Every finding on record at Santa Clarita Post-Acute Care Center

Based on observation, interview, and record review, the facility failed to follow infection prevention standards, when:Certified Nurse Assistant (CNA) 1 did not change gloves and did not perform hand hygiene between handling soiled and clean linen for one in three sampled residents (Resident 1);CNA 1 performed hygiene of female genitals by wiping from back to front for one in three sampled residents (Resident 1); andClean linen was stored on the bottom of resident's individual closet for one in three sampled residents (Resident 3).These failures had the potential to cause urinary tract infection (the invasion and multiplication of harmful germs in the urethra, bladder and kidneys), to cross-contaminate clean linen and surfaces with disease causing germs and further spread the germs.Findings:1. During a review of Resident 1's admission record, undated, the admission Record indicated the facility admitted Resident 1 on 8/24/2026 with diagnoses including after care of partial intestinal obstruction and unsteady gait, hypertension (chronic high blood pressure), diabetes mellitus (chronic metabolic disorder of persistent high blood sugar), hypothyroidism (chronic low thyroid hormone), chronic kidney disease (decreased ability of kidneys to filter blood due to damaged tissue), polymyalgia rheumatica (an inflammatory condition that causes severe pain and stiffness in the muscles and joints of the shoulders, hips, and neck).During a review of Resident 1's History and Physical (H&P), dated 8/26/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Care Plan Report, dated 8/25/2026, the Care Plan Report indicated Resident 1 had alteration in bowel and bladder, and indicated the nursing interventions: Check as required for incontinence, wash, rinse, dry perineum. Change clothing as needed after incontinence (lack of control in bladder or bowel) episodes. Check for incontinence as needed and provide good peri care (care for private parts/genitals) after each incontinent episode. Hand washing before and after delivery of care.During an observation on 8/27/2026 at 5:30 a.m. in Resident 1's room, Resident 1 was lying in bed, awake, alert. CNA 1 performed hand hygiene and put on gloves. CNA 1 brought into the room a clean linen in a plastic bag and used half of water-soaked towel and half dry towel to clean Resident 1. CNA 1 wiped Resident 1's genitals from back to front (standard is to wipe from front to back). CNA 1 did not change gloves between handling dirty linen and clean linen during care of Resident 1. After CNA 1 finished changing pads and diaper, without taking off the gloves, CNA 1 went on to touch Resident 1's side table and personal items.During an interview on 8/27/2026 at 6:30 a.m. with CNA 1, CNA 1 stated that during the care for Resident 1 she did not change the gloves between touching the soiled and clean linen. CNA 1 stated that she should have not touched Resident 3' side table and her items before changing gloves. CNA 1 states the potential negative outcome would be contamination of new clean linen from the dirty linen, and it was an infection control issue. CNA 1 stated she wiped Resident 1's genitals wrong, which could cause urinary tract infection. CNA 1 stated she should have disinfected (clean and sanitize using a special chemical that kills germs) the areas she touched with soiled gloves.During an interview on 8/27/2026 at 11:54 a.m. with the Director of Nursing (DON), the DON stated that nurses should perform hand hygiene and change gloves accordingly to our policy. DON stated potentially CNA 1's practice could cause an infection for residents during perineal care, urinary tract infection and contaminate clean linen.During a review of facility's policy and procedure (P & P) titled, Infection Prevention Quality Control Plan, last revised on 3/20/2025, the P & P indicated a purpose: To provide guidelines for general infection control while caring for residents. The P & P further indicated: Employees must wash their hands for at least twenty (20) seconds using antimicrobial or nonantimicrobial soap and water under the following conditions: before and after assisting a resident with personal care (e.g., oral care, bathing); before and after assisting a resident with toileting; After handling soiled or used linens.2. During a review of Resident 3's admission Record, undated, the admission Record indicated that the facility admitted Resident 3 on 6/30/2026 with diagnoses including aftercare following surgery of neoplasm (an abnormal mass of tissue that forms when cells grow and divide more than they should), encounter of colostomy (surgically made opening in intestine and abdominal wall to empty the bowel) malignant neoplasm of sigmoid colon (cancer of lower part of colon), bladder disorder, and absence of a kidney. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), the MDS indicated that Resident 3's thinking, problem solving and memory skills were intact. The MDS indicated that Resident 3 had functional abilities (the ability to perform tasks of daily living such as dressing, walking, bathing). Resident 1 required set up for meal and oral hygiene. Resident 1 needed supervision to partial assistance with dressing. Resident 1 needed partial assistance with bed mobility and transfer. Resident 1 needed total assistance with toileting and bathing. The MDS indicated Resident 3 used a walker and wheelchair.During a concurrent observation and interview on 8/27/2026 at 7:13 a.m. with Resident 3, in Resident 3's room, Resident 3 stated that nurses place dirty linen mixed with clean linen in her closet. Observed clothes on the hanger inside Resident 3's closet and folded linen on the bottom of the closet. Resident 3 stated that nurses should keep the clean linen on that rack outside the room.During a concurrent observation and interview on 8/27/2026 at 7:48 am in Resident 3's room, CNA 1 checked the closet of Resident 3 and stated the linen and towels lying on the bottom of the closet. CNA 1 stated linen and towels should not be placed inside the resident's closet. CNA 1 stated that clean linen is stored outside the rooms on dedicated racks.During an interview on 8/27/2026 at 9:43 a.m. with CNA 1, CNA 1 stated that per facility's policy CNAs are supposed to check the closets during their shifts and no extra linen should be in the closet, because of linen shortage, or linen can be used for other residents and that was the infection control issue.During an interview on 8/27/2026 at 11:54 a.m. with the DON, the DON stated that linen should not be stored in resident's closet because the linen could be contaminated and a potential for spread of infection. The linen should be stored on special racks or closets outside the resident's room. During a review of facility's policy and procedure (P & P) titled, Laundry and Bedding, Soiled, last revised on 9/2022, the P & P indicated the Policy Statement: Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. The P & P indicated: Clean linen is stored separately, away from soiled linens, at all times. Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination.

Based on observation, interview, and record review, the facility failed to treat with dignity and respect one of three sampled residents (Resident 1). This failure had the potential to negatively impact the psychosocial well-being (is the state of mental, emotional, and social health) of Resident 1.Findings: During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 1 on 5/6/2025, with diagnoses including an encounter for orthopedic aftercare following surgical amputation (is a follow-up medical appointment used to oversee a resident's recovery, functional rehabilitation, and physical adaptation after a limb has been removed), acquired absence of left leg below knee, type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and anemia (is a blood disorder where your body lacks enough healthy red blood cells or hemoglobin to carry sufficient oxygen to your tissues). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 5/13/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 was dependent (helper does all of the effort) with shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 needed set-up or clean up assistance with eating. During a review of Resident 1's Progress Notes, dated 7/7/2026, timed at 4:30 p.m., the Progress Notes indicated on 7/7/2026, at 4:30 p.m., Resident 1 reported to Licensed Vocational Nurse (LVN) 1 regarding an allegation of verbal abuse involving a staff member (not specified), Resident 1 stated that the staff member told him to be quite in the dining room in a loud manner. During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 3/1/2022 and readmitted on [DATE] with diagnoses including type 2 DM. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS indicated Resident 2 needed set-up or clean-up assistance with eating, oral hygiene, upper body dressing, and personal hygiene. During a concurrent observation and interview on 7/9/2026 at 10:20 a.m. with Resident 1, Resident 1 was observed in tears while he narrates what happened to him on 7/7/2026 at around 4:30 p.m. Resident 1 stated he was in the Activity Room playing poker with other residents when another resident's family member (name not specified) came and moved the aircon facing another side of the room causing Resident 1 to complain. Resident 1 stated that Receptionist 1 came and spoke to him in a loud manner, raising her voice and told him to grow up, not act like a child in the Activity room making him feel disrespected and not treated with dignity at the Facility. Resident 1 stated that Receptionist 1 was out of line. Resident 1 stated the residents are scared of Receptionist 1. During an interview on 7/9/2026 at 10:30 a.m. with Resident 2, Resident 2 stated on 7/7/2026 (did not indicate the time) she was in the Activity Room with Resident 1 playing Poker. Resident 2 stated she witnessed another resident's family member (name not specified) switched the aircon to one side making the room hot and Resident 1 told the other resident's family member that he cannot do that . Resident 2 stated she witnessed Receptionist 1 raising her voice telling Resident 1 in the Activity Room to grow up which was unnecessary and that Receptionist should not talk to Resident 1 in a loud manner. Resident 2 stated she fears Receptionist 1 and did not want Receptionist 1 to know about this interview. Resident 2 stated Receptionist 1 was always rude to the residents and that was not the first time she (Receptionist 1) talked down to the residents. During an interview, on 7/9/2026 at 3 p.m., with the Director of Nursing (DON), the DON stated that around 4:30 p.m. (7/7/2026) Receptionist 1 was trying to talk to Resident 1 to calm down but Resident 1 felt that Receptionist 1 verbally abused him. The DON stated Receptionist 1 was suspended pending Investigation.During a review of the facility policy and procedure titled, Dignity, last reviewed and approved on 4/30/2026, the policy and procedure indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level ofsatisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 8. Staff speak respectfully to residents at all times.

Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within residents` reach for five (5) of ten sampled residents (Residents 39, 44, 81, 73, and 117) investigated under environment facility task. These deficient practices had the potential to result in the residents` inability to call for assistance when needed, placing the residents at risk for unmet needs, delayed care, accidents, injury, and harm. Findings: 1.During a review of Resident 39's admission Record (AR), the AR indicated that the facility admitted the resident on 2/27/2026, with diagnoses including dysphagia (difficulty swallowing), spinal stenosis (a tunnel inside the spine gets too narrow, cramping the nerves or spinal cord), anxiety disorder ( an intense, uncontrollable fear and worry about everyday things), and muscle weakness. During a review of Resident 39's History and Physical (H&P), dated 2/27/2026, the H&P indicated that the resident had the capacity to make needs known but cannot make medical decisions. During a review of Resident 39's Minimum Data Set (MDS-a resident assessment tool), dated 3/02/2026, the MDS indicated the resident had a moderate cognitive impairment but can make needs known. The MDS also indicated that Resident 39 required substantial/maximal assistance with eating, personal hygiene, and was dependent on staff for toileting, bathing, and transferring. During a review of Resident 39's Care Plan (CP), initiated on 3/02/2026, the CP had a focus indicated that the resident had an activities of daily living (ADL – routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) self-care and/or mobility performance deficit (.). The care plan intervention was to encourage the resident to use the call light/bell to call for assistance. During a concurrent observation and interview on 6/01/2026 at 10:14 a.m. with Licensed Vocational Nurse (LVN 2), inside Resident 39`s room, LVN 2 stated that the call light was by the resident's right side of the bed close to her shoulder and was not accessible Resident 39. LVN 2 stated that the call light should have been closer to the resident. LVN 2 stated that it is important for the resident to use the call light to address her needs. LVN 2 further stated that the residents may feel neglected if the call light is not within reach, which also creates safety concerns. During an interview on 6/05/2026 at 11:24 a.m. with the Director of Nursing (DON), the DON stated that call light must always be within residents` reach. The DON stated that the purpose of the call light is to allow residents to request assistance for their needs. The DON stated that the policy was not adhered to if a resident was unable to access the call light. The DON further stated that there will be a delay in care if the call light is not accessible for the residents to use. During a review of the facility's Policy and Procedure (P&P) titled, Call light, last revised on 9/2022, the P&P indicated that The purpose of this procedure is to ensure timely responses to the resident's requests and needs. (.) 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 2.During a record review of Resident 44's AR, the AR indicated the facility admitted the resident on 1/11/2023, with diagnoses including Alzheimer's Disease, unspecified (a disease characterized by a progressive decline in mental abilities); dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety(problems with memory, thinking and decision-making caused by another medical condition, the severity is not specified, and person also show behavior or mood changes); contracture, unspecified (tight or stiff, making it hard to straighten or move normally). During a review of Resident 44's H&P, dated 5/20/2026, the H&P indicated the resident did not have capacity to make medical decisions. During a review of Resident 44's MDS, dated [DATE], the MDS indicated the resident rarely had the ability to make self-understood and understand others. The MDS further indicated that Resident 44 had severe cognitive impairment (has major problems with thinking, memory, understanding, and may need significant assistance with daily activities and supervision for safety). The MDS indicated that the resident was dependent on staff for mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a record review of Resident 44's Quarterly Risk Assessment (QRA), dated 4/15/2026, the QRA indicated that the resident was at risk for falls. During a record review of Resident 44's Care Plan (CP) Report, Focus, titled, Resident 44 is at risk for falls related to mobility, cognitive impairment, incontinence (unable to fully control when urine comes out), on antidepressants revised on 4/19/2026, the CP goal was to have no fall/injury through the next review date. The CP intervention was to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. During a concurrent observation and interview on 6/1/2026, at 10:05 a.m., with Certified Nursing Assistant (CNA) 1 inside Resident 44's room, CNA 1 observed call light clipped under the pillow on left side of Resident 44's head. CNA 1 stated Resident 44 would not have been able to call for help because the call light was underneath the pillow on left side and resident had a splint on left hand. During a concurrent interview and record review on 6/4/2026, at 12:23 p.m., with the Minimum Data Set Coordinator (MDSC)1, Resident 44`s CPs were reviewed. The MDSC 1 stated residents use the call light to communicate with staff if requesting assistance. The MDSC 1 stated there was a possibility that Resident 44 would not be able to get to the call light because it was under the pillow on the left side and the resident was wearing a splint on left hand. The MDSC 1 stated that when the call light is not within reach there is no way for the resident to call the staff for assistance. The MDSC 1 stated that Resident 44's needs would not be met, and the resident can potentially fall trying to reach for the call light. The MDSC 1 stated Resident 44 does not have the capacity to look for the call light if not within reach. The MDSC 1 reviewed the CP revised on 4/19/2026 and the QRA dated 4/15/2026 indicated resident was at high risk for falls. The MDSC 1 stated the care plan and policy titled, Call Light were not followed. During an interview on 6/5/2026 at 1:00p.m., with the Director of Nursing (DON), the DON stated the purpose of the call light is for the residents to call when they need assistance and if the call light is not within reach, then there will be a delay in care. The DON stated that the call light should be answered in a timely manner and staff need to make sure that the call light is always within reach of residents. The DON stated the policy titled, Call Light was not followed. 3.During a record review of Resident 81's AR, the AR indicated the facility originally admitted Resident 88 on 1/23/2020 and readmitted on [DATE], with diagnoses including metabolic encephalopathy((confusion or changes in thinking caused by a medical problem in the body); schizophrenia, unspecified(a mental illness that is characterized by disturbances in thoughts); depression, unspecified (a condition that causes sadness, loss of interest in activities, low energy, and changes in sleep, appetite, or concentration, can affect a person's feelings, thoughts, and daily activities). During a review of Resident 81's H&P, dated 5/25/2026, the H&P indicated the resident did not have capacity to understand and make decisions. During a review of Resident 81's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood. The MDS further indicated that Resident 81 had severe cognitive impairment (has major problems with thinking, memory, understanding, and may need significant assistance with daily activities and supervision for safety). The MDS indicated that the resident was dependent or required partial/moderate assistance with mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 81's Quarterly Risk Assessment (QRA), dated 5/13/2026, the QRA indicated that the resident was at risk for falls. During a review of Resident 81's Care Plan (CP) Report, Focus, titled Resident 81 is at risk for falls secondary to impaired mobility (difficulty moving around or performing physical activities normally), prefers to stay in bed, requires assistance in self-care and mobility, incontinence, cognitive impairment, use of anti-anxiety medications, use of anti-depressant medications, use of anti-psychotic medications, psychosis (a condition in which a person has trouble telling what is real and what is not) revised on 5/27/2026. The CP indicated a goal that the resident's risk for falls/injuries will be reduced through implementation of safety devices and other interventions. The CP intervention was to maintain call light within reach. During a concurrent observation and interview on 6/1/2026, at 10:20 a.m., with CNA 6 inside Resident 81's room, CNA 6 observed call light on the floor under the bed. CNA 6 stated Resident 81 would not have been able to call for assistance, which could have resulted in an emergency. CNA 6 stated Resident 81 may have attempted to reach the call light, placing them at risk for a fall. During a concurrent interview and record review on 5/13/2026, at 12:23 p.m., with the Minimum Data Set Coordinator (MDSC)1, Resident 81`s CP revised 5/27/2026 and the QSA dated 5/13/2026 were reviewed. The MDSC 1 stated Resident 81 was at risk for falls. The MDSC 1stated if the call light was under the bed on the floor, the resident would not have been able to reach the call light, and the resident could have potentially fallen. The MDSC 1 stated the care plan and policy titled, Call Light were not followed. During an interview on 6/5/2026 at 1:00p.m., with the Director of Nursing (DON), the DON stated the purpose of the call light is for the residents to call when they need assistance and if the call light is not within reach, then there will be a delay in care. The DON stated that the call light should be answered in a timely manner and staff need to make sure that the call light is always within reach of residents. The DON stated the policy and procedure (P&P) titled, Call Light was not followed. During a review of the facility's P&P titled, Call light, last revised on 9/2022, the P&P indicated the purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines -Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 4. During a review of Resident 117's AR, the AR indicated that the facility admitted the resident on 05/24/2026, with diagnoses including traumatic subdural hemorrhage without loss of consciousness (bleeding between the brain and its outer covering caused by trauma), muscle weakness (reduced muscle strength affecting mobility and function), unsteadiness on feet (impaired balance increasing the risk for falls), unspecified fracture of the lower end of the left femur with routine healing (a healing fracture of the lower thigh bone), periprosthetic fracture around the internal prosthetic left knee joint (a fracture occurring around a knee replacement), anemia (a decreased number of red blood cells reducing oxygen delivery throughout the body), dementia with behavioral disturbance (cognitive impairment associated with changes in behavior and decision-making), epilepsy (a neurological disorder characterized by recurrent seizures), essential hypertension (chronic high blood pressure), gastroesophageal reflux disease (backflow of stomach acid into the esophagus causing irritation), unilateral primary osteoarthritis of the left knee (degenerative joint disease causing pain and decreased mobility), and encounter for other orthopedic aftercare (ongoing care and monitoring following orthopedic treatment). These diagnoses placed the resident at increased risk for mobility limitations, falls, injury, and dependence on staff assistance to meet daily needs and respond to emergencies. During a review of Resident 117's MDS, the MDS indicated that the resident had diagnoses affecting mobility, safety awareness, and ability to summon assistance independently. During a concurrent observation and interview on 06/01/2026 at 10:15 a.m., inside Resident 117`s room, with Certified Nursing Assistant (CNA 2), the resident's call light was observed hanging on the bedside and was not within the resident's immediate reach. CNA 2 stated that Resident 117 would be unable to call for assistance when needed, which could delay staff response to the resident's needs or emergencies. During an interview on 06/05/2026 at 11:24 a.m., with the DON, the DON stated that residents' call lights should be within immediate reach at all times to allow residents to request assistance as needed. The DON stated that if a call light is not accessible, the resident may be unable to summon staff for toileting assistance, pain management, emergencies, or changes in condition. The DON acknowledged that failure to ensure call light accessibility may place residents at risk for delayed care, unmet needs, falls, injuries, and avoidable adverse outcomes. This practice was not consistent with the facility's expectation for maintaining resident safety and prompt access to assistance. During a review of the facility's policy and procedure (P&P), titled Call Light, the P&P indicated the purpose of the procedure is to ensure timely responses to resident requests and needs. The policy further directed staff to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. The facility failed to ensure the resident's call light was accessible and within immediate reach in accordance with facility policy. 5.During a review of Resident 73's AR, the AR indicated the facility admitted the resident on 04/09/2026, with diagnoses including generalized muscle weakness (reduction in muscle strength affecting mobility and daily functioning), unsteadiness on feet (impaired balance increasing the risk for falls), chronic obstructive pulmonary disease (chronic lung disease causing airflow limitation and breathing difficulties), asthma (chronic inflammatory airway disease that can cause wheezing and shortness of breath), dysphagia (difficulty), obesity (excess body), essential hypertension (chronic high blood pressure), lumbar spondylosis with radiculopathy (degenerative spinal condition causing pain, weakness, numbness, and impaired mobility), abdominal wall cellulitis (bacterial infection of the skin and underlying soft tissues of the abdomen), and status post artificial joint replacement (history of surgically replaced joint that may affect mobility and functional independence). During a review of Resident 73's MDS, the MDS indicated that the resident was cognitively intact and able to communicate needs. The MDS further indicated the resident utilized a walker and wheelchair and required staff assistance with transfers, toileting hygiene, bathing, dressing, mobility, and other activities of daily living. During a concurrent observation and interview on 06/01/2026 at 10:15 a.m., inside Resident 73`s room with CNA6, the resident's call light was observed hanging on the bedside and was not within the resident's immediate reach. CNA 6 stated that the resident would be unable to call for assistance when needed, which could delay staff response to the resident's needs or emergencies. During an interview on 06/05/2026, the DON, the DON stated that residents' call lights should be within immediate reach at all times to allow residents to request assistance as needed. The DON stated that if a call light is not accessible, the resident may be unable to summon staff for toileting assistance, pain management, emergencies, respiratory concerns, or changes in condition. The DON acknowledged that failure to ensure call light accessibility may place residents at risk for delayed care, unmet needs, falls, injuries, and avoidable adverse outcomes. This practice was not consistent with the facility's expectation for maintaining resident safety and prompt access to assistance. During a review of the facility`s P&P, titled Call Light, the P&P indicated the purpose of the procedure is to ensure timely responses to resident requests and needs. The policy further directed staff to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. The facility failed to ensure the resident's call light was accessible and within immediate reach in accordance with facility policy.

Based on observation, interview, and record review, the facility failed to ensure the residents` environment was free of accident hazards for two (2) of two (2) sampled residents (Resident 93 and Resident 116) reviewed for accidents by failing to: 1. Ensure that no medications were left unattended at Resident 93`s bedside. This deficient practice had the risk of accidental ingestion or unsafe medication administration. 2. Promptly identify and remove a puddle of water observed on the floor at the foot of Resident 116`s bed. This deficient practice had the potential to result in slips, falls, fractures, head injuries, pain, hospitalization, and other avoidable injuries to residents, staff, and visitors. Findings: a. During a review of Resident 93's admission Record (AR), the AR indicated the facility originally admitted the resident on 10/29/2019, and readmitted on [DATE], with diagnoses including Alzheimer's Disease, unspecified (a disease characterized by a progressive decline in mental abilities); Unspecified dementia, unspecified severity, with other behavioral disturbances (problems with memory, thinking and decision-making caused by another medical condition, the severity is not specified, and person also show behavior or mood changes); neuromuscular dysfunction of bladder, unspecified (the nerves and muscles that control the bladder are not working properly making it difficult to control urination or empty the bladder completely). During a review of Resident 93's History and Physical (H&P) dated 2/2/26, the H&P indicated that the resident was able to make medical decisions. During a review of Resident 93's Minimum Data Set (MDS-a resident assessment tool) dated 4/22/2026, the MDS indicated that Resident 93 was able to make self- understood and had the ability to understand others and had intact cognitive function (normal thinking). The MDS indicated the resident required maximal assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 6/1/2026, at 10:05 a.m., with Certified Nursing Assistant (CNA) 1, inside Resident 93's room, observed an open packet of A&D ointment (is a thick, petroleum jelly containing vitamin A and D, used to protect, soothe dry, or irritated skin) packet on Resident 93's bedside table. CNA 1 stated that an open packet of A&D ointment should not be left at the resident's bedside because they pose an infection control risk and a confused resident may grab it. During an interview on 6/4/2026, at 12:05 p.m., with the Minimum Data Set Coordinator (MDSC) 1, the MDSC 1 stated licensed staff are required to assess the residents to ensure they have the capacity to self-medicate and perform teaching assessment and evaluation to ensure the resident has the knowledge about that medication. The MDSC 1 stated residents need to inform the license nurse when medication was administered. The MDSC 1 stated there needs to be a physician's order, self-administer medication assessment and a care plan for the resident to self-administer medications. The MDSC 1 stated that there was no order for A&D ointment, no assessment or care plan was developed for Resident 93 to self-administer medications. The MDSC 1 stated the A&D ointment was not supposed to be at Resident 93`s bedside because there was no assessment performed for the resident to self-medicate and it is unknown how long the A&D ointment package was opened. The MDSC 1 stated Resident 93 can utilize the medication in the wrong way, and there is a risk for another resident to grab it and potentially ingest it. The MDSC 1 stated the policy and procedure (P&P) titled; Self-Administration of Medications was not followed. During an interview on 6/5/2026, at 11:43 a.m., with the Director of Nursing (DON), the DON stated that by leaving medication at Resident 93`s bedside without an appropriate assessment the resident might apply to area where they are not supposed to and other residents can get the medication. The DON stated the P&P titled; Self-Administration of Medications was not followed. During a review of the facility's P&P titled, Self-Administration of Medication, revised on 2/2021, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administrating medications is safe and clinically appropriate for the resident. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. During a review of the facility-provided A+D Original Ointment, no date, the Information indicated WARNINGS: For external use only, when using this product do not rub on eyes. Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away. b. During a review of Resident 116's AR (Face Sheet), the AR indicated the facility admitted the resident on 05/27/2026, with diagnoses including urinary tract infection (infection affecting the urinary system that may cause pain, confusion, and functional decline), unsteadiness on feet (impaired balance increasing the risk for falls), generalized muscle weakness (reduction in muscle strength affecting mobility and performance of daily activities), type two diabetes mellitus without complications (chronic condition affecting blood sugar regulation), hyperlipidemia (elevated cholesterol levels), depression (mood disorder affecting emotional well-being and functioning), hereditary and idiopathic neuropathy (nerve disorder causing weakness, numbness, pain, and impaired sensation), and essential hypertension (chronic high blood pressure). During a review of Resident 116's MDS, dated [DATE], the MDS indicated that the resident had diagnoses affecting mobility, balance, strength, cardiovascular status, and safety awareness. During a concurrent observation and interview on 06/01/2026 at approximately 09:55 a.m., inside Resident 116`s room, with Certified Nursing Assistant 3 (CNA 3), a puddle of water was observed on the floor at the foot of the resident's bed. CNA 3 stated that someone could slip and fall, resulting in injury to residents, staff, or visitors. CNA 3 stated that the puddle created a potential environmental hazard in the resident care area. During an interview on 06/05/2026 at 11:38 a.m., with the Director of Nursing (DON), the DON stated that water on the floor constitutes an environmental hazard and should be removed immediately, or the area should be secured until it can be cleaned. The DON stated that wet floors increase the risk of slips, falls, fractures, head injuries, pain, hospitalization, and other avoidable injuries. The DON acknowledged that maintaining a safe environment free from accident hazards is the facility's responsibility and is consistent with the facility's falls prevention policy. During a review of the facility's policy and procedure (P&P), titled Falls and Fall Risk, Managing, the policy defined a fall as unintentionally coming to rest on the ground, floor, or other lower level. The policy identified environmental factors that contribute to fall risk, including wet floors, poor lighting, and obstacles in the resident care area. The policy further indicated that staff are responsible for identifying resident-specific fall risks, implementing interventions to reduce the risk of falls, and maintaining a safe environment to minimize complications associated with falling. The facility failed to ensure the resident environment was maintained free of environmental hazards in accordance with facility policy.

Based on observation, and interview, the facility failed to ensure: Residents with a n indwelling catheter (a thin, flexible hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for one of one sampled resident (Resident 93) reviewed for urinary catheter or UTI care area, by failing to ensure the indwelling catheter tubing and bag was not on the floor. The deficient practice had the potential for Resident 93 to develop UTI. Medications were administered in a manner that prevented contamination and maintained infection control standards for one of one sampled resident (Resident 14). This deficient practice had the potential to expose Resident 14 to infectious organisms and contamination, placing the resident at increased risk for infection, medication-related complications, and adverse health outcomes. Findings: a. During a review of Resident 93's admission Record (AR), the AR indicated the facility originally admitted the resident on 10/29/2019, and re-admitted on [DATE], with diagnoses including Alzheimer's Disease, unspecified (a disease characterized by a progressive decline in mental abilities); Unspecified dementia, unspecified severity, with other behavioral disturbances (problems with memory, thinking and decision-making caused by another medical condition, the severity is not specified, and person also show behavior or mood changes); neuromuscular dysfunction of bladder, unspecified (the nerves and muscles that control the bladder are not working properly making it difficult to control urination or empty the bladder completely). During a review of Resident 93's History and Physical (H&P) dated 2/2/26, the H&P indicated that the resident was able to make medical decisions. During a review of Resident 93's Minimum Data Set (MDS- a resident assessment tool) dated 4/22/2026, indicated Resident 93 was able to make self- understood and has the ability to understand others and had intact cognitive function (normal thinking). The MDS indicated the resident required dependent to maximal assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 6/1/2026, at 2:23 p.m., with Certified Nurse Assistant (CNA) 1, inside Resident 93's room, observed the foley catheter bag (a type of indwelling catheter) and tubing on the floor. CNA 1 stated the foley catheter bag and tubing should not be placed on the floor due to infection control concerns. During an interview on 6/4/2026 at 12:05 p.m., with Minimum Data Set Coordinator (MDSC) 1, the MDSC 1 stated the foley catheter is supposed to be at the lowest part of the bladder and the foley catheter tubing and draining bag is not supposed to be on the floor because the floor is dirty and is high risk for bacteria that can lead to possible UTI. The MDSC 1 stated the policy and procedure (P&P) titled, Catheter Care, Urinary was not followed. During an interview on 6/5/2026 at 11:43 a.m., with the Director of Nursing (DON), the DON stated that by placing the foley catheter tubing and draining bag on the floor, there is a risk for Resident 93 to get an infection such as UTI. The DON stated the P&P titled, Catheter Care, Urinary, was not followed. During a review of the facility's P&P titled, Catheter Care, Urinary, revised on 8/2022, the P&P indicated, the purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Infection Control-Be sure the catheter tubing and draining bag are kept off the floor. b. During a review of Resident 14's AR (Face Sheet), the AR indicated that the facility admitted the resident on 04/11/2025 with diagnoses including anorexia (loss of appetite resulting in inadequate food intake), unilateral primary osteoarthritis of the right hip (degenerative joint disease causing pain, stiffness, and decreased mobility in the right hip), hypothyroidism (underactive thyroid gland resulting in decreased hormone production), schizophrenia (chronic mental disorder affecting thought processes, perception, and behavior), depression (mood disorder characterized by persistent feelings of sadness and loss of interest), anxiety disorder (condition characterized by excessive worry, fear, or nervousness), and benign prostatic hyperplasia (noncancerous enlargement of the prostate gland that may affect urinary function). During a review of Resident 14's MDS, dated [DATE], the MDS indicated that the resident had moderately impaired cognition (decisions poor, cues supervision required). The MDS further indicated that the resident demonstrated deficits in temporal orientation and memory recall. The resident required supervision to partial/moderate assistance with activities of daily living (ADLs), including bathing, dressing, personal hygiene, toileting hygiene, footwear management, transfers, and mobility. The MDS further indicated the resident required supervision and assistance with bed mobility, transfers, ambulation, and toileting activities and utilized a walker for mobility. The residents' diagnoses included schizophrenia, depression, and anxiety disorder, requiring ongoing monitoring, supervision, and assistance with care and medication administration. During an observation on 06/01/2026 at 9:02 a.m., observed Registered Nurse 1 (RN1) administered medications to Resident 14. Resident 14 placed the medications on the bedside table and picked up the pills one at a time using a saliva-moistened index finger before placing each pill into his mouth. RN1 observed the resident handling the medications in this manner and allowed the practice to continue without intervention. RN1 was further observed watching Resident 14 ingest the medications using the saliva-moistened finger. During a concurrent interview immediately following the observation, RN1 stated that Resident 14 had been doing this all the time. During an interview on 06/05/2026 at 11:28 a.m., with the Director of Nursing (DON), the DON stated that medications should be administered in a manner that maintains their integrity and prevents contamination. The DON stated that when a resident handles medications with a saliva-contaminated finger, the nurse should intervene and replace contaminated medications as appropriate. The DON further stated that allowing contaminated medications to be ingested without intervention is not consistent with facility policy, accepted standards of nursing practice, or infection control principles. The DON acknowledged that the observed practice did not ensure safe medication administration. The DON stated staff failed to implement appropriate infection prevention and control measures, placing Resident 14 at risk for infection and other adverse outcomes. During a review of the facility's policy and procedure (P&P), titled Infection Prevention and Control Program, revised October 2018, the policy indicated the facility's infection prevention and control program is established to help prevent the development and transmission of communicable diseases and infections. The policy further indicated staff are to adhere to accepted infection prevention and control standards and implement measures to prevent contamination and the spread of infection. The observed practice of allowing a resident to handle medications with a saliva-contaminated finger and ingest contaminated medications without intervention was not consistent with the facility's prevention and control policy.

Based on observation, interview, and record review, the facility failed to honor the resident's right to be treated with dignity and respect for personal privacy for one randomly observed resident (Resident 39) by failing to ensure the resident's buttocks was not exposed to other residents, staff, and visitors while being transported down the hallway to the shower room. This deficient practice violated the resident's right to be treated with respect and dignity potentially resulting in a decline in the psychosocial well-being of the resident. Findings: During a record review of Resident 39's Face Sheet (FS, admission Record), the FS indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included nondisplaced fracture (broken bone) of second cervical (neck region) vertebra (spine), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), unsteadiness on feet, and muscle weakness. During a review of Resident 39's History and Physical (H&P), dated 2/28/2026, the H&P indicated the resident had the capacity to make needs known but could not make medical decisions. During a record review of Resident 39's Minimum Data Set (MDS, resident assessment tool) dated 3/2/2026, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident was dependent on staff for toileting, bathing, lower body dressing, and mobility with shower transfers. During a review of Resident 39's Care Plan (CP) titled, The resident has an Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) self-care and/or mobility performance deficit., initiated 3/4/2026, the CP indicated the resident had interventions that included to provide privacy during care. During a concurrent observation and interview on 6/2/2026 at 8:40 a.m., with the Medical Records Assistant (MRA), while standing in the main hallway near Nursing Station 1, observed Resident 39 exited her room in a shower chair being pushed by Certified Nursing Assistant (CNA) 4. Observed a sheet was placed over the resident that did not provide full body coverage and the resident's buttocks was visible. Observed the MRA walked down the hallway toward the surveyor and stated Resident 39's buttocks was not fully covered and visible. The MRA stated she (MRA) was sorry and a resident should be fully covered while being transported to the shower. Observed the MRA walk down the hallway to the shower room to speak with CNA 4. During an interview on 6/2/2026 at 9:45 a.m., in the hallway near Nursing Station 1 with CNA 4, CNA 4 stated she (CNA 4) transported Resident 39 to the shower. CNA 4 stated she (CNA 4) must not have fully checked that the resident was covered. CNA 4 stated it was important to fully cover a resident for privacy and to protect them because the resident would not know if they were fully covered or not. During a concurrent interview and record review on 6/5/2025 at 11:25 a.m., in the conference room, with the Director of Nursing (DON), facility policy and procedures (P&P) regarding personal privacy and dignity was reviewed. The DON stated residents have the right to privacy and dignity. The DON stated Residents are covered for privacy while being transported to the shower to respect their right to dignity. The DON stated the facility P&P was not followed when Resident 39's buttocks was visible while being transported to the shower room potentially affecting the resident emotionally. During a review of the facility P&P titled, Confidentiality of Information and Personal Privacy, last reviewed 5/28/2026, the P&P indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. 2. The facility will strive to protect the resident's privacy regarding his or her: . d. personal care. During a review of the facility P&P titled, Dignity, last reviewed 5/28/2026, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. During a review of the facility P&P titled, Resident Rights, last reviewed 5/28/2026, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity. 1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:. privacy.

Based on interview and record review, the facility failed to report an allegation of staff-to-resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) or mistreatment (inappropriate treatment or exploitation of a resident) immediately, but no later than two (2) hours after the allegation was made to the State Survey Agency (CDPH, California Department of Public Health), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for one of three sampled residents (Resident 25) reviewed under the Abuse care area. This deficient practice had the potential to result in unidentified abuse and mistreatment in the facility and failure to protect Resident 25 and other residents from harm. Findings: During a review of Resident 25's admission Record (AR), the AR indicated the facility originally admitted the resident on 5/6/2025 and most recently admitted the resident on 5/29/2025 with diagnoses that included encounter for orthopedic (involving the musculoskeletal system) aftercare following surgical amputation (removal of a limb or body part), absence of left leg below the knee (BKA - below knee amputation), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), End Stage Renal Disease (ESRD -irreversible kidney failure), and dependence on renal dialysis hemodialysis (HD - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 25's Minimum Data Set (MDS - resident assessment tool), dated 5/13/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated that the resident was dependent on staff for bathing, lower body dressing, and transfer mobility; required substantial/maximal assistance from staff for toileting, upper body dressing, and rolling left to right; required partial/moderate assistance for personal hygiene; and required setup or cleanup assistance with eating. During a review of Resident 25's History and Physical (H&P), dated 5/20/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's Care Plan (CP) titled, At Risk for emotional distress related to alleged mental abuse, initiated on 5/31/2026, the CP indicated a goal that the resident would not exhibit signs and symptoms of psychosocial or emotional distress with interventions that included to encourage the resident to report fear and feelings of anxiety. During a review of Resident 25's CP titled, At Risk for falls and injuries related to . weakness, left BKA., initiated 2/15/2026, the CP indicated a goal that the resident's risk for falls/injuries will be reduced with interventions that included to assess and anticipate resident's toileting needs and body positioning, bilateral grab bars in bed to aid in mobility. During a review of Resident 25's Grievance/Complaint Resolution Report (GR), dated 9/15/2026, the GR indicated on 9/13/2026 Resident 25 expressed dissatisfaction with Certified Nursing Assistant (CNA) 9's approach and communication style and CNA 9 was removed and would no longer be assigned to Resident 25 as per the resident's request. During a review of the Stop and Watch Early Warning Tool (SWT - a written communication tool for reporting early signs in a potential resident change of condition), dated 9/13/2026 and completed by CNA 9, the SWT indicated on 9/13/2025 at about 6:50 p.m. CNA 9 placed Resident 25 on a bedpan and left to assist another resident. The SWT also indicated when CNA 9 returned, Resident 25 was visibly upset and expressed frustration in the delay in response to the call light (CL). The SWT further indicated while CNA 9 provided care to the resident, Resident 25 yelled, You wanted to throw me out of the bed. During an interview on 6/1/2026 at 11:35 a.m., in the hallway outside Resident 25's room, Resident 25 stated that about a year ago CNA 9 attacked him. Resident 25 stated that night he was on the bedpan for over an hour and kept using the CL to call for assistance. Resident 25 stated CNA 9 came into the room angry and was being rough with him and almost pushed him out of the bed. Resident 25 stated he filed a grievance and they removed CNA 9 from his care, but nothing else was ever done. Resident 25 stated he does not trust the people in charge because they showed their true faces a year ago. Resident 25 stated the situation with CNA 9 made him feel paranoid and he felt the facility Administrator (ADM) tried to make him the villain. During an interview on 6/4/2026 at 10:20 a.m., with CNA 9, CNA 9 stated she (CNA 9) has cared for Resident 25 twice in the last year. CNA 9 stated sometime last September she was assigned to the resident and she placed him on a bedpan at 6:50 p.m. and she was supposed to go on break at 7 p.m. CNA 9 then stated she left Resident 25 on the bedpan to assist another resident. CNA 9 stated when she returned to the room Resident 25 was screaming and shouting and he had a large bowel movement and she had to change all the bed linens. CNA 9 then stated that while she changed the resident, Resident 25 accused her of trying to push him out of the bed. CNA 9 stated she told Registered Nurse (RN) 4 that Resident 25 was upset, she completed a SWT and reported the incident to the facility Director of Staff Development (DSD), but the DSD no longer works at the facility. CNA 9 then stated that Resident 25 made an allegation of abuse that she (CNA) 9 tried to push him out of the bed. CNA 9 stated she could not remember if she told anyone that Resident 25 alleged she tried to push him out of the bed while she was changing him. CNA 9 stated it was important to make sure allegations are reported to ensure there is an investigation and documentation regarding the allegation. During a concurrent interview and record review on 6/10/2026 at 10:47 a.m. with the Director of Nursing (DON), the DON reviewed the GR, dated 9/15/2026. The DON stated the facility protocol for allegations of abuse is to report all allegations of abuse to CDPH, the ombudsman, and the police, monitor the resident, and suspend the staff member involved pending an investigation. The DON stated Resident 25 had an incident with CNA 9 when she cared for him. The DON stated there was a GR dated 9/15/2026 that indicated Resident 25 had a concern regarding CNA 9's approach and communication style. The DON stated she was not aware Resident 25 alleged that CNA 9 tried to push him out of the bed. The DON stated she (the DON) spoke with CNA 9 after the incident in September and CNA 9 did not mention any allegations of abuse at that time. The DON stated CNA 9 should have reported that Resident 25 alleged she tried to push him out of the bed and she (the DON) would have followed the facility protocol. The DON stated it was important to report and investigate allegations of abuse to protect the safety of the residents and ensure the residents feel safe in the facility. The DON stated Resident 25's allegation should have been reported and investigated and was not, potentially resulting in psychosocial issues in the resident. During a follow-up interview on 6/4/2026 at 11:39 a.m., on the patio, with Resident 25, Resident 25 stated last September CNA 9 went to his room and was upset. Resident 25 stated while CNA 9 changed him, he turned to the right side and CNA 9 was pushing him and he had to hold onto the SR to prevent himself from going further. Resident 25 stated at that time, he felt CNA 9 was trying to harm him. Resident 25 stated the facility leadership did not talk to him about the incident. During a concurrent interview and record review on 6/4/2026 at 4 p.m., in the conference room, with the ADM, reviewed Resident 25's SWT dated 9/15/2026 and the facility policy and procedure (P&P) regarding abuse and stated she (the ADM) was the facility abuse coordinator. The ADM stated the SWT indicates that Resident 25 made an allegation of physical abuse on 9/13/2026 that CNA 9 wanted to throw Resident 25 out of the bed. The ADM stated she (the ADM) was not aware of the allegation because the DSD did not inform the ADM of the SWT. The ADM stated the DSD was responsible for following up on the SWT and the DSD no longer works at the facility. The ADM stated if she had been aware that the SWT indicated you wanted to throw me out of the bed, then she (the ADM) would have followed the facility abuse protocol to immediately report and investigate the allegation, but she did not. The ADM stated the facility P&P was not followed potentially resulting in a negative outcome for the resident with another incident of abuse leading to possible injuries in the resident. During a follow up concurrent interview and record review on 6/5/2026 at 10:14 a.m. in the conference room, with the ADM, the ADM reviewed the P&P regarding abuse reporting and investigating. The ADM stated based on the SWT dated 9/13/2026, Resident 25 made an allegation of abuse that should have been reported immediately or within 2 hours of the allegation but was not, the CNA should have been suspended and was not, the resident should have been interviewed and was not, there should have been some documentation of follow-up and there was not, and the physician should have been notified and was not. The ADM stated the facility P&P was not followed. During a review of the facility provided P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last reviewed 5/28/2026, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities. 1.If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected. the suspicion must be reported immediately to the administrator and to other officials according to state law. 4.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 5. Immediately'' is defined as: a. within two hours of an allegation involving abuse or result in physical harm/serious bodily injury; . 7.Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 8. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) by failing to thoroughly investigate an allegation of staff-to-resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) or mistreatment (inappropriate treatment or exploitation of a resident) and report the results of the investigation to in accordance with State law, including to the State Survey Agency (CDPH, California Department of Public Health), the Ombudsman (a resident advocate) for one of three sampled residents (Resident 25) reviewed under the Abuse care area. This deficient practice had the potential to result in unidentified abuse and mistreatment in the facility, retaliation from staff, and failure to protect Resident 25 and other residents from harm. Findings: During a review of Resident 25's admission Record (AR), the AR indicated the facility originally admitted the resident on 5/6/2025 and most recently admitted the resident on 5/29/2025 with diagnoses that included encounter for orthopedic (involving the musculoskeletal system) aftercare following surgical amputation (removal of a limb or body part), absence of left leg below the knee (BKA - below knee amputation), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), End Stage Renal Disease (ESRD -irreversible kidney failure), and dependence on renal dialysis hemodialysis (HD - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 25's Minimum Data Set (MDS - resident assessment tool), dated 5/13/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated that the resident was dependent on staff for bathing, lower body dressing, and transfer mobility; required substantial/maximal assistance from staff for toileting, upper body dressing, and rolling left to right; required partial/moderate assistance for personal hygiene; and required setup or cleanup assistance with eating. During a review of Resident 25's History and Physical (H&P), dated 5/20/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's Care Plan (CP) titled, At Risk for emotional distress related to alleged mental abuse, initiated 5/31/2026, the CP indicated a goal that the resident would not exhibit signs and symptoms of psychosocial or emotional distress with interventions that included to encourage the resident to report fear and feelings of anxiety. During a review of Resident 25's CP titled, At Risk for falls and injuries related to . weakness, left BKA., initiated 2/15/2026, the CP indicated a goal that the resident's risk for falls/injuries will be reduced with interventions that included to assess and anticipate resident's toileting needs and body positioning, bilateral grab bars in bed to aid in mobility. During a review of Resident 25's Grievance/Complaint Resolution Report (GR), dated 9/15/2026, the GR indicated on 9/13/2026 Resident 25 expressed dissatisfaction with Certified Nursing Assistant (CNA) 9's approach and communication style and CNA 9 was removed and would no longer be assigned to Resident 25 as per the resident's request. During a review of the Stop and Watch Early Warning Tool (SWT-a written communication tool for reporting early signs in a potential resident change of condition), dated 9/13/2026 and completed by CNA 9, the SWT indicated on 9/13/2025 at about 6:50 p.m. CNA 9 placed Resident 25 on a bedpan and left to assist another resident. The SWT also indicated when CNA 9 returned, Resident 25 was visibly upset and expressed frustration in the delay in response to the call light (CL). The SWT further indicated while CNA 9 provided care to the resident, Resident 25 yelled, You wanted to throw me out of the bed. During an interview on 6/1/2026 at 11:35 a.m., in the hallway outside Resident 25's room, Resident 25 stated about a year ago CNA 9 attacked him. Resident 25 stated that night he was on the bedpan for over an hour and kept using the CL to call for assistance. Resident 25 stated CNA 9 came into the room angry and was being rough with him and almost pushed him out of the bed. Resident 25 stated he filed a grievance and they removed CNA 9 from his care, but nothing else was ever done. Resident 25 stated he doesn't trust the people in charge because they showed their true faces a year ago. Resident 25 stated the situation with CNA 9 made him feel paranoid and he felt the facility Administrator (ADM) tried to make him the villain. During an interview on 6/4/2026 at 10:20 a.m., with CNA 9, CNA 9 stated she (CNA 9) has cared for Resident 25 twice in the last year. CNA 9 stated sometime last September she was assigned to the resident and she placed him on a bedpan at 6:50 p.m. and she was supposed to go on break at 7 p.m. CNA 9 then stated she left Resident 25 on the bedpan to assist another resident. CNA 9 stated when she returned to the room Resident 25 was screaming and shouting and he had a large bowel movement and she had to change all the bed linens. CNA 9 then stated that while she changed the resident, Resident 25 accused her of trying to push him out of the bed. CNA 9 stated she told Registered Nurse (RN) 4 that Resident 25 was upset, she completed a SWT and reported the incident to the facility Director of Staff Development (DSD), but the DSD no longer works at the facility. CNA 9 then stated that Resident 25 made an allegation of abuse that she (CNA) 9 tried to push him out of the bed. CNA 9 stated she could not remember if she told anyone that Resident 25 alleged she tried to push him out of the bed while she was changing him. CNA 9 stated it was important to make sure allegations are reported to ensure there is an investigation and documentation regarding the allegation. During a concurrent interview and record review on 6/10/2026 at 10:47 a.m. with the Director of Nursing (DON), the DON reviewed the GR, dated 9/15/2026. The DON stated the facility protocol for allegations of abuse is to report all allegations of abuse to CDPH, the ombudsman, and the police, monitor the resident, and suspend the staff member involved pending an investigation. The DON stated Resident 25 had an incident with CNA 9 when she cared for him. The DON stated there was a GR dated 9/15/2026 that indicated Resident 25 had a concern regarding CNA 9's approach and communication style. The DON stated she was not aware Resident 25 alleged that CNA 9 tried to push him out of the bed. The DON stated she (the DON) spoke with CNA 9 after the incident in September and CNA 9 did not mention any allegations of abuse at that time. The DON stated CNA 9 should have reported that Resident 25 alleged she tried to push him out of the bed and she (the DON) would have followed the facility protocol. The DON stated it was important to report and investigate allegations of abuse to protect the safety of the residents and ensure the residents feel safe in the facility. The DON stated Resident 25's allegation should have been reported and investigated and was not, potentially resulting in psychosocial issues in the resident. During a follow-up interview on 6/4/2026 at 11:39 a.m., on the patio, with Resident 25, Resident 25 stated last September CNA 9 went to his room and was upset. Resident 25 stated while CNA 9 changed him, he turned to the right side and CNA 9 was pushing him and he had to hold onto the SR to prevent himself from going further. Resident 25 stated at that time, he felt CNA 9 was trying to harm him. Resident 25 stated the facility leadership did not talk to him about the incident. During a concurrent interview and record review on 6/4/2026 at 4 p.m., in the conference room, with the ADM, reviewed Resident 25's SWT dated 9/15/2026 and the facility policy and procedure (P&P) regarding abuse and stated she (the ADM) was the facility abuse coordinator. The ADM stated the SWT indicates that Resident 25 made an allegation of physical abuse on 9/13/2026 that CNA 9 wanted to throw Resident 25 out of the bed. The ADM stated she (the ADM) was not aware of the allegation because the DSD did not inform the ADM of the SWT. The ADM stated the DSD was responsible for following up on the SWT and the DSD no longer works at the facility. The ADM stated if she had been aware that the SWT indicated you wanted to throw me out of the bed, then she (the ADM) would have followed the facility abuse protocol to immediately report and investigate the allegation, but she did not. The ADM stated the facility P&P was not followed potentially resulting in a negative outcome for the resident with another incident of abuse leading to possible injuries in the resident. During a follow up concurrent interview and record review on 6/5/2026 at 10:14 a.m. in the conference room, with the ADM, the ADM reviewed the P&P regarding abuse reporting and investigating. The ADM stated based on the SWT dated 9/13/2026, Resident 25 made an allegation of abuse that should have been reported immediately or within 2 hours of the allegation but was not, the CNA should have been suspended and was not, the resident should have been interviewed and was not, there should have been some documentation of follow-up and there was not, and the physician should have been notified and was not. The ADM stated the facility P&P was not followed. During a review of the facility provided P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last reviewed on 5/28/2026, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected. the suspicion must be reported immediately to the administrator and to other officials according to state law. 8. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Investigating Allegations. 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating, and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. 4.The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5.The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator. or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; J. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly. 8.The following guidelines are used when conducting interviews:. d. Witness statements are obtained in writing, signed and dated. 9.The investigator notifies the ombudsman that an abuse investigation is being conducted. The ombudsman is invited to participate in the review process. a. If the ombudsman declines the invitation to participate in the investigation, that information is noted in the investigation record. b. The ombudsman is notified of the results of the investigation as well as any corrective measures taken. Reporting Results of Investigations. I. The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 3) had a preadmission screening and annual resident review (PASARR a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level II care plan to personalize the special needs of the resident. This deficient practice placed the residents at risk of not receiving necessary care and/or delay of services that residents need. Findings: During a review of Resident 3's admission Record (AR), the AR indicated that the facility originally admitted the resident on 6/25/2024, and readmitted on [DATE], with diagnoses including multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), functional quadriplegia (a functional paralysis from neck down, including legs, and arms, usually due to a spinal cord injury), schizophrenia (a mental illness that can affect thoughts, mood, and behavior), depression (a mood disorder that causes persistent feeling of sadness and loss of interest), muscle wasting and atrophy (the wasting away or shrinking of a body part, tissue or organ). During a review of Resident 3's History and Physical (H&P), dated 2/06/2026, the H&P indicated that the resident had the capacity to make needs known but cannot make medical decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 5/02/2026, the MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired) and was dependent (requiring assistance) to staff for all activities of daily living (ADLs - routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) and transferring. During a review of Resident 3's Preadmission Screening and Resident Review dated 2/06/2026, the PASARR review indicated that the facility staff will receive this PASARR Individual Determination Report, will discuss the results (.) in a timely manner, and will incorporate the determination into (.) care plan. During a concurrent interview and record review on 6/3/2026 at 9:30 a.m. with Minimum Data Set Coordinator 1 (MDSC 1), the MDSC 1 stated that PASARR is an evaluation to see what residents' needs are and based on the assessment, a determination can be made whether a resident will need a Level II evaluation. The MDSC 1 stated Resident 3 had a positive level two and required to complete a Level II evaluation. The MDSC 1 stated that Resident 3 had a positive Level II and stated that the resident did not have a care plan specific to the PASARR Level II recommendations. The MDSC 1 stated that as part of the personalized plan of care for the resident is to ensure that the facility is providing all the interventions needed like social, behavioral and emotional support to the resident. During an interview on 6/05/2026 at 11:35 a.m. with the Director of Nursing (DON), the DON stated that care plan should be developed for residents with PASARR Level II to ensure the facility can provide appropriate interventions. The DON stated that the process should be completed within 48 hours of admission. The DON stated that absence of a care plan can delay any interventions needed specifically tailored for residents' needs. The DON stated that when there is a delay in specific interventions, it could affect the mental or psychosocial wellbeing of the resident. During a review of the facility's Policy and Procedures (P&P) titled, admission Criteria, revised on 3/2019, the P&P indicate Our facility admits only residents who's medical and nursing care needs can be met. (.) 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) for the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RB. If the level I screen indicated that the individual may meet the criteria for a MD, ID, OR RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

Based on interview and record review, the facility failed to ensure residents who had a positive Level 1 Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) received the required Level II PASARR evaluation and determination for one of two sampled residents (Resident 11) investigated under the PASARR care area by failing to resubmit a Level 1 Screening after Resident 11's case was closed due to the facility staff were unresponsive to two or more separate attempts of communication within 48 hours of a Level I Screening. This deficient practice had the potential to result in a delay of specialized care and services for Resident 11. Findings: During a review of Resident 11's Face Sheet (FS, admission Record), the FS indicated the facility admitted the resident on 3/3/2026 with diagnoses including unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), unspecified dementia (a progressive state of decline in mental abilities), and falling. During a review of Resident 11's History and Physical (H&P) dated 3/3/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS-a resident assessment tool), dated 3/8/2026, the MDS indicated the resident rarely/never had the ability to make herself understood and sometimes understood others. The MDS indicated the resident was dependent on staff for eating, toileting hygiene, shower/bathe self, dressing, and personal and oral hygiene. The MDS indicated the resident was taking antipsychotic medication (used to manage psychosis). During a review of Resident 11's PASARR Level I Screening, dated 3/13/2026, the PASARR Level I Screening indicated a result of positive for serious mental illness (SMI). During a review of Resident 11's Notice of PASARR Level I Screening Results letter, dated 3/13/2026, the Notice of PASARR Level I Screening Results letter indicated Resident 11's positive Level I Screening required a SMI Level II Mental Health Evaluation and the facility would be contacted within two to four days to set up an appointment for an evaluator to conduct an evaluation involving thorough review of the resident's records and may include a telephone contact or visit. The letter further indicated that once the evaluation was completed the resident would receive a report providing recommendations for specialized services. During a review of Resident 11's Notice of Attempted Evaluation letter, dated 3/15/2026, the Notice of Attempted Evaluation letter indicated the facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening and the case was closed. The letter further indicated to reopen the case, the facility must resubmit a new Level I Screening. During a review of Resident 11's Care Plan (CP) titled, The resident has psychosis, initiated 3/9/2026, the CP indicated a goal that staff would anticipate and meet the resident's needs. During a concurrent interview and record review on 6/3/2026 at 9:18 a.m., in the conference room, MDS Coordinator (MDSC) 1 reviewed Resident 11's Notice of PASARR Level I Screening Results letter dated 3/13/2026 and Notice of Attempted Evaluation letter dated 3/15/2026. The MDSC 1 stated the Positive Level I PASARR Screening process is that an evaluator will call the facility requesting additional information like the resident's diagnosis and level of function to determine if there will be an onsite evaluation. The MDSC 1 stated Resident 11 had a positive Level I Screening indicating the resident had a possible SMI and required an evaluation to determine the most appropriate services for the resident's plan of care. The MDSC 1 stated the facility received a letter indicating that the case was closed because the facility staff did not respond. The MDSC 1 stated when the letter was received, one of the licensed nurses (LN) that have access to the PASARR system should have resubmitted the Level 1 Screening, but it was not done. The MDSC 1 stated she (MDSC 1) was one of the LNs that could have resubmitted, but she (MDSC 1) was not aware of the Notice of Attempted Evaluation letter. MDSC 1 stated when a Level 1 Screening was not resubmitted it could potentially result in the facility not meeting the psychological needs of Resident 11 affecting the resident's psychosocial wellbeing. During a concurrent interview and record review on 6/5/2026 at 11:25 a.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding PASARR. The DON stated the facility PASARR process is to provide established interventions after a Level II Evaluation. The DON stated the facility P&P was not followed when the facility did not follow up regarding Resident 11's Notice of Attempted Evaluation letter potentially resulting in a delay of specific interventions for mental, emotional, and psychosocial care for Resident 11. During a review of the facility's P&P titled, admission Criteria, last reviewed on 5/28/2026, the P&P indicated, Our facility admits only residents whose medical and nursing care needs can be met. I. The objectives of our admission criteria policy are to: . admit residents who can be cared for adequately by the facility. 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The state PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation. f. Once a decision is made, the state PASARR representative, the potential resident and his or her representative are notified.

Based on observation, interview, and record review the facility failed to ensure the comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for one of two sampled residents (Resident 9) reviewed during the Respiratory care area and one of one sampled residents (Resident 2) reviewed during the Comm-Sensory care area by failing to: 1.Ensure the CP for Resident 9's use of supplemental oxygen (O2) reflected the physician's order for continuous O2 at four (4) liters per minute (LPM, a measurement of flow rate). 2.Ensure that Resident 2's CP reflected the resident`s correct Primary language. This deficient practice had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives and a potential for delay of necessary care and services to Resident 9 and Resident 2. Findings: a. During a review of Resident 9's Face Sheet (FS - admission record), the FS indicated the facility originally admitted the resident on 2/24/2026, and most recently admitted the resident on 5/14/2026, with diagnoses that included chronic myelomonocytic leukemia (CMML - a blood cancer), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), and pulmonary embolism (PE - a blood clot that blocks and stops blood flow to the lung). During a review of Resident 9's History and Physical (H&P), dated 2/25/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS - resident assessment tool), dated 3/3/2026, the MDS indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS further indicated the resident received continuous O2 therapy while a resident in the facility. During a review of Resident 9's Physician Order Summary Report, the Physician Order Summary Report indicated the following order: - Observe for continuous O2 at 4 LPM via nasal cannula (NC, a thin, flexible tube with two prongs that delivers supplemental O2 to a resident's nose every shift for a diagnosis of COPD, dated 5/11/2026. During a review of Resident 9's Care Plan (CP) titled, The resident has oxygen therapy related to COPD, chronic respiratory failure. on continuous O2 at 4 LPM NC, initiated 5/11/2026, the CP indicated a goal that the resident will have no signs or symptoms of poor oxygen absorption with interventions that included an O2 setting at two (2) LPM via NC continuously. During an observation on 6/1/2026 at 9:18 a.m., observed Resident 9 lying in bed and administered O2 at two (2) LMP via NC. Resident 9 stated she (Resident 9) needed O2 24 hours of every day. During an observation on 6/2/2026 at 8:30 a.m., observed Resident 9 lying in bed being administered O2 at 2 LMP via NC. During a concurrent observation, interview, and record review on 6/2/2026 at 8:51 a.m., in the hallway at Nursing Station 1, with Registered Nurse (RN) 3, Resident 9's physician orders and CPs were reviewed. RN 3 stated the resident has a physician's order for continuous O2 at 4 LPM and the resident should be administered O2 at 4 LPM. Observed RN 3 entered Resident 9's room and stated the resident had O2 administered at 2 LPM via NC. RN 3 stated she would assess the resident and correct the concentrator setting. RN 3 then reviewed Resident 9's CPs O2 administration and stated the O2 CP intervention indicated for oxygen to be set to a flow rate of 2 LPM. RN 3 stated the CP intervention was not correct and did not match the physician's order. RN 3 stated the CP should indicate a flow rate of 4 LPM and did not. During a concurrent interview, and record review on 6/3/2026 at 7:41 a.m., in the conference room, with MDS Coordinator (MDSC) 1, Resident 9's physician orders and CPs were reviewed. The MDSC 1 stated CPs are a communication tool between the facility staff that includes a resident focus problem, the goals for that problem, and the interventions to implement to achieve the goals. The MDSC 1 stated CPs are customized depending on the individual needs of the resident because every resident is different and the approach should be different. The MDSC 1 stated Resident 9 had a physician's order for O2 at 4 LPM via NC and the CP should indicate 4 LPM. The MDSC 1 stated when Resident 9's CP indicated 2 LPM, it was not an appropriate intervention for the resident, and the CP should have been revised but was not. The MDSC 1 stated when Resident 9's CP was not revised to reflect the physician's order of 4 LPM there was the potential to cause confusion leading to the resident not being administered the correct flow rate for supplemental O2. During a concurrent interview and record review on 6/5/2026 at 11:25 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures (P&P) regarding O2 administration and CPs. The DON stated CPs are used as a reference for the interventions to implement for resident care. The DON stated when Resident 9's CP did not indicate the correct amount of LPM for supplemental O2 there was the potential that the resident would not be administered the correct flow rate resulting in a change of condition in the resident leading to respiratory failure. The DON stated the P&Ps were not followed. During a review of the facility P&P titled, Oxygen Administration, last reviewed 5/28/2026, the P&P indicated. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. During a review of the facility P&P titled, Care Plans Comprehensive, last reviewed 5/28/2026, the P&P indicated. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. b. During a review of Resident 2's admission Record (AR), the AR indicated that the facility admitted the resident on 3/1/2026, with diagnoses including metabolic encephalopathy (change in how your brain works due to an underlying condition), muscle weakness generalized (overall, whole-body lack of physical strength), and adult failure to thrive (failing to grow or function at an expected physical or cognitive rate). During a review of Resident 2's H&P, dated 3/1/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 42's MDS, dated [DATE], the MDS indicated the resident's preferred language was Arabic. During a review of Resident 2's Care Plan (CP) Report titled, Resident 2 has a communication problem r/t (related to) cognitive impairment and language barrier, last revised 3/16/2026, the CP indicated the resident speaks Farsi. During an interview on 6/2/2026 at 8:59 a.m. with Resident 2`s Family Member (FM), FM stated that the resident only speaks Arabic and not Farsi. During an interview on 6/2/2026 at 2:45 p.m. with Certified Nurse Assistant (CNA) 8, CNA 8 stated Resident 2 speaks Arabic. Resident 2's care plan did not indicate the resident's correct language, which could negatively affect the resident's care and treatment. During an interview on 6/4/2026 at 11:47 a.m. with the MDSC 1, the MDSC 1 1 stated that care plans must be personalized, goal oriented, and listing the wrong language can cause miscommunication about a resident's care and treatment. During an interview on 6/5/2026 at 11:57 a.m. with the DON, the DON stated care plans must be individualized and accurately document the resident's language; listing Farsi instead of Arabic for Resident 2 could lead to miscommunication and improper care interventions. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, care plans must be updated and revised. During a review of the facility's P&P titled, Charting and Documentation, dated July 2017, the P&P indicated, medical records will be accurate.

Based on observation and interview, the facility failed to ensure residents who were incontinent of bladder received services and assistance for one of one sampled resident (Resident 113) by failing to ensure Resident 113's urinal bottle (a portable, handheld container designed to collect urine) was labeled with the name of the resident. This deficient practice had the potential for Resident 113's urinal bottle to be contaminated (making a substance, surface, or place dirty, impure, or hazardous by introducing a harmful, unwanted, or foreign material) which may lead to development of urinary tract infection (UTI, a common infection that occurs when bacteria enter and multiplies in the urinary system, which includes the kidneys, bladder, and urethra). Findings: During a review of Resident 113's admission Record, the AR indicated the facility admitted the resident on 5/31/2026, with diagnoses including muscle weakness (Generalized) (weakness in many muscles throughout the body); chronic kidney disease, Stage 4 (Severe) (a condition that developed over time where kidneys are severely damaged and most of their function is lost being unable to clean waste and extra fluid from the blood); benign prostatic hyperplasia without lower urinary tract symptoms (the prostate gland is enlarged but it is not causing any urinary problems). During a review of Resident 113's History and Physical (H&P) dated 6/1/26, the H&P indicated the resident had the capacity to understand and make decisions. During a concurrent observation and interview on 6/1/2026, at 10:43 p.m., with Registered Nurse (RN) 2 inside Resident 113's room, observed urinal was not labeled. RN 2 stated it is important to label urinals, so it does not get mixed up with other residents' urinals and for infection control purposes. RN 2 threw the urinal away, got a new one and labeled it with the resident's name. During an interview on 6/4/2026, at 10:33 a.m., with Certified Nurse Assistant (CNA) 10, CNA 10 stated that when a urinal is given to residents, the staff member writes patient's name on urinal. CNA 10 stated if the urinal does not have a name, then it can get mixed up with the other residents' urinal and the resident can get an infection such as UTI. During an interview on 6/4/2026, at 12:35 p.m., with the Minimum Data Set Coordinator (MDSC) 1, the MDSC stated that when a urinal is given to a resident the name of resident is written on the urinal and the urinal is changed as needed. The MDSC 1 stated that when a urinal does not have a name it can be misplaced, other residents can use it and there is a risk for infection like UTI or skin infection. The MDSC 1 stated that if the urinal has no name, it should be disposed and a new one should be given. During an interview on 6/5/2026, at 11:43 a.m., with the Director of Nursing (DON), the DON stated that if the urinal does not have the residents' name the urinal could potentially be used by other residents, resulting in cross-contamination and placing residents at risk for infections such as UTI. During a review of the facility's P&P titled, Cleaning and Disinfecting Non-Critical Resident-Care Items dated 2001, the P&P indicated the purpose of this procedure is to provide guidelines for disinfection of non-critical resident care items. General Guidelines 1. Discard resident-care items when damaged or so grossly soiled that a disinfection process is not effective in rendering the item clean. 2. Single resident use items are for single resident use only. [NAME] with the resident's name and/or room number and discard upon transfer or discharge.

Based on observation, interview, and record review, the facility failed to ensure the water flush bag was labeled with the correct information for one of one sampled resident (Resident 47). This failure had the potential to cause fluid overload (body holds onto more water than it can manage) or dehydration (body loses or uses more fluids than it takes in) to the resident. Findings: During a review of Resident 47's admission Record (AR), the AR indicated the facility admitted the resident on 12/29/2024, with diagnosis of hemiplegia (the severe or complete loss of motor function on one side of the body) and hemiparesis (weakness or partial paralysis affecting only one side of the body) following cerebral infarction (supply of blood to the brain becomes blocked, cutting off oxygen and vital nutrients) affecting left non-dominant side, muscle weakness generalized (an overall, whole-body reduction in physical strength), and encounter for attention to gastrostomy (a routine medical visit for the routine care, cleaning, or changing of a feeding tube). During a review of Resident 47's History and Physical (H&P), dated 12/29/2026, the H&P indicated the resident was alert with periods of confusion. During a review of Resident 47's Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2026, the MDS indicated the resident was rarely/never understood and was dependent with activities of daily living (ADL). During a review of Resident 47's physician order, dated 4/1/2026, the order indicated for the resident to receive 80 milliliters per hour (mL/hr) of water. During a review of Resident 47's physician order, the physician order indicated for the resident to receive 60 mL/hr of Diabetisource (type of tube feeding). During an observation on 6/1/2026 at 9:44 a.m. inside Resident 47's room, a flush bag hanging from a pole with clear liquid, had a label that indicated the bag was filled with Diabetisource. During an interview on 6/3/2026 at 1:42 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the flush bag label should include the rate, time, and date, and must state water instead of Diabetisource.LVN1 stated using Diabetisource on the water bag label is confusing and may lead to errors. During an interview on 6/5/2026 at 12:16 p.m. with the Director of Nursing (DON), the DON stated the flush bag was incorrectly labeled as Diabetisource instead of water, which could cause confusion and possible errors in administering the correct rates for water. This error could potentially affect Resident 47's water intake. Licensed nurses are responsible for proper labeling, but facility policy was not followed, and expectations were not met. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding via Continuous Pump, dated November 2018, the P&P indicated to ensure the safe administration of enteral nutrition.

Based on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for two of two sampled residents (Resident 9 and 114) reviewed under the Respiratory care area by failing to: 1.Ensure oxygen (O2) was administered per physician orders at four (4) liters per minute (LPM, a measurement of flow rate) to Resident 9 on 6/1/2026 and 6/2/2026. 2.Ensure O2 was administered per facility policy and procedure (P&P) with a physician's order and monitored while in use for Resident 114. These deficient practices had the potential to place residents at risk for respiratory distress with a delay in necessary care and treatment. Findings: 1.During a review of Resident 9's Face Sheet (FS - admission record), the FS indicated the facility originally admitted the resident on 2/24/2026 and most recently admitted the resident on 5/14/2026, with diagnoses that included chronic myelomonocytic leukemia (CMML - a blood cancer), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), and pulmonary embolism (PE - a blood clot that blocks and stops blood flow to the lung). During a review of Resident 9's History and Physical (H&P), dated 2/25/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS - resident assessment tool), dated 3/3/2026, the MDS indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS further indicated the resident received continuous O2 therapy while a resident in the facility. During a review of Resident 9's Physician Order Summary Report, the Physician Order Summary Report indicated the following order: - Observe for continuous O2 at 4 LPM via nasal cannula (NC, a thin, flexible tube with two prongs that delivers supplemental O2 to a resident's nose) every shift for a diagnosis of COPD, dated 5/11/2026. During a review of Resident 9's Care Plan (CP) titled, The resident has oxygen therapy related to COPD, chronic respiratory failure. on continuous O2 at 4 LPM NC, initiated 5/11/2026, the CP indicated a goal that the resident will have no signs or symptoms of poor oxygen absorption. During an observation on 6/1/2026 at 9:18 a.m., observed Resident 9 lying in bed and administered O2 at two (2) LMP via NC. Resident 9 stated she (Resident 9) needed O2, 24 hours of every day. During an observation on 6/2/2026 at 8:30 a.m., observed Resident 9 lying in bed being administered O2 at 2 LMP via NC. During a concurrent observation and interview on 6/2/2026 at 8:48 a.m., inside Resident 9's room, observed Certified Nursing Assistant (CNA) 7 entered Resident 9's room and stated she (CNA 7) often cares for Resident 9 and the resident is usually on O2 via NC at 4 LPM. CNA 7 observed the O2 concentrator (device that delivers supplemental O2) and stated the resident was administered O2 at 2 LPM. CNA 5 stated the licensed nurse knows more about the resident's use of O2. During a concurrent observation, interview, and record review on 6/2/2026 at 8:51 a.m., in the hallway at Nursing Station 1, with Registered Nurse (RN) 3, Resident 9's physician orders were reviewed. RN 3 stated the resident has a physician's order for continuous O2 at 4 LPM and the resident should be administered O2 at 4 LPM. RN 3 stated she (RN 3) had been in Resident 9's room earlier and did not check the O2 concentrator setting for O2 flow rate. Observed RN 3 entered Resident 9's room and stated the resident had O2 administered at 2 LPM via NC. RN 3 stated she (RN 3) would assess the resident and correct the concentrator setting. During a concurrent interview and record review on 6/5/2026 at 11:25 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures (P&P) regarding O2 administration. The DON stated supplemental O2 is a treatment that requires a physician's order that includes the flow rate in LPM. The DON stated the P&P was not followed when Resident 9's O2 via NC was not administered per the physician's orders potentially resulting in a change of condition in the resident leading to respiratory failure. During a review of the facility P&P titled, Oxygen Administration, last reviewed 5/28/2026, the P&P indicated. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. Steps in the Procedure. 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. b.During a review of Resident 114's FS, the FS indicated the facility originally admitted the resident on 11/6/2021 and most recently admitted the resident on 5/25/2026, with diagnoses that included acute respiratory failure with hypoxia, pulmonary edema (buildup of fluid in the lungs), PE, and interstitial pulmonary disease (a term for a group of conditions that cause inflammation and scarring in the lungs). During a review of Resident 114's H&P, dated 5/27/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 114's Physician Order Summary Report, the Physician Order Summary Report indicated the following completed order: - Initial application of oxygen at 2 LPM via NC for continuous use, one time only for respiratory failure, for one day, ordered 5/25/2026, completed date 5/26/2026. During a review of Resident 114's Baseline CP, initiated 5/25/2026, the CP indicated the resident was on continuous oxygen while a resident in the facility. During an observation on 6/1/2026 at 10:17 a.m., observed Resident 114 lying in bed and administered O2 at 2 LMP via NC. Family Member (FM) 1 stood at bedside and stated Resident 114 wasn't always on supplemental O2, but the resident needs it now. During an interview on 6/2/2026 at 9:24 a.m., in the hallway outside Resident 114's room, CNA 5 stated Resident 114 has been on supplemental O2 since admission. During a concurrent interview, and record review on 6/2/2026 at 9:27 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 114's physician orders, medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), and Progress Notes were reviewed. LVN 3 stated oxygen is considered a medication and requires a physician's order to administer. LVN 3 stated it was important to obtain a physician's order for O2 because if a resident was on O2 without an order it may be considered a change of condition that should be reported to the physician. LVN 3 stated residents that are administered O2 should be monitored for effectiveness and side effects. LVN 3 stated Resident 114 was admitted on [DATE] on continuous O2 at 2 LPM via NC and did not have an active physician's order for O2 administration from 5/26/2026 to 6/1/2026. LVN 3 then reviewed Resident 114's Weights and Vitals Summary and noted the resident was administered O2 without a physician's order or monitoring on the following dates and times: - On 5/28/2026 at 12:16 a.m., Resident 114's O2 Sat was 97.0% on Oxygen via NC. - On 5/29/2026 at 1:04 p.m., Resident 114's O2 Sat was 96.0% on Oxygen via NC. - On 5/31/2026 at 1:01 a.m., Resident 114's O2 Sat was 96.0% on Oxygen via NC. - On 6/1/2026 at 1:15 a.m., Resident 114's O2 Sat was 96.0% on Oxygen via NC. LVN 3 further stated Resident 114 should have had an order to administer O2 between 5/26/2026 and 6/1/2026 and did not. During a concurrent interview, and record review on 6/3/2026 at 7:41 a.m., in the conference room, with the MDS Coordinator (MDSC) 1, Resident 114's physician orders, MAR, and CPs were reviewed. The MDSC 1 stated O2 use requires an active physician's order during the treatment. The MDSC 1 stated it was important to have a physician's order because the order is the communication between the physician and the nursing staff to ensure that treatments are administered per the physician's indications. The MDSC 1 stated Resident 114 had a completed order to initiate O2 administration on 5/25/2026, but there were no physician's orders to continue the administration of O2 between 5/26/2026 and 6/1/2026 but there should have been. The MDSC 1 stated there was no documented evidence that Resident 114 was monitored while on O2 between 5/26/2026 and 6/1/2026 but there should have been. The MDSC 1 stated when Resident 114 was administered O2 without a physician's order or monitoring there was the potential that the resident could have a negative outcome when the need for supplemental O2 resulted in an unidentified change of condition leading to hospitalization of the resident. During a concurrent interview and record review on 6/5/2026 at 11:25 a.m., with the DON, the DON reviewed the facility policy and procedures (P&P) regarding O2 administration. The DON stated supplemental O2 is a treatment that requires a physician's order and monitoring. The DON stated the P&P was not followed when Resident 114's O2 via NC was not administered per the physician's orders and monitored potentially resulting in a change of condition in the resident leading to respiratory failure. During a review of the facility P&P titled, Physician Orders, last reviewed 5/28/2026, the P&P indicated. Verbal, written and telephone orders may be accepted from each resident's Attending Physician.1. Verbal, written and telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. 3. The receiving nurse with order/s will carry out the order and print the medication or treatment record/s. 4. New order/s will be communicated to the responsible party/agent, charge nurse, pharmacy, other department/s as indicated. During a review of the facility P&P titled, Oxygen Administration, last reviewed 5/28/2026, the P&P indicated. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. Assessment. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following:. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion); Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); Vital signs; Lung sounds; Arterial blood gases and oxygen saturation, if applicable; and Other laboratory results . Steps in the Procedure. 8. Turn on the oxygen. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated .

Based on observation, interview, and record review, the facility failed to ensure one of two food scoopers (used to scoop dry goods food) were clean. This failure had the potential to for the food scooper to carry harmful germs, bacteria, or chemical residues which can contaminate the residents' meals and increase the rise of foodborne illness to the residents.Findings:During a concurrent observation and interview on 6/1/2026 at 8:06 a.m. in the kitchen with the Dietary supervisor, there were one of two food scoopers on top of a food preparation table that had a white residue. Dietary Supervisor (DS) stated this food scooper must be cleaned after each use to prevent contamination risk to the residents. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated the utensils shall be kept clean.

Based on interview and record review, the facility failed to maintain complete clinical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 110) reviewed during the closed records (death) task by failing to ensure Registered Nurse (RN) 2 documented the vital sign numeric values (measurements of the body's most basic functions including temperature [Temp], blood pressure [BP], heart rate [HR/pulse] and respiratory rate [RR], and oxygen saturation level [O2 sat- a measurement of how much oxygen the blood is carrying as a percentage]) for the night shift (11 p.m. to 7 a.m.) on [DATE]. This resulted in an incomplete documentation in Resident 110's medical chart. Findings: During a review of Resident 110's Face Sheet (FS, admission Record), the FS indicated the facility admitted the resident [DATE] with diagnoses including displaced fracture of right femur (hip fracture), presence of right artificial hip joint, essential (primary) hypertension (high blood pressure with an unknown cause), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots [clumps that occur when blood hardens from a liquid to a solid] in the heart), pleural effusion (PE, a collection of fluid around the lungs), and acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen) with hypoxia (low levels of oxygen in your body tissues), and mesothelioma (cancer that forms in the thin tissue that lines many of your internal organs). During a review of Resident 110's Admission/readmission Initial Assessment (AIA) dated [DATE], the AIA indicated the resident arrived at the facility on [DATE] at 1:15 p.m. by ambulance and was oriented (a person's awareness) to person, place, time, and was able to follow simple commands with intermittent confusion. The AIA indicated the resident was able to understand others and make himself understood. During a review of Resident 110's Progress Note, dated [DATE] at 5 a.m., and completed by RN 2, the Progress Note indicated the following: -During routine rounds at 11:00 p.m., resident was observed lying in bed, breathing spontaneously with no signs or symptoms of respiratory distress noted. Vital signs assessed and within normal limits. At 4:00 a.m. Certified Nursing Assistant (CNA) went to the resident's room to provide care and noted the resident appeared pale and was not breathing. Resident DNR (do not resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). During a concurrent interview and record review on [DATE] at 12:48 p.m., in the conference room, with MDS Coordinator (MDSC) 1, Resident 110's Progress Notes dated [DATE] to [DATE] and Weights and Vital Signs form dated [DATE] to [DATE] were reviewed. The MDSC 1 stated vital sign numeric values are important to document to know if there are any changes in the resident. The MDSC 1 stated that the facility process is newly admitted residents` vital signs are measured and the numeric values including HR, BP, RR, Temp, and O2 sat are documented during every shift. The MDSC 1 stated that Resident 110 was admitted on [DATE] at 1:15 p.m. during the day shift (7 a.m. to 3 p.m.) and expired on [DATE] at approximately 4 a.m. on the night shift. The MDSC 1 stated RN 2 documented that vital signs were taken at 11 p.m., but there was no documented evidence of the vital sign numeric values including Resident 110's HR, RR, BP, Temp, and O2 sat, but there should have been. During a concurrent interview and record review on [DATE] at 2:03 p.m., in the conference room with RN 2, Resident 110's Progress Notes dated [DATE] to [DATE] and Weights and Vital Signs form dated [DATE] to [DATE] were reviewed. RN 2 stated that newly admitted residents have the vital signs measured every shift. RN 2 stated she (RN 2) helped care for Resident 110 on the night shift on [DATE]. RN 2 stated she (RN 2) took Resident 110's vital signs but missed documenting the numeric values. RN 2 stated it was important to document the numeric values to show that the resident was stable and there was no change in the resident's condition and the medical record should reflect the care provided. RN 2 stated when she (RN 2) did not document Resident 110's HR, RR, Temp, BP, and O2 sat, the resident's documentation was not complete. During a concurrent interview and record review on [DATE] at 11:25 a.m., in the conference room, the Director of Nursing (DON) reviewed the facility policy and procedure (P&P) regarding vital signs and documentation. The DON stated newly admitted residents have their vital signs measured every shift and the values are documented. The DON stated Resident 110 should have had documented vital sign values on [DATE] for the night shift and did not. The DON stated the facility P&P was not followed when Resident 110's vital sign numeric values were not documented resulting in incomplete medical records for the resident. During a review of the facility P&P titled, Resident Examination and Assessment, last reviewed [DATE], the P&P indicated, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical Exam. 1.Vital Signs: blood pressure (standing and sitting); pulse (carotid); respirations; and temperature. Documentation. The following information should be recorded in the resident's medical record: The date and time the procedure was performed. The name and title of the individual(s) who performed the procedure. All assessment data obtained during the procedure. During a review of the facility P&P titled, Charting and Documentation, last reviewed [DATE], the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record:. c. Treatments or services performed. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review the facility failed to ensure all parts of the call light system (CL, an alerting device for nurses or other personnel to assist a patient when in need) were functional for one of eight sampled residents (Resident 67) investigated under the Environment task. This deficient practice had the potential to result in the delay of care and services and falls with injury in residents. Findings: During a record review of Resident 67's Face Sheet (FS, admission Record), the FS indicated Resident 67 was originally admitted to the facility on [DATE] and most recently admitted [DATE] with diagnoses including sepsis (a life-threatening blood infection), muscle weakness, unsteadiness of feet, and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 67's History and Physical (H&P), dated 6/1/2026, the H&P indicated the resident had the capacity to understand but could not make medical decisions. During a review of Resident 67's Physician Orders Summary Report, the Physician Orders Summary Report indicated the following order: - Dated 3/30/2026 perianal moisture associated skin damage (MASD - skin damage caused from prolonged exposure to moisture), cleanse with normal saline (a sterile solution), pat dry and apply medicated powder, leave open to air, every day shift. During a review of Resident 67's Care Plan (CP) titled, The resident is at risk for falls and injuries., initiated 6/2/2025, the CP indicated interventions to maintain the call light within reach and to assess and anticipate the resident's toileting needs. During a review of Resident 67's CP titled, (Resident 67) has an activities of daily living self-care and/or mobility performance deficit ., initiated 5/30/2025, the CP indicated an intervention to maintain the call light within reach and encourage the resident to use the call light for assistance. During a concurrent observation and interview on 6/1/2026 at 11:01 a.m., inside Resident 67's shared room, observed Resident 67 lying in bed with the CL button placed on the right side of the resident with the cord clipped to the sheet. Resident 67 stated that she (Resident 67) had been calling for assistance all morning and nobody came in. Resident 67 stated her adult brief was wet and she (Resident 67) needed to be changed. Observed Resident 67 pressed the CL button and the notification light at the door did not light up. Resident 67 stated the CL was not working. Observed the CL cord was not connected to the wall mounted control plate, and the end of the CL cord was severed and resting on top of the resident's bed. During a concurrent observation and interview on 6/1/2026 at 11:05 a.m., inside Resident 67's shared room, observed the Social Services Assistant (SSA) entered Resident 67's room and stood at the foot of the bed from where the severed CL cord was visible. Observed Resident 67 stated to the SSA that she (Resident 67) had not been changed all morning and nobody heard her. The SSA stated she (SSA) would find the resident's Certified Nursing Assistant (CNA) to assist. The SSA exited the room and the severed CL cord remained on the bed. During an observation on 6/1/2026 at 11:14 a.m., in Resident 67's shared room, observed the Activities Assistant (AA) entered the room and stood at the foot of the bed from where the severed CL cord was visible. Observed the AA then exited the room and the severed CL cord remained on the bed. During a concurrent observation and interview on 6/1/2026 at 11:20 a.m., in Resident 67's shared room, observed CNA 5 entered the resident's room and stated she would assist the resident. Observed Resident 67 stated she (Resident 67) was wet, and nobody came to assist. Observed Resident 67 pushed the CL button and CNA 5 confirmed the CL was not functioning. CNA 5 then stated the CL cord was broken and not connected to the wall. CNA 5 stated she (CNA 5) was in the room earlier assisting Resident 67's roommate and did not notice the CL cord was broken. CNA 5 stated all staff that enter the resident's room are responsible to check the resident's CL to identify any issues and make sure the CL is functioning, especially when the resident stated they had called and no staff came to the room. During an interview on 6/4/2026 at 12:37 p.m., in the conference room, with MDS Coordinator (MDSC) 1, MDSC 1 stated the CL is the method of communicating any needs between the residents and the staff. MDSC 1 stated the CL should always be functioning. MDSC 1 stated it was important that Resident 67 had a functioning CL because the resident was bedbound and a high risk for falls. MDSC 1 stated Resident 67 also had MASD and should not remain wet because there was the potential for a decline in the resident's skin condition. MDSC 1 stated every staff member that enters the residents' room is responsible for doing an environment check and checking the CL system. MDSC 1 stated when Resident 67 reported to the SSA that nobody was answering the CL, the SSA should have checked the CL and did not potentially resulting in the resident becoming frustrated and sustaining a fall while trying to get staff assistance. During a concurrent interview and record review on 6/5/2026 at 11:25 a.m., the Director of Nursing (DON) reviewed the facility policy and procedures (P&P) regarding CLs. The DON stated CLs should be working and properly placed within reach, so residents have access to staff assistance. The DON stated that when residents do not have a CL it could potentially result in residents not getting what they need. The DON stated the facility policy was not followed when Resident 67's CL was broken. During a review of the facility P&P titled, Call Light, last reviewed on 5/28/2026, the P&P indicated. Purpose . The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines . 1. Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. 2. Ask the resident to return the demonstration. 4. Be sure that the call light is plugged in and functioning at all times. Report all defective call lights to the nurse supervisor promptly.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices by failing to ensure [NAME] 1 verified the internal temperature of grilled chicken prior to service on 2/11/2026 for four of four sampled residents (Resident 4, Resident 5, Resident 6, and Resident 7). This deficient practice had the potential to result in unsafe food temperatures, allowing harmful bacterial growth and increasing the risk of foodborne illness in a medically compromised resident population who received meals prepared in the facility kitchen. Findings:a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 10/29/2019 and readmitted the resident on 10/28/2024 with diagnosis that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and essential (primary) hypertension (HTN-high blood pressure).During a review of Resident 4's Order Summary Report (OSR), dated 9/18/2025 the ORS indicated Resident 4 was ordered a regular diet, easy-to-chew texture, thin liquids, and required meat to be cut up. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 1/21/2026, the MDS indicated Resident 4 had the ability to understand and be understood. The MDS indicated Resident 4 was dependent (helper does all of the effort) in toileting, showering, lower body dressing, and putting on and taking off footwear, and required substantial (helper does more than half the effort) help with oral hygiene, upper body dressing and personal hygiene and required supervision (helper provides verbal cues as resident completes activity) with eating. A review of Resident 4's Lunch Slip dated 2/11/2026 indicated Resident 4 did not consume pork, ham, bacon, or sausage. b. During a review of Resident 5's AR, the AR indicated the facility admitted Resident 5 on 4/29/2025 and readmitted Resident 5 on 1/16/2026 with diagnosis that included dysphagia (difficulty swallowing), type two DM, and HTN.During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 never understood and was never understood. The MDS indicated Resident 5 was dependent on toileting, showering, lower body dressing, putting on and taking off footwear, required substantial assistance with upper body dressing, and required partial (helper does less than half the effort) with oral hygiene, and personal hygiene and eating was not attempted due to medical condition or safety concerns.During a review of Resident 5's OSR dated 2/11/2026, the OSR indicated a consistent or controlled carbohydrate (CCHO- a meal plan for managing diabetes and blood sugar by consuming a similar, set amount of carbohydrates at each meal daily) diet, no added salt (NAS), minced and moist texture, with mildly thick consistency for lunch only for oral gratification. c. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 2/2/2026 with diagnosis that included malignant neoplasm (a cancerous tumor) of pancreas (a large gland behind the stomach which secretes digestive enzymes into stomach), and muscle wasting and atrophy (the wasting away, shrinking, or reduction in size of cells, tissues, or organs). During a review of Resident 6's OSR dated 2/10/2026, the OSR indicated a regular diet puree texture, with mildly thick consistency. During a review of Resident 6's Lunch Slip dated 2/11/2026, indicated Resident 6 had the following dislikes bacon, ham and pork.d. During a review of Resident 7's AR, the AR indicated Resident 7 was admitted on [DATE] with diagnosis that included dysphagia, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and chronic kidney disease (CKD- a long-term condition where the kidneys are damaged and gradually lose their ability to filter waste, toxins, and extra fluid from the blood).During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had the ability to understand and be understood. The MDS indicated Resident 7 required partial assistance with showering, lower body dressing and putting on and taking off footwear, and supervision with oral hygiene, toileting, upper body dressing, and personal hygiene and requires set up or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating.During a review of Resident 7 OSR dated 1/29/2026, the OSR indicated CCHO and NAS diet regular texture, thin liquid consistency, with no milk substitute with non-dairy.During a review of Resident 7's Lunch Slip dated 2/11/2026, Resident 7's dislikes included pork chops and porkDuring a review of the facility provided menu titled, Good for Your Health Menu, for February 9th to February 15th, 2026, the menu indicated lunch on 2/11/2026 included BBQ pork, polenta, Brussels sprouts, wheat roll, and a chocolate chip cookie bar.During a concurrent observation of the kitchen and interview with CK 1 on 2/11/2026 at 11:16 a.m. CK 1 stated grilled chicken was being substituted for residents who did not consume porkDuring an observation of the kitchen on 2/11/2026 at 12:01 p.m. CK 1 was observed checking the internal temperatures of the food on the tray line, however, the internal temperature of the grilled chicken was not verified prior to plating and distribution. During an observation on 2/11/2026 at 12:07 p.m. and 12:15 p.m. CK 1 place grilled chicken onto a plate and placed the trays in the meal cart for distribution without verifying the internal temperature. During a concurrent interview and observation on 2/11/2026 at 12:49 p.m. CK 1 placed a piece of grilled chicken into the blender to prepare a puree for a resident whose diet had been changed. During an interview on 2/11/2026 at 12:59 p.m. with CK 1, CK 1 stated she did not check the temperature of the grilled chicken and acknowledged that failure to do so could result in residents becoming ill. During an interview on 2/11/2026 at 3 p.m. with the Dietary Supervisor (DS), the DS stated the temperature of the food should be taken at the tray line prior to it being served. The DS stated if the temperatures are not taken the food will not be at the required limits and it will be at a high risk for the residents to get sick from the protein. The DS stated can affect the intake as well if the food is not hot affect their appetite may not want to eat it may not be palpable due to the temperature. During an interview on 2/11/2026 at 3:36 p.m. with the Director of Nursing (DON), the DON stated temperature for food is taken prior to the food going out. The DON stated if it is not being done potentially the food may arrive without the right temperature the resident may not eat it, potential for weight loss, and for the residents to be hungry. The DON stated there is a potential risk for gastrointestinal issues, potential for food borne illness.During a review of the facility's policy and procedure (P&P) titled, Meal Service, last reviewed on 5/29/2025, the P&P indicated meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. The Food and Nutrition Services staff members will take the food temperature prior to service of the meal with a thermometer that has been cleaned and sanitized. The food will be served on tray line at the recommended temperatures indicated below:Meat, casseroles, potatoes, rice, pastas, beans, vegetables, gravies, sauces, and hot cereal: 160 Fahrenheit ( F- a scale for measuring temperature primarily used in the United States, where water freezes at 32 F and boils at 212 F) to 180 F. 7. Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot. Recommended temperature at delivery to Resident indicated: Hot entree above 120 F.

Based on interview and record review, the facility failed to follow professional standards of practice for two of three sampled residents (Resident 1 and Resident 3) by failing to: 1. Ensure licensed nurses monitored Resident 1's medical status after the resident's changes of condition (COC) on 11/15/2025 and 11/29/2025. 2. Ensure Resident 1's physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) at two liters per minute was followed. On 1/30/2025, Resident 1's oxygen therapy was at three liters per minute (lpm - unit of measurement). 3. Ensure licensed nurses monitored Resident 3's gastrointestinal (stomach and intestines) status after the resident's COC on 12/4/2025. These deficient practices had the potential to place Resident 1 and Resident 3 at risk for undetected and worsening medical conditions which could negatively impact the residents' health and safety.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/13/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), anemia (condition in which the body does not get enough oxygen-rich blood) and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. During an interview on 12/9/2025 at 11:46 a.m. and concurrent record review of Resident 1's medical records, reviewed with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) Communication Forms indicated the resident had a COC on 1/15/2025 and 1/29/2025. LVN 1 stated on 1/15/2025, Resident 1 had two COCs for low hemoglobin (amount of oxygen-carrying protein in the red blood cells) and hematocrit (percentage of blood volume made up of red blood cells) levels and for a mass on Resident 1's left arm. LVN 1 stated Resident 1's Progress Notes indicated there was no documented evidence that monitoring was done on 1/16/2025 and 1/17/2025, 7 a.m. to 3 p.m. shifts. LVN 1 stated Resident 1's SBAR Communication Form, dated 1/29/2025, indicated the resident had a COC for high blood urea nitrogen (BUN - checks the waste products in the blood to test the kidney function) level, low potassium (a mineral the body needs to work properly), and high ammonia (a waste product from protein breakdown in the blood). LVN 1 stated Resident 1's Progress Notes indicated there was no documented evidence that monitoring was done on 1/29/2025, 3 p.m. to 11 p.m. shift and on 1/30/2025, 7 a.m. to 3 p.m. shift. LVN 1 stated residents should be monitored every shift for 72 hours after a COC. LVN 1 stated Resident 1's medical condition had the potential to be missed and worsen. Resident 1's Physician Orders, dated 1/13/2025, indicated an order for continuous oxygen at two lpm using a nasal cannula (a device used to deliver supplemental oxygen). Resident 1's SBAR Communication Form, dated 1/30/2025, indicated the resident had oxygen at three liters per minute using nasal cannula. LVN 1 stated the licensed nurses did not follow Resident 1's oxygen therapy order. LVN 1 stated Resident 1 had the potential to be over oxygenated that may cause respiratory distress (difficulty breathing). During an interview on 12/9/2025 at 2:57 p.m. with the Director of Nursing (DON), the DON stated Resident 1 should be monitored every shift for at least 72 hours after the resident's COC. The DON stated there was no documented evidence that Resident 1 was monitored on 1/16/2025 and 1/17/2025, 7 a.m. to 3 p.m. shift, after the resident's COC on 1/15/2025. The DON stated there was no documented evidence that Resident 1 was monitored on 1/29/2025, 3 p.m. to 11 p.m. shift, and on 1/30/2025, 7 a.m. to 3 p.m. shift, after the resident's COC on 1/29/2025. The DON stated Resident 1's oxygen therapy was administered at three lpm instead of two lpm. The DON stated not following the physician's oxygen therapy order had the potential to negatively affect the resident's health. The DON stated the facility failed to ensure the licensed nurses monitored and documented Resident 1's condition after the resident's COC. The DON stated the facility failed to ensure Resident 1's physician order on oxygen therapy was followed. During a review of the facility's policy and procedure (PnP) titled, Acute Condition Changes - Clinical Protocol, last reviewed on 5/29/2025, the PnP indicated, The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. During a review of the facility's PnP titled, Oxygen Administration, last reviewed on 5/29/2025, the PnP indicated The purpose of this procedure is to provide guidelines for safe oxygen administration. The PnP indicated verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. During a review of Resident 3's admission Record (undated), the admission Record indicated the facility admitted the resident on 5/8/2024 with diagnoses including gastro-esophageal reflux disease (a condition in which the stomach contents leak backward from the stomach into the esophagus [food pipe]), anemia, and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were intact. During a review of Resident 3's SBAR Communication Form, dated 12/4/2025, the SBAR Communication Form indicated Resident 3 had diarrhea for two days. During a review of Resident 3's Progress Notes, dated 12/4/2025 to 12/8/2025, the Progress Notes indicated there was no documented evidence that Resident 3 was monitored on the following days and shifts: a. 12/4/2025 (3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts),b. 12/5/2025 (7 a.m. to 3 p.m. shift), and c. 12/6/2025 (7 a.m. to 3 p.m. shift). During an interview on 12/9/2025 at 2:57 p.m. with the Director of Nursing (DON), the DON stated Resident 3 should be monitored every shift for at least 72 hours after the resident's COC. The DON stated the facility failed to ensure the licensed nurses monitored and documented Resident 3's condition after the resident's COC. During a review of the facility's policy and procedure (PnP) titled, Acute Condition Changes - Clinical Protocol, last reviewed on 5/29/2025, the PnP indicated The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for two of eight sampled facility staff (Licensed Vocational Nurse [LVN] 1 and Certified Nursing Assistant [CNA] 1) by failing to:1.Ensure CNA 1's N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) was worn while inside a COVID-19 isolation room (a set of precautions used to prevent the spread of COVID-19).2. Ensure LVN 1 wore the N95 mask properly while inside the facility. LVN 1's N95 mask was not covering the nose and mouth while at a resident care area. 3. Ensure LVN 1 performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before touching the computer at nurse station 2.These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19.Findings:During an observation on 9/2/2025 at 10:10 a.m., observed CNA 1 came out of Resident 2's room without a N95 mask. During a review of Resident 2's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/6/2020 with diagnoses including cerebral palsy (a group of conditions that affect movement and posture), COVID-19, and heart failure (a progressive heart disease that affects pumping action of the heart muscles).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 7/11/2025, the MDS indicated Resident 2's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. During a review of Resident 2's SBAR-Infection form, dated 8/27/2025, the SBAR-Infection form indicated the resident had a positive COVID-19 test result. During an interview on 9/2/2025 at 10:23 a.m. with CNA 1, CNA 1 stated she removed and disposed all the personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), including the N95 mask, inside Resident 2's room. CNA 1 stated the N95 mask should be removed, disposed, and replaced outside the COVID-19 isolation room. CNA 1 stated removing the N95 mask inside the COVID-19 isolation room had the potential to expose her and other residents to the infection.During a concurrent observation and interview on 9/2/2025 at 10:50 a.m., observed LVN 1's N95 mask was not worn properly while at nurse station 2. LVN 1's top elastic strap of the N95 mask was not worn over the head. LVN 1's N95 mask was under the chin, not covering LVN 1's nose and mouth. Observed LVN 1 wore his N95 mask and touched the outside part of the mask. LVN 1 did not perform hand hygiene before he touched the computer keyboard at nurse station 2. The Director of Staff Development (DSD) stated the N95 mask should be worn inside the facility and in patient care areas. The DSD stated the nurse stations were considered a patient care area. During an interview on 9/2/2025 at 3:07 p.m. with the Director of Nursing (DON), the DON stated the facility had COVID-19 positive cases. The DON stated N95 masks should be worn while inside the facility and while in patient care areas that included the nurse stations. The DON stated hand hygiene should be done after touching the soiled N95 mask. The DON stated there was potential for the spread of COVID-19 to residents, visitors, and staff. The DON stated the facility failed to follow infection prevention and control protocols. During a review of the facility's policy and procedure (PnP) titled, Personal Protective Equipment, last reviewed on 5/29/2025, the PnP indicated during respiratory outbreak, all staff must wear well-fitted N95 respirators.During a review of the facility's PnP titled, Infection Prevention Quality Control Plan, last reviewed on 5/29/2025, the PnP indicated, employees must wash their hands . after handling soiled equipment or utensils. The PnP indicated employees must perform hand sanitation . after handling used dressings, contaminated equipment, etc.; after contact with objects (e.g. medical equipment).

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care consistent with professional standards of practice to prevent from development of a Stage 3 pressure ulcers ([PU] a localized injury to the skin and/or underlying tissue usually over a bony prominence because of pressure) by failing to: 1. Ensure Resident 1 ' s right heel was elevated ([offloaded] minimizing or removing weight placed on the foot and heel to help prevent development and assisted in pressure ulcers healing) off the mattress and was not continuously laying directly on the mattress thus contributing to the development of Resident 1 ' s right heel pressure ulcer. 2. Provide Resident 1 with a Low Air Loss Mattress ([LALM] a mattress designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown. Air continually flows through tiny laser-made air holes in the top of the mattress surface so that a resident floats on a soft cushion of air) to prevent development of a Stage 3 pressure ulcer to the resident ' s right heel. 3. Ensure Resident 1 had an individualized plan of care with interventions to prevent development of a Stage 3 pressure ulcer to Resident 1 ' s right heel. 4. Ensure Resident 1 ' s Skin and Wound Assessment documentation was completed and accurate in accordance with facility ' s policy and procedure (P&P) titled, Charting and Documentation. 5. Ensure nursing staff inspected Resident 1 ' s skin on a daily basis when performed or assisted the resident with a personal care, or activities of daily living ([ADLs] a basic tasks that must be accomplished every day for an individual to thrive) in accordance with the facility ' s policy titled, Prevention of Pressure Injuries, and as indicated on the care plan titled, Activities of Daily Living. As a result, Resident 1 developed a Stage 3 (full thickness loss of skin in which subcutaneous fat may be visible in the ulcer) PU on the right heel which required Resident 1 to undergo a bone tissue debridement (the surgical process of removing skin and bone close to and surrounding an infected wound associated with bone injuries or diseases). Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 4/19/2024 with diagnoses including nondisplaced fracture (broken bones where the pieces were not moved enough during the break to be out of alignment) of the right femur (thigh bone), hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (commonly known as stroke, caused by a blockage in a blood vessel in the brain, leading to brain damage) affecting the right dominant side, and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A review of Resident 1 ' s Skin Supplemental Assessment, dated 4/20/2024, indicated Resident 1 had a surgical incision (a cut made through the skin and soft tissue to facilitate an operation or procedure) on the right hip and multiple discoloration (a change to the original color of something that makes it look unpleasant or damaged) on both right and left upper extremity (the region of the body that included the arm, forearm, wrist, and hand). There was no documented evidence that Resident 1 had pressure ulcers on admission. A review of Resident 1 ' s Care Plan for ADLs initiated on 4/20/2024, indicated Resident 1 had mobility (ability to move) performance deficit related to activity intolerance (inability to endure), fatigue (an extreme sense of tiredness and lack of energy that can interfere with a person ' s usual daily activities), hemiplegia, history of right femur fracture, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and left knee osteoarthritis (condition that causes the joints to become very painful and stiff). The Care Plan interventions indicated Resident 1 required skin inspection, including observation for redness, open skin areas, scratches, cuts, bruises, and report the changes to the nurse. Resident 1 ' s Care Plan interventions did not indicate the frequency of skin inspections. A review of Resident 1 ' s Care Plan for a Pressure Ulcer, dated 4/20/2024, indicated Resident 1 had the potential for pressure ulcer development. Resident 1 ' s Care Plan goal indicated the resident will have intact skin, free from redness, blisters (a small pocket of fluid in the upper skin layers and one of the body ' s responses to injury or pressure) or discoloration. Resident 1 ' s Care Plan Interventions indicated to follow the facility ' s policies and protocol for the prevention and treatment of skin breakdown. Resident 1 ' s Care Plan indicated there were no listed interventions implemented to prevent the development of right heel PU. A review of Resident 1 ' s History and Physical (H&P), dated 4/22/2024, indicated Resident 1 had a right sided weakness. The H&P indicated Resident 1 had a fall at home that led Resident 1 to undergo surgical intervention for an open reduction internal fixation [(ORIF] a surgical procedure for repairing fractured bones using either plates, screws, or an intramedullary rod to stabilize the bone) of the right femur. The H&P indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1 ' s Minimum Date Set ([MDS]a standardized assessment and care screening tool), dated 4/23/2024, indicated Resident 1 ' s cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were intact. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) from staff to roll left and right (the resident ' s ability to roll from lying on back to left and right side and return to lying back on the bed) in bed. The Skin Condition section of the MDS indicated that Resident 1 was at risk of developing pressure ulcers or injury. The MDS indicated Resident 1 did not have any pressure ulcers or injury. A review of Resident 1 ' s Braden Scale for Predicting Pressure Sore (ulcer) Risk, dated 4/26/2024, indicated the resident ' s score of 16. The score of 16 indicated Resident 1 was at risk for developing a pressure ulcer. A review of Resident 1 ' s Skin Observation Monitoring, dated 5/2024, indicated Resident 1 ' s skin condition was not monitored on 5/5/2024 on day shift (7 a.m. to 3 p.m.) and on 5/10/2024 on night shift (11 p.m. to 7 a.m.). Resident 1 ' s Skin Observation Monitoring indicated the resident ' s skin condition monitoring was not applicable on the night shift on 5/25/2024, 5/27/2024, 5/28/2024, 5/30/2024, and 5/31/2024. A review of Resident 1 ' s Progress Notes, dated 4/19/2024 to 5/25/2024, indicated no documented evidence that Resident 1 was on a pressure relieving mattress (LALM) and that Resident 1 ' s right heel was offloaded from the mattress to prevent the development of a pressure ulcer. A review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR) Communication Form, dated 5/23/2024, indicated Resident 1 had an open wound on the right heel. SBAR section ' Skin Changes ' indicated Resident 1 ' s right heel wound was described as a vascular wound (wounds on the skin that develop because of problems with blood circulation) with 15 percent (%) necrosis (the death of a body tissue), 25% slough (a necrotic tissue formed when dead cells and/or bacteria accumulate in the wound), 30% granulation (a development of new tissue and blood vessels in a wound during the healing process), 30% epithelization (the final stage of wound healing), and mild to moderate serosanguineous (contains or relates to both blood and the liquid part of blood [serum]) exudate (any fluid that had been forced out of the tissue because of inflammation or injury). On 5/23/2024 at 10:40 a.m., Resident 1 ' s Attending Physician (MD 1) and the resident representative 1 (FM 1) was notified about Resident 1 ' s right heel wound. A review of Resident 1 ' s Skin Ulcer (wound) Report-Initial, dated 5/23/2024, indicated Resident 1 had an acquired (developed while in the facility) right heel Unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because the wound bed is obscured by slough or eschar [a collection of dry, dead tissue within an wound]). The Skin Ulcer (wound) Report-Initial section ' Ulcer Dimensions ' indicated Resident 1 ' s right heel PU was measured 3.5 centimeters ([cm]- unit of measurement) in length, 2.5 cm in width, with undetermined depth. The Skin Ulcer Report-Initial indicated Resident 1 ' s right heel PU had a 100% brown to black necrosis, was boggy (feels like it has fluid in it), had macerated (the process of skin softening and breaking down) per-wound (the surrounding area of the wound edge) with stable dry eschar (a collection of dry, dead tissue within a wound). A review of Resident 1 ' s Physician ' s Orders, dated 5/23/2024, indicated an order for STAT (urgent or rush) arterial (blood vessels that distribute oxygen-rich blood to the body) /vascular ultrasound (a noninvasive test to determine how blood flows in arteries and veins in the arms, neck, and legs) of the right lower extremity. A review of Resident 1 ' s Radiology (the branch of medicine that use imaging technology to diagnose and treat disease) Report Interpretation, dated 5/23/2024, indicated Resident 1 had a right lower extremity arterial ultrasound. The Radiology Report ' Impression ' section indicated that Resident 1 had no significant obstruction to arterial blood flow on the right lower extremity. A review of Resident 1 ' s Progress Notes, dated 5/26/2024, indicated the Licensed Vocational Nurse (LVN 3) clarified with MD 1 the change of Resident 1 ' s right heel peripheral vascular disease ([PVD] a reduced circulation of blood to a body part other than the brain or heart) wound to a Stage 3 pressure ulcer. Resident 1 ' s Progress Notes indicated there was no indication of PVD and arterial/venous occlusion. The Progress Notes indicated that FM 1 was notified. A review of Resident 1 ' s Surgical Consult Notes, dated 6/4/2024, indicated MD 2 was consulted for Resident 1 ' s right heel wound. The Surgical Consult Notes indicated Resident 1 ' s right heel wound was a pressure ulcer that was measured 2.0 cm in length, 2.8 cm in width, with undetermined depth, covering 5.6 square cm wound area. The Surgical Consult Notes section ' Tissue Type by Percentage ' indicated Resident 1 ' s right heel wound had 100% necrotic tissue. Resident 1 ' s Surgical Consult Notes indicated Resident 1 had a bone tissue debridement. On 7/1/2024 at 9:30 a.m., during an interview, Resident 1 stated the right heel PU developed in the facility. Resident 1 stated that she required assistance with lifting her right leg. Resident 1 stated the facility staff did not elevate her right leg and her right heel was continuously laying on directly on the mattress. Resident 1 stated facility staff placed the ankle-foot orthoses ([AFO] a supportive device intended to control the position and motion of the ankle, to compensate for weakness, or to correct deformities) while she was on the wheelchair. Resident 1 stated that FM 1 provided the air mattress after the facility staff discovered Resident 1 had right heel PU. On 7/1/2024 at 11:09 a.m., during a concurrent interview and record review, LVN 2 stated that on 5/23/2024, a Certified Nursing Assistant 2 (CNA 2) assisted Resident 1 with shower. LVN 2 stated CNA 2 observed Resident 1 had a wound on the right heel. LVN 2 stated that LVN 1 checked Resident 1 and found a PU on the right heel. Resident 1 ' s Admission Assessment, dated 4/20/2024, was reviewed with LVN 2 and indicated Resident 1 had no PU. LVN 2 stated Resident 1 ' s Braden Scale for Predicting Pressure Sore Risk, dated 4/26/2024, indicated Resident 1 was at risk for developing PU. LVN 2 stated on 5/26/2024 Resident 1 ' s physician ordered to offload the resident ' s right heel, and use of LALM after the right heel PU was discovered. On 7/1/2024 at 12:02 p.m., during a concurrent interview and record review, Resident 1 ' s medical records were reviewed with LVN 1. LVN 1 stated Resident 1 was admitted in the facility on 4/19/2024 without PU. LVN 1 stated Resident 1 was at risk for developing PU because of Resident 1 ' s limited mobility after right hip ORIF and Resident 1 ' s history of hemiplegia and hemiparesis. LVN 1 stated that on 5/23/2024, LVN 2 informed her that Resident 1 complained of right heel pain. LVN 1 stated Resident 1 ' s right heel was brown to black in color with 100% necrotic eschar. LVN 1 stated Resident 1 ' s right heel was boggy with macerated peri-wound Resident 1 ' s Care Plans were reviewed with LVN 1 which indicated there were no interventions to offload the resident ' s heels. LVN 1 stated Resident 1 ' s Care Plan was incomplete and not individualized. LVN 1 stated there was no documented evidence indicating Resident 1 ' s heels were offloaded and a LALM was used to prevent PU. On 7/1/2024 at 2:01 p.m., during an interview, CNA 2 stated that on 5/23/2024, during Resident 1 ' s shower, CNA 2 observed Resident 1 ' s right heel to be purplish in color. CNA 2 stated LVN 1 and LVN 2 were notified. CNA 2 stated that she used pillows to offload Resident 1 ' s right leg. CNA 2 stated that she did not document Resident 1 ' s right leg on a pillow because it was an ongoing intervention to prevent PU. On 7/2/2024 at 10:27 a.m., during an interview, CNA 3 stated Resident 1 had pillows under the right leg to keep the heel off the bed. CNA 3 was not able to provide documented evidence that Resident 1 ' s right leg was offloaded to prevent PU. On 7/2/2024 at 1:55 p.m., during a concurrent interview and record review, Resident 1 ' s medical record from 4/19/2024 through 5/23/2024 was reviewed with RN 2 and indicated Resident 1 was at risk for developing PU. RN 2 stated Resident 1 was status post ([s/p]after surgery or other medical intervention) right hip ORIF, had hemiparesis and hemiplegia on the right dominant side, and had vascular dementia which increased Resident 1 ' s risk in developing PU. RN 2 stated Resident 1 required assistance to reposition the right leg. RN 2 stated that LALM was provided to residents with PU and to those residents who were identified as a high risk for developing PU. Resident 1 ' s Care Plans were reviewed with RN 2 and indicated there were no individualized and specific care plan interventions addressing Resident 1 ' s risk for developing pressure ulcers. Resident 1 ' s Care Plan did not indicate the use of LAL mattress or offloading Resident 1 ' s heels to prevent PU. A review of Resident 1 ' s Weekly Summary, dated 5/28/2024, 6/4/2024, 6/11/2024, 6/18/2024, and 6/25/2024, indicated Resident 1 had no skin breakdown (tissue damage caused by friction, shear, moisture, or pressure and limited to the top layer of the skin). Resident 1 ' s Weekly Summary section ' Pressure Ulcer Prevention Measures ' indicated Resident 1 had pillows. The pressure reducing mattress, turning, and repositioning program, were not included in Resident 1 ' s PU prevention measures. RN 2 stated that Resident 1 ' s Weekly Summary was inaccurate. RN 2 stated that inaccurate documentation had the potential to prevent facility staff to properly identify Resident 1 ' s risk for developing PU. RN 2 stated that the facility failed to provide Resident 1 with interventions to prevent PU, including offloading the resident ' s heels and provide LAL mattress. A review of the facility ' s P&P titled, Prevention of Pressure Injuries, dated 6/27/2024, indicated the purpose was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The policy indicated to inspect the skin on a daily basis when performing or assisting with personal care or ADLs. The policy indicated to reposition the resident as indicated on the care plan. The P&P section ' Support Surfaces and Pressure Redistribution ' indicated to select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. A review of the facility ' s P&P titled, Comprehensive Person-Centered Care Plans, dated 6/27/2024, indicated a comprehensive, person-centered care plan that includes measurable objectives to meet the resident ' s physical, psychosocial, and functional needs were developed and implemented for each resident. The policy indicated that care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The Care Planning Process section indicated to incorporate risk factors associated with identified problems and to aid in preventing or reducing decline in the resident ' s functional status and / or functional levels. A review of the facility ' s P&P titled, Charting and Documentation, dated 6/27/2024, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional, or psychosocial condition, shall be documented in the resident ' s medical record. The policy indicated documentation in the medical record will be objective, complete, and accurate.

Based on interview and record review, the facility failed to ensure medical supervision of the care for one of three sampled residents (Resident 399), who was newly admitted to the facility and had diagnosis of diabetes mellitus (DM - is a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood], causing blood sugar (glucose) levels to be abnormally high). Attending Physician 1 (MD 1), who was a new doctor for Resident 399 at the facility, did not perform a thorough review of Resident 399's discharge documents from General Acute Care Hospital 1 (GACH 1) including diagnoses and medications to meet the resident's diabetic care upon Resident 399's admission to the facility on [DATE]. Resident 399 did not receive the needed insulin for a total of 11 consecutive days (12/26/2023 to 1/6/20224). As a result, on 1/3/2024, Resident 399's blood sugar (BS) level was 475 milligrams per deciliter (mg/dL - unit of measure) abnormally high (normal fasting [not eating for at least eight hours] BS level is below 100 mg/dL and normal BS level at random time is below 200 mg/dL) and Resident 399 did not receive any medication intervention including insulin. On 1/6/2024, Resident 399 required transfer to GACH 2 emergency room (ER) with extremely high BS levels leading to polyuria (frequent urination) and altered mental status ([AMS] - change in mental function characterized by confusion, disorientation, disordered perceptions) requiring hospitalization . On 2/8/2024 at 3:34 p.m., the California Department of Public Health (CDPH) while conducting the investigation of a complaint about quality of care during the facility's annual recertification survey, identified an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.30 Physician Services. The Administrator (ADM) and the Director of Nursing (DON) were notified on 2/8/2024 at 11:18 a.m. of the IJ situation from the facility's failure to ensure Resident 399 was free from any significant medication error. On 2/9/2024 at 4:51 p.m., the IJ situation was removed in the presence of the DON and the Director of Staff Development (DSD), while onsite, after verifying and confirming through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan (includes all actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The acceptable IJ Removal Plan included the following summarized actions: 1. On 2/8/2024, LVN 1 was provided in-service (training intended for staff actively engaged in the practice) on medication reconciliation by reviewing the hospital transfer medication list/another facility medication list/home medication list of the resident and verifying with the admitting physician which medications to continue and which ones to discontinue. Any medication(s) not to be continued at the facility will be documented in the resident's clinical chart. In-service to LVN 1 was also provided on Diabetes Clinical Protocol and Reporting of Test Results policy. 2. On 2/8/2024 and 2/9/2024, MD 1 was provided in-service on the facility's medication reconciliation process for newly admitted residents and facility's policies on diabetes care and test results. 3. On 2/8/2024, the DON and the licensed nurses reviewed all residents admitted to the facility in the last 30 days (between 1/7/2024 and 2/7/2024) for medication reconciliation discrepancies and elevated BS results without any insulin order, without interventions and/or without communication with the physician. No other residents were identified to be affected by the same deficient practice. 4. On 2/8/2024, the facility's Medical Director ((Med Dir 1), the DON, the Quality Assurance (QA) Nurse Consultants, and the DSD started conducting in-service training to all licensed nurses on Diabetes Clinical Protocol, Significant Medication Errors policy, Reporting Test Results policy, reconciliation of hospital medication transfer list, review of BS levels greater than 450 mg/dl with no MD medication order or intervention requiring immediate communication with the physician or the Medical Director if necessary. 5. On 2/9/2024, the QA Nurse Consultants started conducting in-service training to all licensed nurses on faxing the admission medication list along with the facility's admission medication orders to the Pharmacist Consultant (PC) to complete the Interim Medication Regimen Review (IMRR) within 72 hours of a resident's admission to the facility. 6. On 2/9/2024, Med Dir 1 started conducting in-services to residents' attending physicians (MD) on the facility's medication reconciliation, diabetes care and test results policies, and elevated BS levels for follow-up and interventions as indicated. 7. The DON, the nursing supervisors, and the Minimum Data Set (MDS) nurses will review daily the BS level test results to validate communication with MD for new orders or interventions. For BS levels greater than 450 mg/dL without interventions or orders from MD, the DON, nursing supervisor or designee will immediately contact Medical Director. 8. The DON, the nursing supervisor, and the MDS nurses will review within 24 to 72 hours from residents' admission the reconciliation of medications for compliance. 9. The DON, the nursing supervisors, and the MDS nurses will review the fasting BS results during the daily (Monday to Friday) clinical team conference to ensure the MD is informed and interventions are started/implemented. 10. The weekend nursing supervisor will review the fasting BS results and will be responsible to ensure the MD is informed and interventions are started/implemented. 11. The Medical Director will review monthly residents with diagnosis of DM for BS test results and medications with the DON or designee and will make recommendations as appropriate. 12. The Interdisciplinary team (IDT, a group of healthcare professionals from different disciplines involved in the care of the residents) conferences with resident/resident representatives will be held to read the medication list out loud by going through the hospital transfer medication list and the medication orders list in PointClickCare (PCC, electronic health record) and document in the care conference notes the acknowledgement/understanding of the resident/resident representatives. 13. On 2/9/2024, the DSD and the QA Nurse Consultants initiated the knowledge competency with the licensed nurses about medication reconciliation, Diabetes Care Protocol, BS greater than 450 mg/dl with no MD order. 14. The DSD will incorporate medication reconciliation knowledge competency in the orientation program for licensed nurses annually and as needed. 15. The DSD and/or the DON will provide quarterly in-service to licensed nurses on medication reconciliation on admission, Diabetes Care Protocol, reporting labs to MD and to Medical Director for BS greater than 450 mg/dl without MD order or intervention, and faxing the medication list along with the facility's medication admission order to the PC who completes the IMRR within 72 hours of resident admission to the facility. 16. The DON will communicate trends or concerns related to medication reconciliation, Diabetic Care Protocol for abnormal BS results, BS greater than 450 md/dL with no order or intervention by MD, and outcomes of the PC IMMR report of new admits to the Quality Assessment and Assurance (QA&A) committee monthly. The QA&A committee will continue to review for 3 consecutive months or until such time that the deficiency has been proven to be resolved. Cross reference F760 Findings: A review of Resident 399's Admission Record (Face Sheet) indicated Resident 399 was admitted to the facility from GACH 1 on 12/26/2023 with diagnoses including DM. A review of Resident 399's Discharge Summary packet from GACH 1 sent with Resident 399 indicated the following: 1) Diagnosis of DM 2) A1C (a test indicating average BS levels for the last 3 months) level of 6.8% and 7% on 12/22/2023. 3) On insulin at home 4) Diabetic diet 5) Discharge medications included insulin glargine 25 units subcutaneous (SQ, injection under the skin) twice a day. A review of Resident 399's Physician Orders on admission (12/26/2023) did not include an order for insulin glargine as indicated in GACH 1 discharge medication list. A review of Resident 399's Care Plan, dated 12/26/2023, indicated the resident had DM and the interventions included giving medications as ordered by doctor and monitoring and documenting side effects and effectiveness. A review of Resident 399's laboratory test results, with collection date of 1/3/2024, indicated a BS level result of 475 mg/dL on 1/3/2024 and the communication note dated 1/4/2023, by LVN 1 to MD 1 indicated MD 1 did not give any new order (to lower Resident 399's BS level). A review of Resident 399's licensed nurses Progress Notes, dated 1/5/2024, indicated Registered Nurse 1 (RN 1) informed MD 1 about Resident 399's frequent urination. A review of Resident 399's Physician Discharge Note, dated 1/6/2024 at 11:50 a.m., indicated Resident 399 was discharged to GACH 2 by MD 1 due to AMS. A review of Resident 399's Situation, Background, Assessment Recommendation (SBAR, communication form between members of the health care team caring for the resident), dated 1/6/2024 and timed at 1 p.m. by LVN 2 indicated Resident 399 confusion increased and MD 1 and Resident 399's family was notified. A review of Resident 399's Physician Orders dated 1/6/2024 and timed at 3:04 p.m. indicated to administer Resident 399 insulin Humalog (fast-acting insulin) per sliding scale (dosing plan whereby the amount of insulin administered depends on the BS level). A review of Resident 399's GACH 2 ER admission record indicated the resident was admitted on [DATE] at 4:04 p.m. with extremely high BS levels, AMS and polyuria. On 1/6/2024 at 4:17 p.m., Resident 399's BS level was greater than 600 mg/dL; at 4:32 p.m., the BS level was 861 mg/dL; at 8:07 p.m., the BS level was 581 mg/dL; at 9:07 p.m., the BS level was 581 mg/dL. At 11:22 p.m., Resident 399's urine glucose level was greater than 1000 mg/dL and Resident 399 was having seizures (convulsions, burst of abnormal electrical signals in one or more parts of the brain that interrupt normal signals). During an interview on 2/7/2024 at 10:34 a.m., MD 1 stated he reviews and completes resident admission medication orders from the hospital discharge summary orders. MD 1 stated he had reviewed Resident 399's GACH 1 discharge summary, and no DM diagnosis or order for insulin were included. During an interview on 2/7/2024 at 10:44 a.m., LVN 1 stated registered nurses (RN) are responsible for admitting new residents to the facility and addressing discrepancies between the hospital discharge orders and current orders. LVN 1 stated for residents with DM, diabetic interventions should include BS control through diabetic diet, oral medications and/or insulin injections. LVN 1 stated residents with DM and history of insulin use at home or in the hospital should continue insulin upon admission to the facility. LVN 1 stated not continuing insulin can cause hyperglycemia (elevated BS levels) with symptoms of confusion, shakiness, loss of consciousness, polyuria, and in severe cases lead to death. During an interview on 2/7/2024 at 10:50 a.m., Registered Nurse 1/Assistant Director of Nursing (RN 1/ADON) stated for new resident admissions the facility receives paperwork from the discharging hospital including a medication list. RN 1/ADON stated the admitting nurse calls the MD to review the medication list which the MD would continue. RN 1/ADON stated Resident 399 was admitted to the facility on [DATE] and during the admission process the insulin order for glargine was not read to MD 1. RN 1/ADON stated Resident 399 was diabetic and LVN 1 and MD 1 should have identified the lack of medication for DM. RN 1/ADON stated LVN 1 and MD 1 failed to complete appropriate medication reconciliation when not ordering insulin and BS checks for Resident 399. During an interview on 2/7/2024 at 10:51 a.m., RN 3 stated the admitting nurse, usually an RN, admits new residents to the facility. RN 3 stated new residents arrive to the facility with packet of paperwork, and the admitting RN reviews the resident's medication reconciliation list from the discharging hospital with another RN. RN 3 stated the MD reviews the hospital discharge summary orders for diagnosis and medication list to determine which medications to continue or discontinue. During an interview on 2/7/2024 at 11:23 a.m., LVN 1 stated the discharge packet from the hospital is reviewed for new residents admitted to the facility. LVN 1 stated she verified Resident 399's medication orders for Resident 399 with MD 1. LVN 1 stated she later noticed insulin was not ordered but did not follow-up with MD 1 or Nurse Practitioner 1 (NP 1) about the insulin orders for Resident 399. During an interview on 2/7/2024 at 1:18 p.m., the PC stated residents with diagnosis of DM and a care plan for DM should have orders for antidiabetic (to treat diabetes) medications. The PC stated missing 11 days of insulin administration for residents with history of insulin use from home or hospital can lead to AMS, polyuria, and BS levels greater than 500 mg/dL requiring hospitalization s. During an interview on 2/7/2024 at 1:30 p.m., MD 1 stated he did not receive communication from the facility on 1/4/2024 for Resident 399's BS level of 475 mg/dL. MD 1 stated without completing a thorough assessment of a resident or having ruled out factors such as certain medications, urine infections, etc., elevated BS for DM patients may potentially result from not receiving insulin. During an interview on 2/7/2024 at 2:31 p.m., NP 1 stated that a medication reconciliation review is done with the nurses and MD. NP 1 stated that during interdisciplinary team (IDT) conference with the family, missed medications can be identified. NP 1 stated a DM care plan indicating to monitor for side effects and effectiveness indicates there is an order for antidiabetic medication. NP 1 stated BS level of 475 mg/dL is considered high and can lead to fatigue, loss of vision, weakness, polyuria and may require hospitalization . During an interview on 2/7/2024 at 3:22 p.m., LVN 1 stated she contacted MD 1 on 1/4/2024 for Resident 399's BS level of 475 mg/dL and that Resident 399 has DM. LVN 1 stated MD 1 gave no new orders. During an interview on 2/7/2024 at 5:39 p.m., Med Dir 1 acknowledged the failure of MD 1 and LVN 1 not completing a thorough medication reconciliation for Resident 399 resulting in the resident missing insulin glargine for 11 days and subsequently requiring hospitalization . Med Dir 1 stated missing 11 days of insulin for a resident with DM can lead to hyperglycemia, coma, death, and hospitalization , and for Resident 399 the incomplete medication reconciliation led to the omission of 11 days of insulin administration resulting in Resident 399 experiencing AMS and polyuria requiring hospitalization . During an interview on 2/8/2024 at 1:07 p.m., Med Dir 2 (GACH 2 ER Medical Director) stated omitting 11 days of insulin glargine administration was a contributing factor for Resident 399's severe hyperglycemia. During an interview on 2/8/2024 at 1:25 p.m., Doctor of Osteopathy 1 (DO 1) stated he reviewed Resident 399's discharge summary packet from GACH 1 and stated based on the discharge medication list, he would have continued the insulin glargine, upon admission to the facility since Resident 399 had DM. DO 1 also stated he would have intervened with orders for a BS level of 475 mg/dl. DO 1 stated omitting 11 days of insulin administration was a contributing factor for Resident 399's hyperglycemia and the continued hyperglycemia from the insulin omissions led to Resident 399's hospitalization . During an interview and record review on 2/8/2024 at 1:36 p.m., Med Dir 1 stated the discharge summary packet from GACH 1 for Resident 399 and confirmed the packet indicated a diagnosis of DM, diabetic diet, A1C of 6.8 percent (%) and 7%, and an order for insulin glargine 25 units twice a day. Med Dir 1 stated these are indicators that Resident 399 had DM and should have been on antidiabetic medications. Med Dir 1 stated MD 1 should have reviewed the discharge summary packet from GACH 1 for Resident 399 and continued the insulin glargine upon admission to the facility. Med Dir 1 also stated the DM care plan developed on 12/26/2023 for Resident 399 included Diabetes medications as ordered by doctor. Monitor/document for side effects (unwanted effects from medications) and effectiveness. Med Dir 1 stated the facility did not follow or modify Resident 399's care plan if it was not applicable. Med Dir 1 stated several system failures including medication reconciliation not thoroughly reviewed, DM care plan not followed or modified, BS level of 475 mg/dl with no intervention, all causing harm to Resident 399 by the omission of 11 days of insulin glargine administration resulting in hyperglycemia, AMS, polyuria, and ultimately requiring hospitalization . Med Dir 1 stated it is the responsibility of the MD to ensure their residents are thoroughly assessed for diagnosis and medication orders and test results are properly addressed. Med Dir 1 stated going forward to implement a protocol for basic interventions for BS greater than 450 mg/dl and for Med Dir 1 to be notified when licensed nurses are unable to reach MD. During an interview on 2/8/2024 at 4:34 p.m., LVN 1 stated that when MD 1 did not give any orders for Resident 399's BS level of 475 mg/dL on 1/4/2024, she was concerned and flagged the chart for MD 1 to see it on the next visit to the facility. LVN 1 stated she did not know when MD 1 would visit Resident 399. LVN 1 stated she did not notify a supervisor or the DON about Resident 399's elevated BS level on 1/4/2024 and MD 1's the lack of orders or interventions. During an interview on 2/9/2024 at 4 p.m., the DON stated there are clear system failures and the facility needs to have more robust system put in place to prevent these deficiencies. The DON stated there needs to be better clinical judgment from licensed staff to emphasize the importance of continuing medications to MDs and to have more detailed documentation in the resident's chart. The DON stated licensed staff should also communicate to supervisors when they do not feel comfortable not having MD orders for appropriate resident care. The DON stated this was an eye-opening experience of having focus on processes that are clearly deficient in the facility. The DON stated she sees the immediacy of these deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. A review of the facility's policy and procedures (P&P) titled, Reconciliation of Medications on Admission, dated July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: a. Discharge summary from referring facility b. Admission order sheet c. All prescription and supplement information obtained from the resident/family during the medication history; and d. Most recent MAR, if this is a readmission. General Guidelines 1. Medication reconciliation is the process of following post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that medications, routes, and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 4. Review the list carefully to determine if there are discrepancies/conflicts 5. If there are discrepancy or conflict in the medications .determine the most appropriate action to resolve the discrepancy. 6. Document findings and actions Documentation 1. Document the medication discrepancy on the medication reconciliation form. 2. Document what actions were taken by the nurse to resolve the discrepancy. A review of the facility's P&P titled Admission Assessment and Follow Up: Role of the License Nurse, dated September 2012, indicated The purpose of this procedure is to gather information about the resident's physical, emotions, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing the required assessment instruments, including the Minimum Data Set (MDS, a standardized assessment and care screening tool). 7. Conduct an admission assessment, including: c. A list of active medical diagnoses d. Current medications and treatments 11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available,) and the discharge summary from the previous institution, according to established procedures. 12. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. A review of the facility's P&P titled Medication Errors, dated April 2023, the P&P indicated: 5. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professional(s) providing services. 7. The IDT reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. A review of the facility's P&P titled Diabetes - Clinical Protocol, dated November 2020, the P&P indicated: Assessment and Recognition 1. As part of initial assessment, the physician will help identify individuals with elevated BS, impaired glucose tolerance, or confirmed diabetes . 2. For residents who meet the criteria for diabetes testing, the physician will order pertinent screening; for example, A1C, fasting plasma glucose, or 2-hour plasma glucose with oral glucose load. 3. For residents with confirmed diabetes, the nurse shall assess and document/report the following during the initial assessment: a. Dose and time of most recent anti-hyperglycemic given b. All other current medications c. Residents BS history of 48 hours d. Usual patterns of BS over recent months e. Recent labs Treatment/Management 1. Based on the preceding assessment .the Physician will order appropriate intervention, which may include: c. oral hypoglycemia agents; and /or d. insulin Monitoring and Follow-Up 1. The Physician will follow up on any acute episodes associated with a significant sustained change in BS . 2. As indicated, the Physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters a. Examples of blood glucose monitoring . 1) For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin .; monitor 3 to 4 times a day if on intensive insulin therapy or sliding scale insulin; . Monitor A1C on admission .or when diabetes is diagnosed , and every 6 months thereafter . 4. The Physician will order desired parameters for monitoring and reporting information related to BS management. A review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated that: 1. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physician, mental, and psychosocial well-being. g. Incorporate identified problem areas k. Reflect treatment goals . 1. Reflect currently recognized standards of practice for problem areas and conditions. 10. b. The resident's physician (or primary healthcare provider) is integral to this process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A review of the facility's P&P titled Physician Services, dated February 2021, indicated that The medical care of each resident is supervised by a licensed physician. 2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. 3. Supervising the medical care of the resident includes (but is not limited to): a. Participating in the resident's assessment and care planning b. Monitoring changes in the resident's medical status; c. Providing consultation or treatment when called by the facility; d. Prescribing medications and therapy; h. Overseeing a relevant plan of care for the resident. A review of the facility's P&P titled Test Results, dated April 2007, indicated: 1. Results of laboratory, .tests shall be reported in writing to the resident's attending physician or to the facility. 2.the attending physician shall be promptly notified of the results.

Based on interview and record review, the facility failed to: A. Ensure one of three sampled residents (Resident 399), who was newly admitted to the facility and had diagnosis of diabetes mellitus (DM - is a disorder in which the body does not produce enough or respond normally to insulin [a hormone that controls the amount of sugar in the blood], causing blood sugar (glucose) levels to be abnormally high), was free from medication error (any error [of commission or omission] that occurs at any point in the medication use process). Upon Resident 399's admission to the facility on [DATE], Attending Physician 1 (MD 1) and Licensed Vocational Nurse 1 (LVN 1) did not perform medication reconciliation (formal process for creating the most complete and accurate list possible of a resident's current medications and comparing the list to those in the resident's record or medication orders) and an order for the medication administration of insulin glargine (long-acting insulin [covers insulin needs for about one full day]) for twice a day was not verified with MD 1 and not transcribed into the facility's medication admission orders. Resident 399 did not receive the needed insulin for a total of 11 consecutive days (12/26/2023 to 1/6/20224). As a result, on 1/3/2024, Resident 399's blood sugar (BS) level was 475 milligrams per deciliter (mg/dL - unit of measure) abnormally high (normal fasting [not eating for at least eight hours] BS level is below 100 mg/dL and normal BS level at random time is below 200 mg/dL) and Resident 399 did not receive any medication intervention including insulin. On 1/6/2024, Resident 399 required transfer to General Acute Care Hospital 2 (GACH 2) emergency room (ER) with extremely high BS levels leading to polyuria (frequent urination) and altered mental status ([AMS] - change in mental function characterized by confusion, disorientation, disordered perceptions) requiring hospitalization . On 2/8/2024 at 11:18 a.m., the California Department of Public Health (CDPH) while conducting the investigation of a complaint about quality of care during the facility's annual recertification survey, identified an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.45(f)(2) Residents are Free of any Significant Medication Errors. The Administrator (ADM) and the Director of Nursing (DON) were notified on 2/8/2024 at 11:18 a.m. of the IJ situation from the facility's failure to ensure Resident 399 was free from any significant medication error. On 2/9/2024 at 4:51 p.m., the IJ situation was removed in the presence of the DON and the Director of Staff Development (DSD), while onsite, after verifying and confirming through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan (includes all actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The acceptable IJ Removal Plan included the following summarized actions: 1. On 2/8/2024, LVN 1 was provided in-service (training intended for staff actively engaged in the practice) on medication reconciliation by reviewing the hospital transfer medication list/another facility medication list/home medication list of the resident and verifying with the admitting physician which medications to continue and which ones to discontinue. Any medication(s) not to be continued at the facility will be documented in the resident's clinical chart. In-service to LVN 1 was also provided on Diabetes Clinical Protocol and Reporting of Test Results policy. 2. On 2/8/2024 and 2/9/2024, MD 1 was provided in-service on the facility's medication reconciliation process for newly admitted residents and facility's policies on diabetes care and test results. 3. On 2/8/2024, the DON and the licensed nurses reviewed all residents admitted to the facility in the last 30 days (between 1/7/2024 and 2/7/2024) for medication reconciliation discrepancies and elevated BS results without any insulin order, without interventions and/or without communication with the physician. No other residents were identified to be affected by the same deficient practice. 4. On 2/8/2024, the facility's Medical Director ((Med Dir 1), the DON, the Quality Assurance (QA) Nurse Consultants, and the DSD started conducting in-service training to all licensed nurses on Diabetes Clinical Protocol, Significant Medication Errors policy, Reporting Test Results policy, reconciliation of hospital medication transfer list, review of BS levels greater than 450 mg/dl with no MD medication order or intervention requiring immediate communication with the physician or the Medical Director if necessary. 5. On 2/9/2024, the QA Nurse Consultants started conducting in-service training to all licensed nurses on faxing the admission medication list along with the facility's admission medication orders to the Pharmacist Consultant (PC) to complete the Interim Medication Regimen Review (IMRR) within 72 hours of a resident's admission to the facility. 6. On 2/9/2024, Med Dir 1 started conducting in-services to residents' attending physicians (MD) on the facility's medication reconciliation, diabetes care and test results policies, and elevated BS levels for follow-up and interventions as indicated. 7. The DON, the nursing supervisors, and the Minimum Data Set (MDS) nurses will review daily the BS level test results to validate communication with MD for new orders or interventions. For BS levels greater than 450 mg/dL without interventions or orders from MD, the DON, nursing supervisor or designee will immediately contact Medical Director. 8. The DON, the nursing supervisor, and the MDS nurses will review within 24 to 72 hours from residents' admission the reconciliation of medications for compliance. 9. The DON, the nursing supervisors, and the MDS nurses will review the fasting BS results during the daily (Monday to Friday) clinical team conference to ensure the MD is informed and interventions are started/implemented. 10. The weekend nursing supervisor will review the fasting BS results and will be responsible to ensure the MD is informed and interventions are started/implemented. 11. The Medical Director will review monthly residents with diagnosis of DM for BS test results and medications with the DON or designee and will make recommendations as appropriate. 12. The Interdisciplinary team (IDT, a group of healthcare professionals from different disciplines involved in the care of the residents) conferences with resident/resident representatives will be held to read the medication list out loud by going through the hospital transfer medication list and the medication orders list in PointClickCare (PCC, electronic health record) and document in the care conference notes the acknowledgement/understanding of the resident/resident representatives. 13. On 2/9/2024, the DSD and the QA Nurse Consultants initiated the knowledge competency with the licensed nurses about medication reconciliation, Diabetes Care Protocol, BS greater than 450 mg/dl with no MD order. 14. The DSD will incorporate medication reconciliation knowledge competency in the orientation program for licensed nurses annually and as needed. 15. The DSD and/or the DON will provide quarterly in-service to licensed nurses on medication reconciliation on admission, Diabetes Care Protocol, reporting labs to MD and to Medical Director for BS greater than 450 mg/dl without MD order or intervention, and faxing the medication list along with the facility's medication admission order to the PC who completes the IMRR within 72 hours of resident admission to the facility. 16. The DON will communicate trends or concerns related to medication reconciliation, Diabetic Care Protocol for abnormal BS results, BS greater than 450 md/dL with no order or intervention by MD, and outcomes of the PC IMMR report of new admits to the Quality Assessment and Assurance (QA&A) committee monthly. The QA&A committee will continue to review for 3 consecutive months or until such time that the deficiency has been proven to be resolved. Cross reference F710 B. Ensure residents were free of any significant medication errors by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 70) investigated under unnecessary medications. 2. Rotate subcutaneous administration sites of insulin to one out of one sampled resident (Resident 85) investigated under insulin. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross reference F658 Findings: A. A review of Resident 399's Admission Record (Face Sheet) indicated Resident 399 was admitted to the facility from GACH 1 on 12/26/2023 with diagnoses including DM. A review of Resident 399's Discharge Summary packet from GACH 1 sent with Resident 399 indicated the following: 1) Diagnosis of DM 2) A1C (a test indicating average BS levels for the last 3 months) level of 6.8% and 7% on 12/22/2023. 3) On insulin at home 4) Diabetic diet 5) Discharge medications included insulin glargine 25 units subcutaneous (SQ, injection under the skin) twice a day. A review of Resident 399's Physician Orders on admission (12/26/2023) did not include an order for insulin glargine as indicated in GACH 1 discharge medication list. A review of Resident 399's Care Plan, dated 12/26/2023, indicated the resident had DM and the interventions included giving medications as ordered by doctor and monitoring and documenting side effects and effectiveness. A review of Resident 399's laboratory test results, with collection date of 1/3/2024, indicated a BS level result of 475 mg/dL on 1/3/2024 and the communication note dated 1/4/2023, by LVN 1 to MD 1 indicated MD 1 did not give any new order (to lower Resident 399's BS level). A review of Resident 399's licensed nurses Progress Notes, dated 1/5/2024, indicated Registered Nurse 1/Assistant Director of Nursing (RN 1/ADON) informed MD 1 about Resident 399's frequent urination. A review of Resident 399's Physician Discharge Note, dated 1/6/2024 at 11:50 a.m., indicated Resident 399 was discharged to GACH 2 by MD 1 due to AMS. A review of Resident 399's Situation, Background, Assessment Recommendation (SBAR, communication form between members of the health care team caring for the resident), dated 1/6/2024 and timed at 1 p.m. by LVN 2 indicated Resident 399 confusion increased and MD 1 and Resident 399's family were notified. A review of Resident 399's Physician Orders dated 1/6/2024 and timed at 3:04 p.m. indicated to administer Resident 399 insulin Humalog (fast-acting insulin) per sliding scale (dosing plan whereby the amount of insulin administered depends on the BS level). A review of Resident 399's GACH 2 ER admission record indicated the resident was admitted on [DATE] at 4:04 p.m. with extremely high BS levels, AMS, and polyuria. On 1/6/2024 at 4:17 p.m., Resident 399's BS level was greater than 600 mg/dL; at 4:32 p.m., the BS level was 861 mg/dL; at 8:07 p.m., the BS level was 581 mg/dL; at 9:07 p.m., the BS level was 581 mg/dL. At 11:22 p.m., Resident 399's urine glucose level was greater than 1000 mg/dL and Resident 399 was having seizures (convulsions, burst of abnormal electrical signals in one or more parts of the brain that interrupt normal signals). During an interview on 2/7/2024 at 10:34 a.m., MD 1 stated he reviews and completes resident admission medication orders from the hospital discharge summary orders. MD 1 stated he had reviewed Resident 399's GACH 1 discharge summary, and no DM diagnosis or order for insulin were included. During an interview on 2/7/2024 at 10:44 a.m., LVN 1 stated registered nurses (RN) are responsible for admitting new residents to the facility and addressing discrepancies between the hospital discharge orders and current orders. LVN 1 stated for residents with DM, diabetic interventions should include BS control through diabetic diet, oral medications and/or insulin injections. LVN 1 stated residents with DM and history of insulin use at home or in the hospital should continue insulin upon admission to the facility. LVN 1 stated not continuing insulin can cause hyperglycemia (elevated BS levels) with symptoms of confusion, shakiness, loss of consciousness, polyuria, and in severe cases lead to death. During an interview on 2/7/2024 at 10:50 a.m., RN 1/ADON stated for new resident admissions the facility receives paperwork from the discharging hospital including a medication list. RN 1/ADON stated the admitting nurse calls the MD to review the medication list which the MD would continue. RN 1/ADON stated Resident 399 was admitted to the facility on [DATE] and during the admission process the insulin order for glargine was not read to MD 1. RN 1/ADON stated Resident 399 was diabetic and LVN 1 and MD 1 should have identified the lack of medication for DM. RN 1/ADON stated LVN 1 and MD 1 failed to complete appropriate medication reconciliation when not ordering insulin and BS checks for Resident 399. During an interview on 2/7/2024 at 10:51 a.m., RN 3 stated the admitting nurse, usually an RN, admits new residents to the facility. RN 3 stated new residents arrive to the facility with packet of paperwork, and the admitting RN reviews the resident's medication reconciliation list from the discharging hospital with another RN. RN 3 stated the MD reviews the hospital discharge summary orders for diagnosis and medication list to determine which medications to continue or discontinue. During an interview on 2/7/2024 at 11:23 a.m., LVN 1 stated the discharge packet from the hospital is reviewed for new residents admitted to the facility. LVN 1 stated she verified Resident 399's medication orders for Resident 399 with MD 1. LVN 1 stated she later noticed insulin was not ordered but did not follow-up with MD 1 or Nurse Practitioner 1 (NP 1) about the insulin orders for Resident 399. During an interview on 2/7/2024 at 1:18 p.m., the PC stated residents with diagnosis of DM and a care plan for DM should have orders for antidiabetic (to treat diabetes) medications. The PC stated missing 11 days of insulin administration for residents with history of insulin use from home or hospital can lead to AMS, polyuria, and BS levels greater than 500 mg/dL requiring hospitalization s. During an interview on 2/7/2024 at 1:30 p.m., MD 1 stated he did not receive communication from the facility on 1/4/2024 for Resident 399's BS level of 475 mg/dL. MD 1 stated without completing a thorough assessment of a resident or having ruled out factors such as certain medications, urine infections, etc., elevated BS for DM patients may potentially result from not receiving insulin. During an interview on 2/7/2024 at 2:31 p.m., NP 1 stated that a medication reconciliation review is done with the nurses and MD. NP 1 stated that during interdisciplinary team (IDT) conference with the family, missed medications can be identified. NP 1 stated a DM care plan indicating to monitor for side effects and effectiveness indicates there is an order for antidiabetic medication. NP 1 stated BS level of 475 mg/dL is considered high and can lead to fatigue, loss of vision, weakness, polyuria and may require hospitalization . During an interview on 2/7/2024 at 3:22 p.m., LVN 1 stated she contacted MD 1 on 1/4/2024 for Resident 399's BS level of 475 mg/dL and that Resident 399 has DM. LVN 1 stated MD 1 gave no new orders. During an interview on 2/7/2024 at 5:39 p.m., Med Dir 1 acknowledged the failure of MD 1 and LVN 1 not completing a thorough medication reconciliation for Resident 399 resulting in the resident missing insulin glargine for 11 days and subsequently requiring hospitalization . Med Dir 1 stated missing 11 days of insulin for a resident with DM can lead to hyperglycemia, coma, death, and hospitalization , and for Resident 399 the incomplete medication reconciliation led to the omission of 11 days of insulin administration resulting in Resident 399 experiencing AMS and polyuria requiring hospitalization . During an interview on 2/8/2024 at 1:07 p.m., Med Dir 2 (GACH 2 ER Medical Director) stated omitting 11 days of insulin glargine administration was a contributing factor for Resident 399's severe hyperglycemia. During an interview on 2/8/2024 at 1:25 p.m., Doctor of Osteopathy 1 (DO 1) stated he reviewed Resident 399's discharge summary packet from GACH 1 and stated based on the discharge medication list, he would have continued the insulin glargine, upon admission to the facility since Resident 399 had DM. DO 1 also stated he would have intervened with orders for a BS level of 475 mg/dl. DO 1 stated omitting 11 days of insulin administration was a contributing factor for Resident 399's hyperglycemia and the continued hyperglycemia from the insulin omissions led to Resident 399's hospitalization . During an interview and record review on 2/8/2024 at 1:36 p.m., Med Dir 1 stated the discharge summary packet from GACH 1 for Resident 399 and confirmed the packet indicated a diagnosis of DM, diabetic diet, A1C of 6.8 percent (%) and 7%, and an order for insulin glargine 25 units twice a day. Med Dir 1 stated these are indicators that Resident 399 had DM and should have been on antidiabetic medications. Med Dir 1 stated MD 1 should have reviewed the discharge summary packet from GACH 1 for Resident 399 and continued the insulin glargine upon admission to the facility. Med Dir 1 also stated the DM care plan developed on 12/26/2023 for Resident 399 included Diabetes medications as ordered by doctor. Monitor/document for side effects (unwanted effects from medications) and effectiveness. Med Dir 1 stated the facility did not follow or modify Resident 399's care plan if it was not applicable. Med Dir 1 stated several system failures including medication reconciliation not thoroughly reviewed, DM care plan not followed or modified, BS level of 475 mg/dl with no intervention, all causing harm to Resident 399 by the omission of 11 days of insulin glargine administration resulting in hyperglycemia, AMS, polyuria, and ultimately requiring hospitalization . Med Dir 1 stated it is the responsibility of the MD to ensure their residents are thoroughly assessed for diagnosis and medication orders and test results are properly addressed. Med Dir 1 stated going forward to implement a protocol for basic interventions for BS greater than 450 mg/dl and for Med Dir 1 to be notified when licensed nurses are unable to reach MD. During an interview on 2/8/2024 at 4:34 p.m., LVN 1 stated that when MD 1 did not give any orders for Resident 399's BS level of 475 mg/dL on 1/4/2024, she was concerned and flagged the chart for MD 1 to see it on the next visit to the facility. LVN 1 stated she did not know when MD 1 would visit Resident 399. LVN 1 stated she did not notify a supervisor or the DON about Resident 399's elevated BS level on 1/4/2024 and MD 1's the lack of orders or interventions. During an interview on 2/9/2024 at 4 p.m., the DON stated there are clear system failures and the facility needs to have more robust system put in place to prevent these deficiencies. The DON stated there needs to be better clinical judgment from licensed staff to emphasize the importance of continuing medications to MDs and to have more detailed documentation in the resident's chart. The DON stated licensed staff should also communicate to supervisors when they do not feel comfortable not having MD orders for appropriate resident care. The DON stated this was an eye-opening experience of having focus on processes that are clearly deficient in the facility. The DON stated she sees the immediacy of these deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. A review of the facility's policy and procedures (P&P) titled, Reconciliation of Medications on Admission, dated July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: a. Discharge summary from referring facility b. Admission order sheet c. All prescription and supplement information obtained from the resident/family during the medication history; and d. Most recent MAR, if this is a readmission. General Guidelines 1. Medication reconciliation is the process of following post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that medications, routes, and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 4. Review the list carefully to determine if there are discrepancies/conflicts 5. If there are discrepancy or conflict in the medications .determine the most appropriate action to resolve the discrepancy. 6. Document findings and actions Documentation 1. Document the medication discrepancy on the medication reconciliation form. 2. Document what actions were taken by the nurse to resolve the discrepancy. A review of the facility's P&P titled Admission Assessment and Follow Up: Role of the License Nurse, dated September 2012, indicated The purpose of this procedure is to gather information about the resident's physical, emotions, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing the required assessment instruments, including the Minimum Data Set (MDS, a standardized assessment and care screening tool). 7. Conduct an admission assessment, including: c. A list of active medical diagnoses d. Current medications and treatments 11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available,) and the discharge summary from the previous institution, according to established procedures. 12. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. A review of the facility's P&P titled Medication Errors, dated April 2023, the P&P indicated: 5. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professional(s) providing services. 7. The IDT reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. A review of the facility's P&P titled Diabetes - Clinical Protocol, dated November 2020, the P&P indicated: Assessment and Recognition 1. As part of initial assessment, the physician will help identify individuals with elevated BS, impaired glucose tolerance, or confirmed diabetes . 2. For residents who meet the criteria for diabetes testing, the physician will order pertinent screening; for example, A1C, fasting plasma glucose, or 2-hour plasma glucose with oral glucose load. 3. For residents with confirmed diabetes, the nurse shall assess and document/report the following during the initial assessment: a. Dose and time of most recent anti-hyperglycemic given b. All other current medications c. Residents BS history of 48 hours d. Usual patterns of BS over recent months e. Recent labs Treatment/Management 1. Based on the preceding assessment .the Physician will order appropriate intervention, which may include: c. oral hypoglycemia agents; and /or d. insulin Monitoring and Follow-Up 1. The Physician will follow up on any acute episodes associated with a significant sustained change in BS . 2. As indicated, the Physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters a. Examples of blood glucose monitoring . 1) For the resident receiving insulin who is well controlled: monitor blood glucose levels twice a day if on insulin .; monitor 3 to 4 times a day if on intensive insulin therapy or sliding scale insulin; . Monitor A1C on admission .or when diabetes is diagnosed , and every 6 months thereafter . 4. The Physician will order desired parameters for monitoring and reporting information related to BS management. A review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated that: 1. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physician, mental, and psychosocial well-being. g. Incorporate identified problem areas k. Reflect treatment goals . 1. Reflect currently recognized standards of practice for problem areas and conditions. 10. b. The resident's physician (or primary healthcare provider) is integral to this process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A review of the facility's P&P titled Physician Services, dated February 2021, indicated that The medical care of each resident is supervised by a licensed physician. 2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. 3. Supervising the medical care of the resident includes (but is not limited to): a. Participating in the resident's assessment and care planning b. Monitoring changes in the resident's medical status; c. Providing consultation or treatment when called by the facility; d. Prescribing medications and therapy; h. Overseeing a relevant plan of care for the resident. A review of the facility's P&P titled Test Results, dated April 2007, indicated: 1. Results of laboratory, .tests shall be reported in writing to the resident's attending physician or to the facility. 2.the attending physician shall be promptly notified of the results. 44376 B. A review of Resident 70's Admission Record indicated the facility admitted the resident on 9/28/2023 and readmitted the resident on 12/22/2023, with diagnoses including, type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic neuropathy (nerve damage caused by diabetes) and type 2 diabetes mellitus with foot ulcer (an open sore on the foot). A review of Resident 70's History and Physical (H&P), dated 12/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 70's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/31/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a group of drugs used to reduce the amount of sugar in the blood) insulin. A review of Resident 70's Order Summary Report, dated 12/22/2023, indicated an order for insulin glargine solution 100 unit per milliliters (unit/ml, a unit of fluid volume). Inject 10 unit subcutaneously (sq, administering medications beneath the skin) at bedtime for diabetes. A review of Resident 70's Location of Administration Report on 10/2023 indicated Lantus sq Solution 100 unit/ml was administered on: -10/13/2023 at 6:44 p.m. on the Abdomen- Left Upper Quadrant (Abdomen - LUQ) -10/14/2023 at 9:16 a.m. on the Abdomen - LUQ -10/25/2023 at 8:23 p.m. on the Abdomen - Right Lower Quadrant (Abdomen-RLQ) -10/26/2023 at 8:10 p.m. on the Abdomen - RLQ -10/27/2023 at 8:14 p.m. on the Abdomen - LUQ -10/28/2023 at 8:27 p.m. on the Abdomen - LUQ A review of Resident 70's Care Plan titled, The resident has diabetes mellitus on insulin glargine 10 units every night (QHS), last revised on 2/7/2024, indicated an intervention of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Insulin glargine solution 100 unit/ml inject 10 unit subcutaneously at bedtime. Rotate injection sites. During an interview and record review on 2/8/2024, at 8:16 a.m., with Registered Nurse 1/Assistant Director of Nursing (RN 1/ADON), reviewed with RN 1/ADON Resident 70's Location of Administration for 10/2023. RN 1/ADON stated there were multiple instances the administration of insulin administration was not rotated. RN 1/ADON stated it was important to rotate insulin administration site to prevent skin issues such as lipodystrophy. A review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 6/29/2023, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). A review of the facility's Patient Information for Lantus (LAN-tus) (insulin glargine injection) for subcutaneous use, 100 Units/ml (U-100), approved on 7/2015, indicated to change (rotate) injection sites within the area you choose with each those. Do not use the exact spot for each injection. 2. A review of Resident 85's Admission Record indicated the facility admitted the resident on 11/23/2023 and readmitted the resident on 11/29/2023, with diagnoses including type 2 diabetes mellitus with foot ulcer and type 2 diabetes mellitus with diabetic chronic kidney disease (a type of kidney disease caused by diabetes). A review of Resident 85's H&P, dated 11/23/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 85's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication insulin. A review of Resident 85's Order Summary Report indicated at order for: - Insulin lispro injection solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale (the increasing administration of the premeal insulin dose based on the blood sugar level before the meal): if 0 - 149 = 0 units; 150 - 200 = 2 units; 201 - 250 =

Based on interview and record review, the facility failed to provide immediate emergency care including cardiopulmonary resuscitation (CPR- emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) for one of two sampled residents (Resident 73) who was found unresponsive (when a person is at least unconscious[abnormal state in which a person exhibits a complete, or near-complete, inability to maintain an awareness of self and environment], and possibly dead or dying) on [DATE] at 10:40 p.m. This deficient practice resulted in Resident 73's death on [DATE] at 10:45 p.m. On [DATE] at 4:11 p.m., the State Survey Agency (SSA) identified an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation under 42CFR S483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. The Administrator (ADM) and the Director of Nursing (DON) were notified of the IJ situation from the facility's failure to provide CPR immediately to Resident 73 when found unresponsive. On [DATE] at 5:08 p.m., the IJ situation was removed in the presence of the Administrator and DON, while onsite, and after verifying through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan. The IJ removal plan included the following summarized actions which were initiated on [DATE] and ongoing until completed on [DATE]: 1. On [DATE], the Director of Nursing (DON) and a certified CPR Instructor (a third-party vendor) conducted an in-service and return demonstration to all nursing staff, including Certified Nursing Assistant 3 (CNA 3) and Licensed Vocational Nurse 1 (LVN 1), on the timeliness of initiating emergency care, including CPR. 2. On [DATE], the Director of Staff Development (DSD) checked employee records of CPR certification training to all direct care staff nurses in the facility. 3. The DON and CPR Instructor re-trained all nursing staff on initiating emergency care including CPR immediately upon assessment. 4. The DON and CPR instructor in-serviced all nursing staff on the required assessment to initiate CPR immediately. 5. The DSD administered a competency test on emergency care, including CPR, to all nursing staff. 6. The DON and Administrator reviewed and updated the facility's policy and procedure for emergency care to include but not limited to CPR procedures. The policy was brought forth to the Quality Assurance (QA) Committee on [DATE] for review and approval. 7. A root cause analysis was initiated on [DATE] and completed on [DATE]. 8. A second crash cart will be made available at Nurses Station 2 by the Maintenance Supervisor and reviewed by the DON on [DATE]. 9. The Administrator and DON developed a crash cart policy and procedure on [DATE] and will be brought forth to the QA committee for review and approval. 10. At the direction of the QA Performance Improvement (QAPI) committee, the Director of Nurses and/or designee shall review as necessary those residents that required emergency care including CPR to determine the timeliness of when emergency care was provided including CPR. The review of record will be recorded on a tracking log to determine the timeliness of when emergency was initiated. The results of the audits will be presented to the QA committee by the DON at a minimum of quarterly for further action planning and monitoring as necessary. Finding: A review of Resident 73's Admission Record indicated the facility admitted Resident 73 on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm (term for a cancerous tumor) of unspecified ovary (pair of female glands), acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues) and hypotension (abnormally low blood pressure). A review of Resident 73's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated Resident 73 had the ability to make herself understood and understand others. A review of Resident 73's Physician's Orders for Life Sustaining Treatment (POLST- portable medical orders that communicate patient wishes for end-of-life intervention to health care facilities and providers, including emergency medical services, dated [DATE], indicated to attempt resuscitation/CPR and full treatment. A review of Resident 73's nursing Progress Notes, dated [DATE] and timed at 11:52 p.m., indicated that on [DATE] at 10:40 p.m. CNA 3 reported to Licensed Vocational Nurse 1 (LVN 1) Resident 73 was not responsive. LVN 1 was unable to get vital signs (measurements of the body's most basic functions such as body temperature, heart [pulse] rate, respiration rate [rate of breathing], and blood pressure [pressure of circulating blood against the walls of blood vessels]). LVN 1 could not feel Resident 73's pulse. The nursing Progress Note indicated that at 10:45 p.m. (five minutes after Resident 73 was found without vital signs), LVN 1 and LVN 2 initiated CPR and called paramedics (health professionals certified to perform advanced life support procedures) through 911 (a phone number to contact the emergency services). The progress notes indicated Resident 73 was pronounced dead at 10:45 p.m. and paramedics and sheriff (law enforcement) arrived at 11:07 p.m. On [DATE] at 1:26 p.m., during an interview with the DON and concurrent review of Resident 73's POLST, the DON stated Resident 73 wished to be resuscitated. The DON stated on [DATE], there was a delay of five minutes in starting CPR on Resident 73 (from 10:40 p.m. to 10:45 p.m.). The DON stated CNA 3 was trained in CPR and could have started CPR immediately. On [DATE] at 2:33 p.m., during an interview, CNA 3 stated that on [DATE] at past 10 p.m., she stopped by to see Resident 73, who was in bed, and noted her to be pale (loss of color from the skin). CNA 3 stated she left Resident 73's room to notify LVN 1. CNA 3 stated she was CPR certified but had not performed CPR before and was not comfortable doing it and that was the reason she did not initiate CPR on Resident 73. CNA 3 stated she should have not left Resident 73 and instead she should have yelled for help and start CPR. On [DATE] at 3:29 p.m., during an interview, LVN 1 stated CNA 3 came to the nurses' station and reported she believed Resident 73 was dead. LVN 1 stated she went into Resident 73's room and observed Resident 73 was pale and was not breathing. LVN 1 stated Resident 73's room was less than a minute from the nurses' station. LVN 1 stated it took about 3 minutes for her to reposition the resident, check for brachial (artery) pulse (heartbeat felt in the anterior aspect of the elbow), carotid (artery) pulse (heartbeat felt in on either side of the front of the neck just below the angle of the jaw), and wrist (radial artery) pulse. LVN 1 stated LVN 2 came inside Resident 73's room and she asked LVN 2 to help checking Resident 73's condition. LVN 1 stated she did not want to be the one to say that Resident 73 was dead and needed someone else to verify. LVN 1 stated LVN 2 tried to take Resident 73's blood pressure manually but could not hear anything using the stethoscope (a medical instrument used to listen to blood pressure sounds). LVN 1 stated LVN 2 started chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency situation) and LVN 1 called paramedics. LVN 1 stated there was a delay in starting CPR for about four to five minutes. On [DATE] at 2:24 p.m., during an interview, Resident 73's Primary Physician (PP 1) PP 1 stated he was not the one to call the time of Resident 73's death. On [DATE] at 11:04 a.m., during an interview, LVN 1 stated she had a CPR training and learned that an unresponsive resident requires one pulse check and if there is no pulse one should start CPR right away. LVN 1 stated she checked several areas for Resident 73's heart rate and CPR initiation was delayed which could have potentially caused Resident 73's death. On [DATE] at 2:19 p.m., during an interview, the DON stated when a resident is unresponsive, staff should stay with the resident, yell for help, check for pulse and rising and falling of chest, and start CPR if the resident has no heartbeats and is not breathing. The DON stated that the five-minute delay in giving CPR to Resident 73 could have caused Resident 73's death. When asked, the DON was able to give the facility's policies and procedures on Emergency Care and Cardiopulmonary Resuscitation but was not able to give any other policies and procedures related to giving emergency care to residents such as Crash Carts (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest) and Code Blue (a declaration of or a state of medical emergency and call for medical personnel and equipment to attempt to revive a patient from unconsciousness especially when in cardiac arrest or respiratory distress or failure). A review of facility's policy and procedures titled, Emergency Care, revised on [DATE], indicated it was the policy of the facility to provide emergency care which included, but not limited to CPR and / or calling 911 for transfer to an acute care facility for more definitive treatment. The policy indicated that when paramedics arrive, the resident's care is transferred to the paramedics. The following is the procedure: 1. Notify the physician and report changes in condition pursuant to policy. 2. Provide emergency care as necessary. 4. Calling 911 is at the discretion of the charge nurse base on his/her professional judgment. 5. Follow CPR . guidelines as indicated. A review of facility's policy and procedures titled, Cardiopulmonary Resuscitation (CPR), revised on [DATE], indicated to ensure ventilation and establish circulation on a resident with absence of respirations and pulse until emergency personnel arrives. Giving CPR: 1. Check the scene for safety, form an initial impression and use personal protective equipment (PPE). 2. If the person appears unresponsive, check for responsiveness, breathing, life-threatening bleeding or other life-threatening conditions using shout-tap-shout. 3. If the person does not respond and is not breathing or only gasping, call [DATE] and get equipment, or tell someone to do so. 4. Place the person on their back on a firm, flat surface. 5. Give 30 chest compressions. 6. Give two breaths. 7. Continue giving sets of 30 chest compressions and two breaths. Use an automated external defibrillator (AED - it is a sophisticated, yet easy-to-use, medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm) as soon as one is available.

Based on observation, interview, and record review, the facility failed to provide to three of six sampled residents (Resident 18, Resident 48, and Resident 66) an environment free of accident hazards and adequate supervision and assistance to prevent falls and injury for Resident 18 and elopement for Resident 66. 1. For Resident 18, the facility failed to ensure: a. The Interdisciplinary Team (IDT, group of healthcare staff from different disciplines involved in the care of the resident), met, reviewed, and/or revised Resident 18's care plans after each fall to develop and implement resident-centered interventions with measurable goals to prevent falls. b. Monitoring the use and effectiveness of Resident 18's sensor pad alarm (a device used to detect movement of a resident to mitigate falls). As a result, Resident 18 sustained repeated falls, a total 19 falls from 11/22/2019 2019 to 2/3/2022 (exit date of the recertification survey) and was identified with injuries on eight (8) falls as follows: - On 11/22/2019 Resident 18 fell and sustained a head laceration (a deep cut or tear in skin or flesh). - On 1/17/2020, Resident 18 fell and sustained a scratch on the right lower back. - On 6/18/2021, Resident 18 fell and sustained a skin tear on the right elbow. - On 7/19/2021, Resident 18 fell and sustained abrasions (an area damaged by scraping or wearing away) on the right and left knees. - On 10/18/2021, Resident 18 fell and sustained bruise (occurs when small blood vessels break and leak their contents into the soft tissue beneath the skin) and swelling (occurs when a part of the body increases in size, typically because of injury, inflammation, or fluid retention) of the left side of the hip area. - On 11/15/2021, Resident 18 fell and sustained pain on the side of the right knee. - On 12/20/2021, Resident 18 fell and sustained a superficial (on the surface) abrasion on the left knee. - On 1/17/2022, Resident 18 fell and sustained a purplish discoloration to the left occipital (back of the head) area and the left mid-back and left scapular (shoulder) region reddish discolorations. 2. For Resident 48, the facility failed to ensure a fall mat and bed sensor pad alarm were in place. This deficient practice had the potential to result in Resident 48 sustaining an injury from a fall. 3. For Resident 66, the facility failed to: a. Ensure adequate supervision was provided to Resident 66 to prevent elopement. b. Identify and assess Resident 66's risk for leaving the facility without notification to staff and develop interventions to address this risk. These deficient practices resulted in Resident 66 eloping and placed the resident at risk for harm and injury. Findings: 1. On 1/31/2023 at 10 a.m., during an observation and interview Resident 18 was sitting in a wheelchair (WC) and stated he had fallen while in the facility because he forgot to lock the wheels on his WC. A review of Resident 18's Admission Record indicated the facility admitted the resident on 6/24/2019 with diagnoses including muscle weakness, lack of coordination, unsteady on the feet (unable to stand or walk easily), history of falls, and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 18's Morse Fall Scale form (a rapid and simple method of assessing a patient's likelihood of falling), dated 1/5/2023, indicated the resident was a high risk for falling with a history of falls, impaired gait, and the resident overestimated or forgot limits. A review of Resident 18's Minimum Data Set (MDS - an assessment and screening too), dated 2/1/2023, indicated the resident was usually able to understand others and make himself understood, the resident required supervision with bed mobility, transfer, walking in the room, dressing, toilet use, and personal hygiene. The MDS further indicated the resident had two or more falls with injury and two or more falls with no injury since admission. On 2/1/2023 at 3:17 p.m., during an interview with the Director of Nursing (DON) and a concurrent review of Resident 18's medical record, the DON stated the resident had a fall on 11/22/2019 that resulted in a laceration on the forehead requiring transfer to a general acute care hospital (GACH). The review of Resident 18's clinical record indicated: a. Resident 18's Care Plan (CP) titled, At risk for recurrent falls or injuries related to impaired cognition related to dementia, impaired mobility secondary to muscle weakness, unsteadiness on feet, and hypertension (high blood pressure), initiated 7/4/2019 and last revised 12/20/2021, indicated the resident fell on [DATE], 11/15/2021, 11/22/2021, 12/13/2021, and 12/20/2021. The CP indicated a resident goal that the resident would be free from falls through the review date with a target date of 11/1/2022. The CP further indicated to have a floor pad (a cushioned mat designed to help prevent injury from falls out of the bed) at bedside, initiated 2/28/2021. A review of Resident 18's CP titled, The Resident had had actual fall with poor balance, unsteady gait, initiated on 11/12/2019 and last revised on 10/31/2022, indicated the resident fell on [DATE], 1/17/2020, 2/21/2021, 6/18/2021, 6/30/2021, 8/4/2021, 8/17/2021, 9/9/2021, 10/18/2021, 11/15/2021, 11/22/2021, 12/13/2021, 12/20/2021, 1/17/2022, 7/12/2022, 10/31/2022. The CP indicated resident goals that Resident 18 would remain free from injuries by the target date of 11/1/2022. On 2/2/2023 at 9:40 a.m., during an interview with the Director of Staff Development (DSD) and concurrent review of Resident 18's record, the DSD stated Resident 18 was a high fall risk and had fallen in the facility. The DSD stated when a resident has a fall there is a change of condition (COC) reported to the physician and the resident's representative (RP), treatment is ordered as appropriate, and the care plan is reviewed and updated by the IDT with new interventions. The DSD reviewed Resident 18's COC notes, Care Plans, and IDT meeting notes and stated the following: - On 11/22/2019 at 3:30 p.m., Resident 18 had a witnessed fall, sustained a deep laceration to the top of the head measuring approximately 4 cm long x 1 cm, 911 was called (emergency telephone number) for emergency medical services (EMS, paramedics) who took Resident 18 to an emergency room (ER) due to persistent bleeding. Resident 18 returned to the facility the same days with staples to repair the scalp laceration. The DSD stated there was no documented evidence the resident's CP was updated after the fall. - On 1/17/2020 at 9:49 a.m., Resident 18 had an unwitnessed fall in the bathroom and was noted with a scratch on the right lower back. - On 2/21/2021 at 5:45 a.m., Resident 18 had an unwitnessed fall, with no injuries. - On 6/18/2021 at 10:20 p.m., Resident 18 had an unwitnessed fall and sustained a skin tear in the right elbow. - On 6/30/2021 at 12:30 a.m., Resident 18 had witnessed fall with no injuries. - On 7/19/2021 at 10:07 p.m., Resident 18 had unwitnessed fall and sustained abrasions on both right and left knees. - On 8/4/2021 at 1:51 a.m., Resident 18 had unwitnessed fall with no injuries. - On 8/17/2021 at 8:30 p.m., Resident 18 had unwitnessed fall with no injuries. - On 9/9/2021 at 11:30 p.m , Resident 18 had unwitnessed fall with no injuries. - On 10/18/2021 at 3:04 p.m., Resident 18 claimed he fell on [DATE], sustained injuries of bruise, discoloration and swelling of left side of hip area. - On 11/15/2021 at 4:10 a.m., Resident 18 had unwitnessed fall and complained of right lateral knee pain. - On 11/22/2021 at 6:30 p.m., Resident 18 had unwitnessed fall with no injuries. - On 12/13/2021 at 10 a.m., Resident 18 had witnessed fall with no injuries. - On 12/20/2021 at 1:50 p.m., Resident 18 had unwitnessed fall and sustained superficial abrasion on the left knee. - On 1/17/2022 at 6:50 p.m., Resident 18 had unwitnessed fall and was noted to have purplish discoloration to left occipital part of head. Also noted with left mid-back and left scapular region reddish discolorations. - On 7/11/2022 at 8:10 p.m., Resident 18 had unwitnessed fall with no injuries. - On 10/18/2022, Resident 18 reported fall with no injuries. - On 10/31/2022, Resident 18 had unwitnessed fall with no injuries. - On 1/5/2023, Resident 18 had unwitnessed fall with no injuries. The DSD stated there was no documented evidence the IDT met, or the CP was updated after each fall, and the last CP update was on 10/31/2022. The DSD stated there should have been new CP interventions to prevent further falls as per facility's policy on fall mitigation. On 2/2/2023 at 11:10 a.m., during an interview with the Medical Records Designee (MRD) and concurrent review of Resident 18's medical record, the MRD confirmed there was no documented evidence the resident's CPs were reviewed or updated after the resident fell on [DATE] and 1/5/2023. On 2/2/2023 at 11:45 a.m., during an interview with the DON and concurrent review of Resident 18's IDT and CPs, the DON stated the IDT should update CPs after every fall to include a review of and (put in place) new interventions. The DON stated there were no CP updates after the resident fell on [DATE] and 1/5/2023, but there should have been updates per facility's policy. The DON stated the importance (of updating CPs) was to develop new recommendations / interventions to decrease the episodes of falls and injuries. The DON stated interventions are reviews after each fall to determine if they are still current and appropriate. The DON stated Resident 18's fall CPs were also outdated because the target date for the CP goals was for 11/1/2022 and it was 2/2/2023. The DON stated the target date should be in the future. The DON stated the CP goals are updated annually, quarterly, and as needed. The DON stated it was important to have current goals so there was a measurable timeframe for the interventions in place. The DON stated Resident 18's short-term goals and interventions indicated in the CPs should be resolved but were not. The DON stated the CP indicated an intervention for a floor pad at bedside, but the order had been discontinued because it was no longer appropriate. The DON stated the CP interventions were current for Resident 18. The DON stated the MDS Nurse was responsible for ensuring CPs were updated, but she must have gotten behind. On 2/3/2023 at 8:30 a.m., during an observation of Resident 18's room with Licensed Vocational Nurse 5 (LVN 5), it was noted Resident 18's bedside had no floor mat. LVN 5 stated if the CP indicated a floor mat should be at bedside, then it should be there. During an interview and record review on 2/3/2023 at 9 a.m., the DON reviewed Resident 18's CPs and physician orders and stated the order to place a fall mat at bedside was discontinued on 4/30/2021 and it was not removed from the resident's CP. The DON stated the importance of the CP is that it guides the staff in the appropriate care to minimize injury. The DON stated by looking at the CP it looks like all the interventions are current because nothing has been discontinued. The DON stated the CP was not updated based on physician's order and the IDT recommendations. The DON stated the risk of having the CP not reflecting a person-centered care plan would result in inadequate interventions to prevent falls. The DON stated the interventions did not reflect the current care for the resident. During an interview on 2/3/2023 at 2:30 p.m., the MDS Nurse stated CPs are used as a guide to care for the resident and they should be specific, measurable, current, and applicable to the resident's current condition. The MDS Nurse reviewed Resident 18's CPs related to falls and stated the were not updated because she got behind and missed them. The MDS Nurse stated for this resident, if the CPs were not all those things (specific, measurable, current, and applicable to the resident's current condition) the resident could fall resulting in injury. b. A review of Resident 18's Physician's Order, dated 8/27/202, indicated to apply a Sensor Pad Alarm in bed or WC to alert staff of unassisted transfers, getting up or walking every shift for fall risk. The order was dated 8/27/2021 and discontinued 1/30/2023. During an interview and record review on 2/3/2023 at 8 a.m., Registered Nurse 1 (RN 1) stated Resident 18 has fallen multiple times and forgets to call for assistance. RN 1 stated the resident has a sensor pad alarm to alert staff if he gets up unassisted. RN 1 stated the resident has a history of non-compliance and removing the alarm and it was important to monitor the alarm for placement and document in the Medication Administration Record (MAR). RN 1 stated the documenting licensed nurse should indicate each shift (day, evening and night) in the MAR Y for yes, the alarm was in place, or an N for no, the alarm was not in place. RN 1 stated a - (dash) did not indicate if a sensor pad alarm was in place or not. RN 1 stated she did not know what a dash indicated. RN 1 reviewed Resident 18's MAR for sensor pad alarm monitoring and stated the following: - For the month of 11/2022: all day, evening, and night shifts indicated a dash. - For the month of 12/2022: all day, evening, and night shifts (except 12/14/2023 and 12/23/2023 evening shifts), indicated a dash - For the month of 1/2023 (up to 1/30/2023, date the order was discontinued): all day, evening, and night shifts (except 1/15/2023, 1/25/2023, and 1/26/2023 evening shifts), indicated a dash. RN 1 stated the dash did not indicate if the sensor pad alarm was in place or not and was not appropriate documentation. RN 1 stated the importance of appropriate documentation was to ensure accuracy of documentation and to communicate if the sensor was present or not. RN 1 stated the importance of knowing if the sensor was in place or not was to see if the intervention was effective because Resident 18 removes the alarm and had many falls in the facility. During an interview on 2/3/2023 at 9 a.m., the Director of Nursing reviewed Resident 18's MAR and stated she did not know what the dash meant, and Y or N should have been documented. The DON stated the importance was to ensure the alarm was in place and the accuracy of the collection of information to ensure the order should be kept in place and that it was appropriate for the resident. The DON stated the IDT would review the MAR post fall when the team reviewed interventions to prevent falls. A review of the facility's current policy and procedure titled, Documentation Principles, last reviewed 2/24/2022, indicated all health information regarding a resident's stay shall be centralized in the resident's health record. Resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident. The following principles shall be used for documenting: entries must accurate, specific, concise, and clear. A review of the facility's current policy and procedure titled, Fall/Accident Mitigation and Intervention, last reviewed 2/24/2022, indicated it was the policy of the facility to minimize the risk of falls or accidents, and minimize the risk of serious injury associated with fall or accidents. Residents at risk for falls shall have a Care Plan that identifies the risk factors for that individual resident and appropriate interventions based on the risk factors. After a fall or similar accident or occurrence, the resident shall have a physical assessment documented in the nursing notes in accordance with the facility documentation policy. The attending physician and legal representative or interested family member shall be notified of the event. The facility nursing staffs and/or the IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or other event. A review of the facility's current policy and procedure titled, Comprehensive Care Plans - Section III -39, last reviewed 2/24/2022, indicated the interdisciplinary team (IDT) shall develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment within seven days after completion of the comprehensive assessments and after each MDS assessment. The comprehensive care plan shall describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Update the CP to reflect changes to goals, approaches, as necessary: resulting from condition changes and needs, with each MDS assessment. A review of the facility's current policy and procedure titled, Comprehensive Care Plan Reference #8030, last reviewed 2/24/2022, indicated the facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing limitations and goals. Results of assessment shall be used to develop, review and revise the resident's comprehensive plan of care. Care, treatment and services shall be planned to ensure that they are individualized to the resident's needs. Care planning shall be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable. The planning for care, treatment and services shall include the following: the needs of the resident, goals, time frames, required services and the service settings are critical considerations in determining the plan of care; regularly reviewing and revising the plan for care, treatment, and services; documenting the plan for care, treatment, and services. A review of the facility's current policy and procedure titled, Interdisciplinary Team (IDT) / Resident Care Plan Conference Review, last reviewed 2/24/2022, indicated the IDT, in conjunction with the resident and/or representative, as appropriate, shall meet to develop a comprehensive person-centered care plan with quantifiable objectives for the highest level of functioning the resident may be expected to attain, to meet the resident's medical, nursing, mental, and psycho-social needs that are identified in the comprehensive assessment and CAA summary. IDT meetings are an ongoing process through a resident; stay and is an integral part of the daily, IDT discussion / communication to best meet the needs of the resident. These meetings may be informal/stand-up meetings with only 1 specific resident need reviewed to meet the immediate needs of the resident and to update the care plan. The goal of the IDT reviews shall be included in the resident's health record. The purpose (of the IDT): to update as the resident condition changes and as revisions is needed and after each MDS assessment. (IDT) shall be documented in the resident's health record: e.g., various IDT notes, assessment forms, Resident Care Plan Conference Notes, or another appropriate document. 2. A review of Resident 48's Admission Record indicated the facility admitted the resident on 3/12/2019 and readmitted on [DATE] with diagnoses that included Parkinson's Disease (a progressive disorder that affects the nervous system that causes unintended or uncontrollable movements), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and a history of falls. A review of Resident 48's MDS, dated [DATE], indicated the resident sometimes had the ability to understand others and rarely/never had the ability to make self-understood. The MDS indicated Resident 48 was totally dependent on staff for dressing, eating, toilet use and personal hygiene. A review of Resident 48's physician orders indicated an order for the following: -Floor mat on one side of the floor next to bed to minimize injury in case of fall, dated 2/2/2021. -Sensor pad alarm in bed and/or WC to alert staff of unassisted transfers, getting up or ambulation, dated 2/2/2021. A review of Resident 48's Care Plan (CP) titled, Resident is a high risk for falls related to dementia, gait/balance problems, initiated 3/25/2019, indicated a floor mat next to bed for fall management and sensor pad alarm while in bed and in WC to alert staff to unassisted transfers. During an observation on 1/31/2023 at 9:25 a.m., Resident 48 lay in bed with no floor mat at bedside and a tab alarm on the nightstand, not connected to the resident. Resident was not verbally responsive. During an observation and interview on 1/31/2023 at 11:42 a.m., Certified Nursing Assistant 7 (CNA 7) stated Resident 48 had a yellow star on her door name marker that indicated she was a high risk for falls. CNA 7 stated the yellow star indicated the interventions in place for Resident 48 included a floor mat and bed sensor alarm. CNA 7 assessed Resident 48 and stated the resident did not have a floor mat or bed alarm. CNA 7 stated a tab alarm was disconnected from the resident and was on top of the nightstand. CNA 7 stated Resident 48 did not need alarms or a floor mat because she did not try to get out of bed anymore, but she did before. CNA 7 stated it had been a while since she tried to get up and the yellow star should be updated. During an observation, record review and interview on 1/31/2023 at 11:53 a.m., Licensed Vocational Nurse 6 (LVN 6) reviewed Resident 48's CPs and stated the resident was a high risk for fall. LVN 6 reviewed Resident 48's physician orders and stated the interventions in place to prevent injury from fall were a floor mat and a bed alarm. LVN 6 stated the floor mat and sensor alarm should be in place because the resident had dementia and (one) never knew when she could be more active. LVN 6 assessed Resident 48 and stated the resident was in bed and there was no sensor pad alarm and there was no floor mat at bedside. During an interview and record review on 2/2/2023 at 11:50 a.m., the Director of Nursing reviewed Resident 48's physician orders and the facility policy and procedures and stated the floor mat and bed alarm should have been in place, even if the resident was declining. The DON stated the devices were used to minimize the risk of serious injury if the resident did have a fall. A review of the facility policy and procedure titled, Fall/Accident Mitigation and Intervention, last reviewed 2/24/2022, indicated it was the policy of the facility to minimize the risk of falls or accidents, and minimize the risk of serious injury associated with fall or accidents. Residents at risk for falls shall have a Care Plan that identifies the risk factors for that individual resident and appropriate interventions based on the risk factors. After a fall or similar accident or occurrence, the resident shall have a physical assessment documented in the nursing notes in accordance with the facility documentation policy. The attending physician and legal representative or interested family member shall be notified of the event. The facility nursing staff and/or the IDT shall update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or other event. 45978 3. A review of Resident 66's Admission Record, indicated that the resident was initially admitted on [DATE] for surgical aftercare following surgery of the brain. The resident's diagnoses included cerebral aneurysm (a bulging, weakened area in the wall of an artery in the brain), epilepsy (a disorder in which brain activity becomes abnormal, causing seizures), and generalized muscle weakness. A review of Resident 66's Minimum Data Set (MDS- a standardized care assessment tool) dated 12/6/2022, indicated that the resident had severe cognitive impairment and needed limited assistance with one person assist on all activities of daily living (ADL). A review of the Admit/Readmit Screener (assessment tool) dated 12/6/2022, indicated Resident 66's was assessed with episodes of confusion and was a wanderer (define). The screener did not indicate that an Elopement Risk Assessment was completed for the resident. A review of Resident 66's comprehensive care plans indicated that there was no care plan developed addressing the resident's wandering behavior prior to the resident's elopement. A review of Resident 66's Change of Condition (COC), dated 1/2/2023, indicated the resident had an episode of elopement. Resident 66 was last seen on 1/1/2023, between 7 p.m. and 8 p.m., sitting in the lobby. Noted by 11p-7a staff, during rounds, that the resident was not in bed. After failed attempts to find the resident, the staff decided to ask the help of the sheriff on 1/2/2023 at 12:45 a.m. who was currently in the facility for another incident. Resident 66 was found by the Sheriff two miles away from the facility and brought the resident back at 1:30 a.m. The resident stated to the nurse that he was very cold. A review of Resident 66's medical record indicated that the facility did not assess the resident for elopement risk after the elopement incident. On 2/3/2023 at 11:05 a.m., during a concurrent interview and record review of Resident 66's medical record with the Director of Nursing (DON), the DON stated that the facility did not create an elopement risk assessment for Resident 66 on admission and after the elopement incident. The DON stated that there should have been an assessment conducted to ensure that a person-centered care plan was developed with interventions to keep the resident safe. The DON stated the elopement incident placed the resident at risk for injury. A review of the facility's policy and procedure on Elopement, reviewed on 2/24/2022, indicated that it is policy of the facility to minimize the risk of elopement; residents who are at risk for elopement will have an appropriate plan of care developed to address risk.

Based on observation, interview, and record review, the facility failed to provide treatment to manage a resident's behavior associated with the acquiring and self-administration of an illegal substance (heroin) while in the facility, that resulted in recurrent loss of consciouness and heroin toxicity for one out of 19 sample residents (16) by failing to: 1. Conduct a comprehensive assessment, and develop a plan of care with effective and useful interventions in the management of the resident's behavior related to known drug-abuse tendencies. 2. Monitor the resident's activities, including visitors, in an attempt to prevent him from obtaining and self-administering illegal drugs while he was under the facility's care. 3. Ensure Resident 16 attended scheduled Mental Health Clinic appointments to receive [MEDICATION NAME] treatments as ordered by the physician, after displaying drug-seeking behaviors. Findings: The Department received a complaint alleging the overdose of a resident. An unannounced complaint investigation was conducted during the annual survey. A review of the admission record indicated Resident 16 was first admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was readmitted on [DATE], with additional [DIAGNOSES REDACTED]. The Diagnostic Interview, Mental and Behavioral Note visit form dated June 3, 2011, indicated the resident had maladaptive behaviors that included setting fire to his mobile home after having a blackout from taking a "bunch" of medications. Management recommendations to be considered included followup with appropriate support regarding his substance dependence. A plan of care initiated on June 8, 2011, indicated the resident was at risk for alteration in comfort due to [DIAGNOSES REDACTED]. The interventions on the plan of care included to monitor adverse reactions and notify the physician if there was a change in level of consciousness, and to monitor the vital signs. The Minimum Data Set ((MDS) - a standardized comprehensive assessment of the resident's problems and conditions) dated June 14, 2011, indicated the resident was able to make himself understood and had the ability to understand others, had intact cognitive skills for daily decision-making, required supervision with eating and personal hygiene, limited assistance with transfers and dressing, and extensive assistance with bathing. The MDS also indicated the resident manifested behavior of rejecting care 1 to 3 days during the prior seven days. The Care Area Assessment had "behavior" triggered as a health concern, indicating the need for a plan of care that focused on the resident's safety, and to identify areas in which staff interventions might be useful in controlling behavior. Following the completion of the MDS, the licensed staff did not utilize the information available to them when developing a plan of care with interventions to address the resident's [DIAGNOSES REDACTED]. A review of the Licensed Personnel Weekly Progress Notes revealed that on June 15, 2011, at 1 p.m., Resident 16 was allowed to go out of the facility on pass from 12:15 p.m. to 3:10 p.m. According to the "Release of responsibility for Out on Pass/Leave of Absence" form, the resident was in a stable condition when he left the facility with his friend. The resident had a physician's orders [REDACTED]. First Incident: A review of the Licensed Personnel Weekly Progress Notes dated June 16, 2011 at 12:55 p.m., revealed a certified nursing assistant (unidentified) informed the charge nurse that Resident 16 was found in his room unresponsive. The charge nurse noted the resident was lying in bed with his eyes fixed, pupils pin point, skin warm and dry to touch, bluish color to the face, positive carotid pulse, but not responsive to tactile stimuli. The paramedics were called and the resident was transferred to the general acute care hospital (GACH) emergency department (ED) at 1:15 p.m. The physician was notified. A review of the ED report obtained from the GACH dated June 16, 2011, indicated the resident was brought to the ED due to an altered mental status. The record indicated the resident had a history of [REDACTED]. The GACH toxicology screen report dated June 16, 2011, indicated the resident was positive for opiates from possible narcotic overdose. He was hospitalized until discharged to the facility on [DATE]. The Licensed Personnel Weekly Progress Notes dated June 20, 2011, at 3 p.m., revealed the resident was readmitted to the facility. The administrative staff did not thoroughly investigate the circumstances surrounding the resident's source of the illegal controlled substance in order to ensure the incident would not reoccur, and to prevent potential danger to other residents who may be affected by or exposed to illegal substances. Second Incident: According to the Licensed Personnel Weekly Progress Notes admission note dated June 20, 2011, at 4 p.m., approximately one hour after the resident was readmitted from the GACH to the facility via gurney, he was found in his room for the second time unresponsive. The vital signs were: blood pressure 96/58 millimeters of mercury (mm Hg), pulse was 76 beats per minute, respirations were 14 breaths per minute, and oxygen saturation on room air was 82 percent (%). A saturation of 97% of the total amount of hemoglobin in the body is filled with oxygen molecules. A range of 97% to 99% is generally considered normal on room air. Anything below 90% could quickly lead to life-threatening complications. The margin between "healthy" saturation levels (95-98%) and [MEDICAL CONDITION] (usually 85-90%) is narrow. (American Journal of Nursing: June 2009 - Volume 109 - No.6, pages 52-59). The Licensed Personnel Weekly Progress Notes indicated the physician was notified and he gave orders to transfer the resident to the GACH emergency department (ED) for further evaluation. The resident was transported to the ED via paramedics on the same day. The Licensed Personnel Weekly Progress Notes revealed the resident was discharged from the GACH, and readmitted to the facility on [DATE], at 2:30 a.m. The admission note indicated the resident arrived at the facility via taxi and ambulatory by himself. According to the Patient Instruction form, the resident was issued five pages of patient instructions. According to the instructions, the use of heroin (street drugs) is illegal in the United States. A review of the Licensed Personnel Weekly Progress Notes dated June 21, 2011, some time after 6 p.m. (no time indicated), revealed a Certified Nursing Assistant (CNA) reported to the charge nurse that there was something inside the resident's right sock. She found a small plastic bag containing a syringe, a spoon, and a very dark-in-color sticky substance. The note also indicated the DON and the physician were notified, and the resident was to be monitored closely. Following the June 21, 2011, readmission, the licensed nursing staff did not develop a plan of care utilizing the information contained in the five pages of Patient Instructions. These instructions were filed in the resident's clinical record, but the facility did not use the information to develop a plan of care to prevent similar events associated with the resident's actions surrounding the use of illegal controlled substances while in the facility. There was no indication that the Interdisciplinary Team was involved with the decisionmaking to prevent Resident 16's drug-seeking behaviors. In addition, the facility did not attempt to find the resident's source providing the illegal drugs in order to protect Resident 16 and all other residents from accessing the drugs. On August 4, 2011, at approximately 7:25 p.m., during an interview with the Director of Nursing (DON), in the presence of the Social Services Designee and the MDS coordinator, the DON stated the facility had not incorporated Resident 16's repeated drug-seeking behaviors in the care plan with interventions to protect him and all other residents in the facility, from illegal drugs. During an interview on August 22, 2011 at 2:10 p.m., the DON stated after the CNA found the items in Resident 16's sock, on June 21, 2011, she gave instructions to notify the physician and to monitor the resident closely when he was readmitted on [DATE]. According to the DON she did not speak to the resident about the substance found in his sock, but did speak to the resident's friend, who stated she did not have any idea what the unknown substance was. The DON stated she instructed the staff members to closely watch any visitors who came to visit the resident and to ensure they signed in and out. On July 22, 2011, there was a physician's orders [REDACTED]. According to the Licensed Personnel Weekly Progress Notes dated July 22, 2011, at 8:30 a.m., an appointment was scheduled for July 26, 2011 at 7:30 a.m., as ordered. [MEDICATION NAME] is a drug used in approved [MEDICATION NAME] maintenance programs, that can substitute for heroin, or other illicit narcotics in persons who want to terminate a drug use. Lippincott's Nursing Drug Guide, 2003, p. 767. A review of the care plans revealed the licensed staff did not develop a plan of care related to the [MEDICATION NAME] treatment program. There was no documentation that indicated the resident had attended the [MEDICATION NAME] treatment program on July 26, 2011 at 7:30 a.m., as scheduled. According to the Licensed Personnel Weekly Progress Notes dated July 26, 2011, at 2 p.m., the scheduled [MEDICATION NAME] treatment was missed for unknown reasons and another appoitment was rescheduled for July 28, 2011. On July 28, 2011, the physician ordered to schedule the resident to have [MEDICATION NAME] treatment at the clinic on July 29, 30, and 31, 2011, and August 1, 2, and 3, 2011. The Licensed Personnel Weekly Progress Notes dated July 28, 2011, at 7 a.m., indicated the resident was "out" with the CNA to his first [MEDICATION NAME] treatment, and returned from the clinic with instructions to return for the remaining six treatments. According to the instructions, after the completion of the scheduled six treatments, the physician would give a prescription for the resident to continue the treatment at the facility. There was no note dated July 29, 2011, to indicate that the resident attended his appointment as scheduled for the day. There was no note in the social service notes to address this appointment. On July 30, 2011, at 7 a.m., the Licensed Personnel Weekly Progress Notes indicated that the resident was picked up by a shuttle for his second scheduled appointment. While the third [MEDICATION NAME] treatment scheduled for July 31, 2011, was pending, the resident had another incident of illegal drug consumption that resulted in an altered mental status and admission to the GACH on July 31, 2011. Third Incident: A review of the Licensed Personnel Weekly Progress Notes dated July 31, 2011 at 7 a.m., revealed the resident, for the third time, was found in his room with an altered mental status, with vital signs of: blood pressure 110/65, heart rate of 86 beats per minute, respiratory rate of 18 breaths per minute, temperature 98.2 degrees Fahrenheit, and oxygen saturation of 85%. The resident was transferred by paramedics to the GACH emergency room (ER). A review of the ER Report dated July 31, 2011, revealed the resident was found with an altered mental status at the nursing home. Paramedics administered [MEDICATION NAME] 2 milligrams, and his mental status improved dramatically. According to the report, the resident admitted using heroin the morning of July 31, 2011. The patient was unable to provide medical history details due to his altered mental status from the narcotic overdose. The ER documentation reflected the resident was intermittently somnolent (sleepy, drowsy), and had PVC ((premature ventricular contractions) a heart condition). According to the H&P dated July 31, 2011, from the GACH, the resident is a heroin addict, and admits to using heroin while in the facility. When asked how (he aquired the drugs), he said that he had family members sneak them in to him. He stated he had been on heroin for many years. According to the H&P, one of the [DIAGNOSES REDACTED]. Resident 16 was admitted to the hospital Telemetry Unit (a unit where patients with heart conditions are observed and treated) with the [DIAGNOSES REDACTED]. According to the physician's progress note dated July 31, 2011, 5:45 p.m., the resident was treated with intravenous (IV) fluids of normal saline 1000 cubic centimeters (cc) at the rate of 80 cc per hour, antibiotic therapy ([MEDICATION NAME] 500 milligrams (mg) IV), and anticoagulant therapy ([MEDICATION NAME] 40 mg subcutaneous). The resident was discharged back to the skilled nursing facility on August 1, 2011. A review of the Licensed Personnel Weekly Progress Notes dated August 1, 2011, (no time) revealed Resident 16 was readmitted with [DIAGNOSES REDACTED]. After the readmission of Resident 16 from the GACH after displaying drug-seeking behaviors that resulted in three incidents of altered mental status secondary to heroin abuse, the licensed nursing staff did not utilize critical existing information to develop a plan of care with specific interventions to address the drug-seeking needs and behaviors of Resident 16 to protect him while under their care. The treatment plan that was supposed to be in place, was not implemented as ordered by the physician. On August 4, 2011 at 5:05 p.m., during an interview, the resident was very forthcoming with information. He admitted having a substance abuse problem and an addiction to heroin. When asked how he obtained the drugs in the facility, he stated that a person (he would not identify) would come to visit him, would not sign in at the front desk, and would deliver the heroin to him. According to the resident, this person visited three times, delivering one "bag" of heroin on one visit, and two "bags" of heroin on another visit. According to Resident 16, other supplies needed to self-administer the drug, such as syringe and needles, were brought into the facility hidden in his socks. The resident stated he self-administered the drug on his left forearm vein whenever he needed to. Usually this was done in the bathroom, which was convenient for him to self-administer unnoticed by the facility staff members. On August 4, 2011 at 7:20 p.m. during an interview with the DON regarding the unusual occurrences, she stated that an investigation of the three incidents of the heroin overdose on June 16, 2011, June 20, 2011, and July 31, 2011, had not been done by the facility. She stated there was no plan of care initiated to prevent further incidents associated with Resident 16's drug overdose. The DON could not provide documented evidence to reflect that licensed nursing staff had identified or assessed the injection site on Resident 16's left forearm vein, as he indicated by the resident during the Department's interview, in order to develop a comprehesive plan of care with interventions to prevent the resident's recurrent self-administering of heroin. Cross Refer to F225 - 483.13(c)(1)(ii)-(iii) and (c)(2)-(4) Investigate/Report Allegations/Individuals, and F406 - 483.45(a) Provide/obtain Specialized Rehab Services

Based on observation, interview and record review, the licensed nursing staff failed to prevent a severe weight loss of 8 percent in three months by not providing the volume of gastrostomy tube (GT) feeding as ordered by the physician, failed to follow-up on the registered dietitian's (RD) recommendation to increase the GT feeding to 95 cubic centimeters (cc) per hour for 20 hours to provide 1900 cc per 2289 kcal (kilocalories) for one in a sample of 19 residents (2). Findings: According to the admission information, Resident 2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment updated May 6, 2011 indicated the resident had moderatly impaired cognitive skills, unclear speach, and was totally dependent on staff for all needs, including feeding through a GT. The nutritional screening completed by the RD on January 25, 2011, indicated the resident had a weight and height of 137 pounds and 64 inches respectively. According to the RD's recommendation, the resident was to receive enteral feeding of Diabetisource at 70 cc per hour for 20 hours to provide 1400 cc per 1680 calories, and to flush the GT with 300 cc of water every shift, and to provide 62-74 grams of protein and 1550 cc of fluids. The estimated calories were 1764 kcal, protein was 62- 4 grams, and fluid needs were 1550 cc. On January 25, 2011, the physician ordered Diabetisource GT feeding at 75 cubic centimeters (cc) per hour for 20 hours to provide 1500 cc per 1800 kilocalories (kcal); flush the tube with 300 cc of water every shift. There was also an order [REDACTED]. The care plan dated February 6, 2011, indicated to monitor the resident's thirst due to the [DIAGNOSES REDACTED]. The approach was to give the GT feeding formula as ordered by the physician, flush the GT with water as ordered, and monitor the resident for signs and symptoms of dehydration. The Physician's Progress Notes indicated on May 12, 2011, June 6, 2011, July 3, 2011, and August 1, 2011, the resident was thirsty and asked for water. There was no documentation that indicated the licensed nursing staff addressed the resident's thirst and/or updated the plan of care to include interventions to monitor the resident's hydration and overall nutritional status. A review of the resident's weight record indicated the following: On January 24, 2011, 137 pounds (lbs) On February 2, 2011, 137 lbs On March 3, 2011, 137 lbs On April 4, 2011, 137 lbs On May 2, 2011, 137 lbs On June 1, 2011, 135 lbs, the resident lost two 2 lbs. On July 2, 2011, 132 lbs, the resident lost five lbs. While the resident was progressively losing weight during the months of May, June and July, 2011, the licensed nursing staff did not assess the cause(s) of the weight loss and ensure that the resident received the volume of GT feeding as ordered. The RD's Nutritional Progress Notes dated July 6, 2011, indicated the resident had a three pounds weight loss from June 2011, to July 2011. The RD's assessment did not account for the cumulative weight loss from the resident's baseline weight. For example, on July 2, 2011, four days before the RD wrote the progress note the resident weighed 132 pounds, which indicated a net weight loss of five lbs. The RD recommended increasing the resident's GT feeding from 75 cc per hour to 85 cc per hours. The physician's orders [REDACTED]. On August 1, 2011, the resident weighed 126 pounds. The resident had lost 11 lbs since May 2, 2011. This was a weight loss of 8.02 percent in less than three months. According to the State Operations Manual (SOM), a weight loss of greater than 7.5 percent in three months is considered a severe weight loss (SOM October 2010, Page 306). The RD's Nutritional Progress Note dated August 2, 2011, indicated the resident had a significant weight loss of six pounds from July 1, 2011, to August 1, 2011. The RD's assessment indicated only a one month weight loss of six pounds and did not account the cumulative weight loss of 11 pounds (two pound on June 1, 2011, five pounds on July 2, 2011, and six pounds on August 1, 2011). Based on the six-pound weight loss, the RD recommended to increase the GT feeding from 85 cc to 95 cc per hour for 20 hours to provide 1900 cc per 2289 kcal due to weight loss, to get laboratory tests that included a complete metabolic panel, Hgb A1C, and a [MEDICAL CONDITION] panel. However, a review of the resident's clinical record revealed there was no documented evidence that indicated the RD's recommendations were brought to the attention of the attending physician to ensure prompt action, and to obtain physician's orders [REDACTED]. During an interview on August 8, 2011, at 9:45 a.m., the RD stated she visits the facility once a week. The RD further stated she visits residents with weight loss weekly if they are on weekly weights. The RD also stated she follows up with her recommendations on the following visit. On August 3, 2011, at 8:30 a.m. during the initial tour of the facility, the resident was observed lying in bed. The resident looked frail and thin with a thick white coated tongue and dry teeth and mouth. The resident had a GT feeding running at a rate of 85 cc per hour, not 95 cc per hour as the RD recommended. The capacity of the GT feeding tube was 1500 cc and there was 1300 cc left in the bottle at the time of the observation. According to the label on the bottle, the GT feeding was started on August 3, 2011, at 4:40 a.m. which was approximately four hours at the time of the observation. During this time (from 4:30 a.m. to 8:30 a.m.) the resident should have received 85 x 4 = 340 cc of feeding. However, since there was 1300 cc left in the bottle, the resident received only 200 cc, which was less than what the resident should have received by approximately 140 cc (340 cc - 200 cc) . There was no intake and output record in the resident's clinical record to evaluate whether the resident had received the volume of feeding as ordered by the physician. On August 4, 2011, at 8 a.m. the GT feeding was observed still running at a rate of 85 cc per hour and approximately 150 cc left in the bottle. According to the label, it was the same bottle of GT feeding started on August 3, 2011, at 4:30 a.m. At a rate of 85 cc per hour for 20 hours, 1700 cc should have been provided and therefore, the 1500 cc bottle should have been completed and a new feeding bottle shouls have started. Instead, the same bottle was hung from August 3, 2011, at 4:30 a.m. until the second observation on August 4, 2011, at 8 a.m. or for a total of 27.5 hours. Since the resident was on a 20 hour feeding cycle, out of the 27.5 hours the resident should have received uninterrupted feeding for 23.5 hours. During this time the resident should have received (23.5 x 85 cc) 1997.5 cc of formula. However, he received only 1350 cc which was less than the prescribed amount by a volume of 647.5 cc. Furthermore, after the facility recognized the resident's weight loss, the RD's recommendations dated August 2, 2011, to increase the GT feeding to 95 cc per hour for 20 hours was not implemented to immediately and not delay remedy of the resident's severe weight loss. The failure of the facility to implement the RD's recommendations recorded on the progress note dated August 2, 2011, to increase the GT feeding to 95 cc per hour for 20 hours resulted in delayed intervention to remedy the resident's severe weight loss of 11 pounds in three months. On August 4, 2011, at 8:15 a.m. during an interview, LVN 4, who was present during the observation, was asked about the resident's GT feeding. LVN 4 stated the GT feeding bottle that was started on August 3, 2011, at 4:30 a.m., should have finished by 4:30 a.m. on August 4, 2011, and a new bottle should have been started. The GT feeding should have been infusing all night. During the interview, LVN 4 was questioned why the RD's recommendations dated two days earlier on August 2, 2011, had not been carried out or followed up on. She stated she was not aware of the RD's recommendations, and that LVN 1 was the nurse responsible for following up on the recommendations. LVN 4 stated the recommendation was faxed to the physician's office on August 2, 2011, to obtain an order. However, there was no follow up made by the facility when the physician did not respond to the RD's recommendations faxed to his office. According to the facility's policy, (undated) the nurses are to discard opened formula not used within 24 hours. The policy also indicated the GT feeding bags, tubing and syringes were to be changed at least every 24 hours.