on, indicating a need for assistance, and multiple staff were observed passing by without responding to the call light. Unlicensed Staff A, when stopped, stated she was a new employee and looked at the call light but did not respond to the residents in room [ROOM NUMBER] that were signaling for assistance. During an interview on 6/3/25 at 11:23 a.m., Resident 1 in room [ROOM NUMBER] acknowledge the call light was on for assistance and stated staff does not respond to the call light promptly. Resident 1 stated previously she had to wait for hours before staff answered her call light. Resident 1 stated sometimes she would yell and still no one would come. Resident 1 stated when staff do not respond to the call light promptly, she felt like staff did not care about her. During a concurrent observation and interview on 6/3/25 at 11:39 a.m., Licensed Nurse (LN) B verified the call light for room [ROOM NUMBER] was still on. LN B stated everyone was responsible for answering call lights, and added, since everyone oversees answering call lights, call lights must be answered promptly, at least within 3 to 5 minutes. LN B stated there was no reason why a call light should not be answered promptly since anyone could answer it. LN B stated it was not acceptable for residents to wait over 15 minutes for call light to be answered. LN B stated not answering call light timely could make residents feel like staff did not recognize their needs or that the residents' needs did not matter. During an interview on 6/3/25 at 11:44 a.m., Unlicensed Staff C stated it was every staff's responsibility to respond to and answer call lights. Unlicensed Staff C added, call lights should be answered promptly, within two to three minutes, and it was not acceptable for residents to wait over 10 minutes for a call like to be answered. During an interview on 6/3/25 at 11:53 a.m., Resident 2 stated she had experienced waiting for about 30 minutes to an hour before staff have answered her call light. Resident 2 stated some staff just don't answer call lights timely. Resident 2 explained, it was very frustrating when her call light was on but no one was coming and she felt disrespected. During an interview on 6/3/25 at 1:30 p.m., the Director of Staff Development (DSD) stated answering a call light was everyone's responsibility per the facility's policy. The DSD stated call lights should be answered immediately within 2 to 3 minutes and it was not acceptable for residents to wait over 10 minutes for the call light to be answered. The DSD stated call lights should be answered in a timely manner to ensure the residents were safe and to prevent accidents and injuries. A review of the facility's policy and Procedure (P&P) titled Communication-Call System, revised 1/1/12, the P&P indicated, Purpose .To provide a mechanism for resident to promptly communicate with nursing staff . nursing staff will answer call bells promptly . 2. During a concurrent observation and interview on 6/3/25 at 11:23 a.m., Resident 1 had a FC hanging on the right side of the bed with no cover on the drainage bag. Resident 1 stated staff never placed a cover on her FC drainage bag and did not think the facility had any FC drainage bag covers. During a concurrent observation and interview on 6/3/25 at 11:32 a.m., LN B verified Resident 1s FC drainage bag had no cover. LN B stated the facility policy was to ensure FC drainage bag were covered even when in bed to protect residents' privacy and dignity. LN B stated not placing a cover on the drainage bag could make the resident feel upset, ashamed, humiliated and could lead to increase discomfort around visitors. During an interview on 6/3/25 at 11:44 a.m., Unlicensed Staff C stated it was the facility's policy to ensure FC drainage bag was covered even when resident was in bed. Unlicensed Staff C stated it was a dignity issues cause not putting a cover on a FC drainage bag could result in resident feeling humiliated or undignified. During an interview on 6/3/25 at 1:30 p.m., the DSD stated it was the facility's policy to ensure FC drainage bags were covered. The DSD stated if the FC drainage bag was not covered it meant the facility policy was not followed and would be a privacy and dignity issue for the resident. A review of the facility policy and procedure (P&P) titled Catheter- Care of, revised 6/10/21, the P&P indicated, . the resident's privacy and dignity will be protected by placing cover over drainage bag . A review of the facility's P&P titled Resident's Rights revised 1/1/12, the P&P indicated, .Purpose .To promote and protect the rights of all residents .state and federal laws guarantee basic rights to all residents of the facility, these right includes privacy and confidentiality .

Based on observations, interviews and record reviews, the facility failed to provide service aligned with professional standards for one out of five sampled residents (Resident 1) when medication was left unattended on Resident ' s overbed table. This failure had the potential for the medication to be taken by unintended persons with potentially serious consequences. Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in May of 2025 with diagnoses including Dysphagia (difficulty swallowing). A review of Resident 1's care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed), date initiated 10/25/24, indicated, The resident requires tube feeding [TF, a medical device used to provide nutrition and medication to people who are unable to swallow safely] r/t [related to] dysphagia . During a concurrent observation and interview on 6/3/25 at 11:23 a.m., in Resident 1's room, there was a whitish watery substance in plastic cup and a syringe in a cup on Resident 1's overbed table. Resident 1 verified the whitish watery substance in plastic cup was her medication that the nurse left there. Resident 1 indicated she did not know why the medication was left and added, staff would sometimes leave her medications at her bedside or overbed table. During a concurrent observation and interview on 6/3/25 at 11:39 a.m., Licensed Nurse (LN) B verified the whitish watery substance in the medicine cup on Resident 1's overbed table, appeared to be Resident 1's medication. LN B stated it was the facility's policy not to leave medications at residents' bedside as it was a big safety concern. LN B added, the facility had a lot of confused residents who wandered around that could go to another residents' rooms and ingest the medication that was left unattended at the bedside. During an interview on 6/3/25 at 1:22 p.m., the Director of Staff Development (DSD) verified Resident 1's medications were given via feeding tube and Resident 1's medication was left unattended at Resident 1's overbed table. The DSD stated the nurse in charge of Resident 1 had called her because she was having trouble administering the medication. The DSD stated the nurse left the medication at Resident 1's bedside unattended. The DSD acknowledged it was a safety issue to leave a medication at bedside unattended and could lead to serious consequences which could harm residents. A review of the facility's policy and procedure (P&P) titled Specific Medication Administration Procedure effective 4/2008, the P&P indicated, .To administer medications in a safe and effective manner .[medication] once removed from the package or container, unused doses should be disposed of in accordance with the medication destruction policy . A review of the facility's policy and procedure (P&P) titled, .Self-Administration of Medications, dated 4/2008, indicated, .Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms .

Based on observation, interviews and record reviews, the facility failed to a safe and sanitary environment for three out of five sampled residents when: 1. Toothbrushes found in a shared bathroom were not labeled with the resident names, and 2. Resident's foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine) tubing (a thin, flexible tube connected to a catheter that drains urine from the bladder into a collection bag) was on a contaminated surface. These failures put the residents at risk for the transmission of infections. Findings: 1.During a concurrent observation and interview on 6/3/25 at 12:19 p.m., Licensed Nurse (LN) B in Resident 3's and Resident 6's room, verified Resident 3 did not have a toothbrush on or in the bedside table/bedside drawer. During a concurrent observation and interview on 6/3/25 at 12:49 p.m., in the shared bathroom for Resident 3 and Resident 6, Unlicensed Staff D verified there were 2 toothbrushes in the bathroom that were not labeled with names. Unlicensed Staff D stated if the toothbrushes were not labeled with the residents' name it meant the facility policy was not followed. Unlicensed Staff D stated, I'm not sure which toothbrush belonged to which resident since they were unlabeled. Unlicensed Staff D stated staff should put the resident names on their toothbrush and toothpaste to prevent confusion and accidental use of a toothbrush that does not belong to the resident. During an interview on 6/3/25 at 1:45 p.m., the Director of Staff Development (DSD) verified residents' toothbrushes, especially when kept in the bathroom that was shared with a roommate, should be labeled with their names. The DSD added, toothbrushes labeled with each resident's name was important for infection control and to ensure each resident used their own toothbrush. A review of the facility's policy and procedure (P&P) titled Oral Care, revised 1/1/12, the P&P indicated, .each toothbrush of a resident must be labeled with resident's name, unless kept in the resident's bedside drawer 2. During an observation on 6/3/25 at 11:23 a.m., Resident 1 had a FC hanging on the right side of her bed while the FC tubing was touching a fall mattress (mat placed on the floor that decreases the impact of a fall and reduces the risk of fall-related injuries). During a concurrent observation and interview on 6/3/25 at 11:32 a.m., LN B verified Resident 1's FC tubing was touching the fall mattress and added, the FC tubing should not touch the floor or the fall mattress because those were dirty/contaminated surfaces. LN B stated allowing the FC tubing to touch the fall mattress was unsanitary and could result in resident getting sick with an infection. During an interview on 6/3/25 at 11:44 a.m., Unlicensed Staff C stated it was the facility's policy to ensure FC tubing did not touch the floor or the fall mattress because these surfaces are dirty and contaminated. Unlicensed Staff C stated allowing the FC tubing to touch the floor or fall mattress could result in the resident getting an infection. During an interview on 6/3/25 at 1:30 p.m., the DSD stated the FC tubing should not touch the floor or the fall mattress because these were considered dirty surfaces. The DSD stated if the FC tubing lays on the floor or fall mattress, it could cause an infection. A review of the facility P&P titled Catheter- Care of, revised 6/10/21, the P&P indicated, . the catheter tubing, bag or spigot will be anchored to not touch the floor . A review of the facility's P&P titled Infection Control- Policies and Procedures dated 1/1/12, the P&P indicated, . to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections .

Based on interviews and record reviews, the facility failed to ensure: 1. An alleged sexual abuse incident on 4/28/25 was reported to the local ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), the California Department of Public Health (the state) and local law enforcement within 2 hours after the allegation was made, 2. Staff were knowledgeable of the abuse reporting guidelines: whom to report abuse allegations and the time frame for reporting abuse allegations, and 3. The facility ' s Abuse Policy and Procedure (P&P) titled Reporting Abuse, revised 1/8/2014, reflects the current reporting guidelines. These failures could put all 52 residents of the facility at risk for abuse without timely interventions. Findings: 1. A review of the Report of suspected Dependent Adult/Elder Abuse, received by the state on 4/28/25 at 12:06 p.m., indicated, .on 4/28/25 at 9:00AM [Resident 2] was getting coffee and greeted [Resident 3]. [Resident 3] responded by saying let ' s go while grabbing [Resident 2 ' s] genital area . and [Resident 2] reported it to the facility dietary Supervisor . During an interview on 5/7/25 at 3:48 p.m., the Social Services Director (SSD) stated abuse allegations should be reported to the state, ombudsman and the police immediately within two hours of incident. The SSD stated the alleged sexual abuse reported by Residents 2 qualified for the two-hour reporting guideline. The SSD stated it was important to report abuse allegations immediately, so it does not happen again, for resident safety and to protect residents from further harm. During a concurrent interview and record review on 5/7/25 at 4:39 p.m., with the Director of Staff Development (DSD), the Report of suspected Dependent Adult/Elder Abuse, dated 4/28/25, was reviewed. The DSD verified that this sexual abuse allegation was reported at 9:00 a.m. and the fax confirmation to CDPH indicated it was sent at 12:06 p.m. The DSD verified the initial report did not meet the 2-hour reporting guideline. The DSD stated all abuse allegations should be reported to the ombudsman, the state and the police within 2 hours of the incident. The DSD stated it was important that abuse allegations were reported timely to ensure residents ' safety. 2. During an interview on 5/7/25 at 4:08 p.m., Licensed Nurse (LN) A stated all abuse allegations should be reported to the ombudsman and CDPH. She stated if the abuse allegation resulted to harm, then it should be reported to the police. LN A stated all abuse allegations should be reported immediately within 24 hours of the incident. She stated it was important to report immediately to provide quick intervention and protect residents from further harm. During an interview on 5/7/25 at 4:10 p.m., LN B stated all abuse allegations should be reported to the state and ombudsman. LN B stated if the abuse was egregious, then it should be reported to the police. LN B stated all abuse allegations should be reported immediately within 24 hours. LN B stated reporting abuse allegations timely ensure events were still fresh on the reporters ' mind, ensure residents safety and could stop the abuse from happening again. During an interview on 5/7/25 at 4:13 p.m., Unlicensed Staff C stated all abuse allegations should be reported to the ombudsman and the state as soon as possible within 24 hours of the incident. Unlicensed Staff C stated it was important to report abuse allegations immediately for residents ' safety and to protect residents from further harm. 3. A review of the All Facilities Letter (AFL, information contained may include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) 21-26, dated 7/26/21, indicated, . Pursuant to Title 42 CFR section 483.12(c)(1) . facilities must report any instance of suspected or alleged abuse neglect, exploitation, and/or mistreatment of elders or dependent adults to their local law enforcement agency, LTC ombudsman, and [the state]. When to Report . for incidents that involve abuse or result in serious bodily injury, facilities must: Call local law enforcement immediately, but no later than two hours after the allegation is made. File a written or electronic report to the LTC ombudsman, local law enforcement, and [the state] within two hours . for any other reasonable suspicion that does not result in abuse or serious bodily injury, facilities must: Call local law enforcement as soon as possible, but no later than 24 hours after the allegation is made. File a written or electronic report to the LTC ombudsman, local law enforcement and DO within 24 hours . A review of the facility ' s P&P titled Reporting Abuse, revised 1/8/2014, indicated, .If the reportable incident results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately and no later than 2 hours of the observation, knowledge or suspicion of the physical abuse. In addition, a written report shall be made to the local ombudsman, the California Department of Public Health and the local law enforcement agency within 2 hours of the observation, knowledge or suspicion of the physical abuse .If the reportable incident does not result in serious bodily injury, the Administrator or his/her designee, will make a telephone report to the local law enforcement agency within 24 hours of the observation knowledge or suspicion of the physical abuse. In addition, a written report shall be made to the local ombudsman, the California Dept of Public Health and the local law enforcement agency within 24 hours of the observation, knowledge or suspicion of the physical abuse .If the suspected abuse is allegedly caused by a resident who has been diagnosed with dementia, and a license nurse reasonably determines that there is no serious bodily injury, the administrator, or his/her designee, shall report to the Ombudsman or law enforcement agency telephone report shall be made to the local law enforcement agency by telephone as soon as practically possible and write a written report within 24 hours of the observation, knowledge or suspicion of the abuse .

Based on observation, interview, and record review, the facility failed to ensure four of five sampled residents (Resident 1, Resident 3, Resident 4 and Resident 5) could call for staff assistance through a communication system when the call lights (a device that allows residents to signal staff for assistance) were not found within the residents' reach. These failures had the potential to result in residents ' inability to notify staff when needing help and could lead to safety issues. Findings: During a concurrent observation and interview on 4/23/25 at 12:47p.m, Resident 1 was in her room in bed and her call light was hanging on a dresser in a box. Resident 1 stated she did not know where her call light was. In a concurrent observation and interview on 4/23/25 at 12:50 p.m. with Licensed Nurse (LN) 1, LN 1 entered Resident 1 room, LN 1 confirmed that the call light was not within reach of Resident 1 and that it should have been. During an observation and interview on 4/23/25 at 1:07 p.m., Resident 3 was in her room lying in bed. She gestured, trying to reach the call light but was unable to reach it as it was clipped to the curtain out of her reach. During a concurrent interview and observation on 4/23/25 at 1:08 p.m. with LN 2, LN 2 entered Resident 3 ' s room and confirmed the call light was not within Resident 3's reach. LN 2 stated the call light should be within the resident ' s reach and being out of reach would be a problem if the resident needed to call for help. During a concurrent interview and observation on 4/23/25 at 1:11p.m. with Resident 4, Resident 4 was alone in her room, sitting up in bed with a tray table with food in front of her. Resident 4 stated she did not know where her call light was. During a concurrent interview and observation on 4/23/25 at 1:12 p.m. with the Social Services Director (SSD), the SSD confirmed that Resident 4 ' s call light was attached to the curtain, where it should not be because the resident could not reach it. During a concurrent interview and observation on 4/23/25 at 1:15p.m with the Registered Dietician (RD) in Resident 5 ' s room, Resident 5 was alone in her room in a reclined chair next to her bed. The RD confirmed the call light was behind Resident 5, on the dresser in a drawer, and not in reach of the resident. During an interview on 4/24/25 at 2:42 p.m. with the Director of Nursing (DON), the DON stated it was her expectation that call lights would be in easy reach of the residents. The DON added, call lights out of reach of residents could be a potential safety issue for example, if a resident fell. A review of the facility ' s policy and procedure titled, Communication-Call System, revised 1/1/12, the policy stipulated, .Call cords will be placed within the resident ' s reach in the resident ' s room .

Based on observation, interview, and record review, the facility failed to ensure pain management was provided to 1 of 3 sampled residents (Resident 1), when Resident 1 ' s pain intensity level was not re-assessed for effectiveness one hour after administration of pain medication administration. This failure resulted in Resident 1 ' s report of experiencing pain, feeling like she had a ball inside her, while grimacing and holding her hands around her abdomen. Findings: A review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility in July 2024, with diagnoses including chronic pain syndrome (a condition in which a person experiences pain longer than 3 months), stage IV pressure ulcer (wound with full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) to sacrum area (lower back area) and recently placed on hospice care (compassionate care for people who are near the end of life provided at the person ' s home or within a health care facility). During a review of Resident 1 ' s Acute Pain [sudden pain] / Chronic Pain [long term pain] . care plan, initiated on 12/30/24, indicated, . Goal Resident will report satisfactory pain control Interventions [actions taken to prevent, diagnose or treat health condition] . Administer pain medications per order, if non-medication interventions are ineffective . Medicate with PRN [as needed] medications if non-medication interventions are ineffective . Monitor for factors/activities that precipitate [bring about abruptly] or aggravate pain . A review of Resident 1 ' s MAR and active medication orders, for April 2025, indicated, Resident 1 had been prescribed oxycodone-acetaminophen (oxycodone, a pain medication) 3/325 mg (milligram, unit of measure) every four hours as needed (PRN) for pain and morphine sulphate (morphine, a pain medication) solution, 0.25 ml (milliliters, a unit of measure) every one hour PRN. During an interview on 4/23/25 at 12:05 p.m., with Licensed Nurse 1 (LN 1), LN 1 stated when assessing a resident ' s pain, she used the pain scale tool (a tool used to help residents communicate the intensity of their pain to medical professionals on a scale zero to 10, with zero is no pain and 10 is the worst pain imaginable). LN 1 added, after giving pain medication to a resident, she would re-assess the resident in one hour to monitor the effectiveness of the pain medication. During an interview on 4/24/25 at 10:50 a.m. with LN 1, LN 1 stated she administered morphine to Resident 1 around 8:03 a.m. to treat her pain. As of 10:50 a.m., LN 1 stated she had not yet performed the follow-up pain level re-assessment for determination of medication effectiveness, and/or whether Resident would need additional medication to treat any possible remaining pain. An observation on 4/24/25 at 10:52 a.m. LN 1 entered Resident 1 ' s room and asked Resident 1 if she was in any pain. Resident 1 replied yes, and added she felt like she had, a ball inside her, while motioning with her hands around her abdominal area. LN 1 asked Resident 1 what her pain level was. Resident 1 stated, while she grimaced and held her abdomen, she was still in pain at a pain level of five. During a record review of Resident 1 ' s MAR, dated April 2025, LN 1 had documented a follow up pain assessment to her 8:03 a.m. administration of morphine sulphate at 10:53 a.m. as Effective with a pain level of 5. During a concurrent interview and record review on 4/24/25, at 2:42 p.m., with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Administration of Pain Medication, undated, was reviewed. The DON stated the facility ' s policy for reassessing pain level after a pain medication administration was to occur 1 hour after the pain medication is given and read the verbiage directly off the facility P&P. The DON explained, her expectation is that the licensed nurses follow the facility policy for pain medication administration, including re-assessment of intensity of the resident ' s pain one hour after pain medication has been administered, and acknowledged the risk of not doing so is the resident may experience pain which could have been prevented if the pain had been assessed timely, after a pain medication administration, per the facility ' s policy.

Based on observation, interview, and record review, the facility failed to honor the residents' right to be informed of the plan of care when five of nine sampled residents were not told before admission that their physical therapy (treatment that helps improve how the body performs physical movements) would be done via telehealth (health-related services through live video call) or that they would only receive one session per week. This failure caused residents to feel let down, feel that their progress was slower than they expected, and caused Resident 7 and Resident 8 to not participate in physical therapy. Finding: During an observation on 4/3/25 at 10:35 a.m., a staff member donned a gown and gloves at the doorway to Resident 1's room, and then entered the room bringing a walker and an iPad on wheels to Resident 1's bedside. A voice from the iPad gave instructions to Resident 1 to get up from the bed and go for a walk. The staff in the room assisted Resident 1 to get up and put a gait belt on the resident. The voice from the iPad instructed the Resident 1 to walk five laps in the room. Resident 1 walked back and forth to the door and his bed. The voice on the iPad stated, You're doing great, [Resident 1]! Resident 1 got back in bed, and the voice on the iPad stated, Wonderful! Great job, [Resident 1]. Thank you. The voice on the iPad asked the staff in the room how many feet she thought the resident walked and the staff responded, 20 feet. The voice on the iPad said goodbye to the resident and the staff rolled the iPad out of the room. During an interview on 4/3/25 at 10:48 a.m., Restorative Nursing Assistant (RNA, a healthcare aide who helps patients with activities of daily living, mobility, and strengthening exercises, working under the supervision of other healthcare professionals like nurses or therapists) verified the voice on the iPad was a physical therapist located in a city approximately 390 miles away. RNA stated she began assisting the physical therapist with telehealth sessions about two months ago when the facility's physical therapist resigned. During an interview on 4/3/25 at 11:05 a.m., Resident 2 stated she was here for rehabilitation. Resident 2 stated she worked with Physical Therapist (PT) A on Zoom and Occupational Therapist (OT, a healthcare professional who helps people of all ages who have physical, sensory, or cognitive problems regain independence in all areas of their lives) B in person. During an interview on 4/3/25 at 11:42 a.m. Rehabilitation (Rehab) Director stated PT coverage had been a challenge. Rehab Director stated they had been looking at all avenues with no success finding a PT to hire. Rehab Director stated they currently had PT A who did telehealth physical therapy sessions two days a week, and PT C who did telehealth physical therapy evaluations. Rehab Director stated the facility currently had 14 residents with orders for physical therapy. Rehab Director stated PT A was seeing 9 residents today. Rehab Director stated some residents got physical therapy once a week, and some got physical therapy twice a week. Rehab Director verified the residents were limited to physical therapy no more than twice per week. Rehab Director stated PT A could see up to 10 or 11 residents per day. During an interview on 4/3/25 at 2:58 p.m., Rehab Director verified that one to two sessions per week of physical therapy was lower than industry standard and the residents would benefit from more. Rehab Director verified PT C was recommending only one to two sessions per week in her evaluations because she knew that was all they could accommodate. During an interview on 4/7/25 at 2:19 p.m., Resident 3 verified he was here to get therapy. Resident 3 stated he had the same strength now as when he got here. Resident 3 stated he had been here for several weeks and was getting less exercise now than in the beginning. Resident 3 stated that initially he thought he was making more progress, but now not so much. When queried, Resident 3 stated his wife had talked to the staff more than he had about his lack of progress. Resident 3 stated his plan was to go home but was not sure yet if he would be strong enough. Review of Resident 3's face sheet revealed an admitted [DATE] and multiple diagnoses including left knee pain and difficulty in walking. Review of Resident 3's MDS (minimum data set, an assessment tool) dated 2/24/25 revealed a BIMS score of 13 (Brief Interview for Mental Status, a score of 13 to 15 indicates intact cognition). During an interview on 4/7/25 at 2:46 p.m., Resident 4 stated she had been here at the facility since late December 2024. Resident 4 stated she was supposed to be discharged home when she could walk, but currently could only take a few steps. Resident 4 stated she took advantage of as much physical therapy as she was able to. Resident 4 stated she had one telehealth session with PT A and RNA last week. Resident 4 stated she would like more physical therapy. Resident 4 stated she saw a man (another resident) walking today and said to herself, That's what I want to be able to do. Resident 4 stated she had been getting one session a week of physical therapy since December, I want more than that, I need more than that obviously if I'm going to be able to walk. Resident 4 stated when her husband was in a skilled nursing facility for rehab, he went daily. Resident 4 stated she thought she would be doing the same here. Resident 4 stated she did not know the physical therapy here would be telehealth. Resident 4 stated that when she found out the physical therapy was telehealth, I felt let down. Review of Resident 4's face sheet revealed and admitted [DATE] with multiple medical diagnoses including difficulty in walking. Review of Resident 4's MDS dated [DATE] revealed a BIMS score of 14. During an interview on 4/7/25 at 3:20 p.m., Resident 5 verified he was getting physical therapy. Resident 5 stated, I desperately need physical therapy. Resident 5 stated he needed to be able to walk. Resident 5 stated his physical therapy sessions were with PT A on telehealth. Resident 5 stated his goal was to go home eventually. Resident 5 stated that at the hospital he was told this facility was skilled nursing and he would get the physical therapy that he needed. Resident 5 stated he was not told the physical therapy would be by telehealth. Resident 5 stated his social worker in the hospital told him the physical therapy would be three times a week. Review of Resident 5's face sheet revealed an admitted [DATE] and multiple diagnoses including spinal stenosis (a condition where the spinal canal, which houses the spinal cord and nerves, narrows, causing pressure on these structures) and difficulty in walking. Review of Resident 5's MDS dated [DATE] revealed a BIMS score of 15. Review of Resident 5's physical therapy evaluation, dated 3/25/25, revealed the treatment approach would be one session per week. Further review of Resident 5's physical therapy evaluation revealed at the end of the document that the original treatment approach entered by PT C had been for three physical therapy sessions per week and Rehab Director had changed the frequency of physical therapy sessions from three to one. During an interview on 4/8/25 at 2:55 p.m., Rehab Director verified that she changed PT C's recommendation for Resident 5 to get three days a week of physical therapy to one day a week. Rehab Director stated, I changed it because we couldn't provide [physical therapy] 3 times a week. During an interview on 4/9/25 at 2:17 p.m., PT A stated she began doing telehealth physical therapy sessions for the facility about six weeks ago. PT A stated she would like to do more than one to two sessions per week with the residents, but she was unable to due to her schedule. PT A stated the residents were introduced to the fact that physical therapy was done through telehealth during the initial evaluation with PT C. PT A stated she got a verbal consent from the residents to do her sessions through telehealth at the beginning of each session, but she was not aware of any written consent for telehealth. During an interview on 4/9/25 at 2:30 p.m., with Director of Staff Development (DSD) and Medical Records Director, DSD stated she was involved in the admission process for new residents. DSD stated there was no consent for telehealth that she knew of. DSD stated the marketing director informed prospective residents that physical therapy was done by telehealth. Medical Record Director stated there was no written consent for telehealth, the consent for telehealth was verbal. During an interview on 4/10/25 at 1:34 p.m., Marketing Director stated she sometimes interacted with residents before their admissions, depending on the situation. Marketing Director stated she did not talk to prospective residents about therapy but told them they would have an initial evaluation on admission and the therapist would provide further detail about therapy. Marketing Director verified she did not tell residents the physical therapy would be via telehealth. When queried, Marketing Director stated all consents were obtained after admission. Marketing Director stated she had not shared with the case managers at the transferring hospitals that the physical therapy program was telehealth or that it was limited to one to two days per week. During an interview on 4/10/25 at 1:39 p.m., Family Member (FM) 6 verified she was Resident 3's spouse. When queried, FM6 stated she did not feel the facility was providing any therapy. FM6 stated Resident 3 had had no improvement in his mobility. FM6 stated they were not told about the physical therapy program here before Resident 3 came here. FM6 verified she was not told physical therapy would be one day per week and was not told it would be telehealth. FM6 stated this made her feel horrified. During an interview on 4/10/25 at 2:36 p.m., OT B stated part of the occupational therapy realm was to make sure the resident was strong enough to walk from the bed to the bathroom to the wheelchair. OT B stated that since there was no fulltime PT, the residents were not walking often enough so it was slowing down his progress with the residents. OT B stated physical therapy and occupational therapy complimented each other, so when the residents did not get full time physical therapy it took him longer to reach his goals for the residents. During an interview on 4/10/25 at 3:03 p.m., Resident 7 stated he was originally sent here for therapy. Resident 7 stated no one told him physical therapy would be telehealth. Resident 7 stated that when he found out it was telehealth, I didn't like that at all. Resident 7 stated he did one session of telehealth physical therapy and did not like it. Resident 7 stated he did not do any more physical therapy after that. When queried, Resident 7 stated he did not like that the telehealth was not one-on-one. Review of Resident 7's face sheet revealed an admitted [DATE]. Resident 7's MDS dated [DATE] indicated a BIMS score of 13. During an interview on 4/10/25 at 3:08 p.m., Resident 8 stated she was not that big on telehealth physical therapy. Resident 8 stated she had a fractured right knee. Resident 8 stated she needed to do physical therapy, and she needed it to be one-on-one. Resident 8 stated she did not know physical therapy was telehealth before she came here. Resident 8 stated she called the hospital after she got here to tell the case managers (that the physical therapy was via telehealth) and they were shocked. Resident 8 stated she got a printout at the hospital that showed the facility had a full rehab department. Resident 8 stated she tried doing the telehealth physical therapy, but it didn't work for me. Resident 8 stated, If I had gotten both therapies twice a day every day, I would have been further along than I am. Resident 8 stated she would not be coming back here after her knee surgery next week. Review of Resident 8's face sheet revealed an admitted [DATE] and multiple medical diagnoses that included a fractured lateral condyle of the right tibia (a break at the top of the larger bone of the lower leg) and difficulty in walking. Review of Resident 8's MDS dated [DATE] indicated a BIMS score of 15. During an interview on 4/10/25 at 3:26 p.m., Administrator stated prospective residents were informed by Marketing Director that certain services at the facility were telehealth. Administrator stated she was not aware that Marketing Director was not telling people about telehealth physical therapy or that physical therapy was one or two days per week. Administrator stated, They should know it's going to be telehealth. Administrator stated she was not aware Rehab Director was changing the recommendations of PT C on the evaluations. Administrator stated, I would think we would want to go with the initial recommendation. Review of facility policy Resident Rights, last revised 1/2012, indicated, Residents of skilled nursing facilities have a number of rights under state and federal law. The facility will promote and protect those rights. These rights include, but are not limited to, a resident's right to: . Choose a physician and treatment and participate in decisions and care planning .

Based on interview and record review, the facility failed to implement and monitor the effectiveness of interventions of a care plan for one resident (Resident 1) of three sampled residents when Resident 1 had a fall on 3/3/25 and the facility did not ensure: 1. A physician's order for Physical Therapy (PT) so Resident 1 could receive PT; 2. Nursing staff documented frequent room checks had been conducted; and, 3. The Pharmacist's recommendations to monitor Resident 1 for behaviors which could be objectively (data or information collected free from biases or opinions) measured and quantified (measured as a numerical value). This failure resulted in another fall on 3/14/25 in which Resident 1 obtained a left intertrochanteric (a bone below the hip joint) fracture (a break) and a T3 (the 3rd bone of the middle spine) fracture that changed Resident 1's mobility from independent to chairbound. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] for dementia (a progressive state of decline in mental abilities) and anxiety disorder (a condition characterized by persistent and excessive worry or fear that can interfere with daily life and cause significant distress). A review of Resident 1's order summary report indicated physician's order dated 10/18/23 which indicated, Rehab [a course of treatment designed to optimize functioning and reduce disability] potential: (Fair,). A review of a care plan initiated on 11/14/23 indicated Resident 1 was a moderate risk for falls related to psychoactive drug (a drug that affect a person's mental state and behavior) use. A review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 1/15/25, indicated Resident 1 completed the activity of moving from a sitting to standing position, moving from a chair or bed to another chair, and walk 150 feet independently; the helper only assisted prior to or following the activity. This MDS also indicated Resident 1 did not use a mobility device (i.e. a wheelchair, walker, etc.). A review of a Medication Administration Record (MAR), dated March 2025, indicated Resident 1 received lorazepam (a medication used to treat anxiety disorders by slowing activity in the brain) 1 milligram (mg-a unit of measure) every 12 hours for anxiety. A review of Resident 1's progress note dated 3/3/25 at 2:58 p.m., indicated, [Resident 1] had an unwitnessed fall around 14:40pm [2:40 p.m.] today in the dining room .was found on the floor .had hit his head on the floor .had a 3 cm [centimeter, a unit of measure] x [by] 2 cm laceration [a cut or tear in the skin caused by trauma or injury] to the back of the head .had a left-hand skin tear 2 cm x 2 cm .transferred to [a hospital] for further evaluation. 1. A review of Resident 1's IDT [Interdisciplinary Team-different professionals gathering to discuss resident needs] progress note dated 3/4/25 at 3:24 p.m., indicated, .Post Fall IDT Meeting .[In attendance were] .DOR [Director of Rehabilitation (oversees PT)] .Nursing . BIMS [Brief Interview for Mental Status, a tool used to determine impairment in a person's cognition (understanding and thought process) with a range from 0-15, with higher scores indicating better cognition)] score of 02 [severely impaired cognition] Prior to hospitalization functional mobility [the ability to move efficiently and effectively] was independent walking .New orders have been reviewed, and care plans have been updated. Fall intervention recommendations .[are] PT eval [evaluation] will be completed .wheelchair for ambulation [to walk] .Post hospitalization [Resident 1] requires assistance with all ADL's [Activities of Daily Living, i.e. toileting, transferring, etc]. A review of a care plan initiated 3/4/25 indicated Resident 1 had an actual fall which resulted in a laceration to the head and wrist related to poor communication/comprehension, psychoactive drug use, and unsteady gait (manner of walking). The care plan also indicated Resident 1's goal was to resume usual activities without further incident and staff were expected to implement the following goals to assist Resident 1 to meet his goal: -PT consult for strength and mobility, -Provide activities that promote exercise and strength building where possible, -Provide frequent room checks when in bed with offers of assistance with toileting, -Assist resident when ambulating, and -Educate the caregivers about safety reminders. A review of a facility document titled PT Evaluation & Plan of Treatment dated 3/5/25, indicated, Plan of Treatment .therapeutic exercises, gait training therapy, therapeutic activities .Frequency: 3 time(s) [per] week .Duration: 26 days .Intensity: Daily .Period: 3/5/25- 3/30/25 .Reason for Therapy .[Resident 1] requires skilled PT services to increase functional activity tolerance [a person's ability to engage in daily activities without excessive fatigue or pain], increase independence with gait, increase LE [lower extremity] ROM [range of motion] and strength, minimize falls and promote safety awareness in order to perform functional mobility [the ability to move effectively and independently to perform everyday activities] with reduced risk of falls .[Resident 1] is at risk for: falls and further decline in function . A review of Resident 1's MDS dated [DATE] indicated Resident 1 required a helper to provide verbal cues and/or touching/steadying while he completed the activity of moving from a sitting to standing position; Resident 1 required a helper to lift, hold, or support the trunk [central part of body including chest, abdomen, pelvis and back] but provide less than half of Resident 1's effort to move from a chair or bed to another chair; and Resident 1 was unable to walk at least 10 feet. A review of Resident 1's order summary report indicated an order dated 3/12/25 which stipulated, Resident Requires Reclining Wheelchair. A review of Resident 1's care plan dated 3/14/25, indicated Resident 1 had an actual fall on 3/14/25 and to .Assist resident with ambulation, offer assist to the bathroom q [every] 2 hours .Pharmacy consult to evaluate medications .PT consult for strength and mobility. A review of a hospital document titled Imaging Results dated 3/14/25 at 5:17 p.m., indicated, .[X-ray of] Hip .Acute [a sudden occurrence] left greater trochanteric fracture seen on CT [Computed Tomography- a type of x-ray) from same day prior .CT [of] Spine .Partially visualized acute T3 vertebral body [the thick, front part of the bones that make up the spinal column which holds the weight of a person's head and trunk] fracture with 25% height loss and anterior wedging deformity [a wedge-shaped deformity of the front of front part of the bones that make up the spinal column], new compared to 3/3/25 . A review of the facility's untitled document dated 3/19/25 indicated, On March 14, 2025, [Resident 1] was found on the floor next to his bed, entangled in his privacy curtain. Prior to the incident, [Resident 1] had been in bed. Upon investigation, it was determined that the [Resident 1] became tangled in the curtain, leading to the fall .[Resident 1] was admitted to the hospital on [DATE]. According to the transfer documentation received upon the resident's return .[Resident 1 sustained] a T3 vertebral fracture and a left intertrochanteric hip fracture. The resident underwent appropriate medical treatment and was discharged back to the facility on March 19, 2025 .Interventions Implemented .Initiated one-on-one [1:1, one staff member to provide supervision and care one resident] sitter supervision to ensure increased safety and supervision until the resident is assessed to be stable .Conducting frequent monitoring and repositioning as needed. Continuing fall risk assessments and implementing interventions to prevent future incidents .Providing assistance with .ADLs, mobility, and transfers as needed. Follow-Up Actions .Coordination with therapy services to support mobility and rehabilitation. Maintaining open communication with the resident's physician . A review of Resident 1's order summary report printed on 3/27/25 at 3:23 p.m. indicated no active order for PT treatment as indicated in Resident 1's PT Evaluation & Plan of Treatment dated 3/5/25. During an interview on 3/27/25 at 3 p.m., the DOR confirmed Resident 1 had not participated in PT after the evaluation and plan of treatment conducted on 3/5/25. 2. During an interview on 3/27/25 at 11:15 a.m., Certified Nursing Assistant A (CNA A) stated fall preventions measures included rounding (checking on residents) to ensure safety. She stated she usually rounded on residents about every two hours but did not chart it. During an interview on 3/27/25 at 1:27 p.m., Licensed Nurse C (LN C) stated she monitored her residents who were fall risks. She stated the communication used for monitoring fall risk residents was placed on a communication sheet which was updated every shift and passed along to the next shift. The LN C stated it was not part of the resident's medical record. During an interview on 3/27/25 at 1:53 p.m., the Director of Nursing (DON) and the Director of Staff Development (DSD) stated after Resident 1's falls, .monitoring were used. We also did fall evaluations and assessments. Both the DON and DSD stated documentation of fall interventions should be in the electronic medical record, but neither could find it. The DSD then stated monitoring was on a paper form. The DON then stated, It should be in [the electronic medical record system], but I don't know where it is. The DON stated the expectation was nursing staff document each time fall monitoring interventions were conducted. During an interview on 3/27/25 at 2:30 p.m., the Assistant Administrator (AA) stated he was uncertain about the resident fall monitoring process but would ask Medical Records if they could find any documentation regarding fall monitoring. During an interview on 3/27/25 at 2:52 p.m., the DON stated no fall monitoring documentation for Resident 1 could be found. 3. A review of Resident 1's document titled Consultant Pharmacist Medication Regimen [the plan followed when taking medication] Review dated 3/14/25 indicated, For Recommendations Created Between 3/1/2025 and 3/14/2025 .Can we monitor behaviors and side effects of medications for lorazepam? Behaviors should be able to be objectively measured and quantified. During an interview at 4/21/25 at 12:27 p.m., the DSD and AA explained monitoring behaviors on the MAR indicated whether a behavior was observed. The DSD confirmed the responses yes and no in the MAR indicated whether a behavior was observed. The DSD stated the behavior the staff observed would have been agitation. The DSD confirmed agitation was not noted on the MAR as a behavior to monitor, and no other side effects of lorazepam were listed for nurses to monitor. The DSD further confirmed the facility had not correctly monitored Resident 1 for lorazepam side effects for his high fall risk status. The DSD and AA acknowledged many interventions, such as the frequent monitoring and weekly summaries had not been documented in the medical record to evaluate whether they were working. The DSD stated, Care plans were not updated as they should have been, including the weekly summaries . The DSD and the AA both stated this fall has been a true learning experience .and [staff] is working to make changes to reflect the care given. A review of facility document titled Fall Management Program, dated 3/13/21, indicated .If a fall risk factor is identified, document interventions on the Resident's care plan. Document interventions for every Resident regardless of fall risk evaluation score .The licensed nurse will evaluate the Resident's response to the interventions on the Weekly Summary and update the Resident's care plan as necessary . During a review of facility document titled Comprehensive Person-Centered Care Planning , dated 9/7/23, indicated The baseline care plan must include .healthcare information necessary to properly care for each resident .address resident-specific health and safety concerns to prevent decline or injury and would identify needs for supervision, behavioral interventions .It should also reflect changes to approaches .resulting from significant changes in condition or needs.

Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was free from unnecessary psychotropic medications (drugs that affect the brain and central nervous system to treat mental health conditions) when prescribed a psychotropic medication without: 1. non-pharmacologic interventions (NPIs, treatments or therapies that do not involve the use of medications) in place to address residents' behavior, and 2. monitoring of behaviors, response to the anti-anxiety (AA, psychotropic medication used to reduce symptoms of anxiety- fear, worry) medication, including side effect (SE, reaction to a medicine) or adverse drug reaction (ADR, dangerous harmful reaction to drugs) in place These failures put the Resident 1 at risk of side effects and adverse drug reactions related to psychotropic medication use. Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 admitted to the facility in November of 2024 with diagnoses of dementia (a progressive state of decline in mental abilities), cognitive communication deficit (CCD, a communication difficulty stemming from impairments in thought processes like attention, memory, or executive functions). A review of Resident 1s electronic medical record (EMAR, a digital version of a traditional paper medication administration record used in healthcare settings to track and document medication administration), for 11/2024, indicated there was no NPI, target behavior monitoring, SE or ADRs monitoring while Resident 1 was prescribed an AA. A review of Resident 1's progress notes dated, 11/22/25 to 11/23/25, indicated there was no NPI, target behavior monitoring, SE or ADRs monitoring while Resident 1 was prescribed an AA medication. During an interview on 3/24/25 at 11:50 a.m. Licensed Nurse (LN) A stated NPI would be used to address residents' behavior first, then if ineffective, LN may give psychotropic medications. LN A stated staff should monitor residents' response to AA medication. LN A stated behavior, SE and ADRs should also be monitored when residents were prescribed an AA medication. LN A stated monitoring behaviors was important to determine if AA medication was effective in addressing behaviors. LN A stated monitoring for SE/ADRs were important to ensure residents safety. During an interview on 3/24/25 at 12:57 p.m., the Director of Nursing (DON) stated NPIs should be attempted first in addressing residents' behavior and if ineffective, the LN may administer psychotropic medication. The DON stated behavior monitoring, SE and ADR monitoring was important for residents on AA medication to ensure current dose of AA medication was effective in addressing residents' behavior. The DON stated monitoring for SE and ADRs was important to identify and mitigate risk associated with taking AA medications. The DON stated these monitoring would be on EMAR. During an interview on 3/24/25 at 2:30 p.m., the DON verified Resident 1s EMAR did not indicate Resident 1s behavior, SE and ADR were monitored while prescribed an AA medication. The DON also verified there were no NPIs in place when Resident 1 was ordered an AA medication. A review of the facility's policy and procedure (P&P) titled, Behavior/Psychoactive Medication Management , revised 1/25/24, indicated .any order for psychoactive medication must include a specific behavior manifestation .depending on the specific classification of psychoactive medication, the resident should be observed and or monitored for SE or ADRs .

Based on interviews and record reviews, the facility failed to ensure a copy of the notice of transfer was sent to the representative of the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one out of two sampled residents (Resident 1), when the facility was not able to provide evidence that the notice of transfer was sent to the Ombudsman. This failure had the potential to put Resident 1 at risk of being inappropriately transferred or discharged from the facility. Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 admitted to the facility in November of 2024. During an interview on 3/24/25 at 12:05 p.m., the Social Services Director (SSD) stated a notice of transfer form should have been completed by the nurse when Resident 1 was transferred out of the facility to an emergency department (ED, a hospital facility that provides immediate, unscheduled medical care for those with urgent or life-threatening conditions) on 11/22/24. The SSD stated a copy of this form should be in Resident 1's electronic health record and be sent to the Ombudsman. SSD stated it was important to send a copy of the form to the Ombudsman to protect the resident's rights. During an interview on 3/24/25 at 12:57 p.m., the Director of Nursing (DON) confirmed the facility failed to notify the Ombudsman when Resident 1 was transferred to the ED on 11/22/24 because this regulation [law] was pretty new . The DON stated it was important to notify the ombudsman when a resident was transferred to the hospital to protect the resident from an unsafe discharge. During an interview on 3/24/25 at 1:50 p.m., the Medical Record Director (MRD) verified there was no documentation nor evidence to indicate the Ombudsman was notified when Resident 1 was transferred to the ED on 11/22/24. A review of All Facilities Letter (AFL, a communication sent to health facilities, providing information on changes in healthcare requirements, enforcement, new technologies, scope of practice, or general information affecting the health facility) AFL-17-27, dated 12/26/2017, indicated . Effective January 1, 2018, . 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 . transfer or discharge occurs .The facility is required to provide a copy of the notice to the LTC Ombudsman . if a resident is subject to . transfer to a general acute care hospital on an emergency basis .

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when: 1. Resident 54 did not receive scheduled medications in a timely manner. 2. Certified Nurse Assistant (CNA) 1 was observed laying in Resident 37's bed using her personal cellphone. These failures increased the resident's potential to have unmet health needs and decreased the facility's potential to provide responsible and accurate care for residents. Findings: 1. During a concurrent observation and interview on 3/17/25 at 11:44 a.m. with Resident 54 in her room, Registered nurse (RN) 1 brought Resident 54 a medicine cup with 10 pills in it. RN 1 informed Resident 54 the medications in the cup were ibuprofen (medication used to treat pain), docusate (medication used to treat constipation), multivitamin and ascorbic acid (vitamin c supplement). Resident 54 stated her medications were always late and they should have been given with breakfast around 8 a.m. During a concurrent interview and record review on 3/20/25 at 3:21 p.m. with the Administrator (Admin), Resident 54's Medication Admin Audit Report (MAAR), dated 3/20/25 was reviewed. Resident 54's MAAR indicated Resident 54's docusate and ibuprofen were scheduled for 8 a.m. and were not received until 11:42 a.m. The MAAR further indicated Resident 54's ascorbic acid, ensure (supplement used to gain or maintain weight) and multivitamin were scheduled for 9 a.m. and were not received until 11:42 a.m. The Admin stated, That's not good and medications should have been administered an hour before or an hour after the scheduled time. During a review of the facility's policy and procedure (P&P) titled, Medication- Administration, dated 1/1/12, the P&P indicated, Medications may be administered one hour before or after the scheduled medication administration time . 2. During a concurrent observation and interview on 3/19/25 at 12:20 p.m. with CNA 1 in Resident 37's room, the privacy curtain separating Bed A from Bed B was drawn. Behind the curtain, CNA 1 was laying on Resident 37's bed and was using her personal cell phone. CNA 1 stated Resident 37 was in the dining room for lunch and further stated she should not have been in a resident's bed. During an interview on 3/19/25 at 3:59 p.m. with the Director of Nursing (DON), the DON stated staff should never be on their cellphones while in patient care areas and all staff were needed during mealtimes to ensure residents safety. The DON further stated staff should never lay in any resident's bed. During an interview on 3/19/25 at 4:38 p.m. with the Administrator (Admin), the Admin confirmed CNA 1 was in Resident 37's bed. The Admin stated staff should never be in residents bed or on their cellphones during work hours. During a review of the facility's policy and procedure (P&P) titled, Employee Relations Conduct, dated January 2024, the P&P indicated, The Company considers professional conduct and compliance with the Company's policies and procedures to be an essential responsibility of an employee's job . the following are examples of conduct that are prohibited and will not be tolerated . malingering on the job . any use of a personal communication device in resident care areas . 51225

Based on observation, interview, and record review, the facility failed to ensure insulin (medication used to reduce blood sugar) was not administered when blood sugar was below 120 (target range for blood sugar when insulin is not required) for one of 26 sampled Residents (Resident 7) for 10 out of 19 days in March 2025. This failure had the potential to result in low blood sugar symptoms for Resident 7. Findings: During a review of Resident 7's Face Sheet (demographics), the Face Sheet indicated Resident 7 was admitted on [DATE] with the diagnoses including diabetes mellitus type 2 (disease that causes high blood sugar), hypertension (high blood pressure, Cognitive Communication Deficit (medical condition involving thinking process and attention), need for assistance with personal care. During a concurrent observation and interview on 3/19/25 at 7:51 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 7's room, LVN 1 administered Insulin Glargine 15 units via prefilled syringe to Resident 7. LVN 1 stated the Resident 7's blood sugar level (BS) was 74. During review of Resident 7's Pharmacy Order Summary Report, dated 3/19/2025, the Pharmacy Order Summary Report indicted the Insulin Glargine Solution be administered once a day for diabetes, hold if b/s (blood sugar) is less than 120, start date 2/9/25. During an observation on 3/19/25 at 10:50 a.m. in Resident 7's room, Resident 7 was observed lying in bed, sweating and lethargic (sleepy) but able to respond to questions. During a concurrent interview and record review on 3/19/2025 at 11:15 a.m. with LVN 1, Resident 7's Medication Administration Record (MAR) dated 3/19/2025 was reviewed. The MAR indicated that Resident's blood sugar during the 8:00 a.m. administration was 74. LVN 1 confirmed the Insulin order indicated to hold the insulin when blood sugar was under 120. LVN 1 stated, I made a mistake. During a concurrent observation and interview on 3/19/25 at 11:45 a.m. with LVN 1, LVN 1 verified Resident 7 had symptoms of low blood sugar; was sweating and lethargic. LVN 1 obtained Resident 7's blood sugar and stated it was 78. LVN 1 further stated she needed to treat the low blood sugar with orange juice and call the physician. During a concurrent record review and interview on 3/19/2025 at 11:50 a.m., Resident 7's March 2025 Medication Administration Record (MAR) was reviewed with the Director of Nursing (DON). DON confirmed LVN 1 documented the administration of Insulin Glargine at 8:00 a.m. when Resident 7's blood sugar was 74. DON stated LVN 1 should have held insulin administration for a blood sugar less than 120. Resident 7's MAR indicated blood sugar was below 120: 3/6/25- BS= 99, 3/7/25 -BS= 18, 3/12/25- BS= 87, 3/13/25- BS=79, 3/14/25- BS=98, 3/15/25- BS=110, 3/17/25- BS=88, 3/18/25 BS= 92, 3/19/25 BS=74. DON confirmed there was a pattern of administering the am dose of insulin when Resident 7's blood sugar was below 120 on March 6, 7, 12, 13, 14, 15, 17, 18, 19. During an interview on 3/20/2025 at 7:15 a.m. with the Pharmacist, the Pharmacist stated that standard of practice was for a nurse to assess the resident's the blood sugar prior to administration of insulin and follow the physician's orders. During a review of the facility's policy and procedure (P&P) titled, Medication - administration, dated 1/1/12, the P&P indicated, Medications . will be administered as prescribed . Tests . upon which administration of medications . are conditioned, will be performed . and the results recorded . i.e. finger stick blood glucose monitoring (blood sugar).

Based on observation, interview, and record review the facility failed to ensure medications, supplements, and supplies were appropriately labeled and stored in accordance with accepted standards of practice when: 1. A prescription nystatin powder (a medication to treat yeast or fungal infection of the skin) was found at Resident 9's bedside table. 2. Two medication bubble packs were left unattended on top of a medication cart. 3. Two used topical medications had no caps to cover the tubes in the treatment cart. 4. A collagen matrix dressing (a type of wound dressing that promotes wound healing) package and a Xeroform (a type of wound dressing that promotes wound healing) package dressing were found open in the treatment cart. 5. Five expired syringes with needles were found in the emergency cart. 6. The refrigerator storage for medications was not maintained at a safe temperature. 7. Expired medications were observed in one of two medication carts, cart one. 8. Unsecured medication was observed at the bedside for one of 26 sampled residents (Resident 26). These failures had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes for drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings: 1. During a review of Resident 9's Admission Record, dated 3/18/25, the Admission Record indicated Resident 9 was admitted to the facility on [DATE] with a diagnosis of obesity. During a concurrent observation and interview on 3/17/25 at 11:26 a.m., with Resident 9, in Resident 9's room, a bottle of nystatin powder was on the bedside drawer. Resident 9 stated she used the nystatin powder underneath her skin folds. Resident 9 stated she ordered the bottle of nystatin powder from an outside pharmacy because she was told by the facility that her insurance would not pay for it. During a concurrent observation and interview on 3/17/25 at 11:35 a.m., in Resident 9's room, with the Director of Nursing (DON), the DON confirmed the bottle of nystatin powder on Resident 9's bedside drawer. DON stated Resident 9 did not have an order to keep medication by her bedside. During the review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly . 2. During a medication administration observation on 3/19/25 at 8:50 a.m., for Resident 12, with Licensed Vocational Nurse (LVN) 1, LVN 1 left two medication bubble packs on top of the medication cart and went inside Resident 12's room. LVN 1's back was towards the medication cart while tending to Resident 12. During an interview on 3/19/25 at 9:03 a.m., with LVN 1, LVN 1 confirmed that she had left a bubble pack of Propranolol (a medication for high blood pressure) and a bubble pack of Losartan (a medication for high blood pressure) on top of the medication cart and stated she should not have left the two medications bubble packs unattended. During an interview on 3/19/25 at 9:13 a.m., with the Director of Nursing (DON), the DON stated medications should be put back inside the medication cart and not be left unattended on top of the medication cart. During the review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. During a concurrent medication storage observation and interview on 3/18/25 at 4:30 p.m., with the Infection Preventionist (IP), a rolled up tube of Santyl ointment (a topical medication used to remove damaged or burned skin) and a rolled up tube of Ketoconazole cream (a medication used to treat fungal skin condition) were found with no cap covering in the treatment cart (a cart with wound care medications and supplies). IP confirmed the Santyl ointment and the Ketoconazole cream did not have cap coverings. IP stated the Santyl ointment and the Ketoconazole cream should have been discarded. During the review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly. M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 4. During a concurrent medication storage observation and interview on 3/18/25 at 4:32 p.m., with the Infection Preventionist (IP), a Collagen matrix dressing package and a Xeroform gauze dressing package were found opened in the treatment cart (a cart with wound care medications and supplies) unlabled and undated. IP stated the Collagen matrix and Xeroform gauze packages could be reused but should be labeled with open date and time and placed inside a secure plastic bag. During an interview on 3/20/25 at 11 a.m., with the Director of Staff Development (DSD), the DSD stated once the Collogen dressing and Xeroform gauze packages were opened, they should be discarded. During the review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly. M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 5. During a concurrent emergency cart inspection and interview on 3/18/25 at 3:28 p.m., with the Director of Nursing (DON), five expired 1 milliliter (a unit of measurement) syringe with hypodermic safety needle (a very thin, hollow tube with one sharp tip) were found in the emergency cart drawer. The five syringes with the needles had an expiration date of 2/28/25. DON confirmed the five expired syringes with the needles in the drawer and she stated they should not be in the emergency cart drawer. The DON stated the night shift nurse checks the cart supplies and for expired supplies. During the review of the Emergency Cart Supply Checklist, dated March 2025, the checklist indicated, Nurses on 11 p.m. - 7 a.m. shift is responsible to check Emergency Cart every day . Nurses will sign and date to reflect that they have checked and everything is in place as required. 51225 6. During a concurrent interview, and record review on 3/18/25 at 2:15 p.m. with the Director of Nursing (DON), in the medication room, the Medication Refrigerator Temp Log dated March 2025 was reviewed. The Medication Refrigerator Log indicated, Medication refrigerator needs to be 36 - 46 degrees Fahrenheit or is out of range. The log also directed staff to document interventions when the temperature was out of range. Staff documented the temperature was below 36 degrees 24 out of 40 times during the month of March 2025. No comments were documented regarding the temperatures being out of range. DON stated she was unaware that the temperatures were out of range and staff should have notified the DON and the Director of Maintenance so they could correct the issue. During an interview on 3/20/25 at 7:15 a.m. with the Pharmacist, the Pharmacist stated that refrigerated medications need to be kept at a temperature between 36 - 46 degrees Fahrenheit to preserve their therapeutic effectiveness. During a review of the facility's policy titled, Medication Storage in the Facility, dated April 2008, the policy indicated, Medications requiring refrigeration . between 36 - 46 Fahrenheit. 7. During a concurrent observation and interview on 3/19/2025 at 12:50 p.m. with Director of Staff Development (DSD), at medication cart 1, two Bisacodyl suppositories were observed with expiration dates of 11/2024 and 8/2024. DSD confirmed the medications were expired and should not be in the medication cart. During a review of the facility's policy titled, Medication Storage in the Facility dated April 2008, the policy indicated, outdated . medications . are immediately removed from stock. 8. During a review of Resident 26's Face Sheet (demographics), the Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with the diagnoses including heart failure (disease of the heart), anxiety (disorder of excessive worry or fear), and depression (mental health condition with persistent sadness). During a concurrent observation and interview on 3/19/25 at 8:15 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 26's room, a medicine cup of clear yellow tinged liquid was observed on Resident 26's bedside table. LVN1 stated the clear yellow liquid in the medicine cup was Lactulose (liquid medication used to treat constipation) and was left from the previous shift. During an interview on 3/19/25 at 9:13 a.m. with Director of Nursing (DON), DON stated the expectation was for nursing staff to observe residents consume medications during administration. The DON stated medications were never to be left at the bedside because another resident could take them. DON stated it was not safe to leave medication on Resident 26's bedside table. During a review of Order Summary Report, dated 3/19/25, the Order Summary Report, indicated Resident 26 was prescribed Lactulose Oral Solution . two times a day. During a review of Medication Administration Report (MAR), dated 3/20/25, the MAR indicated Resident 26 was administered Lactulose twice a day at 8:00 a.m. and 5:00 p.m. During a review of the facility's policy and procedure (P&P) titled, Medication - Administration, dated 1/1/2012, the P&P indicated, Medications . will be administered as prescribed . During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications . are stored safely and securely . accessible only to licensed personnel.

Based on observation, interview, and record review, the facility failed to ensure that food was stored in safe and sanitary conditions in the food service department when: 1. The kitchen refrigerator and the Dry Food Storage Area contained food that was not labeled and not covered. 2. The emergency food storage area contained food that was not labeled and expired. These failures had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks). Findings: 1. During an observation on [DATE] at 8:30 a.m., in the kitchen refrigerator, there were seven cucumbers, inside an open box uncovered with no date. During an interview on [DATE] at 8:36 a.m. with DM in the kitchen, DM stated the expectation was for staff to label and date all food to prevent cross-contamination and food-borne illnesses. DM further stated the expiration date was important to ensure the residents consumed a safe food product. During an observation on [DATE] at 8:46 a.m., in the Dry Food Storage Area, there were individual-packed Italian dressings and yellow mustards in a box with no received and/or expiration date. DM confirmed that these items had no date and they should. During a review of the facility's policy and procedure (P&P) titled, P-DS52 Food Storage and Handling, dated [DATE], the P&P stated 9. Fresh Vegetable Storage . f. Label and date all food items . c. Label and date all food items . 13. Dry Storage Area . h. Label and date all storage products. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].11, titled Packaged and Unpackaged Food - Separation, Packaging, and Segregation, dated [DATE], the FDA food code indicated, FOOD shall be protected from cross contamination by: . storing the food in packages, covered containers, or wrapping. 2. During a concurrent observation and interview on [DATE] at 11:00 a.m., with Dietary Manager (DM) in the emergency food storage area, there were six gelatin boxes with no received and/or expiration date and six cans of three-bean salad with expiration date of [DATE]. DM confirmed the six gelatin boxes and six cans of three-bean salad were expired and not safe to consume. DM further stated it could cause food-borne illnesses and should be discarded right away. DM stated she was the only one restocking and checking the emergency food storage area. During a review of the facility's policy and procedure (P&P) titled, P-DS52 Food Storage and Handling, dated [DATE], the P&P stated 10. Canned Vegetable Storage . c. Label and date all food items . 13. Dry Storage Area . h. Label and date all storage products.

Based on observation, interview, and record review, the facility failed to ensure the call light for one of 26 sampled residents (Resident 13) was within her reach. This failure had the potential for Resident 13's needs not being met. Findings: During a review of Resident 13's Admission Record, dated 3/18/25, the Admission Record indicated Resident 13 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing). During a concurrent observation and interview on 3/17/25 at 10:53 a.m., in Resident 13's room, Resident 13 was lying in bed. Resident 13's call light was tied on the left bed rail and was hanging off the bed. Resident 13 stated she could not reach the call light where it was located. Resident 13 stated she uses her call light to call for assistance. During a concurrent observation and interview on 3/17/25 at 10:55 a.m., in Resident 13's room with the Director of Nursing (DON), the DON confirmed the location of Resident 13's call light. DON stated Resident 13 uses her call light. DON stated Resident 13's call light should be within Resident 13's reach. During an interview on 3/18/25 at 11:15 a.m., with Occupational Therapist (OT) 1, OT 1 stated Resident 13's call light should be placed on her lap in front of her because Resident 13 has limited range of motion with her arms. During the review of the facility's policy and procedure (P&P) titled, Communication- Call System, dated 10/9/24, the P&P indicated, The Facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities. Purpose: To ensure that residents have a means of contacting Facility Staff for assistance.

Based on interview and record review, the facility failed to ensure appropriate dementia treatment and services for one resident (Resident 1) when facility staff: 1. Failed to follow Resident 1's care plan for Cognitive Loss/Dementia; 2. Failed to follow the facility policy and procedure titled Behavior Management for Resident 1; 3. Terminated care and services by allowing Resident 1 to self-discharge to an unsafe environment against medical advice; 4. Failed to update Resident 1's Baseline Care Plan to reflect the assessment findings from speech therapy's cognitive assessment of Resident 1, Resident 1's scheduled conservatorship hearing (a court hearing to determine whether an individual is incapable of managing personal, financial, or healthcare decisions) affairs in court, and Resident 1's elopement risk. These failures did not meet Resident 1's needs for behavioral health care and services, and exposed Resident 1 to an unsafe and unsanitary environment without the supervision and care necessary to help Resident 1 achieve the highest practicable physical, mental, and psychosocial well-being. Findings: 1. During a review of the clinical record for Resident 1, the resident's Facesheet (a portion of the medical record containing socioeconomic and diagnostic information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's Certification and Recertification form (the form used by physicians to indicate whether post-acute, skilled nursing services were required after hospitalization ), dated 6/5/20, indicated the resident had dementia, and was estimated to be admitted to the facility for 30 days. Resident 1's Montreal Cognitive Assessment (MoCA, a comprehensive assessment used to evaluate multiple aspects of cognitive ability), dated 6/7/20, indicated the resident exhibited abnormal cognitive function. On 6/11/20, the facility received notice that Lake County had scheduled a probate hearing for 6/15/20, to decide whether Resident 1 required guardianship for healthcare and financial decision-making due to being gravely disabled. On 6/11/20, the facility assessed Resident 1 and determined the resident exhibited exit-seeking behaviors constantly, and the resident's memory deficits increased her risk of eloping from the facility. On 6/14/20, the facility facilitated Resident 1's request to self-discharge against medical advice (AMA), not even 10 days into the resident's admission. During an interview on 8/21/20, at 3:00 p.m., Social Services Director (SSD) and Administrator were present. SSD stated her duties included coordinating residents' discharge planning and assisting residents to meet their essential needs. SSD stated Resident 1 had no skilled need to necessitate admission to a skilled nursing facility and the resident insisted on going home. SSD stated Resident 1 self-discharged AMA. During electronic correspondence with Administrator, between 9/1/20 and 9/23/20, Administrator was asked to provide the facility's policy and procedure for determining a resident's capacity for healthcare decision-making. Administrator provided no formal, written policy, but replied that facility staff determined a resident's capacity to make health care decisions with usually the [Brief Interview for Mental Status (BIMS)] score and or [Minimum Data Set (MDS, an assessment tool)]. During an interview on 10/6/20, at 1:50 p.m., Director of Rehab stated the facility's speech therapists used the MoCA (Montreal Cognitive Assessment) form to conduct a cognitive assessment for residents. The Director of Rehab stated the facility retained no policy for the MoCA assessment. The Director of Rehab stated the MoCA was not always incorporated into nursing or interdisciplinary team processes at the facility. During an interview on 10/26/20, at 3:50 p.m., Licensed Staff B stated she recalled a resident who self-discharged AMA via a rideshare (e.g., Uber or Lyft) vehicle in early June 2020. Licensed Staff B stated she had worked on-call for the facility in June. Licensed Staff B stated she worked as a mid-shift supervisor. Licensed Staff B stated the facility's nursing services, either the mid-shift or a resident's assigned nurse, completed the documentation required to process a resident's AMA. Licensed Staff B stated the facility's nursing services scheduled the rideshare vehicle for Resident 1. Licensed Staff B stated she was not sure how the facility judged a resident competent to make healthcare decisions. Licensed Staff B stated Licensed Staff C had been Resident 1's nurse during her shift. Interviews with Licensed Staff C were attempted on 10/7/20, at 4:55 p.m., 10/26/20, at 5:00 p.m., and 11/19/20, at 11:01 a.m. To date, Licensed Staff C has not made himself available for interview. During an interview on 10/27/20, at 3:56 p.m., Speech Therapist stated he worked at the facility as a speech therapist through June 2020. Speech Therapist stated speech therapy staff were tasked to assess residents' cognitive communication ability. Speech Therapist stated the facility's therapy service utilized the MoCA to assess residents' cognitive ability because it is a standardized assessment of short- and long-term memory. Speech Therapist stated the MoCA is primarily used to plan care for speech and occupational therapy services. Speech Therapist stated a total score of 26 on the MoCA, or higher, indicated normal cognitive function, while a score of 14 on the MoCA indicated moderate to severe cognitive deficits. Comparing the BIMS to the MoCA, Speech Therapist stated the MoCA is much more comprehensive for assessing a resident's cognitive ability. Speech Therapist stated the BIMS only assessed short-term memory; immediate recall and orientation. During an interview on 10/28/20, at 3:06 p.m., the Administrator stated he did not remember the facility consulting psychology or psychiatry for Resident 1 before the resident discharged AMA. The Administrator stated Interdisciplinary Team (IDT) meetings took place after stand-up, everyday. The Administrator stated the facility allowed anyone to leave AMA, even residents with pending court hearings for conservatorship. The Administrator stated he had overheard Resident 1 say she would walk a total of 9 miles to purchase alcohol from a liquor store near her home. When asked whether Resident 1 knew whether her behaviors negatively affected her health, the Administrator stated I just thought it was no big deal. During an interview on 10/29/20, at 9:26 a.m., SSD stated she had coordinated Resident 1's discharge and transport from the facility. SSD she participated on the facility's IDT meetings. SSD stated the IDT used a resident's BIMS to determine changes in mental status, to tailor care to meet residents' needs, but not competency. SSD stated Family Member 2 informed the facility that Resident 1 should not be discharged home because there was no one available to assist the resident. SSD stated she did not recall reviewing any of Resident 1's care plans. SSD stated she did not recall IDT consulting psychology or psychiatry for Resident 1 before the resident discharged AMA. SSD stated she was new to her role, and the facility had not provided her orientation to the facility's policies and procedures relevant to the SSD role. During a review of the clinical record for Resident 1, the care plan for Cognitive Loss/Dementia, initiated 6/7/20, indicated Resident 1 had periods of confusion, disorientation, and forgetfulness. The care plan indicated Resident 1 had short term memory loss and long term memory loss, and had poor judgment and was unable to make decision[s]. The care plan indicated Resident 1 could not recall the current season, location of [her] room, staff names and faces, or that the resident was admitted to a nursing home. In response to these healthcare needs, the care plan indicated the facility would provide interventions including reality orientation, and would refer [Resident 1] for psychologist/psychiatric consultation when indicated. The care plan indicated goal[s] that facility staff would cue Resident 1 when making routine daily decisions, and facility staff would maintain the resident's current level of self-performance for activities of daily living (e.g., hygiene, bowel and bladder management, dressing, feeding, and ambulation). During a review of the clinical record for Resident 1, the Baseline Care Plan Summary, dated 6/8/20, indicated the facility's desired to discharge Resident 1. The care plan indicated facility staff had left [a] message for . [Family Member 2] to find transportation home for Resident 1. The care plan did not incorporate information from Resident 1's Cognitive Loss/Dementia care plan, and did not indicate the goals the facility sought to achieve when managing Resident 1's dementia or related behaviors. The facility policy and procedure titled Comprehensive Person-Centered Care Planning, dated 11/2018, indicated the facility's Policy was to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting . safety . [and] behavioral . needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. 2. During an interview on 8/21/20, at 3:00 p.m., Social Services Director (SSD) and Administrator were present. SSD stated her duties included coordinating residents' discharge planning and assisting residents to meet their essential needs. SSD stated Resident 1 had no skilled need to necessitate admission to a skilled nursing facility and the resident insisted on going home. SSD stated Resident 1 self-discharged AMA, or against medical advice. During an interview on 10/7/20, at 9:05 a.m., SSD stated she recalled performing Resident 1's cognitive assessment (BIMS, or the Brief Interview for Mental Status) for the resident's 5-day MDS (Minimum Data Set, an assessment tool), on 6/12/21. SSD stated Resident 1 was doing better when SSD performed the BIMS, as compared to the resident's day of admission. SSD believed the resident's improvement was because the alcohol may have worn off; [she] was up, functioning, and walking around. SSD stated the family did not want [Resident 1] to come home, and was not receptive to in-home support services. SSD stated the family was concerned that if Resident 1 was home the resident would go to the store and buy alcohol. During an interview on 10/28/20, at 3:06 p.m., the Administrator stated he did not remember the facility consulting psychology or psychiatry for Resident 1 before the resident discharged AMA (against medical advice). The Administrator stated the facility's Interdisciplinary Team (IDT) meetings were going on, but as MDS assessments. The Administrator then stated IDT meetings took place after stand-up, everyday. During an interview on 10/29/20, at 9:26 a.m., SSD stated she had coordinated the transport for Resident 1's AMA discharge from the facility. SSD stated she participated on the facility's IDT meetings. SSD stated she did not recall reviewing any of Resident 1's care plans. SSD stated she did not recall IDT consulting psychology or psychiatry for Resident 1 before the resident discharged AMA. SSD stated she was new to her role, and the facility had not provided her orientation to the facility's policies and procedures relevant to the SSD role. During a review of the clinical record for Resident 1, the care plan for Cognitive Loss/Dementia, initiated 6/7/20, indicated Resident 1 had periods of confusion, disorientation, and forgetfulness. The care plan indicated Resident 1 had short term memory loss and long term memory loss, and had poor judgment and was unable to make decision[s]. The care plan indicated Resident 1 could not recall the current season, location of [her] room, staff names and faces, or that the resident was admitted to a nursing home. The care plan indicated the facility would provide interventions including reality orientation, and would refer [Resident 1] for psychologist/psychiatric consultation when indicated. The care plan indicated a goal for facility staff to cue Resident 1 when making routine daily decisions, and to maintain the resident's current level of self-performance for activities of daily living (e.g., hygiene, bowel and bladder management, dressing, feeding, and ambulation). During a review of the clinical record for Resident 1, the Elopement Risk Tool, dated 6/11/20, indicated Resident 1 exhibited exit-seeking behaviors constantly, to everyone multiple times a day. The tool indicated Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The tool indicated Resident 1 displayed cognitive deficits, disorientation, intermittent confusion, and other cognitive impairments that contributed to poor decision-making skills. During a review of the clinical record for Resident 1, the Baseline Care Plan Summary, dated 6/8/20, indicated the facility desired to discharge Resident 1. The care plan indicated facility staff had left [a] message for . [Family Member 2] to find transportation home for Resident 1. The care plan did not incorporate information from Resident 1's Cognitive Loss/Dementia care plan, and had not been updated to reflect goals the facility sought to achieve when managing Resident 1's dementia or exit-seeking behaviors. During a review of the complete clinical record for Resident 1, no Medicare Skilled Daily Notes or nursing Progress Notes through the period of Resident 1's admission indicated the facility's IDT had assessed or documented Resident 1's behavior symptoms. The facility's IDT notes concerning Resident 1's care were requested from the Administrator on 10/28/21, at 3:40 p.m., but no IDT notes were ever produced. The facility policy and procedure titled Behavior Management, dated 1/16/20, indicated the facility will ensure that when a resident displays a mental disorder . they will receive appropriate treatment to address the problem or attain the highest practicable mental and psychosocial well-being. The policy indicated it applied to the facility's social services, and indicated the facility's Interdisciplinary Team (IDT) would assess a resident's mood and behavior, and document in the medical record when a resident exhibited mood/behavior symptoms. 3. During an interview on 8/21/20, at 3:00 p.m., Social Services Director (SSD) and Administrator were present. SSD stated Resident 1 had no skilled need to necessitate admission to a skilled nursing facility and the resident insisted on going home. SSD stated Resident 1 had self-discharged AMA. During an interview on 10/7/20, at 9:05 a.m., SSD stated Resident 1 was served court documents for a conservatorship hearing while admitted because the family was trying . to take over [Resident 1's] property. SSD stated the family did not want [Resident 1] to come home, and was not receptive to in-home support services. SSD stated something was wrong with [Resident 1's] house. SSD also stated the family was concerned that if Resident 1 was home the resident would go to the store and buy alcohol. During an interview on 10/7/20, at 10:50 a.m., Physician A stated he did not recall Resident 1, the name does not ring a bell. Physician A stated there are so many patients it is hard to remember each one. Physician A stated it was typical for patients to refuse being at a skilled nursing facility. Physician A stated the facility should contact the resident's attending physician if a resident vocalized a desire to leave AMA. Physician A stated he did not recall writing a letter dated 6/12/20, addressed to the facility, which indicated Resident 1 was well enough to be discharged . During an interview on 10/26/20, at 3:50 p.m., Licensed Staff B stated she recalled a resident who self-discharged AMA via a rideshare (e.g., Uber or Lyft) vehicle in early June. Licensed Staff B stated she had worked on-call for the facility in June 2020. Licensed Staff B stated she worked as a mid-shift supervisor and did not have a patient assignment in that role. Licensed Staff B stated the facility's nursing staff, either the mid-shift or a resident's assigned nurse, completed the documentation required to process the resident's AMA. Licensed Staff B stated the facility must notify a responsible party, if indicated, the doctor, and the Director of Nursing Services (DON) when a resident vocalized the desire to leave the facility AMA. Licensed Staff B stated the facility's nursing services scheduled the rideshare vehicle for Resident 1. Licensed Staff B stated she was not present when the rideshare car arrived at the facility for Resident 1 because her shift ended before its arrival. Licensed Staff B stated Licensed Staff C had been Resident 1's nurse during her shift. Interviews with Licensed Staff C were attempted on 10/7/20, at 4:55 p.m., 10/26/20, at 5:00 p.m., and 11/19/20, at 11:01 a.m. Licensed Staff C did not make himself available for interview. During an interview on 10/26/20, at 4:40 p.m., MTM Transport Agent confirmed the facility coordinated a rideshare transport for Resident 1, on 6/13/20 and 6/14/20. MTM Transport Agent stated notations in his company's logbook indicated the first names of two facility representatives responsible for coordinating transport. One first name is the same as Licensed Staff B's first name. The second first name sounded similarly to SSD's first name. During an interview on 10/27/20, at 9:24 a.m., the DON stated she had no idea what nursing's role was when a resident requested to self-discharge AMA. The DON stated I don't know the policies. I am new here. The DON stated the condition of a resident's home environment would not factor into whether a facility allowed a resident to discharge AMA. During an interview on 10/20/20, at 11:34 a.m., Family Member 2 stated the facility allowed Resident 1 to self-discharge home AMA to an unsafe environment. Family Member 2 stated she learned about Resident 1's AMA discharge when Family Member 2 went to check-on the safety of Resident 1's home and found Resident 1 there. Family Member 2 stated Resident 1's home had a rotted subfloor, and it contained food that was moldy and harbored pests. Family Member 2 stated she did not receive any calls or voicemails from the facility prior to Resident's discharge. Family Member 2 stated SSD called Family Member 2 one week before discovering Resident 1, and asked Family Member 2 to sign [Resident 1] out, but Family Member 2 stated she refused SSD's request. Family Member 2 stated SSD called her, specifically, as opposed to Family Member 3, because Family Member 2 had signed [Resident 1] in and completed Resident 1's admission paperwork. Family Member 2 stated the facility never contacted her again between the time of SSD's phone call and when Family Member 2 discovered Resident 1 alone at home. Family Member 2 stated she called the facility and spoke with Physician A, who stated Resident 1 had signed herself out AMA. Family Member 2 stated Physician A could not answer why, when, who, or how Resident 1 discharged home. Family Member 2 stated the facility's practice made her feel absolutely furious and disgusted. Family Member 2 stated Resident 1 smelled ripe, looked disheveled, had not showered, and had matted hair upon encountering the resident at the residence. Family Member 2 stated allowing Resident 1 to self-discharge AMA was unsafe, as Resident 1 [was not] feeding herself. Describing Resident 1's cognitive issues, Family Member 2 stated Resident 1's long-term memory was better than her short-term memory, Resident 1 often confused Family Member 2 for Family Member 3, and Resident 1 would ask the same questions over and over, in a loop. Family Member 2 stated Resident 1 is now safe, admitted to a memory care unit and under full conservatorship. During an interview on 10/28/20, at 3:06 p.m., the Administrator stated he did not remember the facility consulting psychology or psychiatry for Resident 1 before the resident discharged AMA. The Administrator stated the facility allowed anyone to leave AMA, even residents with pending court hearings for conservatorship. The Administrator stated he personally served Resident 1 with the court's notice of her pending conservatorship hearing. The Administrator stated a resident retained his or her right to leave against medical advice until a court ruled the resident incompetent. The Administrator stated he had overheard Resident 1 say she would walk a total of 9 miles to purchase alcohol from a liquor store near her home. When asked whether Resident 1 knew whether her behaviors negatively affected her health, the Administrator stated I just thought it was no big deal. During an interview on 10/29/20, at 9:26 a.m., SSD stated had coordinated Resident 1's discharge and transport from the facility. SSD she participated on the facility's IDT meetings. SSD stated the IDT used a resident's BIMS to determine changes in mental status, to tailor care to meet residents' needs, but not competency. SSD stated the facility IDT did not determine a resident's competency, rather the doctor should determine competency. SSD stated Family Member 2 informed the facility Resident 1 should not be discharged home because there was no one available to assist the resident. SSD stated she did not recall reviewing any of Resident 1's care plans. SSD stated she did not recall IDT consulting psychology or psychiatry for Resident 1 before the resident discharged AMA. SSD stated she was new to her role, and the facility had not provided her orientation to the facility's policies and procedures relevant to the SSD role. During a review of the clinical record for Resident 1, the Facesheet, no date, indicated Physician A was Resident 1's attending physician. During a review of the clinical record for Resident 1, a Medicare Daily Skilled Note was completed for Resident 1 on 6/6/20, 6/7/20, 6/10/20, and 6/11/20, and indicated Resident 1's cognitive status on those days. The 6/6/20 note indicated Resident 1 was oriented to person and place, but not time. The 6/7/20 note indicated Resident 1 was oriented to person and time, but not place. The 6/10/20 note indicated Resident 1 was oriented to person, place, and time. The 6/11/20 note indicated Resident 1 was oriented to person and place, but not time. During a review of the clinical record for Resident 1, the MoCA (Montreal Cognitive Assessment) form, dated 6/7/20, indicated Resident 1's cognition was assessed across eight domains: visuospatial/executive, naming, memory, attention, language, abstraction, delayed recall, and orientation. The form indicated Resident 1 could not draw a copy of a cube's image or draw a clock showing the time of ten-past-eleven. The form indicated Resident 1 could not recall a list of five words, five minutes after Resident 1 heard and repeated them. The form indicated Resident 1 was not oriented to the date, month, year, day, or place. During a review of the clinical record for Resident 1, the care plan for Cognitive Loss/Dementia, initiated 6/7/20, indicated Resident 1 had periods of confusion, disorientation, and forgetfulness. The care plan indicated Resident 1 had short term memory loss and long term memory loss, and had poor judgment and was unable to make decision[s]. The care plan indicated Resident 1 could not recall the current season, location of [her] room, staff names and faces, or that the resident was admitted to a nursing home. The care plan had not been closed at the time Resident 1 self-discharged AMA. The care plan indicated the facility would provide interventions including reality orientation, and would refer [Resident 1] for psychologist/psychiatric consultation when indicated. The care plan indicate a goal for facility staff to cue Resident 1 when making routine daily decisions, and to maintain the resident's current level of self-performance for activities of daily living (e.g., hygiene, bowel and bladder management, dressing, feeding, and ambulation). During a review of the clinical record for Resident 1, the Elopement Risk Tool, dated 6/11/20, indicated Resident 1 exhibited exit-seeking behaviors constantly, to everyone multiple times a day. The tool indicated Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The tool indicated Resident 1 displayed cognitive deficits, disorientation, intermittent confusion, and other cognitive impairments that contributed to poor decision-making skills. During a review of the clinical record for Resident 1, the Section C of the MDS, dated [DATE], indicated Resident 1 scored a 14 on the BIMS, which indicated Resident 1 exhibited intact cognition. During a review of the clinical record for Resident 1, the Discharge Against Medical Advice Form, dated 6/13/20, indicated the facility allowed Resident 1 to self-discharge AMA at her own insistence and against the advice of [her] physician and the Facility. The form indicated Resident 1 received information about the risk involved and of possible dangers to my life as a result of her departure, and that she assumed risks and consequences involved. The form was signed by Resident 1, Licensed Staff B, and Licensed Staff C. The form was dated 6/13/20, one day prior to Resident 1's discharge. During a review of the clinical record for Resident 1, the Progress Notes, dated 6/13/20, at 11:26 p.m., indicated Resident 1 had signed-out to return home AMA that morning, and DON and the Administrator were notified. The note indicated delays in transport caused the resident to spend another night at the facility. The note did not indicate the facility had notified Resident 1's family, Physician A, or Adult Protective Services. During a review of the clinical record for Resident 1, the Progress Notes, dated 6/14/20, at 6:20 p.m., indicated Resident 1 had discharged from the facility earlier that day, at 11:18 a.m. The note indicated Resident 1's family arranged the Resident's transportation. The note did not indicate the facility notified Resident 1's family, Physician A, or Adult Protective Services. The facility policy and procedure titled Discharge Against Medical Advice, dated 12/1/14, indicated the facility's Policy was to make reasonable attempts to ensure the safety of residents wishing to leave the Facility against medical advice. The policy and procedure indicated a Licensed Nurse will notify the attending physician . of the resident/responsible party's desire to leave the Facility against medical advice (AMA). The policy and procedure indicated that if a resident exhibited impaired judgment, or had an unsafe discharge environment, then the charge nurse was required to notify the facility Administrator/designee, Director of Nursing/designee, Attending Physician, Responsible Party, and Adult Protective Services (APS). The MDS 3.0 Resident Assessment Instrument (RAI) Manual v1.17.1 (a reference manual for completing MDS assessments), dated 10/2019, on page C-15, indicated how to use the BIMS when planning a resident's care. The RAI Manual indicated The BIMS is a brief screener that aids in detecting cognitive impairment. It does not assess all possible aspects of cognitive impairment. The final determination of the level of impairment should be made by the resident's physician or mental health specialist . 4. During a concurrent interview and record review on 10/6/20, at 2:40 p.m., MDS Coordinator stated the facility had performed its 5-day MDS (Minimum Data Set, an assessment tool) assessment on Resident 1. However, MDS Coordinator stated Resident 1 had not been admitted to the facility long enough for the facility to care plan Resident 1's comprehensive needs based on indications from a comprehensive MDS assessment. During an interview on 10/7/20, at 9:05 a.m., SSD stated Resident 1 was served court documents for a conservatorship hearing while admitted because her family was trying . to take over [Resident 1's] property. SSD stated the family did not want [Resident 1] to come home, and was not receptive to in-home support services. SSD stated something was wrong with [Resident 1's] house. SSD also stated the family was concerned that if Resident 1 was home the resident would go to the store and buy alcohol. During an interview on 10/27/20, at 9:24 a.m., DON stated she had no idea what nursing's role was when a resident requested to self-discharge AMA. The DON stated I don't know the policies. I am new here. During an interview on 10/29/20, at 9:26 a.m., SSD stated she participated on the facility's IDT (Interdisciplinary Team) meetings. SSD stated she was new to her role, and the facility had not provided her orientation to the facility's policies and procedures relevant to the SSD role. SSD stated she did not recall reviewing any of Resident 1's care plans. During a review of the clinical record for Resident 1, the MoCA (Montreal Cognitive Assessment) form, dated 6/7/20, indicated Resident 1's cognition was assessed across eight domains: visuospatial/executive, naming, memory, attention, language, abstraction, delayed recall, and orientation. The form indicated Resident 1 could not draw a copy of a cube's image or draw a clock showing the time of ten-past-eleven. The form indicated Resident 1 could not recall a list of five words, five minutes after Resident 1 heard and repeated them. The form indicated Resident 1 was not oriented to the date, month, year, day, or place. During a review of the clinical record for Resident 1, the care plan for Cognitive Loss/Dementia, initiated 6/7/20, indicated Resident 1 had periods of confusion, disorientation, and forgetfulness. The care plan indicated Resident 1 had short term memory loss and long term memory loss, and had poor judgment and was unable to make decision[s]. The care plan indicated Resident 1 could not recall the current season, location of [her] room, staff names and faces, or that the resident was admitted to a nursing home. The care plan had not been closed at the time Resident 1 self-discharged AMA. The care plan indicated the facility would provide interventions including reality orientation, and would refer [Resident 1] for psychologist/psychiatric consultation when indicated. The care plan indicated a goal for facility staff to cue Resident 1 when making routine daily decisions, and to maintain the resident's current level of self-performance for activities of daily living (e.g., hygiene, bowel and bladder management, dressing, feeding, and ambulation). During a review of the clinical record for Resident 1, the Baseline Care Plan Summary, dated 6/8/20, indicated the facility desired to discharge Resident 1. The care plan indicated facility staff had left [a] message for . [Family Member 2] to find transportation home for Resident 1. The care plan did not indicate any care needs or goals arising from Resident 1's MoCA, Elopement Risk Assessment, or dementia diagnosis, or any details concerning the known, scheduled court proceeding determine Resident 1's competency. During a review of the clinical record for Resident 1, the Elopement Risk Tool, dated 6/11/20, indicated Resident 1 exhibited exit-seeking behaviors constantly, to everyone multiple times a day. The tool indicated Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The tool indicated Resident 1 displayed cognitive deficits, disorientation, intermittent confusion, and other cognitive impairments that contributed to poor decision-making skills. During a review of the clinical record for Resident 1, the Notice of Requested Appointment of Temporary Conservator, dated 6/10/21, indicated Resident 1 had been noticed of a probate hearing in Lake County scheduled for 6/15/20, at 1:20 p.m., to decide wheth[TRUNCATED]

Based on interviews, record reviews, and a review the actual 911 (Medical Emergency) dispatch call, the facility failed to assess Resident 1's medical emergency in a timely manner when he was found face down on the floor while the upper part of his body was resting over a waste basket, and provide Basic Life Support (BLS, generally refers to the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing [CONDITION(S)], respiratory distress or an obstructed airway), including CPR (Cardiopulmonary Resuscitation is an emergency lifesaving procedure performed when the heart stops beating. CPR can double or triple the chances of survival after a [CONDITION(S)]) prior to the arrival of emergency medical personnel, subject to accepted professional guidelines, and the facility's policy and procedure for CPR. This failure resulted in Resident 1 not surviving his medical emergency. Findings: On [DATE], at 12:06 p.m., the California Department of Public Health, Licensing and Certification (CDPH L&C), received a Facility-Reported Incident (FRI) from the Administrator of a facility regarding an unusual occurrence, the resident named in the Intake Information report was Resident 1. The intake details of the FRI indicated, Date of alleged event: [DATE], no time was specified. UNUSUAL OCCURRENCE-DEATH. CLEANING WOMAN FOUND RESIDENT UNRESPONSIVE CALLED LVN (Licensed Vocational Nurse). LVN ASSESSED & PERFORMED CPR. CALLED 911. PARAMEDIC RESUMED CPR. REPORT FILED WITH POLICE. On [DATE], at 12:22 p.m., a complaint was called in to CDPH L&C, indicating that CPR was not performed on Resident 1 prior to the arrival of emergency medical personnel. During a review of Resident 1's Discharge Summary Notes, dated, [DATE], at 1:58 p.m., from the acute care hospital, the Discharge Summary Notes indicated, Resident 1 was WDWN (Well Developed, Well Nourished, with no acute distress. During this hospitalization , Resident 1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's vital signs (Vital signs are a group of the four to six most important medical signs that indicate the status of the body's vital (life-sustaining) functions) at discharge were stable. Resident 1's condition at discharge was fair. Resident 1's code status was FULL CODE (Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Resident 1 was admitted to this facility on [DATE]. During an interview on [DATE], at 11:35 a.m., with Housekeeping Staff A, Housekeeping Staff A stated she saw Resident 1 face down inside his room and she called LVN B (Licensed Vocational Nurse) B. Housekeeping Staff A stated LVN B came to Resident 1's room and started CPR. During an interview on [DATE], at 12 p.m., with LVN B, he stated that he was called to Resident 1's room by a housekeeper and saw him in a prone position (face down) and stated Resident 1's upper chest was resting over a waste basket and he was not moving. LVN B stated Resident 1 was unresponsive when he assessed his LOC (level of consciousness). LVN B stated he could not feel Resident 1's pulses and he was not breathing. LVN B stated he started CPR because he knew that Resident 1 was a full code. LVN B stated CNA C helped him to lay Resident 1 on his back on the floor so he could start CPR. LVN B stated RN (Registered Nurse) D came and took over the CPR so he, (LVN B), could call 911. LVN B stated he performed chest compressions for 30 seconds before RN D took over. LVN B stated he did not give rescue breathing (first aid technique that's done when someone has stopped breathing (also known as respiratory arrest). Rescue breathing is also referred to as mouth-to-mouth resuscitation. LVN B stated he had already stopped providing CPR when the EMT's (Emergency Medical Technicians) arrived. During an interview on [DATE], at 1:51 p.m., with CNA C, CNA C stated he responded to the emergency in Resident 1's room and saw RN D performing CPR on Resident 1.When CNA C was asked if he helped LVN B place Resident 1 on his back before starting CPR, he stated, No, CNA C stated he did not see LVN B perform CPR on Resident 1. During a review of Resident 1's Progress Notes, dated [DATE], at 10:47 p.m., authored by LVN B, the progress notes indicated,[DATE] @ 1140 am inside resident's (Resident 1's) room. Resident (Resident 1) is found to have fallen forward on the floor, face down, with upper chest area resting on top of waste basket. Upon assessment, BLS was immediately initiated and performed. After visually & verbally confirming no responses from the resident, [NAME]-stokes (sic) ([NAME]-Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called apnea) breathing is being observed, pulse was neither unable to be determined nor present, CPR was applied until EMT arrives outside resident's (Resident 1's) room. During a review of the facility document titled, Witness Statement Incident Reporting, (no date and time provided), handwritten by LVN B, stated, My attention was called by the housekeeping of the resident's (Resident 1's) situation. As I enter the room, I found him on the floor, w/c (which) looked like he has fallen forward, face down, upper half of chest was resting over the waste basket. Upon assessment with no response, I continue to perform BLS, CPR included. Once the other Charge Nurse (RN D) comes inside, we switched so I can call 911, as she (RN D) continues CPR. I go back and forth the room as I was talking with the 911 dispatch. Once 911 arrives, I went to switch with the nurse (RN D) to apply CPR, and she (RN D) opens up the door for them (EMT). CPR is finally interrupted as soon as EMT arrives (I see them outside the resident's (Resident 1's) room, inside the facility). On the same document, RN D's handwritten note stated, I was called by a staff member (housekeeper) because the other nurse (LVN B) needs help at room xx. When I arrived (LVN B) and the resident (Resident 1) was on the floor. LVN B is giving a CPR. He (LVN B) told to call 911, we twitch (switch) so he can call 911, then I continue doing CPR while he was on the phone. When he came back into the room after two to three minutes or more, again we twitch (switch), and he told me to let the EMT inside. After letting them in, I gave one of the EMT the POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE], at 3:55 p.m., with RN D, stated she did not hear LVN B calling a facility code for medical emergency which was a Code Blue. RN D stated she was called to Resident 1's room by a female housekeeper because LVN B needed help. RN D stated LVN B was on the floor starting CPR. RN D stated she switched with LVN B because she did not know what happened to Resident 1 and may not provide the correct information to the 911 dispatcher. RN D stated she checked for Resident 1's pulse and breathing, and when these were absent, she continued to perform CPR. RN D stated she did two to three cycles of CPR. RN D stated she performed CPR on Resident 1 for about three to five minutes. RN D stated she did not give Resident 1 rescue breaths during the CPR. RN D stated she opened the door for the EMT and handed over Resident 1's POLST and History to one of the EMT. RN D stated Resident 1 was a full code. During a review of the 911 dispatch call between the dispatcher (911 is the national number in the United States to dial when emergency help is needed, and 911 dispatchers are the people who take those calls and send fire, police, or ambulance services where needed) and LVN B that was recorded on [DATE], at 11:56 a.m. the call indicated the following: 911 Dispatcher: Medical 911, what's the address of the emergency? LVN B: Responded by stating the name of the facility and the address. 911 Dispatcher: In what city? LVN B: Responded by stating the name of the city. 911 Dispatcher: What number are you calling from in case we get disconnected? LVN B: Responded by stating the facility's phone number. 911 Dispatcher: Ok, is there a room number or a unit number there? LVN B: Responded, Yes, and stated the room and bed numbers. 911 Dispatcher: Verified the room and bed numbers and asked, What's happening today? LVN B: I'm sorry? 911 Dispatcher: Tell me exactly what is happening? LVN B: He is face down on the floor 911 Dispatcher: Did he fall? LVN B: I would say so, but he is uh, he is uh, I just went here and told the nurse that, that uh, that, that about his condition and I'm not quite sure if he is breathing or not. 911 Dispatcher: You don't know if he is breathing or not? LVN B: Yeah. 911 Dispatcher: Can you roll him over and check his breathing? LVN B: Um, I have to go over there, can you give me a second? 911 Dispatcher: Yes. LVN B: Ok. After 43 seconds, LVN B: Yes, he is breathing but he is stiff as a rock right now. 911 Dispatcher: Ok, but he is breathing right? LVN B: He is, he is. 911 Dispatcher: How old is he? LVN B: Um, I would say 911 Dispatcher: About how old is he? LVN B: Forty-six. 911 Dispatcher: He is forty-six?' LVN B: 1946. 911 Dispatcher: 1946, ok. Is he awake? LVN B: No, I would say no. 911 Dispatcher: No, ok, is his breathing completely normal? LVN B: Um, I couldn't, I couldn't, yeah it is but um, I'm concerned because he is stiff but he is breathing, he is as stiff and I couldn't even get to turn him. 911 Dispatcher: Ok, is he still unconscious? LVN B: Yes, he is actually, yes, 911 Dispatcher: Ok, we have everyone on the way, are you able to go check on him and check his breathing for me again? LVN B: Ok, let me go. 911 Dispatcher: Oh my God, this guy is . After two minutes and two seconds, 911 Dispatcher: Hello, Hello, forgot about me. End of recording. During an interview on [DATE], at 11:11 a.m., with Paramedic 1, Paramedic 1 stated that on [DATE], at about 11:57 a.m., he received a 911 call regarding a fall victim, patient was unresponsive but breathing. Paramedic 1 stated that he and his crew, (four other paramedics), arrived at the facility at around 12:03 p.m. Paramedic 1 stated that when they arrived in the patient's (Resident 1's) room, there were four staff members inside the room, all were standing and nobody was performing CPR. Paramedic 1 stated he asked the staff if CPR was performed and nobody gave him an answer. Paramedic 1 stated his crew started accessing the patient (Resident 1) but he was deceased of [CONDITION(S)]. Paramedic 1 stated that all four facility staff members in the room were stunned to know the patient (Resident 1) was dead. Paramedic 1 stated that there was absolutely no evidence that CPR was performed on the patient (Resident 1). Paramedic 1 stated that there was no evidence that the staff attempted to open the patient's (Resident 1's) airway. Paramedic 1 stated that his crew would attest to his assessment that there was no evidence that the patient (Resident 1) received emergency medical attention prior to their arrival. Paramedic 1 provided the names of the other four paramedics who responded to the emergency. During a review of certifications provided by the facility titled, Basic Life Support, these documents indicated that LVN B and RN D are certified BLS providers. During an interview on [DATE], at 2:30 p.m., with Administrative Staff E, Administrative Staff E stated that Resident 1 does not have a POLST form filed on his medical record. Administrative Staff E stated that Resident 1 will automatically be a Full Code at the facility until a POLST form was prepared for him. During an interview on [DATE], at 3 p.m., the DON was asked to clarify a progress note she wrote on [DATE], at 2:22 p.m. stating that Resident 1's death was expected. The DON clarified and stated that Resident 1's death was unexpected because the facility would not have reported it as an unusual occurrence. During an interview on [DATE], at 3:40 p.m., with Resident 1's Attending Physician, Physician F, Physician F was reminded of his patient Resident 1, he acknowledged that Resident 1 was his patient. Physician F briefly talked about Resident 1's discharge summary which indicated that Resident 1 expired on [DATE], and cause of death was CVA (Cerebrovascular Accident or Stroke) most likely ischemic (Ischemic strokes occur when blood flow is blocked). Physician F stated that during medical emergencies such as Resident 1's, he expects the facility staff to provide CPR. Per the 2015 updated AHA (American Heart Association) ECC (Emergency Cardiovascular Care) Guidelines, the BLS for Healthcare Professionals Steps for CPR for Adults and Older Child are as follows: NOTE: non-relevant guidelines were intentionally omitted. 1. Verify Scene Safety- Don't enter a an unsafe environment. Call 911. 2. Activate 911- If you are alone and do not have a mobile device, leave the victim to call 911 first, Return to perform CPR. 3. Determine if the victim is breathing and has a pulse- Simultaneously check for breathing and pulse for no more than 10 seconds. Note: Agonal breaths are not considered signs of breathing. Check carotid artery on your side of the victims neck. 4. Rescue Breathing, if victim has a DEFINITE detectable pulse, but is not breathing- one breath every five to six seconds. Check pulse every 2 minutes. 5. If victim has no detectable pulse: Begin CPR, minimize interruptions- 1 Rescuer: 30 compressions: 2 breaths, 2+ Rescuers: 30 compressions: 2 breaths 6. Compression rate- ,d+[DATE] compressions per minute 7. Hand placement- two hands on lower half of breastbone 8. Compression depth: 2 to 2.4 inches (,d+[DATE] cm) 9. Chest recoil- Allow for full chest after each compression 10. Minimize interruptions- Limit interruptions in chest compressions to no more than 10 seconds. During a review of the facility's Policy and Procedure (P&P) titled, Cardiopulmonary Resuscitation, dated, [DATE], provided by the facility Administrator on [DATE], at 1:50 p.m., the P&P indicated the Purpose: Cardiopulmonary Resuscitation (CPR) is instituted in cases of recognized cardiac and/or pulmonary arrest until medical emergency personnel are available to take over the resuscitation efforts. Policy: Cardiopulmonary Resuscitation is instituted on all residents except those designated as No Code or No CPR. Procedure: 1. Responding to CPR Emergency A. Call for Help and send someone to contact the EMS (Emergency Medical Services) for emergency medical assistance. Announce your facility code for medical emergencies. Send someone for the emergency cart and supplies. B. Assess the resident to determine if conscious. Gently shake the resident's shoulders and shout, Are you okay? This helps ensure that you don't start CPR on a person who's conscious. C. Open the resident's airway, check for breathing, assess for circulation, and begin cardiopulmonary resuscitation using one person or two person rescue (whichever is appropriate). D. If alone, activate the call light and start one person rescue. If call light is not available, continue one person rescue for one minute before leaving resident to call for help. (If you suspect a head or neck injury, move the resident as little as possible to reduce the risk of paralysis). E. Continue CPR until EMS arrives and assumes care of the resident. 2. Documentation A. The facility staff who performed the CPR will document the following information and keep the documentation in the resident's medical record. 1. Why and who initiated CPR; vital signs including pupil size and response to light stimulus 2. Whether the resident suffered from [CONDITION(S)], respiratory arrest or both. 3. When you found the resident and when you started CPR 4. Any other measures taken such as ; administration of 02 (oxygen) and liter flow, oxygen saturation (Oxygen saturation refers to the amount of oxygen that's in your bloodstream), and blood sugar results if obtained, etc. 5. How long the resident received CPR 6. The residents response to CPR 7. Any complications and any interventions taken to correct complications 8. When EMS arrived and assumed care for resident. 9. The final disposition of the resident

Based on observation, interview and record review, the facility failed to provide services to prevent pressure ulcers to one of 13 residents (Resident 24) when the facility did not provide Resident 24 with pressure redistributing devices for her bed and wheelchair and did not keep Resident 24 clean and dry as required by the resident's skin care plans. These failures resulted in Resident 24 developing moisture associate skin damage (inflammation of the skin due to exposure of skin to prolonged moisture) on her buttocks and subsequently a stage 2 and a stage 3 pressure ulcer (damage to skin and underlying tissues from prolonged pressure) on her buttocks. Findings: A review of Resident 24's facesheet indicated Resident 24 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of Resident 24's Braden Scale Score for Predicting Pressure Sore Risk (a pressure ulcer evaluation risk tool), dated 11/20/18, indicated Resident 24 was at a HIGH RISK for developing pressure ulcers. The 11/20/18 assessment indicated Resident 24's mobility was very limited (meaning Resident 24 makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently) and that Resident 24's skin was often moist. A review of Resident 24's Minimum Data Set (MDS - an assessment tool), dated 11/7/18, indicated Resident 24 required extensive assistance with regards to bed mobility, transferring to and from surfaces and dressing and total assistance with respect to bathing. The MDS indicated Resident 24 was always incontinent of bowel and bladder. A review of Resident 24's Skin Care Plan, initiated 5/18/18 and last reviewed 11/20/18, indicated Resident 24 was at risk for pressure ulcers due to impaired mobility, incontinence, thin fragile skin and others. The Skin Care Plan indicated the following pressure ulcer prevention interventions: provide skin care frequently, clean resident's skin after each episode of incontinence and provide pressure redistributing devices and assess for effectiveness. The 11/7/18 MDS indicated Resident 24 used a wheelchair for locomotion. A nurses progress note dated 1/12/19, at 3 p.m., indicated Resident 24 was up in wheelchair all shift. A review of Resident 24's progress notes indicated Resident 24 was not kept clean and dry as required by the care plan. Progress note dated 01/10/19, at 8:15 p.m., indicated: (Resident 24) soaked and very wet, very saturated pants and blouse up to abdomen with urine. A review of prior progress notes did not indicate Resident 24 refused continent care on 01/10/19. A review of Resident 24's SBAR Form (a form used to communicate new resident conditions to the physician), dated 1/11/19, indicated Resident 24 developed moisture associated skin damage (MASD) to both buttocks on 1/11/19. According to the National Institutes of Health (NIH), Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including urine or stool . MASD is characterized by inflammation of the skin, occurring with or without erosion . To prevent MASD, clinicians need to be vigilant both in maintaining optimal skin conditions and in diagnosing and treating minor cases of MASD prior to progression and skin breakdown. (https://www.ncbi.nlm.nih.gov/pubmed/ 547) A review of Resident 24's SBAR Form, dated 1/15/19, indicated Resident 24 developed a stage 2 pressure ulcer on the left buttock measuring 2 x 1 cm and a stage 3 pressure ulcer on the right buttock measuring 3 x 1.5 cm. The SBAR Form indicated the facility detected these pressure ulcers on 1/15/19. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury/ulcer is localized damage to the skin and underlying soft tissue usually over a bony prominence . the injury can present as intact skin or an open ulcer . the injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (shear is stress/deformation of the skin from movement). Pressure injuries/ulcers are classified or staged according to the degree of injury to tissue, from Stage 1 (least injury) to Stage 4 (greatest injury). Stage 2 pressure injuries/ulcers involve the loss of the first skin layer (epidermis), thus exposing the second skin layer (dermis). The wound appears pink and moist. Stage 3 pressure injuries/ulcers involve a wound with total loss of the skin, revealing the layer of fat underneath. Stage 4 pressure injuries/ulcers involve the total loss of the skin and the underlying fat tissue, revealing muscle, bones and other tissues. A pressure injury/ulcer may also be classified as unstageable, which occurs when the wound is covered by slough or eschar (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2016) and www.npuap.org/wp-content/uploads/2012/02/Shear_slides.pdf). During an interview on 1/16/19, at 10:30 a.m., the Nursing Supervisor (NS) stated no pressure redistributing devices - either for the bed or wheelchair - were provided to Resident 24 prior to 1/15/19, when the pressure ulcers were detected. The NS stated the pressure ulcers were caused by moisture related to Resident 24's incontinence and refusal to allow staff to clean her. The NS stated for incontinent residents like Resident 24 staff should check and clean the resident every 2 hours. The NS stated that Resident 24 often refused to be checked and cleaned by staff. During an interview on 1/16/19, at 10:45 a.m., the Director of Nursing (DON) stated Resident 24 was provided a pressure redistribution mattress on 1/15/19, but prior to 1/15/19 Resident 24's bed had a regular, non-pressure redistributing mattress. The DON stated when not in bed Resident 24 used a wheelchair and was on her wheelchair all the time. The DON was asked if Resident 24 was provided a pressure redistributing cushion for her wheelchair. The DON stated Resident 24 had a foam to sit on top of in her wheelchair but there was no pressure redistributing device. The DON stated a ROHO (a pressure ulcer prevention) cushion had now been provided to Resident 24 to use on her wheelchair. During the same interview on 1/16/19, at 10:45 a.m., the DON stated Resident 24 was supposed to be checked and cleaned for incontinence every 2 hours. The DON was asked for records indicating staff checked and cleaned Resident 24 every two hours. The DON stated staff did not document this intervention. The DON stated Resident 24 refused to be cleaned all the time and the accumulated moisture resulting from the refusal to be cleaned caused the pressure ulcers. A review of Resident 24's clinical record indicated Resident 24 was compliant with incontinence care. Resident 24's Treatment Administration Record (TAR) for (MONTH) (YEAR) and (MONTH) 2019 (the TARs) indicated Resident 24 had skin treatments consisting of cleansing the groin and buttocks with soap and water and applying a skin protectant every shift. The TARs indicated Resident 24 received and complied with this treatment every day, three times a day, from (MONTH) 1 to 31st, (YEAR) and from (MONTH) 1 to 15th, 2019, with no refusals of treatment documented on any of those days. A review of Resident 24's progress notes indicated Resident 24 cooperated with care. Progress note dated 1/13/19 at 7 a.m. indicated Cooperates with staff. Progress note dated 1/12/19 at 7 a.m. stated Cooperates w/ care staff. Progress note dated 12/28/18 at 8 p.m. indicated pt (patient) cooperative with care. Progress note dated 12/27/18 (no time) stated Cooperative with staff. Facility policy titled Pressure Injury Prevention, dated 8/12/16, indicated: The Nursing Staff will implement interventions identified in the Care Plan based on the individual risk factors, which may include, but are not limited to: (A) Pressure redistributing devices when in bed and chair . (H) Bowel and bladder training, scheduled toileting or incontinence management program.

This Requirement is not met as evidenced by: Based on food storage, production and distribution observations, dietary and administrative staff interview and dietary and administrative document review the facility failed to ensure meals were prepared in a sanitary manner when the facility was unable to demonstrate that one dish machine effectively sanitized dishes in accordance with standards of practice and facility policy for greater than six months. This resulted in notification of the facility Administrator, Director of Nurses, Director of Staff Development, and Administrative Staffs M and N an Immediate Jeopardy Situation on 11/8/16 at 12:02 p.m., the Immediate Jeopardy was abated with the Administrator, Director of Nurses, Director of Staff Development, and Administrative Staffs L, M and N on 11/10/16 at 12:32 p.m. Additional findings included: The temperature in the dry storage area registered 78 degrees Fahrenheit for two of two days; Two dietary staff failed to wash hands, don and doff gloves during ware washing (the cleaning and sanitizing of utensils and food-contact surfaces of equipment) and food preparation; A serving scoop was left in the coffee on two separate days; Multiple areas of the kitchen were either not or ineffectively cleaned; There was no effective air gap in either of the food production sinks; Food production staff did not wear aprons; Multiple staff plating meals were observed wiping perspiration from their faces during meal plating; the ambient room temperature in the kitchen during evening meal production on 11/9/16 ranged from 88-90 degrees Fahrenheit; The ice machine was not sanitized in accordance with manufacturer's guidance and; The nutritional supplement utilized by license nursing staff was observed to be held at greater than 41 degrees Fahrenheit, 11 hours after being opened. Failure to ensure effective dietetic services operations may result in practices associated with cross contamination and foodborne illness (food poisoning caused by eating contaminated food)resulting in symptoms of gastrointestinal distress, decreased dietary intake, nausea/vomiting and in severe instances may result in death. These deficient practices had the potential to affect all residents. Findings: The standard of practice for sanitation of dishware, in a dishwasher, would include accurate determination of the sanitizing solution in accordance with manufacturer ' s guidance. Quaternary ammonium compounds are synthetic surface action agents. These compounds are not recommended for use in dishwashers as they are not compatible with most detergents and produce foam in mechanical operations, therefore are limited to use in manual dishwashing operations and as a surface sanitizer. Manufacturer's guidance for testing quaternary ammonia strength would be accomplished using a color reagent test strip, which when placed in the sanitizing solution for 15 seconds, would turn various shades of green (Ecolab.com). As a result the most commonly used sanitizer for dishwashers is chlorine. (Alabama Public Health, Food Code 2013) Manufacturer's guidance of the chlorine sanitizer utilized by the facility specified it was intended for mechanical spray warewashing machines. For sanitizing tableware in low-temperature ware washing machines, inject the chlorine sanitizer into the final rinse water at concentration of 100 ppm (parts per million) available chlorine. To ensure available chlorine concentration does not fall below 50 ppm (parts per million), periodically test the rinse solution with a suitable test kit and adjust the dispensing rate accordingly (Ecolab.com). On 11/8/16 beginning at 10:30 a.m., dish machine operations were reviewed with Dietary Staff (DS) W. When asked him to describe the process for ensuring the machine was working properly. He described a process of checking the temperature of the wash cycle which he demonstrated as 120°F (degrees Fahrenheit). He demonstrated he routinely recorded the temperature on a document titled Dish Machine. oncurrent observation of the chemicals utilized in the dish machine included a five-gallon bucket of chlorine sanitizer. After inquiring about an additional column on the form titled test strip which consistently was recorded at a value of 100. DS W described this column as depicting the strength of the sanitizer. DS W proceeded to demonstrate testing with the use of a quaternary ammonia test strip. The reaction was a burnt orange color. DS W proceeded to state this depicted a value of 100 parts per million (ppm) which was acceptable. During the interview DS AA brought over a bottle of chlorine test strips, provided by the chemical distribution vendor, and guided DS W to use this particular strip. DS W proceeded to place the strip in the bottom water reservoir of the dishwasher, holding it for approximately 15 seconds. There was no discernable color change to the strip. DS AA then presented a second bottle of chlorine test strips, lot number 5 with an expiration of January 2017, again holding the strips in the reservoir for approximately 15 seconds. There was no discernable color reaction to the strip. Using a same strip from the same bottle and in accordance with manufacturer's guidance, wet the strip with a water droplet and read immediately, There was no discernable reaction of the strip. In a concurrent interview with Dietary Staffs W, Z, AA, and BB, all stated that they routinely utilized the quaternary ammonia strips rather than chlorine strips to test the strength of the chemical sanitizer. They confirmed this was how they were trained. DS BB also stated that the chemical used for surface sanitation was the same as that for the dishwasher, except that, it was a different strength. In an interview on 11/8/16 at 11:55 a.m., Maintenance Director stated that an outside vendor provided the chemicals. He also stated that the last time the facility had documentation of the vendor checking the effectiveness of the dish machine was April 2016. He also stated that over the last several months he attempted to contact the technician responsible for the account, utilizing a cellular phone number; however, the technician did not return calls. An immediate jeopardy was called on November 8, 2016 at 12:02 p.m., in the presence of the Administrator, Director of Nurses, Director of Staff Development and Administrative Staffs M and N, in relationship to the lack of effective sanitation and monitoring of chemical effectiveness of the dish machine. Specifically, the dish machine was not sanitizing dishes. The last documented testing, that demonstrated the dish machine was properly sanitizing dishes was completed by an outside vendor was dated April 22, 2016. In an interview on 11/8/16 at 12:30 p.m., Administrative Staff M and Q provided monthly reports beginning 5/6/16-9/30/16 that were prepared from an outside consultant Registered Dietitian (RD). They stated the RD was testing the effectiveness of the sanitizer during these visits. In an interview on 11/9/16 at 10:10 a.m., with Contract Staff R, a consultant Registered Dietitian, she stated that she evaluated the effectiveness of the dish machine by reviewing the dish machine logs. She further stated that she had not witnessed the staff performing the testing, nor did she independently test the dish machine chemical level. In an interview on 11/8/16 beginning at 1:10 p.m., with the Contracted Vendor (CV) S, he was unsure of the last time the chemical dispensing of the machine was evaluated. He stated historically visits were on a monthly basis. CV S acknowledged that he was receiving phone calls from the facility on his cell phone; however, his employer did not allow him to arrange service calls. Rather, all calls must go through the corporate office. Review of facility document titled Dish Machine Temperature Log (low-temp (temperature) machine) from August-October 2016 consistently recorded the strength of the sanitizer as 100 ppm, three times a day for 90-93 entries per month. Review of facility procedure titled Dish Machine Temperature Recording, dated October 1, 2014 VI. The concentration of the sanitary solution during the rinse cycle is 50 ppm for chlorine sanitizer. This is used in low temperature dish machines. VII. A P.H. test is used daily and may be obtained from the chemical supplier for low temperature dish machine. The definition of P.H. is the level of acidity or alkalinity of a solution. The facility did not recognize that testing of the solution is exhibited as the strength of the solution in parts per million, rather than the acidity or alkalinity of the chemical. Review of dietary department in-services revealed that on 1/20/16 there was training on dish machine temperature; however there was no documented training and/or competency in relationship to chemical sanitizer testing specific to the dish machine. Review of the undated facility contract titled Phase II Dish machine Lease Agreement revealed that the contract was limited to the lease of the equipment. The agreement did not include a provision for preventative maintenance. In an interview on 11/8/16 at 2 p.m., the Administrator stated this was the only information regarding the dish machine . The following actions on the part of the facility contributed to the abatement of the immediate jeopardy on 11/10/16 at 12:32 p.m. The contracted vendor repaired the machine on 11/8/16 prior to dish washing items from the midday meal. Facility dietary staff was retrained by the contracted vendor and Administrative Staff M beginning on 11/8/16 and evaluated for competency in relationship to the proper functioning of the dish machine. Additionally, dietary staff were instructed and deemed competent to perform manual dish washing should there is an issue with the dishwasher in the future. The Dietary Services would instruct staffs that were unable to attend the training prior to beginning their next scheduled shift. During kitchen observation on 11/7/16 beginning at 9:40 a.m.: The main dry food storage was located in the basement of the building. There was no thermometer in the room. In a follow up observation on 11/8/16 at 3:05 p.m., the facility placed a thermometer in the room. The temperature was noted as 78°F (degrees Fahrenheit). Also noted, there was no ventilation in the room. In a follow up interview and review of construction building plans on 11/9/16 beginning at 8 a.m., with the Maintenance Director he was unable to demonstrate whether the area was approved for dry food storage. Review of facility' s policy titled Food Storage dated 11/1/14 noted that the dry storage area should be .ventilated with a temperature of 50°F to 70°F. At 10:05 a.m., Dietary Staff B, without changing gloves - put dirty utensils in the dishwasher. Removed clean utensils from the clean rack of the dishwasher, wiped down a food cart, stored clean pitchers and plate, put dirty glasses in the dishwasher, dipped her gloved hands in the red bucket, removed clean utensils from the dishwasher, removed food particles from the tray, dipped her gloved hands in the red bucket and removed cleaned utensil from the dishwasher. At 10:35a.m., Dietary Staff B, with clean gloves, put dirty trays in the dishwashers, removed clean plates from the dishwasher, picked up a trash bag, removed clean trays from the dishwashers, wiped down a cart, dipped her gloved hands in the red bucket then removed clean utensils from the dishwasher. When asked, Dietary Staff B stated the red bucket contained sanitizer. At 4 p.m., a green handled scoop was stored in the coffee container. Follow up observation on 11/8/16 at 10:25 a.m., the scoop continued to be stored in the coffee. In an interview on 9/10/16 beginning at 10:30 a.m., with DS BB, he acknowledged that scoops should not be stored in food products. Facility policy titled Food Storage dated 11/1/14 failed to note guidance for staff with respect to the storage of scoops in relationship to dry storage guidelines. At 4:25 p.m., the drawer under the toaster, containing cleaned and sanitized serving utensils, had multiple unidentified food particles dried on the side as well as the bottom of the drawers. The large drawer under the toaster containing loaves of bread had caked on food particles. A drawer adjacent to the steam table contained steam pan lids, all of which had unidentified, dried on food particles. the floors throughout the kitchen had food remnants as well a buildup of a material resembling dust and black material resembling general outside dirt. During a kitchen observation on 11/8/16 beginning at 10:30 a.m., a tan sticky substances covered multiple areas of the cabinets and handles. The refrigerator doors and handles had dried on food particles. The top of the resident meal carts had a sticky substance resembling grease as well as a grey fuzzy material resembling dust on the top of the cart in addition to unidentified food particles were on the inside and wheels of the equipment. In confidential staff interviews with dietary staff on 11/8/16 and 11/9/16, between the hours of 8 a.m. and 6:30 p.m., staff members related while they were assigned cleaning duties, the scheduled work hours did not allow for enough time to fully complete position duties, in addition to cleaning duties, as outlined in the job description. Their primary function was to produce resident meals, generally completing these duties just a few minutes before required to clock out. During general food production observation on 11/9/16 beginning at 2:55 p.m., DS AA was observed cleaning food contact surfaces. He cleaned the counter with soap after which he wiped the counter with a towel from a red bucket containing quaternary ammonia sanitizer. There was no rinsing of the detergent prior to the application of sanitizer. In an interview with DS Z on 11/10/16 at 10:30 a.m., he stated to his knowledge there was no standardized procedure for cleaning food surfaces. The effectiveness of quaternary ammonia may be compromised by the presence of detergents (Cross Reference F371, Finding 1). The standard of practice would be to develop effective cleaning procedures of food contact equipment by ensuring a three-step process that included 1) washing with a detergent to effectively remove or loosen soils; 2) followed by a rinse step to ensure cleaning chemicals are removed; 3) followed by a sanitizing step (Food Code, 2013). Review of ten RD consultant reports from 1/29/16 through 10/28/16 revealed consistent identification of issues related to physical environmental concerns such as overall kitchen and equipment cleanliness. Review of five facility documents titled Dietary Department Cleaning Schedule and Checklist revealed there were multiple lapses in documentation of cleaning. As an example, there was no documentation that the floors were cleaned on a daily basis, despite it being on the checklist. Similarly, walls, doors and refrigerators were scheduled to be cleaned weekly; however, there was no documentation that the task was completed. It was also noted that in the cleaning log book facility staff had completed the log for future dates. As an example, the form for 11/28/16-12/4/16 was already filled out as completed for cleaning of the can opener, sinks, food carts, dishwasher, drains, disposal, garbage cans, and janitor closet. At 4:40 p.m., Dietary Staff W was draining vegetables for the evening meal in a two-compartment sink. The sink did not have an air gap, rather plumbed directly into the sewer system. In an observation on 11/8/16 beginning at 11:30 a.m., Dietary Staff X was washing produce in the single compartment sink. Concurrent observation revealed that while the sink did not directly drain into the sewer system, the vertical space requiring an air gap was obstructed, as it was covered with a bell shaped receptacle. The standard of practice within food service would be to ensure the presence of an air gap in all food production related equipment, including sinks. An air gap (an unobstructed vertical space) between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch (Food Code, 2013). At 4:45 p.m., Dietary Staff (DS) Y was not wearing an apron. His clothing was soiled and stained. Additional observations on 11/8/16 beginning at 10:30 a.m., revealed while DS Z was wearing an apron, it did not cover the upper half of his body, rather was folded in half. Similarly, DS AA was not wearing an apron. DS AA's clothing was soiled with food remnants and his pants visibly soiled. Review of facility ' s policy dated 6/1/14 titled Dietary Department Infection Control for Dietary Employees required staff to wear clean working attire as well as clean aprons. In an interview with Dietary Management Staff BB on 11/10/16 at 10:30 a.m., he stated that the facility did not provide clean uniforms for employees; however, aprons were provided and should be worn. At 5 p.m., the ambient temperature of the kitchen was warm. Dietary Staff (DS) X was perspiring along his forehead and face. During the course of meal service, DS X repeatedly wiped his face with his forearm. He did not perform hand hygiene after wiping his face. During an observation on 11/8/16 beginning at 10:30 a.m., the kitchen was warm. In a concurrent interview on 11/8/16 at 10:30 a.m., DS Z, stated that it was typical for the kitchen because the cooler did not work very well. During an observation on 11/9/16 at 2:55 p.m., the ambient air temperature of the kitchen was 85°F. In an interview with Maintenance Director on 11/9/16 at 3 p.m., he acknowledged that he did not monitor the ambient room temperature of the kitchen. Review of outside temperatures from 11/7/16 to 11/9/16 ranged from 70-74°F. Additionally, actual temperatures in the area beginning 7/1/16 through 10/30/16 ranged from 75-93°F (National Weather Service, 2016). The facility was unable to provide documentation that the issue, in relationship to ambient air temperature in dietetic services, was identified or addressed. Surveyor thermometer was calibrated for accuracy in the presence of DS AA on 11/9/16 at 5 p.m. During observation of meal service with DS AA on 11/9/16 at 5:10 p.m., revealed ambient room temperatures ranging from 88-90°F. During plating DS AA repeatedly wiped perspiration from his face with his forearm without hand hygiene before returning to meal distribution. During concurrent interview on 11/9/16 at 5:10 p.m., DS AA these were typical temperatures and it was worse during summer months. Facility policy titled Dietary Department-Infection Control for Dietary Employees dated 6/1/14 guided staff to wash hands after touching bare human body parts other than clean hands and clean, exposed portions of arms. During general food production observations on 11/8/16 beginning at 11:30 a.m., Dietary Staff (DS) X with clean gloves, washed the outside of oranges in prep for the noon meal. DS X touched multiple unclean drawers, and returned to cut the oranges. All the tasks were completed without changing gloves or hand hygiene. Facility policy titled Dietary Department-Infection Control for Dietary Employees, dated 6/1/14, noted that proper handwashing would occur immediately before engaging in food preparation as well as after handling soiled equipment covered On 11/8/16 beginning at 3:25 p.m. the preventative maintenance for the facility ice machine was reviewed with the Maintenance Director. He described a quarterly process that included the addition of a chemical cleaner to the ice production reservoir that was circulated for a period of 20 minutes, after which he produced ice and discarded the first two batches. Review of the manufacturer's guidance for the ice machine revealed that the preventative maintenance required a two-step, rather than a one-step process. The manufacturer recommended that, in addition to cleaning, there be circulation of a sanitizer through the interior components. During observations on 11/9/16 beginning at 8 a.m., license nursing staff had a small ice chest on the medication cart containing a protein based nutritional supplement. In an interview on 11/9/16 beginning at 5:50 p.m., Licensed Staff T stated the supplement was opened by the day shift, usually between 7 and 8 a.m., at which time it was placed in the ice chest with ice at the bottom. She further stated both the day shift and afternoon shift would to use the supplement throughout the day. She confirmed the observed supplement was opened by the day shift. While it was dated, the time it was opened was not recorded. She also stated that a Registered Dietitian told them that as long as the product was on ice it would be acceptable to use for 24 hours. Temperature of the nutritional supplement on 11/9/16 at 5:50 p.m., was 59°F (degrees Fahrenheit) for the 1.7-calorie supplement and 62°F for the 2-calorie supplement. The temperatures, based on interview, were recorded approximately 10.5 hours after opening. In an interview on 11/9/16 at 6:30 p.m., with Licensed Staff U he stated that he uses the same protein supplement as the day shift. He described if there was leftover supplement he would leave it in the ice chest for the night shift. Manufacturer's recommendations for the protein-based supplement were to discard after six hours if the product temperature exceeded 41°F. Potentially hazardous foods are those capable of supporting bacterial growth associated with foodborne illness. Protein-based foods are considered to be potentially hazardous and require time/temperature control for food safety (Food Code, 2013).

Based on observation, interview and policy and manufacturers information, the facility failed to ensure infection control procedures were followed when: 1. One staff member, Staff H cleaned glucometers (blood sugar testing device) between five out of 14 sampled residents ( 4, 5, 11, 13,14). This resulted in the potential for transfer of blood borne organisms and infection between residents through cross contamination. Due to the failure for the facility to clean the glucometer between the use of five residents, an immediate jeopardy was identified on 11/3/15 at 5:45 p.m. The Administrator, Director of Nurses and the Nurse Quality Consultant were informed that License Staff H did not clean the glucometer between sampled residents (4,5,11,13,14). Immediate Jeopardy was abated on 11/6/15 at 12:51 p.m., when all licensed nurses were in-serviced begining 11/3/15 on glucometer disinfection between resident usage with focus on the contact time of the disinfectant per manufacture's instructions. The Administrator, Director of Nurses and the Nurse Quality Consultant were present. 2. One out of two housekeeping staff (Q) were not aware of the contact cleaning time for a disinfectant cleaner used to clean resident's room. This could result in the spread of infection to another resident. 3. License Staff H and K were not washed their hands after the removal of gloves which could lead to cross contamination and illness among facility residents. 4. Sterile urine culture cups were stored out of the way of possible water droplet or spray contact. 5. One family member obtained water from a container on the medication cart after assisting a resident to eat and without washing her hands, which could lead to cross contamination of bacteria between residents. Findings: During an observation on 11/3/15 at 5:55 a.m., Licensed Staff H pulled a blood testing meter device (glucometer) out of the medication cart. Licensed Staff H did not clean the meter and placed it on Resident 11's bedside table. There was a small blood strip inserted in the meter from which Licensed Staff H touched to Resident 11's finger, for completing the blood sugar test. After finishing, Licensed Staff H brought the meter back to the medication cart, discarded the strip in the trash and set the meter back on the medication cart without cleaning or disinfecting it. During an observation on 11/3/15 at 6:15 a.m., Licensed Staff H took the meter which had not been cleaned or sanitized into Resident 13's room and placed it on the bedside table with a new meter strip inserted. Licensed Staff H pricked Resident 13's finger with a lancet (sharp pointed surgical instrument used to make a small incision)and handled the meter with gloves and brought Resident 13's bleeding finger up to touch the strip in the meter. Licensed Staff H then brought the meter back to the medication cart and placed it on the cart without cleaning it. During an observation on 11/3/15 at 6:21 a.m., Licensed Staff H took the glucometer which had not been sanitized into Resident 14's room and placed it on her bedside table. Licensed Staff H then used the glucometer with a new strip inserted to touch her finger which had been lanced to withdraw blood. Licensed Staff H then returned to the medication cart and discarded the strip in the trash before putting the glucometer back on the medication cart. Licensed Staff H did not clean the glucometer or disinfect the glucometer after use. During an observation on 11/3/15 at 6:40 a.m., Licensed Staff H took the glucometer from the medication cart and placed it on Resident 5's bedside table. Licensed Staff H used the lancet device to prick her finger and squeezed her finger as he brought the glucometer with the meter strip up to the finger to touch the blood on the finger. He then took the meter back out to the cart and disposed of the strip from the glucometer and placed the glucometer back on the cart without cleaning or disinfecting it. During an observation on 11/3/15 at 6:50 a.m., Licensed Staff H took the glucometer from the medication cart and took it in to Resident 4's room and placed it on the bedside table. Licensed Staff H lanced Resident 4's finger and brought the meter with the strip inserted up to Resident 4's finger to touch the blood from the finger. Licensed Staff H then took the meter back to the cart and disposed of the strip before putting the meter back in the cart. Licensed Staff H did not clean or disinfect the meter before putting it back in the cart drawer. During an interview on 11/3/15 at 7:40 a.m., Licensed Staff H stated that he cleaned the glucometers at night time with alcohol or the red disinfectant wipes, located on the bottom of the medication cart, but did not always clean after each resident use. During an interview on 11/3/15 at 4:55 p.m., Administrative Staff B stated that staff were supposed to use the red top disinfectant wipes to clean the glucometer between residents, to prevent the spread of blood bourne pathogens and infection between residents. On 11/3/15, review of the Diabetic Care policy revised 1/1/12, indicated that all licensed nurses should maintain blood glucose equipment per vendor recommendations. Review of the user instruction manual for the blood glucose monitoring device indicated that contact with blood presents a potential infection risk and the meter should be cleaned and disinfected between patient use. Cleaning and disinfection is completed using a EPA, (Environmental Protection Agency) disinfectant or germicide wipe. During an interview on 11/9/15 at 9:00 a.m., Administrative Staff C stated the facility followed CDC guidelines for infection control. Review of CDC (Centers for disease Control and Prevention) guidelines dated 5/2/12, indicated if blood glucose meters are shared, the device should be cleaned and disinfected after every use per the manufacturer's instructions to prevent carry-over of blood and infectious agents. The CDC guidelines indicated a risk of glucose testing is the opportunity for exposure to blood borne viruses (HIV (human immunodeficiency virus), hepatitis C virus .) through contaminated equipment and supplies if devices for testing are shared. 2. During an observation of the housekeeping closet on 11/9/15 at 8:20 a.m., there was an automatic mixer dispenser for the disinfectant cleaner. On the shelf next to the dispenser were containers of 3M (a global innovation company) concentrated cleaner for floors, resident rooms and bathrooms. During an interview at this time, Unlicensed Staff Q stated that she used the Quaternary disinfectant cleaner (cleans, disinfectants and deodorizes in one step. For use on hard, non-porous surfaces like floors, walls, toilet bowl surfaces, sinks, showers, lavatory fixtures, finished woodwork, vinyl and plastic upholstery, etc.) for cleaning resident beds and put the solution in the spray bottle from the mixer, sprayed it on the resident bed and wiped it off. Unlicensed Staff Q stated she did not keep track of the time the solution stayed wet on the bed and didn't know how long it was supposed to be left wet on the bed to be a effective disinfectant. The label on the 3M Quat cleaner indicated it was to remain wet on the surface for 10 minutes to kill all organisms. During an interview on 11/9/15 at 10:50 a.m., Unlicensed Staff R, who was the supervisor for Unlicensed Staff Q, stated that each bottle of disinfectant cleaner had different contact times and staff should be aware of the contact times to ensure organisms were killed. During an interview on 11/9/15 at 1:55 p.m., Administrative Staff C stated that the contracted cleaning agency was supposed to train their staff on the disinfectants they use. On 11/9/15, review of the facility's contract with the housekeeping service company titled Master Agreement for Services dated 2/1/10, indicated the contractor was to oversee services provided, do quality control inspections and monthly in services of staff. On 11/9/15, review of the 3M HB Quat disinfectant cleaner technical data provided by the contractor, dated 8/12, indicated, in order for the cleaner to be used as a disinfect, distroy fungus and kill viruses, staff should use .35 ounces per gallon of water for hard non-porous surfaces and treated surfaces. The surfaces must remain wet for 10 minutes contact time to destroy viruses. Review of the orientation manual dated 10/14/08, for infection control, indicated that precautions designed to intercept transmission of infection included environmental control to ensure the health care establishment has adequate procedures for the routine care, cleaning and disinfection of the environmental surfaces, beds, bed rails, bedside equipment and other frequently touched surfaces and monitoring that these procedures are being followed. 3. During an observation on 11/3/15 at 6:06 a.m., Licensed Staff H removed his gloves and did not wash hands after checking Resident 11's blood sugar. During an observation on 11/3/15 at 9:05 a.m., Licensed Staff K administered po (by mouth) medication to Resident 6 and prepared to administer medication to Resident 1. Licensed Staff K pulled up his pants, did not wash his hands or use hand sanitizer before administering medication to Resident 1. During an observation on 11/3/15 at 11:30 a.m. Licensed Staff K checked Resident 5's blood sugar, took off his gloves and did not use hand sanitizer or wash his hands before he handled his keys and opened the medication cart drawer. During an observation on 11/3/15 at 11:40 a.m., Licensed Staff M took his gloves off after checking Resident 12's blood sugar and did not wash his hands or use hand sanitizer before handling his keys and opening the medication drawer. During an observation on 11/3/15 at 12:10 p.m., Licensed Staff K removed his gloves after administering insulin to Resident 13, and did not use hand sanitizer or wash his hands after removing the gloves. During an observation on 11/4/15 at 5:05 p.m., Licensed Staff K removed his gloves after checking blood sugar on Resident 5, and did not wash his hands before putting on another pair of gloves. On 11/4/15 at 5:45 p.m., Licensed Staff K took off his gloves after giving insulin to Resident 13 and did not wash his hands or use hand sanitizer before handling the drawers of the medication cart and putting on other gloves. When asked about washing hands after removal of gloves, Licensed Staff K stated that no one explained to him that he should sanitize his hands after taking off his gloves. During an interview on 11/9/15 at 1:50 p.m., Administrative Staff C stated when staff remove gloves they should wash their hands or use hand sanitizer, to prevent cross contamination of surfaces. Review of the infection control procedures from the orientation manual dated 10/14/08 indicated staff were to remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another patient. Staff must wash hands immediately to avoid transfer of microorganisms to other patients or environments. Review of the facility's Hand Hygiene policy and procedure dated 2/1/13 indicated that staff were to use alcohol-based hand hygiene to decontaminate hands after removing personal protective equipment (gloves) and before moving to another resident in the same room or exiting the room. 4. During an observation of the medication room at the nurses station on 11/2/15 at 10:20 a.m., under a functioning sink in the cabinet was an open plastic bag of multiple containers with orange caps, and labels indicating they were sterile containers. During an interview at this time, Licensed Staff L stated that they were sterile containers for urine cultures and there were about 50 to 100 in the bag. Licensed Staff L stated that they were usually kept above the sink. Licensed Staff L stated the sterile urine cups should not be stored under the sink as a leak from the pipes could happen and contaminate the sterile containers. During an observation, Licensed Staff L then removed the cups and placed them on the counter above the sink. During an observation on 11/5/15 at 8 a.m., the sterile urine specimen containers that were in the open plastic bag remained under the sink. During an interview on 11/10/15 at 5 p.m., Administrative Staff A stated the facility did not have a policy and procedure for storage of sterile supplies. During an interview on 11/9/15 at 9 a.m., Administrative Staff C stated the facility followed CDC guidelines for infection control. Review of CDC guidelines for the disinfection and sterilization in healthcare facilities dated 2008, indicated medical supplies should not be stored under sinks or in locations where they can become wet as sterile items that become wet become contaminated, as moisture brings microorganisms from air and surfaces. 5.During a concurrent observation and interview on 11/2/15, at 12:30 p.m., a resident's family was assisting the resident for lunch in the dining room. The family stated the facility did not provide water in the dining room sometimes. At 12:35 p.m., the family asked a CNA (Certified Nursing Assistant) who was assisting a resident at a different table for water. The CNA did not leave the table to provide water to the family. The family went to a medication cart in front of room [ROOM NUMBER] and obtained water from a water container without staff assistance while a staff was working at the medication cart. The family did not wash hands between assisting the resident and obtaining water from the medication cart. During an interview on 11/10/15, at 9:15 a.m., Administrative Staff C stated staff should help the family for obtaining water because of infection control and minimizing the spread of infection. Review of the facility's Hand Hygiene policy and procedure dated 2/1/13 indicated that Facility staff, visitors and volunteers must perform hand hygiene procedures before eating, before and after food preparation and before and after assisting residents with dining if direct contact with food is anticipated or occurs.

Based on observation, staff interview, and resident record review, policies and procedure review, the facility failed to ensure that 3 out of 5 randomly selected residents, who received rapid acting insulin (Residents 14,16, and 18) received Humalog and [MEDICATION NAME]/[MEDICATION NAME] (both which are rapid acting insulins), within 15 minutes of the residents meals, as recommended by the insulin manufacturers, consulting pharmacists, and the resident's attending physician. This caused a potential for harm to the resident's health, including [DIAGNOSES REDACTED] (low blood sugar) which can result in loss of consciousness, [MEDICAL CONDITION], coma, and possible death. An Immediate Jeopardy was called on 10/19/10 at 5:25 p.m. The Executive Director, Director of Nursing Services, Director of Operations, and Director of Clinical Operations were present. Findings: On 10/19/10 at 6:58 a.m., Licensed Staff C was asked if she could be observed administering medications to the residents, this morning. She stated she had administered all of her medications which included the insulin injections (medication used to treat high blood sugar.) She stated that she liked to administer them around 6:30 a.m. to get them done early. Licensed Staff C stated she administered insulin injections to five residents, three of which were on Humalog and [MEDICATION NAME]/[MEDICATION NAME] (both are rapid acting insulins which are absorbed in the body quickly and begins lowering blood glucose quickly, 10 to 20 minutes after the injection, as per manufacturer's insert). On 10/19/10 at 7:05 a.m., review of the medication administration records (MAR) for those residents on rapid acting insulin showed the times of insulin administration to be 6:30 a.m., 11:30 a.m., and 4:30 p.m. The resident's meal times were scheduled at 7:00 a.m., 12:00 noon, and 5:00 p.m. The MAR indicated that Resident 14's physician's orders [REDACTED]. On 10/19/10, Resident 14, 16, and 18's records were reviewed. Resident 14 was readmitted to the facility on [DATE], Resident 16 was readmitted to the facility on [DATE], and Resident 18 was readmitted to the facility on [DATE]. Resident 14, 16, and 18's [DIAGNOSES REDACTED]. On 10/19/10, observations revealed that Resident 16 and 18 began to eat their breakfast meal at 7:45 a.m., and 7:43 a.m. This was approximately 45 minutes after Licensed Staff C stated she liked to administer the insulin at 6:30 a.m. On 10/22/10 at 9:10 a.m., Licensed Staff C was questioned regarding her knowledge of administering rapid acting insulin in correlation with the resident's meals. She stated that she knew that the resident's meals were supposed to be administered right after the rapid acting insulin injection however she stated she gave the residents the insulins early because she had to give report at 7:00 a.m. On 10/19/10, the facility's pharmacy staff faxed the facility staff with the rapid insulin inserts (a written description of the medication, instructions on how and when to administer the medication, and any side effects to watch for when taking the medication) for [MEDICATION NAME]/[MEDICATION NAME]and Humalog. [MEDICATION NAME]/[MEDICATION NAME]insert indicated " Take [MEDICATION NAME] exactly as prescribed. You should eat a meal within 5 to 10 minutes after using [MEDICATION NAME] to avoid low blood sugar." The manufacturer's insert further indicated "Severe low blood sugar can cause unconsciousness (passing out) [MEDICAL CONDITION], and death." The Humalog inserts indicated " when used as a meal-time insulin, the dose of Humalog should be given within 15 minutes before or immediately after the meal." On 10/19/10 at 11:36 a.m., Licensed Staff F was observed to administer 2 units of Humalog ([MEDICATION NAME], rapid acting insulin) to Resident 14. Resident 14 arrived in the dining room at 12:15 p.m., and began to eat at 12:25 p.m., almost 50 minutes after the resident had received her rapid acting insulin. On 10/22/10 at 8:30 a.m., Licensed Staff F was questioned regarding her knowledge of administering rapid acting insulin in correlation with the resident's meals. She stated she knew that the resident needed to eat her meal within 15 to 30 minutes after her insulin injection and that was why she had asked Resident 14, on 10/19/10, directly after her insulin injection, to hurry to the dinning room. She stated she didn't know that the kitchen would be late in serving the meals. On 10/19/10 at 3:10 p.m., Administrative Staff B (Director of Nursing) was questioned regarding the administration of rapid acting insulin in correlation with the resident's meals. She stated that the nurses should administer the rapid acting insulin, within 15 minutes of the resident's meals. On 10/19/10 at 2:40 p.m., the facility's Pharmacist, Pharmacy Staff K, was interviewed by telephone. When asked the time frame that rapid acting insulin should be administered in correlation with the resident's meal, he stated that each insulin administration was individualized to the specific resident and that the correlation of the administration of the insulin and the meal was based on the reaction each resident had to the insulin. When questioned as to whether he had reviewed or observed the times the nurses administered the rapid acting insulin in correlation with the meal times, he stated that he did however, Resident 14,16, and 18,'s clinical records revealed no documentation, from the facility's pharmacist, to support any monitoring of the nurses administration of the resident's rapid acting insulin in correlation with their meals times. On 10/19/10 at 4:30 p.m., The facility's medical director and Resident 14,16, and 18's physician, Physician Staff L, was interviewed on the telephone. He was asked what his expectations of the nursing staff were in regards to the administration of the rapid acting insulin in correlation with their meals. He stated that the rapid acting insulin injections should be close to the meals "within 30 minutes" of insulin injection to prevent a hypoglycemic reaction (low blood sugar.) When informed that the [MEDICATION NAME]/[MEDICATION NAME]insert indicated that the insulin should be administered within 15 minutes of the insulin, he stated that administering the rapid acting insulin within 15 minutes of the meal would be the target time (ideal time). On 10/19/10, at approximately 4:45 p.m., the facility's policy and procedures regarding Diabetes Mellitus, Guidelines for Management and [DIAGNOSES REDACTED], dated 4/28/09, failed to address the administration of rapid insulin administration in correlation with the resident's meal. Administrative Staff B was requested to provide the facility's policy and procedure regarding insulin administration however, a policy and procedure was not provided. The survey team called an Immediate Jeopardy on 10/19/10 at 5:25 p.m. based on the facility's failure to have a system in place to ensure administration of the [MEDICATION NAME]/[MEDICATION NAME] and Humalog insulin for the residents on rapid acting insulin as evidenced when residents received their meals more than 15 - 30 minutes after their rapid acting insulin administration. This failure placed the residents at risk for hypoglycemic reaction which includes [MEDICAL CONDITION], loss of consciousness, coma and possibly death. The Director of Nursing Services, Executive Director, District Director of Operations, and District Director of Clinical Operations were present during the meeting. On 10/19/10, review of the manufacturer's insert under the section titled "Warnings." indicated "[DIAGNOSES REDACTED] is the most common adverse effect associated with insulins, including Humalog. Severe low blood sugar can cause unconsciousness (passing out), [MEDICAL CONDITION], and death." On 10/19/10 at 6:40 p.m., the Executive Director presented an Action Plan to the surveyors. The action plan consisted of the following elements: (1) The attending physician for all 5 residents will assess their blood glucose history and insulin administration regimen. (2) The care plan for all patients receiving rapid acting insulin will be reviewed and updated as necessary. (3) On 10/19/10 education was started for licensed nurses on Diabetes Management, Hypoglycemic Protocol, and review literature on the rapid acting insulin. (4) On 10/20/10, education will be provided to CNA's and licensed nurses on changes to the meal delivery process. Licensed nurses will be educated on the changes to the MAR and insulin management process. (5) Patients with sliding scale insulin orders will be monitored for signs and symptoms of [DIAGNOSES REDACTED] every shift. Monitoring will be documented in the MAR. (6) Patients with orders for rapid acting insulin will receive their meals within 15 minutes of administration of insulin. (7) Effective with the breakfast meal on 10/20/10, meals for patients with orders for rapid acting insulin will be delivered at the beginning of the tray line and the tray line will start as follows: Breakfast - 7 a.m., tray to be delivered by 7:15 a.m. Lunch - 12 noon, tray to be delivered by 12:15 p.m. Dinner - 5 p.m., tray to be delivered by 5:15 p.m. (8) Effective 10/20/10, rapid acting insulin will be administered at 7:15 a.m., 12:15 p.m. and 5:15 p.m. (9) Effective 10/20/10, rapid acting insulin will not be administered unless the meal tray has been delivered to the patient for consumption within 15 minutes. Licensed Nurses will document the following in the MAR: Time the rapid acting insulin was administered Verification that meal was available for resident to eat Blood glucose level Signature (10) Effective 10/20/10, licensed nurse will monitor meal consumption for patients with orders for rapid acting insulin to ensure that at least 50% of meal is consumed within 30 minutes of receiving rapid acting insulin. Substitute will be offered to any patient who received rapid acting insulin who did not consume 50% or more of the meal. The licensed nurse shall follow the hypoglycemic protocol if the patient continues to refuse the substitute. Licensed nurse will document signs and symptoms of [DIAGNOSES REDACTED]. (11) On 10/21/10, tray cards will be marked to identify patients at risk for [DIAGNOSES REDACTED] due to insulin administration. (12) Effective 10/20/10, MARs will be updated to reflect monitoring of meal delivery to patient who have orders for rapid acting insulin. (13) Effective 10/21/10, a daily audit will be implemented of rapid acting insulin, delivery, and meal service verification for patients with orders for rapid acting insulin. Results will be reported to the Director of Nursing Services (DNS) or designee daily. Responsible person: (14) The licensed nurses will be responsible to ensure that patients receiving rapid acting insulin have their meals within 15 minutes of insulin administration and will also be responsible for assessment and care plan updates as necessary. (15) The DNS will be responsible for coordinating physician assessment. (16) The Staff Development Coordinator will be responsible for education. (17) Licensed Nurses will be responsible for signs and symptoms of [DIAGNOSES REDACTED] and documentation in the MAR. (18) The DNS will be responsible for ensuring timely administration of insulin. (19)The Licensed Nurses shall be responsible for updating the MARs to reflect necessary systemic changes. (20) Medical Records or designee shall be responsible for daily audits. (21) DNS is responsible for ongoing compliance. The immediate action plan was accepted on 10/19/10 at 7:00 p.m. The Director of Nursing Services, District Director of Operations, Executive Director, and District Director of Clinical Operations were present at the meeting. On 10/20/10 at the 12:00 noon meal, residents with orders for rapid acting insulin were observed and were provided with their meals at the appropriate times. Insulin injections were administered to the resident's within 15 minutes of their meal as per the action plan. On 10/21/10 at 12:00 noon, all residents, with physician orders [REDACTED]. Plan. Licensed Staff in-servicing logs were provided. Interviews with licensed staff indicated they had been in-serviced and were knowledgeable regarding the administration of the rapid acting insulin in conjunction with the resident's meals. The resident's care plans were updated with interventions to indicate that the meals will be given to patient's within 15 minutes post administration of rapid acting insulin. The MARs reflected the time changes to coordinate the rapid acting insulin administration with the resident's meals as per standard of practice. Based on the implementation of the Action Plan, the Immediate Jeopardy was abated on 10/21/10 at 4:30 p.m. The Executive Director, Director of Nursing Services, Director of Operations, and Director of Clinical Operations were present during the abatement of the Immediate Jeopardy.