Every finding on record at Santa Rosa Post Acute

Based on observations, interviews, and record reviews, the facility failed to provide a safe smoking environment for six out of six sample residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) when:The outside environment accessible to residents was not free from hazards and the door to the maintenance shed was left open and unattended,Adequate supervision was not provided in the smoking section and safe measures were not monitored for the extinguishing of cigarettes, andSmoking care plans were not initiated for Resident 4 and Resident 6.These deficiencies increased the risk of fire hazards and resident exposure to hazardous materials. Additionally, insufficient supervision led to an incident of resident-to-resident abuse and raised other safety concerns such as limited access to assistance, burns, fires, falls, wandering, elopement, exposure to or acquisition of external resources (including contraband), and trespassing. These failures also resulted in unmet care needs and inadequate care planning. Please refer to F600 for further information.Resident 1 A review of Resident 1's admission record indicated he was admitted to the facility in April 2020 with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebrovascular disease (conditions that affect blood flow to the brain), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 1/23/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 12 which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 1's document titled, NURSING- SMOKING OBSERVATION/ASSESSMENT V2.0, dated 2/24/26 at 3:55 p.m., indicated, Level of Assistance [check marked as] Independent/supervision not required.IDT [interdisciplinary team] Decision [check marked as] May smoke without supervision. A review of a facility policy and procedure (P&P) titled, Smoking Policy- Resident, indicated Resident 1 understood the rules and regulations of smoking at the facility. The P&P was signed and dated by Resident 1 on 5/12/22. A review of a facility document titled, RESIDENT SMOKING CONTRACT, indicated Resident 1 acknowledged the smoking rules and agreed to follow and abide by the smoking contract. Resident 1 signed and dated the contract on 5/12/22. Resident 2 A review of Resident 2's admission record indicated he was admitted to the facility in February 2026 with medical diagnosis which included paranoid schizophrenia (a chronic mental disorder characterized by intense irrational delusions [false beliefs] and auditory hallucinations [hearing voices]), and systemic lupus erythematosus (a chronic autoimmune disease where the immune system attacks healthy tissue). A review of Resident 2's MDS dated [DATE], indicated his BIMS score was five which indicated his cognition was severely impaired. A review of Resident 2's document titled, NURSING- SMOKING OBSERVATION/ASSESSMENT V2.0, dated 2/24/26 at 4:04 p.m., indicated, Level of Assistance [check marked as] Independent/supervision not required.IDT Decision [check marked as] May smoke without supervision. A review of a facility P&P titled, Smoking Policy- Resident, indicated Resident 2 understood the rules and regulations of smoking at the facility. The P&P was signed and dated by Resident 2's conservator (a court ordered, designated person who manages the financial affairs or personal care of an adult who cannot handle their own responsibilities) on 2/19/26. A review of a facility document titled, RESIDENT SMOKING CONTRACT, indicated Resident 2 acknowledged the smoking rules and agreed to follow and abide by the smoking contract. Resident 2's conservator signed and dated the contract on 2/19/2026. Resident 3 A review of Resident 3's admission record indicated he was admitted to the facility in January 2025 with medical diagnosis which included primary osteoarthritis (a chronic degenerative [progressive and irreversible] joint disease) of the right ankle and foot, and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). A review of Resident 3's MDS dated [DATE] indicated his BIMS score was 15 which indicated his cognition was intact. A review of Resident 3's document titled, NURSING- SMOKING OBSERVATION/ASSESSMENT V2.0, dated 2/11/26 at 12:12 p.m., indicated, Level of Assistance [check marked as] Independent/supervision not required.IDT Decision [check marked as] May smoke without supervision. A review of a facility P&P titled, Smoking Policy- Resident, indicated Resident 3 understood the rules and regulations of smoking at the facility. The P&P was signed and dated by Resident 3 on 8/07/25. A review of a facility document titled, RESIDENT SMOKING CONTRACT, indicated Resident 3 acknowledged the smoking rules and agreed to follow and abide by the smoking contract. Resident 3 signed and dated the contract on 8/07/25. Resident 4 A review of Resident 4's admission record indicated he was admitted to the facility in October 2025 with medical diagnosis which included COPD, and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). A review of Resident 4's MDS dated [DATE], indicated his BIMS score was 11 which indicated his cognition was moderately impaired. A review of Resident 4's document titled, NURSING- SMOKING OBSERVATION/ASSESSMENT V2.0, dated 1/30/26 at 5:16 p.m., indicated, Level of Assistance [check marked as] Supervision required.IDT Decision [check marked as] May smoke with supervision. A review of a facility P&P titled, Smoking Policy- Resident, indicated Resident 4 understood the rules and regulations of smoking at the facility. The P&P was signed and dated by Resident 4 on 10/26/25. A review of a facility document titled, RESIDENT SMOKING CONTRACT, indicated Resident 4 acknowledged the smoking rules and agreed to follow and abide by the smoking contract. Resident 4 signed and dated the contract on 10/26/25. Resident 5 A review of Resident 5's admission record indicated he was admitted to the facility in July 2025 with medical diagnosis which included displaced intertrochanteric fracture of right femur (a serious hip fracture involving the pelvis and thigh bone), and history of falling. A review of Resident 5's MDS dated [DATE], indicated his BIMS score was 11 which indicated his cognition was moderately impaired. A review of Resident 5's document titled, NURSING- SMOKING OBSERVATION/ASSESSMENT V2.0, dated 2/03/26 at 9:08 a.m., indicated, Level of Assistance [check marked as] Supervision required.IDT Decision [check marked as] May smoke with supervision. A review of a facility P&P titled, Smoking Policy- Resident, indicated Resident 5 understood the rules and regulations of smoking at the facility. The P&P was signed and dated by Resident 5's responsible party (RP) on 7/31/25. A review of a facility document titled, RESIDENT SMOKING CONTRACT, indicated Resident 5 acknowledged the smoking rules and agreed to follow and abide by the smoking contract. Resident 5's RP signed and dated the contract on 7/31/25. Resident 6 A review of Resident 6's admission record indicated she was admitted to the facility in December 2025 with medical diagnosis which included Colles fracture of left radius (a fracture of the wrist) and repeated falls. A review of Resident 6's MDS dated [DATE], indicated her BIMS score was 15 which indicated her cognition was intact. A review of Resident 6's document titled, NURSING- SMOKING OBSERVATION/ASSESSMENT V2.0, dated 12/22/26 at 2:15 p.m., indicated, Level of Assistance [check marked as] Independent/supervision not required.IDT Decision [check marked as] May smoke without supervision. A review of a facility P&P titled, Smoking Policy- Resident, indicated Resident 6 understood the rules and regulations of smoking at the facility. The P&P was signed and dated by Resident 6 on 1/13/26. A review of a facility document titled, RESIDENT SMOKING CONTRACT, indicated Resident 6 acknowledged the smoking rules and agreed to follow and abide by the smoking contract. Resident 6 signed and dated the contract on 1/13/26. 1. During an observation on 3/10/26 at 10:45 a.m., the smoking area was located outside at the back of the facility. The smoking area was observed to be a covered, shaded space that measured approximately 10 feet (ft- a unit of measure) by 10 ft with no marked parameter and open to the back parking lot. The smoking section contained one table, one wooden chair, one standing cigarette butt receptacle, and one carpet mat measuring approximately 3 ft x 4 ft. During an observation on 3/10/26 at 11:18 a.m., in and around the smoking area, numerous cigarette butts were scattered on the ground under the shade structure. Approximately 10 - 12 ft past the shade structure appeared to be a maintenance shed. Observed between the maintenance shed and the smoking section were approximately 10 empty to full card board boxes [scattered], a tarped card board box on a pallet, a large table covered with a tarp with broken furniture pieces, pallets, empty boxes, and random articles of debris on top, and wood pallets, wood slabs, and a plastic crate with two spray bottles and one plastic bottle that appeared to contain cleaning solution, and more debris under the table. The area also contained two overfilled garbage bins, one with bagged garbage, and one with broken down cardboard boxes, a rusty shovel, and a flat screen television leaning against the shed. Dry leaves and fallen tree twigs and debris covered the surrounding, unpaved ground. One of the four observed shed doors adjacent to the smoking area was found open and unattended. The room accessible through this door contained maintenance supplies, tools, chemical solutions, aerosols, documentation, broken equipment, and several glass fluorescent tube lights. The inside of the maintenance shed was also in disarray. The back room had no clear walking path and was cluttered with approximately 14 cardboard boxes of glass fluorescent tube lights and approximately six of those boxes were left open. During a concurrent interview and observation on 3/10/26 at 11:38 a.m., Resident 4 was seated in his wheelchair and smoking outside just past the exit/entrance door to the smoking area. Resident 4 confirmed that there were cigarette butts all over the ground. Resident 4 further stated that not everyone put their cigarettes out in the ashtray (cigarette butt receptacle). Resident 4 looked towards the maintenance shed and stated, Yeah, there is a bunch of junk back there. During a concurrent interview and observation at 3/10/26 at 11:43 a.m., Certified Nurse Assistant 1 (CNA 1) observed the smoking section and stated, There are boxes everywhere. It looks like trash. CNA 1 confirmed there was a rug on the ground under the shade structure and that cigarette butts were everywhere on the ground. CNA 1 further stated, That can be a fire hazard- it's not safe. During a concurrent interview and observation on 3/10/26 at 11:51 a.m. outside the facility with the Activities Director (AD), she stated the shed behind the smoking section was for maintenance and housekeeping. AD confirmed there were cardboard boxes and various items left outside of the shed and close to the designated smoking area. During a concurrent interview and observation on 3/10/26 at 11:55 a.m. outside with Life Safety/Housekeeping Director (HD), he confirmed the smoking area was in close vicinity to the housekeeping and maintenance shed. The HD also confirmed there were empty and full cardboard boxes left outside, dry wood pallets, and random debris in the surrounding area. Subsequently, the door to the maintenance shed was left open, and the HD confirmed the front door to the maintenance shed should be closed and locked for resident safety. The HD further confirmed that the maintenance shed was hazardous. The HD confirmed that aerosol items (pressurized propellants like butane, isobutane, or propane [all three are liquified gases], along with flammable active ingredients; they pose significant fire hazards), notably two cans of [brand name of aerosol spray] and four cans of [brand names of aerosol sprays], were stored inside the maintenance shed by the entrance. The HD stated the protocol was for flammable items to be kept in the back of the shop [maintenance shed]. The HD opened the locked housekeeping shed [directly attached to the left side of the maintenance shed] which housed several cleaning solutions and boxes of hand sanitizer containing ethyl alcohol [ethyl alcohol is known to be highly flammable and poses a significant fire risk]. The HD further acknowledged the two garbage bins outside and confirmed the two bins were overflowing. The HD stated, It's [the garbage bins] a hazard for infection control reasons. It can draw insects and animals, and they should be dumped. The HD verified that cigarette butts were scattered on the ground. The HD further stated a resident (no name mentioned) dumped the ashtray. During an observation on 3/10/26 at 12:25 p.m., outside in the smoking area, Resident 5 was overheard telling the AD, Wow, they finally swept out here! During an interview on 3/10/26 at 1:24 p.m., Resident 3 stated the condition of the smoking area was dirty. Resident 3 stated today was the second time they [facility staff] swept the ground in weeks. Resident 3 further stated, They only swept it today because you are here. Resident 3 stated that Resident 2 made it worse because he shook the cigarette butts out of the ashtray. Resident 3 further stated, But it's always a mess out there, and confirmed that the cigarette butts on the ground bothered him. Resident 3 stated, It's terrible! Resident 3 further stated that other residents threw their cigarette butts on the ground and it could be a fire hazard. Resident 3 stated, It [smoking area and surrounding area] kind of looks like a dump yard. During an interview on 3/10/26 at 2:07 p.m., the HD stated the floor technician, housekeeping or his assistant were responsible for cleaning and maintaining the smoking and surrounding area once a week. The HD stated his expectation was that the leaf blower be used, rocks removed from the area, and that trash was collected and disposed of properly. The HD stated there was no log to document when and who completed these tasks. During an interview on 3/10/26 at 2:50 p.m., Resident 5 stated the outside smoking area looked like a storage area. Resident 5 stated, It's a mess, but I've learned to live with it. Resident 5 further stated when it was raining outside, residents did not go where they should and they just threw their cigarette butts on the floor. During an interview on 3/11/26 at 1:24 p.m., the Administrator (ADM) stated his expectation for the upkeep of the facility grounds and the facility was to maintain it in a way that was presentable, safe, and functionable. The ADM stated once a day a housekeeper was expected to go outside and check for debris and miscellaneous items. The ADM stated he expected areas to be maintained and free of hazards. The ADM was offered to review the photographs taken of the outside grounds upon the abbreviated survey entrance, and he declined. The ADM further stated, No, I believe you. The ADM stated that the back area by the maintenance shed and smoking section could be a hazard if it caught on fire. 2a. A review of Resident 2's progress notes, type, Social Service Note, dated 2/24/26 at 3:07 p.m., indicated, [Resident 2] was outside in the smoking area. [Resident 2] explains that the other male resident [Resident 1] elbowed him, and that is when [Resident 2] admitted ly hit patient [Resident 1] and states it was self-defense. A review of Resident 2's progress notes, type IDT (interdisciplinary team, typically includes the nursing leadership, social services, and medical records) NOTE, dated 2/25/26 at 8:13 a.m., indicated, IDT met to discuss [Resident 2] involvement in incident with male peer [Resident 1] .Will.continue to monitor residents when smoking. A review of Resident 2' s care plan initiated on 2/25/26 indicated, [Resident 2] got involved with incident with male peer [Resident 1] and hit male peer [Resident 1] on right side of face. [Staff were expected to] .continue to monitor smoking area. A review of Resident 1' s care plan initiated on 2/25/26 indicated, [Resident 1] got involved with incident with male peer [Resident 2] stating that the male peer [Resident 2] hit him on right side of face. [Staff were expected to] .continue to monitor smoking area. During an observation and concurrent interview with the DON on 3/10/26 at 10:45 a.m., Resident 2 and Resident 3 were observed sitting in their wheelchairs smoking unsupervised in the smoking area. Resident 3 was smoking in the parking lot past the first row of cars. Resident 2 was smoking under the shaded area of the smoking area. The Director of Nursing (DON) stated Resident 2 and Resident 3 did not require supervision, and she confirmed they were currently unsupervised. During a concurrent interview and observation on 3/10/26 at 11:21 a.m. with Resident 2, he stated he could go outside and smoke on his own. Resident 2 was observed with two small holes in the front of his coat. Resident 2 stated the holes were from a burning cigarette. Resident 2 stated he did not remember when it happened. Resident 2 further stated, It went out on its own. Resident 2 verified he was alone when it happened. During an observation on 3/10/26 at 12 p.m., Resident 2 was sitting in his wheelchair, unsupervised in the smoking section. During an interview on 3/10/26 at 1:24 p.m., Resident 3 stated there was a period after the altercation [between Resident 1 and Resident 2] when more staff were outside to supervise but that only happened for about a day only. Resident 3 further stated, The facility doesn't stick to the rules like they should. 2b. During a concurrent observation and interview on 3/10/26 at 11:38 a.m., Resident 4 was smoking outside unsupervised, seated in his wheelchair just past the exit/entrance door to the smoking section. Resident 4's legs were both wrapped in kerlix gauze (100% woven cotton; should be kept away from open flames and sparks) from the ankles to the knees. Resident 4 stated he can keep his own cigarettes and lighter, and that he can go outside to smoke anytime he wanted unsupervised. Resident 4 stated that he was upset, and further stated, A CNA brought me outside to smoke and left me in the sun. I'm wearing a jacket and it's hot out here! I need help and this is where he left me. Resident 4 stated that since his legs have been wrapped, he can't help himself and required assistance. Resident 4 was observed putting his lit cigarette out with his right-hand fingers and put the cigarette butt in the pocket of his coat. Resident 4 stated he will put the cigarette out with his hand if he is not by the ashtray, or he will flick it. Resident 4 asked for assistance to turn his wheelchair and to open the door since he was unattended and could not do it independently. 2c. During an observation on 3/10/26 at 12:25 p.m., Resident 1 was smoking in the smoking section in attendance of the AD. Resident 1 was observed with what appeared to be a plastic cup holder attached to his wheelchair near his thigh. Resident 1 flicked his cigarette into the attached plastic cup holder. The inside of the plastic cup holder was coated with ash. During an observation on 3/10/26 at 2 p.m. in the activities room, Resident 1 was observed with two cigarette butts inside the plastic cup holder attached to his wheelchair. During an interview on 3/10/26 at 11:43 a.m., CNA 1 stated there were set smoking times and supervision was provided by the activities department. CNA 1 stated that supervision should be provided to all residents who wanted to smoke and that residents should not be by themselves while smoking. During an interview on 3/10/26 at 11:50 a.m., the DON stated some residents did not require supervision to smoke. The DON further stated, There are independent smokers and they will not follow the smoking schedule. The DON stated it was facility policy that they [residents who smoke] adhered to smoking times. During an interview on 3/10/26 at 11:51 a.m., the AD stated smoking times with supervision were 9 a.m., 11 a.m., 2 p.m., and 4:30 p.m. The AD further stated there are not enough staff to always supervise smoking times. During an interview on 3/10/26 at 1:41 p.m., the AD stated that Resident 1 and Resident 2 were unsupervised when the resident-to-resident altercation between them occurred. The AD stated she was told to supervise the two of them [Resident 1 and Resident 2] when they were outside smoking. The AD further stated, We don't have the manpower to always be outside to supervise the smoking outside of smoking times. The AD stated that staff could not prevent the residents from going outside to smoke outside of the smoking times. The AD stated to her knowledge, Resident 1 had a cup holder attached to his wheelchair. The AD further stated, He should not be putting cigarettes out in the cup holder because it's plastic. It could be flammable, and he could burn himself. During an interview on 3/11/26 at 11:36 a.m., LN 2 stated she was made aware of the resident-to-resident incident that occurred between Resident 1 and Resident 2. LN 2 stated after the incident, staff were expected to supervise them [Resident 1 and Resident 2] when smoking. LN 2 further stated, Especially since they [Resident 1 and Resident 2] had an altercation while smoking outside. During a concurrent interview, and record review on 3/11/26 at 11:58 a.m., with the DON, safety concerns were discussed and the DON stated that staff were not prepared for the interaction that occurred between Resident 1 and Resident 2 in the smoking area. The DON further stated, Everything we do can have safety concerns. The DON stated if a resident could not wheel himself back into the facility, then the resident should not be outside unsupervised. When asked how unsupervised residents accessed assistance when outside, the DON stated residents could yell for help. No other examples were provided by the DON. The DON stated, Residents who require supervision, they have to be supervised by staff. The DON further stated some residents were self-determined and they did what they wanted. The DON confirmed that the facility smoking rules were not enforced. The facility documents that pertained to the residents' smoking contracts, smoking policy, and zero tolerance were concurrently reviewed and conclusively the documents indicated that the residents agreed to smoking during the set smoking times. The DON confirmed that was the expectation. The DON stated after hours, residents were not allowed to go outside to smoke but they did. The DON confirmed that residents who smoked went outside at any hour of the night. The DON verified and addressed that some safety concerns included residents obtaining contraband or prohibited items, risk for fires, and falls. The DON stated she was not aware that Resident 1 utilized his cup holder attached to his wheelchair as an ashtray. The DON confirmed it was not allowed, and stated, Well, it can be a fire hazard. The DON confirmed that supervision was required for Resident 4 while smoking. The DON stated Resident 4 was not ambulatory and required assistance to get back into the building. The DON confirmed that Resident 4 should not have been left outside unsupervised. The DON further confirmed that it was not safe to extinguish cigarettes with the fingers and it was not appropriate to put cigarette butts inside pockets of clothing. The DON stated that practice could harm the residents, and it was a fire hazard. 3. A review of Resident 4's care plan report indicated no evidence that a smoking care plan was initiated. A review of Resident 6's care plan report indicated that a smoking care plan was initiated on 3/10/26 [during the abbreviated survey]. The care plan indicated, Smoking: [Resident 4] is a smoker and is at risk for smoking related injury r/t [related to] .noncompliance with smoking times. There was no evidence that a smoking care plan was initiated prior to the abbreviated survey. During an interview on 3/10/26 at 11:51 a.m., the AD stated per policy, if the residents were independent and did not require supervision, they could smoke unsupervised as long as it was care planned. During an interview on 3/11/26 at 11:36 a.m., LN 2 stated care plans planned the care for the residents. LN 2 stated care plans provided information about resident monitoring and the plan of action. LN 2 provided an example and stated that a resident should be assessed if he/she was safe to use and keep a lighter. LN 2 stated if the resident dropped the lighter and another resident found it and was confused; it could be a safety issue. LN 2 further stated, This is why care plans are important. During a concurrent interview and record review on 3/11/26 at 11:58 a.m., the DON reviewed Resident 4's care plan report and confirmed his smoking status was not care planned. The DON stated, Without the care plan, staff don't know that he [Resident 4] is a smoker and that he needs supervision to go outside. The DON further stated the purpose of the care plans was, So staff are aware of residents needs and plan of care. The DON confirmed that she expected a resident's smoking status to be care planned within seven days of admission. The DON further stated a resident's care plan was a growing document throughout the resident's admission. The DON reviewed Resident 6's care plan report and confirmed her smoking status was not care planned within seven days of admission. A review of the facility's P&P titled, Safety and Supervision of Residents, revised in 2017, indicated, Our facility strives to make the environment as free from accident hazards as possible.Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Safety risks and environmental hazards are identified on an ongoing basis.Resident supervision is a core component of the system approach to safety. A review of the facility's P&P titled, Maintenance Service, revised in 2009, indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable condition.Functions of the maintenance personnel include.maintaining the building in good repair and free from hazards.maintaining the grounds.in good order.Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. A review of the undated facility's document titled, Job Description: Maintenance Director, indicated, The primary purpose of your job position it to.assure that our facility is maintained in a safe and comfortable manner.Inspect storage rooms, workrooms, utility/janitorial closets, etc., for upkeep.Supervise safety and fire protection and prevention programs by inspecting work areas . A review of the undated facility's document titled, Job Description: Housekeeper Prepared, indicated, Define the roles and responsibilities of the Housekeeper.the purpose is to maintain a safe, orderly, and clean environment free of obstacles.Maintain all public and common areas. A review of the undated facility's document titled, [Name of company] Safety Data Sheet Spectrum Advance Hand Sanitizer Gel, indicated, FLAMMABLE LIQUIDS.and vapor.Keep away from heat/sparks/open flames.No smoking. A review of the facility's P&P titled, Smoking Policy-Residents, revised in 2023, indicated, This facility.maintains safe resident smoking practices.Any resident with smoking privileges requiring monitoring shall have the supervision of a staff member, family member, visitor, or volunteer worker while smoking.Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco. expect under supervision.residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents. A review of the undated facility's P&P that was provided to, signed and dated by the smoking residents, titled, Smoking Policy-Residents, indicated, Any smoking related privileges, restrictions, and concerns [for example, need for close monitoring] shall be noted on the care plan.Smoking times will be 9:00 AM, 11:00 AM, 2:00 PM and 5:00 PM.Residents with smoking privileges may not have or keep any smoking articles.outside of designated smoking times.By signing this agreement, I understand the rules and regulations of smoking at [name of facility]. If I violate these rules and regulations, I will not be privileged to smoke on the facility premises. A review of an undated facility document titled, RESIDENT SMOKING CONTRACT, indicated, I agree to the designated smoking times as stated in the Smoking Policy.I understand if I violate this contract, I forfeit my privilege to smoke and my actions could result in discharge from the facility. A review of an undated facility document titled, CURRENT SMOKERS ROSTER, indicated, Location: Smoking area is in back parking lot in designated smoking area .Supervised smoking times: 9 A.M., 11 A.M., 2 P.M., 4:30 P.M. A review of the facility's P&P titled, Care Plans, Comprehensive Person Centered, revised in 2022, indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment, and no more than 21 days after admission.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.reflects currently recognized standards of practice for problem areas.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. A review of the undated facility's document titled, Job Description: Registered Nurse (RN), indicated, Participate in the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care.Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs.

Based on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 2) were protected from abuse and remained free from abuse when:A physical altercation occurred between Resident 1 and Resident 2 during which Resident 2 hit Resident 1 on the face,72-hour monitoring was not completed for Resident 1 and Resident 2 following the change of condition (COC), and;Immediate corrective actions were not implemented.This failure presented a risk of harm to Resident 1 and may have resulted in additional abuse or complications affecting both Resident 1 and Resident 2 after their COC. Cross reference F689. A review of Resident 1's admission record indicated he was admitted to the facility in April 2020 with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebrovascular disease (conditions that affect blood flow to the brain), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 1/23/26, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 12 which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a COC among the residents) form, dated 2/24/26, indicated Resident 1 and Resident 2 had been involved in a resident-to-resident altercation in the smoking section of the facility. The form indicated, . [Resident 2] then hit him [Resident 1] on the right side of his face. The form indicated no injuries were sustained. A review of Resident 1's progress notes, type, IDT (interdisciplinary team, typically includes the nursing leadership, social services, and medical records) NOTE, dated 2/25/26 at 8:43 a.m., indicated, IDT met to discuss [Resident 1's] involvement in incident with male peer [Resident 2].He [Resident 1] stated male peer [Resident 2] then hit him on the right side of the face.Male peer [Resident 2] reported that [Resident 1] first elbowed him. A review of Resident 2's admission record indicated he was admitted to the facility in February 2026 with medical diagnosis which included paranoid schizophrenia (a chronic mental disorder characterized by intense irrational delusions [false beliefs] and auditory hallucinations [hearing voices]), and systemic lupus erythematosus (a chronic autoimmune disease where the immune system attacks healthy tissue). A review of Resident 2's MDS dated [DATE], indicated his BIMS score was five which indicated his cognition was severely impaired. A review of Resident 2's SBAR form, dated 2/24/26, indicated, Aggressive behavior/punch another resident. A review of Resident 2's progress notes, type, Social Service Note, dated 2/24/26 at 3:07 p.m., indicated, [Resident 2] explains that the other male resident [Resident 1] elbowed him, and that is when [Resident 2] admitted ly hit patient [Resident 1] and states it was self-defense. A review of Resident 3's admission record indicated he was admitted to the facility in January 2025. A review of Resident 3's MDS dated [DATE], indicated his BIMS score was 15, which indicated his cognition was intact. During an interview on 3/10/26 at 11:21 a.m., Resident 2 stated, Maybe, but I don't remember, when asked about the altercation between him and Resident 1. During an interview on 3/10/26 at 12:25 p.m., Resident 1 stated he was outside smoking and Resident 2 approached him and asked for a cigarette and lighter. Resident 1 stated he told Resident 2, no and then Resident 2 hit him on the right side of the face. Resident 1 stated the incident upset him and he wants Resident 2 to stay away from him. Resident 1 stated the incident was witnessed by Resident 3. During an interview on 3/10/26 at 1:24 p.m., Resident 3 stated he witnessed the altercation between Resident 1 and Resident 2. Resident 3 stated Resident 2 asked Resident 1 for a cigarette and lighter. Resident 3 stated Resident 1 said no to Resident 2 and Resident 1 swung up his arm towards Resident 2. Resident 3 stated Resident 2 then hit Resident 1 in the head. During an interview on 3/10/26 at 2:18 p.m., the Social Service Director (SSD) stated she completed follow-up interviews with Resident 1, Resident 2, and Resident 3 regarding the abuse allegation. SSD confirmed that the facility concluded a physical altercation occurred between Resident 1 and Resident 2. During an interview on 3/11/26 at 11:58 a.m., the Director of Nursing (DON) confirmed that the facility concluded physical contact occurred between Resident 1 and Resident 2. The DON verified that it is the facility's responsibility to keep residents free from abuse. The DON further stated staff were not prepared for the interaction that occurred between Resident 1 and Resident 2 in the smoking area. During an interview on 3/11/26 at 1:24 p.m., the Administrator (ADM) confirmed he completed the five-day follow-up investigation report of the abuse allegation between Resident 1 and Resident 2. The ADM confirmed that physical contact occurred between Resident 1 and Resident 2. 2. A review of Resident 1 and Resident 2's progress notes, type, eINTERACT SBAR Summary for Providers, dated 2/24/26 indicated the resident-to-resident altercation occurred during the day shift (AM). A review of Resident 1's progress notes, type Nurse's Note, indicated his COC was monitored on: 2/24/26 during evening (PM) and night (NOC) shift, 2/25/26 and 2/26/26 during AM, PM, and NOC shift, and; There was no evidence that 72-hour (hr.) monitoring post COC was completed on 2/27/26 during AM, PM, and NOC shift. A review of Resident 2's progress notes, type, Nurse's Note, indicated his COC was monitored on: 2/24/26 during PM and NOC shift,2/25/26 during AM and PM shift, with no evidence that 72 hr. monitoring was completed during NOC shift, 2/26/26 during AM shift, with no evidence that 72 hr. monitoring was completed during PM and NOC shift, and;There was no evidence that 72 hr. monitoring post COC was completed on 2/27/26 during AM, PM, and NOC shift. During an interview on 3/10/26 at 4:15 p.m., Licensed Nurse 1 (LN 1) stated nurse staff were expected to evaluate a resident's COC for three days and document every shift [AM, PM, and NOC] with a progress note that summarized the resident's COC and any changes noted. LN 1 stated in the first 72 hr. post COC it was important to assess if changes to the resident, such as further decline or change in psychosis (a mental health condition that involves a mix of cognitive, emotional and behavioral changes), required attention and if changes to care required adjustment. During an interview on 3/11/26 at 11:36 a.m., LN 2 stated any COC required 72 hr. monitoring every shift by nurse staff. LN 2 stated that 72 hr. monitoring was expected to be documented under progress notes as a nursing note. LN 2 stated it was important to monitor the resident for changes the first 72 hrs. post COC because that was the time frame most changes commonly occurred. LN 2 stated it was especially important to conduct 72 hr. monitoring to any residents involved in an abuse allegation to ensure their safety. During a concurrent interview and record review on 3/11/26 at 11:58 a.m., the DON stated she expected 72 hr. monitoring to be completed after a COC. The DON further expected 72 hr. monitoring to be documented every AM, PM and NOC shift by nurse staff. The DON reviewed Resident 1's SBAR dated 2/24/26. The DON confirmed Resident 1's 72 hr. monitoring status post COC was not completed on 2/27/26 for AM, PM, and NOC shifts. The DON reviewed Resident 2's SBAR dated 2/24/26. The DON confirmed Resident 2's 72 hr. monitoring status post COC was not completed on 2/25/26 for NOC shift, and on 2/26/26 for PM and NOC shift, and no 72 hr. monitoring was documented on 2/27/26 for AM, PM, and NOC shifts. The DON stated it was important to monitor them [residents] for changes because the chance of changes occurring usually happened within that first 72 hr. period. 3. A review of the facility submitted SOC 341 (the official California Department of Social Services document used by mandated reporters to report suspected elder or dependent adult abuse) form, dated 2/24/26, indicated the altercation between Resident 1 and Resident 2 occurred on 2/24/26 at approximately 12:30 p.m.A review of Resident 2' s care plan initiated on 2/25/26 indicated, [Resident 2] got involved with incident with male peer and hit male peer on right side of face. [Staff were expected to] .continue to monitor smoking area. A review of Resident 2's document titled, NURSING- SMOKING OBSERVATION/ASSESSMENT V2.0, dated 2/24/26 at 4:04 p.m., indicated, Level of Assistance [check marked as] Independent/supervision not required.IDT [interdisciplinary team] Decision [check marked as] May smoke without supervision. During a concurrent observation and interview on 3/10/26 at 10:45 a.m. in the outdoor smoking area, Resident 2 was observed smoking without supervision. The DON stated Resident 2 did not require supervision and confirmed he was currently unsupervised. During an interview on 3/10/26 at 11:21 a.m., Resident 2 stated he could go outside and smoke on his own. During an observation on 3/10/26 at 12 p.m., Resident 2 was sitting in his wheelchair, unattended in the smoking area. During an interview on 3/10/26 at 1:24 p.m., Resident 3 stated there was a period after the altercation when more staff were outside to supervise but that only happened for, about a day only. Resident 3 further stated, The facility doesn't stick to the rules like they should. During an interview on 3/10/26 at 1:41 p.m., the Activities Director (AD) stated she was made aware of the resident-to-resident altercation that occurred between Resident 1 and Resident 2. The AD stated she was told to supervise the two of them [Resident 1 and Resident 2] when they were outside smoking. The AD further stated, We don't have the manpower to always be outside to supervise the smoking outside of smoking times. The AD stated that staff could not prevent the residents from going outside to smoke outside of the smoking times. During an interview on 3/11/26 at 11:36 a.m., LN 2 stated she was made aware of the resident-to-resident altercation that occurred between Resident 1 and Resident 2. LN 2 stated after the incident, staff were expected to supervise them [Resident 1 and Resident 2] when smoking. LN 2 further stated, Especially since they [Resident 1 and Resident 2] had an altercation while smoking outside. During a concurrent interview and record review on 3/11/26 at 11:58 a.m., the DON reviewed Resident 2's document titled, NURSING- SMOKING OBSERVATION/ASSESSMENT V2.0, dated 2/24/26 at 4:04 p.m. and confirmed the smoking assessment was completed after the abuse allegation. The DON further confirmed Resident 2's smoking assessment conflicted with the recent abuse allegation and the immediate action of the facility's 5-day summary investigation report. The DON agreed that Resident 2's smoking assessment required reconsideration, and it was not appropriate for Resident 2 to be unsupervised when smoking. A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, indicated, Residents have a right to be free from abuse.Protect residents from abuse.by anyone including.other residents.Ensure adequate staffing and oversight.Protect resident from any further harm during investigations. A review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2021, indicated, The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the facility's document titled, FACILITY REPORTED INCIDENT - 5-DAY FOLLOW-UP INVESTIGATION REPORT, conducted by the facility in response to the alleged resident-to-resident altercation on 2/24/26, indicated, Upon discovery of the allegation, the facility immediately implemented the following protective interventions: COC monitoring initiated.Increased staff supervision in the smoking area.Care plans updated to include.supervised smoking times.

Based on interview and record review the facility failed to protect one resident (Resident 1) of two sampled residents from physical abuse when Resident 2 bit Resident 1 on the hand.This failure decreased the facility's potential to ensure residents did not experience abuse.Findings:A review of Resident 1's admission record indicated admission to the facility in November 2025 with diagnoses which included diabetes mellitus, difficulty walking, and morbid obesity. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/30/25 indicated a Brief Interview for Mental Status (BIMS) score of 15 which indicated no memory impairment.A review of Resident 2's admission record indicated admission to the facility in December 2025 with diagnoses which included vascular dementia and anxiety disorder. A review of Resident 2's MDS dated [DATE] indicated a BIMS score of 1 which indicated severe memory impairment.A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR) communication form dated 1/13/26 indicated, [Resident 1 has] bite on the hand by another Res. [Resident 2] .[Resident 1] had a Res. [Resident 2] wander into his room, [Resident 2] was confused/angry .[Resident 2] bit [Resident 1] on the hand .A review of Resident 1's care plan initiated on 1/14/26 indicated, .1/13/26 [Resident 1] has impaired skin integrity as evidenced by a human bite to his R [right] hand and is at risk for: Pain or discomfort, infection .In an interview on 2/6/26 at 1:12 p.m., Licensed Nurse 1 (LN 1) stated she was in the hallway on 1/13/26 when she noticed Resident 2 walking in the hallway in disarray. LN 1 called for a Certified Nurse Assistant (CNA) to help Resident 2 back to his room. The CNA was assisting another resident at the time when LN 1 heard Resident 1 call out, He bit me. LN 1 then ran to Resident 1's room and escorted Resident 2 out of the room and found a CNA to help Resident 2 to his room. When LN 1 returned to Resident 1's bedside and conducted an assessment, she observed obvious bite marks with droplets of blood. LN1 then cleaned the wound, wrapped it loosely, and reassured Resident 1 until he felt comfortable.In an interview on 2/6/26 at 3:40 p.m., Resident 1 stated he was in bed with his head down and feet up when Resident 2 charged toward him and said, I'm going to kill you and I hate you then punched him and bit him.A review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated, Resident have the right to be free from abuse .

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) out of three sampled residents was free from a significant medication error when:Resident 1 did not have a person-centered care plan that included the administration of glucagon (emergency treatment to raise blood sugar levels) during a hypoglycemic episode (when a person's blood sugar level drops below 70 milligrams per deciliter (a unit of measurement)) nor one for Resident 1's risk for refractory hypoglycemia;Licensed Nurse 2 (LN 2) documented that insulin was administered at 11:30 a.m. when it was supposed to be given at 6:30 a.m.;The facility's glucometer had not been tracking accurate dates or times;LN 2 did not document Resident 1's blood glucose value of 434 mg/dl and did not notify the physician;LN 2 administered a total of 16 units of insulin to Resident 1 within 1 hour and 18 minutes;LN 2 did not use a Spanish language interpreter to communicate with Resident 1 when LN 2 administered insulin; and,LN 1 did not administer glucagon per the facility's protocol via intramuscular (into a large muscle) injection when Resident 1 became unresponsive with a blood glucose level of 50.This failure resulted in Resident 1 receiving life-threatening and invasive treatment at a local hospital emergency room.Findings:A review of Resident 1's admission record indicated admission to the facility on 4/23/25 with diagnoses of End Stage Renal Disease (ESRD- a condition in which kidneys are severely damaged and can no longer function on their own) with dependence on renal dialysis (a life-sustaining treatment that filters waste and excess fluid from the body when the kidneys fail) and Type 2 Diabetes Mellitus (DM- a chronic condition in which the body has difficulty in controlling blood sugar levels).A review of Resident 1's focused care plan, dated 4/23/25, for DM indicated Resident 1's goal was to be free of signs or symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) and to minimize the risk of DM. To assist Resident 1 to reach his goal, nursing staff were expected to: monitor for signs and symptoms of hypo/hyperglycemia; implement interventions to manage hypo/hyperglycemic events; and perform blood glucose checks as ordered. The care plan also indicated Resident 1 experienced a hypoglycemic event on 8/1/25 at which time Resident 1 was given glucagon, but the administration of glucagon was not included in the care plan as a nursing intervention. A further review of all of Resident 1's care plans dated 4/23/25 to 11/2/25 showed no documented evidence of a focused person-centered care plan that indicated he had refractory hypoglycemia.A review of Resident 1's weights and vitals summary indicated Resident 1's blood glucose level on 8/1/25 was 45 mg/dL.A review of Resident 1's Minimum Data Set (an assessment tool) dated 8/5/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident 1 had moderate impairment to his ability to process knowledge and understanding.A review of MD orders dated 10/8/25 at 4:30 p.m., indicated the physician ordered [Brand name insulin lispro (a rapid acting insulin used to decreased high levels of blood glucose; it starts working within 5 minutes and its maximum effect occurs between 30 to 90 minutes)] Subcutaneous Solution Pen-injector [a pre-filled, disposable insulin pen which delivers insulin] 100 UNIT/ML [milliliter-a unit of measure] Inject as per sliding scale [a method of determining a dosage based on a person's current blood glucose level]: if 70 - 150 = 0. If BG [Blood Glucose] under 70, give 0 units, and initiate hypoglycemic protocol, recheck in 30 min [minutes] and notify MD [physician]; if [BG] 151- 200= [give] 2 [units of insulin]; 201- 250= 4; 251-200= 6; 301-350= 8; 351- 400= 10; 401+= 12.before meals and at bedtime for DM.A review of Resident 1's Medication Administration Record (MAR) dated November 2025 indicated on 11/2/25:-At 6:30 a.m. Resident 1's blood glucose level was 317 and he was given 8 units of insulin lispro.-At 11:30 a.m. Resident 1's blood glucose level was 317 and he was given 8 units of insulin lispro.A review of Resident 1's Location of Administration Report dated November 2025 indicated on 11/2/25 at 11:07 a.m. LN 2 administered insulin to Resident 1 at 11:07 a.m. when it was scheduled to be administered at 6:30 a.m. LN 2 also administered a second dose of insulin to Resident 1 at 12:25 p.m. resulting in Resident 1 receiving two doses of insulin within a time frame of 1 hour and 18 minutes.A review of Resident 1's facility document titled .Healthcare Providers-Return to Acute (Unplanned Discharge) dated 11/2/25 at 7:12 p.m., indicated, .Change of Condition.[Resident 1 is] insulin Dependent DM, Received insulin this AM [morning] with breakfast. Nursing team noted [Resident 1] to have AMS [Altered Mental Status]. BS [blood sugar] = 50. Unable to give oral dextrose [glucose gel- over the counter medication to rapidly treat low blood sugar].Intervention attempted: Called 911 for refractory hypoglycemia [a severe, prolonged low blood sugar state that resists standard treatments like consuming sugar; causes include extremely high insulin doses; unlike typical hypoglycemia that resolves quickly, refractory episodes can last for extended periods].[Resident 1] was sent to the ED [emergency department] for emergent evaluation.A review of Resident 1's progress note dated 11/2/25 at 10:01 p.m., indicated, at [2:40 p.m.].assessed [Resident 1] and found [Resident 1] not very responsive and very sweaty. After a sternal [sic] rub [Resident 1] tried to speak but could not complete a sentence.tried to give [Resident 1] orange juice and glucose gel but [Resident 1] would spit it out.called 911.paramedics arrived and took [Resident 1] at [3:20 p.m.]. At about [9:30 p.m.] received call from.[hospital nurse].wanted to investigate how [Resident 1] got to how he was. [Resident 1] arrived back into facility at [9:35 p.m.] and states that he was unhappy with AM nurse. A review of Resident 1's hospital Emergency Department provider note dated 11/2/25 indicated, .[3:49 p.m. Resident 1] BIBA [brought in by ambulance] as code critical.EMS [Emergency Medical Services] reported secretions, required suctioning.facility reported high BG, [Resident 1] received 8u [units] insulin [Resident 1] presents to ED with a chief complaint of AMS, low blood sugar. Per EMS staff at his facility noted he was altered and had low blood sugar of 36. [Resident 1] is normally GCS [Glascow Coma Scale (a neurological assessment tool used to measure a person's level of consciousness scoring 3-15, where a low score indicates a more severe impairment of consciousness] 15, AOX4 [Awake, oriented to person, place, time, and event] but upon EMS arrival [Resident 1] was GCS 8 and had blood sugar of 30.EMS states they had issues with access and had to place IO [Intraosseous device- a large bore needle which enables rapid access for healthcare providers to administer fluids and medications directly into the marrow cavity of a large bone]. [Resident 1] has had half a bag of D10 [an IV fluid with high sugar content] and had improvement of his mentation.[9:31 p.m. Hospital Nurse] talked to [LN 1]. He [LN 1] arrived at 2 [p.m.]. States [LN 2].gave.insulin earlier today around lunch time states [Resident 1's] BS [blood sugar] = 200 prior to lunch.[LN 1] unsure about how much [insulin] was given. At some point the blood sugar after was 70 and [Resident 1] was awake at the time.[Resident 1] states that he didn't like [LN 2].States he didn't listen to [Resident 1].A review of the Interdisciplinary Team (IDT-a group of healthcare professionals who meet to discuss and provide comprehensive care) note, dated 11/3/25 at 9 a.m., indicated, On 11/2[/25] at [2:40 p.m.] [Resident 1] had a hypoglycemic episode in which his [glucose] was 50, had decreased responsiveness and sweaty. He was unable to take OJ [orange juice] po [by mouth] and did not respond fully to sternal rub. Per MD [physician] [Resident 1] was sent to the ER [Emergency Room]. [Resident 1] returned at [9:35 p.m.] that evening to resume his normal plan of care, no new orders received.During an interview in the facility conference room on 11/6/25 at 12:32 p.m., with the use of an interpreter service Resident 1 stated he has had diabetes for over 20 years and was recently started on insulin. Resident 1 stated he has learned that he does not feel well when he was given too much or too little insulin, and how his blood sugar levels are dependent upon what he eats. Resident 1 stated that on Sunday, 11/2/25, he was not feeling well. Resident 1 stated his stomach felt off and he had been vomiting. Resident 1 stated when LN 2 came into his room with his insulin shot, Resident 1 stated he did not want it. Resident 1 stated he told LN 2 he had been vomiting and was not feeling well; however, LN 2 administered the insulin despite Resident 1's refusal. Resident 1 stated when he looked at the syringe that contained the insulin, it appeared like it was too much. Resident 1 stated Spanish was his primary language and LN 2 did not use an interpreter to communicate with him when he came in to give him his insulin. During an interview on 11/6/25 at 1:27 p.m., LN 3 stated the hypoglycemic protocol was to administer glucagon intramuscularly for blood sugars below 70 with an unresponsive resident. LN 3 further stated if the resident was responsive, then give the resident a snack. During a concurrent interview and record review in the Director of Nursing (DON) office on 11/6/25 at 2:51 p.m., the DON and the Assistant Director of Nursing (ADON) stated Resident 1 informed the ADON he had not wanted all the insulin, but LN 2 administered it to him anyway. The DON reviewed the Location of Administration report and confirmed it appeared as though LN 2 gave insulin twice within 1 hour and 18 minutes.During a follow-up interview on 11/6/25 at 3:15 p.m., with the use of an interpreter service, Resident 1 stated LN 2 only gave him one dose of insulin on 11/2/25.During a phone interview on 11/6/25 at 3:26 p.m., LN 2 stated the night shift nurse (LN 4) obtained Resident 1's blood sugar value before she left on 11/2/25 but did not document the blood sugar value in Resident 1's MAR. LN 4 reported to LN 2 Resident 1's blood sugar level was 317. LN 2 stated he manually entered the blood sugar value (317) in the MAR and gave 8 units of insulin lispro as per sliding scale before breakfast when he noticed the breakfast carts were in the hallway. LN 2 stated he did not normally administer insulin based on another blood sugar value that was obtained by another nurse nor documented but knew Resident 1 had an insulin order. LN 2 further stated the insulin had not been administered late but was documented late. LN 2 stated he obtained another blood glucose value for Resident 1 when the lunch carts arrived around 12 p.m. LN 2 stated the blood sugar value at that time was 349 but accidentally entered a value of 317 in the MAR. LN 2 then stated he administered another 8 units of insulin lispro to Resident 1. LN 2 stated he did not speak Spanish and had asked his co-worker, Certified Nursing Assistant 1 (CNA 1) to translate for him during the shift. LN 2 stated Resident 1 did not refuse his insulin, nor did Resident 1 tell CNA 1 he wasn't feeling well or had vomited. LN 2 stated he obtained another blood sugar value from Resident 1 before leaving for the day and it was 77. LN 2 further acknowledged his documentation in Resident 1's chart on 11/2/25 was very minimal and reiterated he was very busy. During a further interview and equipment review in the facility conference room on 11/6/25 at 3:55 p.m., the DON stated she had not thought to review the history of blood sugars on Resident 1's glucometer. The DON stated the glucometer was shared by other residents in the same hall as Resident 1. The DON acknowledged the glucometer did not have the correct date or time displayed on the screen; therefore, all historical blood sugar values were off by a considerable number of days and hours. The DON also acknowledged that the glucometer did not have any resident names or ID numbers associated with any blood sugar values. Through a process of elimination, the following blood sugar values were located and confirmed by the DON as belonging to Resident 1 on 11/2/25: 317, 434, 77, 50. The DON stated she could not find a blood sugar value of 349 as reported by LN 2 during the interview. The DON confirmed that the value of 434 would have necessitated a call to the physician.During a phone interview on 11/6/25 at 5:24 p.m., CNA 1 stated he translated once for Resident 1 and LN 2 on 11/2/25. CNA 1 did not recall the conversation exactly but stated it did not involve insulin.During a phone interview on 11/7/25 at 10:39 a.m., LN 2 corrected his earlier statement and stated CNA 1 translated for him once on 11/2/25. LN 2 stated that on 11/2/25 at 11:30 a.m., he obtained a blood sugar value of 434 and had incorrectly stated 317 and 349. LN 2 stated, . I might have made a mistake and mixed up some insulins or gave the wrong dose. It was a bad day. LN 2 stated he felt very overwhelmed on 11/2/25, as he normally worked the night shift and did not realize day shift was so busy. LN 2 stated he did not have time to think. He had multiple residents with blood sugar checks and insulin in the morning and again at lunchtime. LN 2 stated he did not document his morning insulin administration until later that morning around 11 a.m. and further stated, I must have forgot, it was so busy. During a phone interview on 11/6/25, at 12:20 p.m., LN 4 stated she normally took Resident 1's blood sugar value in the morning and would only give insulin on days Resident 1 was scheduled to leave for dialysis (medical treatment to remove excess waste and fluid from the blood when the kidneys fail) because Resident 1 was given an early breakfast tray on those days. LN 4 remembered giving LN 2 Resident 1's blood sugar value during shift change report on 11/2/25 but did not document the value in the MAR. LN 4 stated not documenting information was not normal practice, but she was attending to the need of another resident. During a phone interview on 11/7/25 at 3:33 p.m., the Medical Director 1 (MD 1) stated because Resident 1 had ESRD with DM, he was prone to erratic swings in blood sugar levels. MD 1 confirmed glucagon administration would have been appropriate in this situation.A review of Resident 1's order listing report indicated the physician placed the following order for Resident 1 on 11/7/25, Glucagon Emergency Kit 1 mg [milligram, a unit of measurement].Inject 1 mg intramuscularly as needed for (Severe Hypoglycemia/DM) Notify MD. Inject 1 mg as needed if receiving insulin, unresponsive, or unable to take PO snack or glucogel. Recheck FSBG [fingerstick blood glucose] in 30 minutes.A review of Resident 1's blood sugar values, dated 7/4/25-11/18/25, indicated Resident 1's blood sugar values remained stable with three values below 70 over a period of four months.During an interview in the DON's office on 11/18/25 at 12:05 p.m., the DON stated she and MD 1 reviewed all residents on sliding scale insulin and placed orders for glucagon to be given in cases of severe hypoglycemia.During a phone interview on 11/18/25 at 4:01 p.m., LN 1 stated he entered Resident 1's room for the first time that shift on 11/2/25 after a co-worker told him Resident 1 didn't look right. LN 1 stated Resident 1 was not making any sense. LN 1 stated he took a blood glucose value from Resident 1, and the value was 50. LN 1 stated, I tried giving him orange juice, but he wouldn't swallow it. It just ran out of his mouth. LN 1 stated he then tried the glucose gel, thinking it was thicker, and Resident 1 would be able to get it down better, but that fell out of his mouth too. LN 1 stated he quickly tried to look for the glucagon in the medication room and could not find it. LN 1 stated he did not think to open the Emergency Kit (E kit- a pre-assembled supply of essential and emergency medications kept in skilled nursing facilities) to obtain the glucagon. LN 1 further reported that during shift change report, LN 2 reported Resident 1 had received insulin, and a recheck of Resident 1's blood sugar value was 77. LN 1 stated he did not question why LN 2 rechecked Resident 1's blood sugar when it was not time for it to be checked. A review of the facility's policy titled Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame.The individual administering the medication checks.to verify.the right resident, right medication, right dosage, right time.before giving the medication.A review of the facility's policy titled Charting and Documentation revised July 2017 indicated, The following information is to be documented in the resident medical record.Objective observations; Medications administered; Treatments or services performed; Changes in the resident's condition; Events, incidents, or accidents involving the resident.Documentation in the medical record will be objective.complete, and accurate.Documentation of procedures and treatments will include care-specific details, including.whether the resident tolerated the procedure/treatment; whether the resident refused the procedure/treatment; notification or family, physician or other staff.A review of facility policy titled Management of Hypoglycemia, revised 3/25, indicated If a resident has .hypoglycemia and is unresponsive .administer 1 mg [milligram-a unit of measure] of glucagon subcutaneously [a method of administering medications underneath the skin]. A review of the American Diabetes Association's guideline titled Hypoglycemia for healthcare professionals, dated 2025, indicated, Hypoglycemia is categorized into three levels based on glucose levels and symptom severity.Level 2 Blood glucose less than 54 mg/dL.Level 3 [most severe] Altered mental and/or physical status requiring assistance, irrespective of glucose level.Assess hypoglycemia risks.such as recent episodes, insulin.kidney disease.Reevaluate treatment plan if experiencing level 2 or 3 hypoglycemia.Prescribe glucagon for all on insulin. Glucagon preparations not requiring reconstitution [to be mixed prior to being used] are preferred. Glucagon is indicated for hypoglycemia treatment when people are unable to.consume carbohydrates [sugar] by mouth.Non-health care professionals can safely administer glucagon.

Based on interview and record review, licensed nurses (LNs) did not provide accurate and safe pharmaceutical services to one resident (Resident 1) of three samples residents when:LNs did not ensure Resident 1 had a physician's order for glucagon (emergency treatment injected into a large muscle using a needle to immediately raise blood sugar levels) after Resident 1 had four episodes of hypoglycemia (when a person's blood sugar level drops below 70 milligrams per deciliter [mg/dl, a unit of measurement]) between 7/4/25 and 11/1/25;LN 2 administered insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) to Resident 1 at 11:30 a.m. when it was supposed to be administered at 6:30 a.m.;LN 2 did not ensure accurate documentation in Resident 1's medical chart when: LN 1 documented insulin was administered at 11:07 a.m. and it was scheduled at 6:30 a.m., LN 2 did not document Resident 1's blood glucose level of 434 mg/dl (a normal range is 80 mg/dl to 130 mg/dl), and there was no documented evidence that the physician was notified when Resident 1's blood glucose level was outside of his set parameters;LN 1 did not administer glucagon when Resident 1 had an episode of hypoglycemia on 11/2/25; and,LNs did not ensure the facility's only glucometer was properly working when it had not been tracking accurate dates or times.These failures decreased the facility's potential to provide standard nursing care for residents with a diagnosis of Diabetes Mellitus Type 2.Findings:A review of Resident 1's admission record indicated admission to the facility on 4/23/25 with diagnoses of Type 2 Diabetes Mellitus (DM- a chronic condition in which the body has difficulty in controlling blood sugar levels).A review of Resident 1's focused care plan, dated 4/23/25, for DM indicated Resident 1's goal was to be free of signs or symptoms of hypoglycemia or hyperglycemia (high blood sugar) and to minimize the risk of DM. The care plan also indicated Resident 1 experienced a hypoglycemic event on 8/1/25 at which time Resident 1 was given glucagon. To assist Resident 1 to reach his goal, nursing staff were expected to:-monitor for early signs and symptoms of hypo/hyperglycemia [hyperglycemia is when a person's blood sugar level higher than 250 mg/dl];-to conduct blood glucose checks as ordered and report to the physician if the blood glucose level was outside of the set parameters; and,-implement interventions to manage hypo/hyperglycemic events.A review of MD orders dated 10/8/25 at 4:30 p.m., indicated the physician ordered [Brand name insulin lispro (a rapid acting insulin used to decreased high levels of blood glucose; it starts working within 5 minutes and its maximum effect occurs between 30 to 90 minutes)] Subcutaneous Solution Pen-injector [a pre-filled, disposable insulin pen which delivers insulin] 100 UNIT/ML [milliliter-a unit of measure] Inject as per sliding scale [a method of determining a dosage based on a person's current blood glucose level]. If BG [Blood Glucose] under 70, give 0 units, and initiate hypoglycemic protocol, recheck in 30 min [minutes] and notify MD [physician].[if] BG above 401 give 12 units, recheck in 30min [minutes] and notify MD [physician].A review of Resident 1's Location of Administration Report (LAR) dated November 2025 indicated on 11/2/25 at 11:07 a.m. LN 2 administered insulin to Resident 1's right lower abdomen at 11:07 a.m. when it was scheduled to be administered at 6:30 a.m.A review of Resident 1's facility document titled .Healthcare Providers-Return to Acute (Unplanned Discharge) dated 11/2/25 at 7:12 p.m., indicated, .Change of Condition.[Resident 1 is] insulin Dependent DM, Received insulin this AM [morning] with breakfast. Nursing team noted [Resident 1] to have AMS [Altered Mental Status]. BS [blood sugar] = 50. Unable to give oral dextrose [glucose gel- medication to rapidly treat low blood sugar].A review of Resident 1's progress note dated 11/2/25 at 10:01 p.m., indicated, at [2:40 p.m.].assessed [Resident 1] and found [Resident 1] not very responsive and very sweaty. After a sternal [sic] rub [Resident 1] tried to speak but could not complete a sentence.tried to give [Resident 1] orange juice and glucose gel but [Resident 1] would spit it out.called 911.paramedics arrived and took [Resident 1] at [3:20 p.m.].A review of the Interdisciplinary Team (IDT-a group of healthcare professionals who meet to discuss and provide comprehensive care) note, dated 11/3/25 at 9 a.m., indicated, On 11/2[/25] at [2:40 p.m.] [Resident 1] had a hypoglycemic episode in which his [glucose] was 50, had decreased responsiveness and sweaty. He was unable to take OJ [orange juice] po [by mouth] and did not respond fully to sternal rub [an emergency medical technique used to assess a patient's level of consciousness by applying painful stimulus]. Per MD [physician] [Resident 1] was sent to the ER [Emergency Room]. [Resident 1] returned at [9:35 p.m.] that evening to resume his normal plan of care, no new orders received.During an interview on 11/6/25 at 1:27 p.m., LN 3 stated the hypoglycemic protocol included the administration of glucagon intramuscularly for blood sugars below 70 mg/dl with an unresponsive resident.On 11/6/25 at approximately 2 p.m., a review of Resident 1's progress notes dated 11/2/25 showed no documented evidence of a glucose reading of 434 mg/dl nor a progress note or change of condition note to indicate LN 2 notified the physician of the reading which was outside of Resident 1's set parameters.In a concurrent interview and record review on 11/6/25 at 2:51 p.m., Director of Nursing (DON) stated Resident 1's LAR appeared as though LN 2 administered insulin twice because LN 4 (the nurse assigned to Resident 1 during the overnight shift on 11/1/25) did not administer insulin to Resident 1 at 6:30 a.m. Therefore, when LN 2 administered insulin to Resident 1 at 11:30 a.m. it was documented in the 6:30 a.m. slot in error.In an interview on 11/6/25 at 3:26 p.m., LN 2 acknowledged his documentation in Resident 1's chart on 11/2/25 was very minimal.In a concurrent interview and record review on 11/6/25 at 3:55 p.m., the DON stated the glucometer was shared by other residents in the same hall as Resident 1. The DON acknowledged the glucometer did not have the correct date or time displayed on the screen; therefore, all historical blood sugar values were off by a considerable number of days and hours. The DON also acknowledged that the glucometer did not have any resident names or ID numbers associated with any blood sugar values. The DON reviewed the glucose readings and found a glucose reading of 434 mg/dl which was obtained on 11/2/25. Through a process of elimination, the DON determined that the reading of 434 mg/dl belonged to Resident 1. The DON also reviewed Resident 1's documented blood glucose readings and progress notes dated 11/2/25. The DON acknowledged that LN 2 did not document nor notify the physician of Resident 1's glucose reading of 434 mg/dl per the facility's protocol. The DON confirmed that the value of 434 mg/dl would have necessitated a call to the physician.During a phone interview on 11/7/25 at 10:39 a.m., LN 2 stated that on 11/2/25 at 11:30 a.m., he obtained a blood sugar value of 434 mg/dl. LN 2 also stated he administered Resident 1's morning medications at 8 a.m. on 11/2/25 but did not document the medications were given upon administration.During a phone interview on 11/7/25 at 3:33 p.m., the Medical Director 1 (MD 1) confirmed glucagon administration would have been appropriate in Resident 1's situation when he was unresponsive and unable to take anything orally.A review of Resident 1's order listing report indicated the physician placed the following order for Resident 1 on 11/7/25, Glucagon Emergency Kit 1 mg [milligram, a unit of measurement] .Inject 1 mg intramuscularly as needed for (Severe Hypoglycemia/DM) Notify MD [physician]. Inject 1 mg as needed if receiving insulin, unresponsive, or unable to take PO [by mouth] snack or glucogel [oral glucose]. Recheck FSBG [fingerstick blood glucose] in 30 minutes.A review of Resident 1's weights and vitals summary printed on 11/18/25 indicated Resident 1 had four episodes of hypoglycemia between 7/4/25 and 11/1/25 (62 mg/dl on 7/4/25; 60 mg/dl on 7/9/25; 45 mg/dl on 8/1/25; and 65mg/dl on 9/3/25).During an interview in the DON's office on 11/18/25 at 12:05 p.m., the DON stated she and MD 1 reviewed all residents on sliding scale insulin and placed orders for glucagon to be given in cases of severe hypoglycemia.During a phone interview on 11/18/25 at 4:01 p.m., LN 1 stated he entered Resident 1's room for the first time that shift on 11/2/25 after a co-worker told him Resident 1 didn't look right. LN 1 stated Resident 1 was not making any sense. LN 1 stated he took a blood glucose value from Resident 1, and the value was 50. LN 1 stated, I tried giving him orange juice, but he wouldn't swallow it. It just ran out of his mouth. LN 1 stated he then tried the glucose gel, thinking it was thicker, and Resident 1 would be able to get it down better, but that fell out of his mouth too. LN 1 stated he quickly tried to look for the glucagon in the medication room and could not find it. LN 1 stated he did not think to open the Emergency Kit (E kit- a pre-assembled supply of essential and emergency medications kept in skilled nursing facilities) to obtain the glucagon.A review of the facility's policy and procedure (P&P) titled Charting and Documentation revised July 2017 indicated, All services provided to the resident, progress toward the care plan goals .shall be documented in the resident's medical record.The medical record shall facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record.Objective observations.Treatments or services performed; Changes in the resident's condition; Events, incidents.involving the resident.Documentation in the medical record will be.complete, and accurate.Documentation of procedures and treatments will include care-specific details, including.any unusual findings obtained during the procedure/treatment.A review of the facility's P&P titled Administering Medications revised April 2019 indicated, Medications are administered in accordance with prescriber orders, including any required time frame.The individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones.A review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 indicated, The nurse will notify the resident's.physician.when there has been a.significant change in the resident's physical condition.need to alter the resident's medical treatment significantly.specific instruction to notify the physician of changes in the resident's condition. A 'significant change' of condition is a major decline.in the resident's status that will not normally resolve itself without intervention by staff.impacts more than one area of the resident's health status.The nurse will record in the resident's medical record information relative to changes in the resident's medical.condition or status.A review of an untitled ADA guideline titled Blood Glucose Meters Can Play an Important Role in Diabetes Care indicated, BGMs [Blood Glucose Meters] provide accurate blood glucose.readings. In fact, the Food and Drug Administration (FDA) required all BGMs to be accurate within about 15-20% above or below the actual reading.BGMs can be the only device you use to track your blood glucose.Blood glucose monitoring is a very important part of diabetes management.A review of the facility's P&P titled Management of Hypoglycemia, revised March 2025, indicated, If a resident has .hypoglycemia and is unresponsive .administer 1 mg of glucagon subcutaneously [a method of administering medications underneath the skin].A review of the American Diabetes Association's (ADA) guideline titled Hypoglycemia for healthcare professionals, dated 2025, indicated, Hypoglycemia is categorized into three levels based on glucose levels and symptom severity.Level 2 Blood glucose less than 54 mg/dL.Level 3 [most severe] Altered mental and/or physical status requiring assistance, irrespective of glucose level.Assess hypoglycemia risks.such as recent episodes, insulin.kidney disease.Reevaluate treatment plan if experiencing level 2 or 3 hypoglycemia.Prescribe glucagon for all on insulin. Glucagon preparations not requiring reconstitution [to be mixed prior to being used] are preferred. Glucagon is indicated for hypoglycemia treatment when people are unable to.consume carbohydrates [sugar] by mouth.Non-health care professionals can safely administer glucagon.

Based on interview and record review, the Licensed Nurse 2 (LN 2) failed to ensure one resident's (Resident 1) right to communication of three sampled residents, when LN 2 did not use a language interpreter to communicate with Resident 1.This failure decreased the facility's potential to support self-determination and the right to a dignified existence among residents.Findings:A review of Resident 1's admission record indicated admission to the facility on 4/23/25 with diagnoses of Type 2 Diabetes Mellitus (DM- a chronic condition in which the body has difficulty in controlling blood sugar levels). This admission record also indicated Resident 1's primary language was Spanish and that he was his own Responsible Party (a person who is able to make healthcare and financial decisions).A review of Resident 1's Minimum Data Set (an assessment tool) dated 8/5/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident 1 had moderate impairment to his ability to process knowledge and understanding.In an interview in the facility conference room on 11/6/25 at 12:32 p.m., with the use of an interpreter service Resident 1 stated he has had diabetes for over 20 years and was recently started on insulin. Resident 1 stated he has learned that he does not feel well when he was given too much or too little insulin, and how his blood sugar levels are dependent upon what he eats. Resident 1 stated that on Sunday, 11/2/25, he was not feeling well. Resident 1 stated his stomach felt off and he had been vomiting. Resident 1 stated when LN 2 came into his room with his insulin shot, Resident 1 stated he did not want it. Resident 1 stated he told LN 2 he had been vomiting and was not feeling well; however, LN 2 administered the insulin despite Resident 1's refusal. Resident 1 stated when he looked at the syringe that contained the insulin, it appeared like it was too much. Resident 1 stated Spanish was his primary language and LN 2 did not use an interpreter to communicate with him when he came in to give him his insulin.In an interview on 11/6/25 at 3:26 p.m., LN 2 stated he did not speak Spanish and had Certified Nursing Assistant 1 (CNA 1) translate for him that day. LN 2 stated Resident 1 did not refuse his insulin when he went to administer it to him.In a phone interview on 11/6/25 at 5:24 p.m., CNA 1 stated he translated once for Resident 1 and LN 2 on 11/2/25. CNA 1 stated the conversation he translated for that day did not involve insulin.In an interview on 11/6/25 at 4:35 p.m., the Administrator stated staff had options to use for translation which included other staff, their phone, or a website.A review of this facility's policy and procedure (P&P) titled Translation and/or Interpretation of Facility Services revised November 2020 indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English.A review of this facility's P&P titled Resident Rights revised December 2016 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.self-determination.communication with and access to people and services, both inside and outside the facility.participate in, his.treatment.

Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 98 residents who received food prepared from the kitchen, when:1. Four containers of spices past their use-by date labels were found available for use on the kitchen shelf;2. Staff cleaning dishes touched cleaned dishes with dirty gloves;3. Dish machine sanitizing solution was not at the required concentration levels.These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.Findings:1. During a concurrent observation and interview on 9/9/25 at 11:17 a.m. with the [NAME] (CK 1) in the kitchen, four containers of spices were observed on the kitchen shelf past use by dates (Ground Nutmeg with use-by date of 7/27/25, Rubbed Sage with use-by date of 7/5/25, Ground [NAME] with use-by date of 7/5/25, and Poultry Seasoning with use by-date of 8/24/25). CK 1 confirmed that the spices had expired. During an interview on 9/11/25 at 2:54 p.m. with Registered Dietitian (RD 1), RD 1 confirmed that spices should not be stored in the kitchen past their use-by date and should be discarded. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised November 2022, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. 2. During a concurrent observation and interview on 9/11/25 at 9:39 a.m. with Dietary Supervisor (DS) near the kitchen's dishwashing area. Dietary Aide (DA 1) was observed using the dish machine to wash the dishes. DA 1 assembled, touched, and prepared dirty dishes on one side of the machine. When the dish machine cycle was over, DA 1 used the same gloves to push clean dishes over to the clean side of the machine. DS confirmed the observation and stated that DA 1 needed to perform hand hygiene before moving to the clean side or touching clean dishes. 3. During a concurrent observation and interview on 9/11/25 at 10:19 a.m. with DS in the kitchen. The Dish Machine was observed in active use and connected to a chlorine container stored at the bottom. DS performed a sanitizing chemical test by using chlorine test strips. DS dipped the test strip in the solution at the bottom of the dish machine and compared it to the indicator on the test strip container. The test strip did not change color [indicating that the sanitizing chemical was not present at detectable levels]. A sign posted on the wall indicated that the solution must be at 100 ppm [parts per million, unit of concentration]. DS stated that the solution was not at the correct concentration.During an interview on 9/11/25 at 2:54 p.m. with the RD 1, RD 1 confirmed that staff should perform hand hygiene when moving from dirty to clean dishes. RD 1 further stated that staff should test the dish machine sanitizing solution, and she expected it to be at appropriate concentrations to sanitize the dishes. A review of the facility's policy and procedure (P&P) titled, Dishwashing Machine Use, dated 07/2018, the P&P indicated, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine. Wash hands before handling clean dishes. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows. Chlorine 50-100ppm 10 seconds.

Based on observation, interviews and record reviews, the facility failed to ensure they had an effective pest control program for all residents of the facility when there were flies inside the facility.This failure put the residents at risk for the possible spread of infections.Based on observation, interviews and record reviews, the facility failed to ensure they had an effective pest control program for all residents of the facility when there were flies inside the facility.This failure put the residents at risk for the possible spread of infections.Findings:During an interview on 09/09/2025 at 12:07 PM, Resident 82 had a fly hovering around her food but landed on her blanket. Resident 82 stated there had been a lot of flies in the facility which upset her because she thought flies were unsanitary, especially when they land on food. Resident 82 stated whatever the facility was doing to eliminate the flies were not effective. During an observation on 9/9/25 at 2:36 P.M., 2 flies were flying around Resident 73 and both ultimately landed on his blanket.During an interview on 09/09/2025 PM at 2:49 P.M., there were 3 flies noted hovering over Resident 73, 2 had landed on his blanket and 1 landed on his LAL control unit. Resident 73 stated there were lots of flies in the facility and they irritate him especially when they land on his food. During an interview on 09/09/2025 at 2:51 PM, Resident 45 noted there was a fly buzzing around him. Resident 45 stated he noticed there were more flies these past few days. Resident 45 stated it was gross when the flies touch their food and stated it was very unsanitary. Resident 45 stated he thinks the facility could be better in flies in the facility. During an interview on 09/11/2025 at 9:38 AM, the Infection Preventionist (IP) stated she had heard reports of flies in the facility. The IP stated it was not acceptable to have flies in the facility as they can contaminate food when they land on it. The IP stated flies were not supposed to be in the facility as it was an infection control issue and could get the resident's sick.During an interview on 09/11/2025 at 11:48 AM, Licensed Nurse (LN) C stated had witnessed flies in the facility. LN C stated it was the facility's responsibility to ensure there were no flies in the facility as they put the residents at risk of getting sick.During an interview on 09/12/2025 at 8:20 AM, the Maintenance Director (Maint Dir) stated he had received reports that flies were seen in the facility. The Maint Dir stated flies should not be in the facility because it could make the residents sick. The MD stated one of the recommendations from the facility's pest exterminator was to have a blowing fan on the doors that would push out flies when they try to enter the facility. The Maint Dir acknowledged the facility has not implemented the pest exterminator's recommendation. During an interview on 09/12/2025 at 10:11 AM, the Minimum Data Set coordinator (MDSC) stated it was the facility's responsibility to ensure there were no flies inside the facility. The MDSC stated having flies inside the facilities could be an indication the facility's pest control management was ineffective. During an interview on 09/12/2025 at 1:18 PM, LN C stated having flies inside the facility indicate the facility's pest control system was ineffective.A review of the facility's policy and procedure (P&P) titled Pest Control, revised 5/2008, the P&P indicated, .our facility should maintain an effective pest control program.

Based on interviews and record reviews, the facility failed to ensure sufficient staff members possessed the basic competencies and skills sets to meet the behavioral health needs of residents with mental disorders and those with a history of trauma and/or post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) as reflected in the facility assessment, when: 1. 12 Certified Nursing Assistants (CNAs - also known as nurse aides) did not receive training related to the care of residents with dementia (a progressive state of decline in mental abilities), 2. CNA D was allowed to start work without a competency check (a process that evaluates an individual's knowledge, skills, and abilities to perform a specific role or task effectively) completed, and3. 32 CNAs did not receive training related to the care of residents with a history of trauma and/or PTSD. These failures could result in an inability to provide quality care to residents with mental disorders and a history of trauma.Findings: During an interview on 9/11/2025 at 4:08 PM, the Director of Staff Development (DSD) stated she had been in her role since November of 2024 but did not know how many staff had completed mandatory Dementia trainings. The DSD stated she could not provide documentation that the Dementia training had been provided to and completed by staff. During continued interview on 9/11/2025 at 4:23 PM, the DSD stated staff are required to complete continuing education to ensure they are competent to do their job. During a concurrent interview and record review on 9/12/2025 at 10:08 AM, with the DSD, 12 CNA personnel folders ( for CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O) did include a signed acknowledgement of dementia training being provided or completed. During a concurrent interview and record review on 9/12/2025 at 10:22 AM, CNA D's competency check list, dated 9/2/25, was reviewed. The DSD confirmed the competency check list was not marked/filled out to identify the specific competencies CNA D had satisfactorily passed or completed. The DSD confirmed that CNA D was working with residents of the facility. During a review of a facility record titled, Facility Inservice, on Dementia and PTSD: Managing difficult and challenging behaviors for CNAs, dated 6/19/25, indicated 29 of 61 CNAs signed and attended the training. No other in-service training on PTSD was provided for other staff. During a review of the facility assessment, updated and reviewed on January 2025, the assessment indicated the facility resident profile included residents with memory problems, PTSD, and dementia. The facility assessment also indicated the facility offered services and care for those with memory problems, and care of individuals with trauma/PTSD. Staff training and competencies included required in-services training for nursing aides on dementia management and competency training on caring for residents with mental and psychosocial disorders, as well as resident with a history of trauma and/or post-traumatic stress disorder. During a review of the resident matrix (a tool for nursing homes to document residents and their care needs), for dates 9/9-9/12/25, indicated the facility had a total of 96 residents, with 37 residents diagnosed with Alzheimer's (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline)/dementia and 7 residents with a history of PTSD/Trauma.

Based on interview and record review, the facility failed to complete performance reviews (formal meetings where a supervisor evaluates an employee's job performance, providing feedback and setting goals for the future) for more than 12 months for three out of three randomly selected Certified Nursing Assistants (CNAs also known as nurse aides).This failure can prevent identification of skill gaps leading to decline in quality of care. Findings:During a concurrent interview and records review of competency evaluations of five randomly selected staff on 9/12/2025 at 11:18 AM, the DSD confirmed the most recent performance evaluations were more than a year ago as follows:1. CNA Q's last competency was on 4/2/23,2. CNA R's last competency was 4/1/23 3. CNA S' last competency was 4/1/23The DSD stated staff competency reviews should be conducted annually so that staff remain competent and able to provide proper care for the residents. During a review of the State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities revision 232, Issued on 7/23/25, Code of Federal Regulations (CFR) Tag F730 S483.35(e)(7) for Regular in-service education, the CFR indicated, .The facility must complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews.

Based on observation, interviews and record reviews, the facility failed to ensure adequate pain relief for one out of 20 sampled residents (Resident 45), when using a numeric pain rating scale where 0 as no pain, 1 to 3 as mild pain, 4 to 6 as moderate pain, and 7 to 10 as severe pain, Resident 45 complained of moderate to severe pain daily.This failure resulted in Resident 45 feeling frustrated and complaining of lack of quality of life.Findings:A review of Resident 45's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date in June 2025 with a diagnosis of fracture of unspecified part of neck of left femur (a break in the part of the left thigh bone just below the hip joint) and pain due to internal orthopedic prosthetic devices (an artificial replacement part for the body), implants (devices or tissues that are placed inside or in the body) and grafts (skin or bone cut from one part of a person's body or other source and used to repair a damaged part).A review of Resident 45's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 7/31/25, indicated Resident 45 had intact cognition (a person has healthy mental functions, including sufficient judgment, memory, planning, and problem-solving abilities to manage daily life). A review of Resident 45's Nursing Pain Observation Assessment, dated 6/3/25, indicated Resident 45 experienced frequent aching, stabbing pain on his hips and pain that affects his sleep, rest, social activities, physical activities and mobility.A review of Resident 45's Physician Order Summary (a healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive), for active order as of 9/11/25, indicated Resident 45 was receiving: Acetaminophen (a medication that can be used to treat pain) 325 milligram (mg, a unit of measurement) 2 tablets by mouth (po) every 6 hours as needed (prn) for mild pain, and hydromorphone hydrochloride HCL(a medication used to treat pain) 2 mg 1 tablet po every 4 hours prn for moderate to severe pain (5-10).A review of Resident 45's Electronic Medication Administration Record (EMAR, a digital system used to track and document the administration of medications, ensuring accuracy and timeliness in medication delivery) for 8/2025 indicated: Resident 45 received hydromorphone HCL daily, as often as 5 times a day, Resident 45 reported experiencing severe pain on 8/1/25, 8/4/25, 8/5/25, 8/9/25, 8/10/25, 8/11/25, 8/12/25, 8/13/25, 8/14/25, 8/16/25, 8/17/25, 8/22/25, 8/23/25, 8/24/25, 8/28/25, 8/29/25 and 8/31/25. Resident 45 reported on 8/22/25 a pain level of 8 out of 10 and the hydromorphone HCL was ineffective, however, there was no indication an alternative medication was provided to Resident 45 for pain relief. Resident 45 reported on 8/7/25, 8/23/25, and 8/31/25 severe pain but was administered acetaminophen (ordered for mild pain)A review of Resident 45's EMAR, for 9/2025, indicated: Resident 45 continued to receive hydromorphone HCL daily, as often 5 times a day, and Resident 45 continued to report experiencing severe pain on 9/3/25, 9/4/25, 9/5/25, 9/7/25 9/9/25 and 9/10/25.A review of Resident 45's care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed) titled discomfort due to: status post [s/p, after] left hip arthroplasty [surgical reconstruction or replacement of a joint] with surgical wound to left thigh. dated 6/4/2025 it further indicated to notify physician if resident experiences unmanageable or intolerable pain.During a concurrent observation and interview on 09/09/2025 at 2:51 PM, Resident 45 was lying awake in bed, brows furrowed. Resident 45 stated he had pain at his hip. Resident 45 stated his current pain level was 7 but creeping up to an 8. Resident 45 stated the nurse already knew he was in pain, but he needed to wait for about 1 1/2 hours before staff could give his hydromorphone HCL because it was not time yet. Resident 45 stated this was how it was all the time. Resident 45 stated he was in pain daily and some nurses administered acetaminophen when he was experiencing moderate to severe pain. Resident 45 acknowledged he took the acetaminophen knowing it wouldn't work but he was desperate for some sort of pain relief. Resident 45 stated being in pain and waiting for pain medication was cruel but he could not do anything. Resident 45 stated he had requested the nurse to contact the doctor to let him know the pain regimen was ineffective, but nothing ever changed. Resident 45 acknowledged his realistic goal was to have mild pain but added, having unrelieved moderate to severe pain was very frustrating, negatively affected his mood and his desire to go out and socialize, and negatively affected his quality of life. During a concurrent interview and record review on 09/12/2025 at 08:45 AM, Resident 45's 8/2025 and 9/2025 EMARs were reviewed with the Minimum Data Set coordinator (MDSC). The MDSC confirmed the facility defined mild pain as pain level of 1 to 3, moderate for pain level of 4 to 6 and severe pain for pain level of 7 to10. The MDSC verified that based on 8/2025 EMAR, acetaminophen was only ordered prn for mild pain. The MDSC verified based on 8/2025 EMAR, Resident 45 received acetaminophen PRN despite complaint of severe pain on these dates: 8/7/25, 8/23/25 and 8/31/25. The MDSC stated it was not acceptable to administer acetaminophen for moderate to severe pain because it would be ineffective. The MDSC verified that based on 8/2025 and 9/2025 EMAR, Resident 45 was receiving the prn hydromorphone HCL daily 4 times sometimes as much as 5 times a day and had been complaining of moderate to severe pain almost daily. The MDSC stated based on the 8/2025 and 9/2025 EMAR and Resident 45 daily complaints of moderate to severe pain, the current pain regimen was ineffective since Resident 45's pain was not adequately controlled.During a telephone interview on 09/12/2025 at 11:07 AM, the pharmacist (RPh) stated it was not appropriate to administer acetaminophen for moderate to severe pain, as the physician's order was to give it only for mild pain. The Rph stated per her records, she could see Resident 45 had been receiving the prn order for the hydromorphone HCL everyday as much as 4 to 5 times daily. The Rph stated she would recommend Resident 45's physician reevaluate Resident 45's pain management regimen to make changes to better manage Resident 45's pain. The Rph stated ineffective pain management could result in more severe pain and affect Resident 45's quality of life. During a concurrent interview and record review on 09/12/2025 at 1:18 PM, Resident 45's 8/2025 and 9/2025 EMAR were reviewed with Licensed Nurse (LN) C. LN C stated she was familiar with Residents 45's care and his complaints of pain. LN C stated she even administered hydromorphone HCL to Resident 45 as a preventative measure because she knew Resident 45 would have pain later and the pain would be harder to control then but Resident 45 remains in pain. LN C verified Resident 45 complained of moderate pain to severe pain daily and that Resident 45 received hydromorphone HCL daily, as often five times daily. LN C stated the frequency of Resident 45 receiving the hydromorphone suggested his current pain regimen was ineffective and that Resident 45 pain was not adequately controlled. LN C stated she had never had the physician reviewed Resident 45's EMAR to see if changes in pain regimen need to be made. During a concurrent interview and record review on 09/12/2025 at 1:37 PM, the 8/2025 and 9/2025 Resident 45s EMAR were reviewed with Resident 45's physician. Resident 45's physician stated the EMARs might indicate Resident 45's pain was not adequately controlled by the current pain regimen. Resident 45's physician stated the nurses had never sent him a copy of Resident 45's EMARs, had not discussed with him the frequency of Resident 45's hydromorphone HCL use, nor Resident 45's goal in pain relief.A review of the facility's policy and procedure (P&P) titled Pain Assessment and Management, revised 10/2022, the P&P indicated, .the pain management is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan and resident choices related to pain management.pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals.pain management is a multidisciplinary care process that includes the following: modifying approaches as necessary.review the medication administration record to determine how often the individual request and receives prn pain medication and to what extent the administered medication relieve the resident's pain.

Based on interviews and record reviews, the facility failed to ensure a written summary of the baseline care plan (BCP, a document created within 48 hours of a resident's admission, outlining the initial care needed, focusing on basic needs and resident-specific information) was provided to the resident and/or the responsible party (RP, a person who is designated in making decisions about health care and financial matters) for two out of five sampled residents (Residents 31 and Resident 82) when no documented evidence that the BCP summary was provided.This failure could compromise residents' safety, hinder effective communication, and could lead to adverse events, especially during the critical initial days of admission.Findings: A review of Resident 31's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 7/2025 with a diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and muscle weakness.A review of Resident 31s Baseline Care Plan Person-Centered Care Planning form-V3, dated 7/24/25, did not indicate the printed BCP summary was provided to the resident or the RP.A review of Resident 82's face sheet indicated an admission date of 3/2024 with a diagnosis of Multiple Sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and muscle weakness.A review of Resident 31s Baseline Care Plan Person-Centered Care Planning form-V3, dated 3/5/24, did not indicate the printed BCP summary was provided to the resident or the RP.During a concurrent interview and record review on 09/11/2025 at 11:08 AM, Residents 31's and Resident 82's BCP Person-Centered Care Planning form-V3 was reviewed with the Social Services Director (SSD). The SSD stated she was part of the team that creates a BCP along with nursing and rehabilitation services. The SSD verified that based on Residents 31's and Resident 82's BCP Person-Centered Care Planning form-V3 documentation, there was no indication the BCP summary was provided to the resident and or the RP. The SSD stated BCP summary should be given to the residents and or the RP. The SSD stated it was important that residents and or the RP were aware of what care they will be receiving at the facility.During a concurrent interview and record review on 09/11/2025 at 11:30 AM, Residents 31 and 82s BCP Person-Centered Care Planning form-V3 was reviewed with the Minimum Data Set Coordinator (MDSC) A. The MDSC A verified the BCP summary was not provided to Residents 31 and 82 nor to their RPs. The MDSC A stated it was important to provide the BCP summary to RP and the residents per facility policy so they know the residents' plan of care that they were going to be receiving at the facility, to provide safe care and prevent miscommunication.A review of the facility's policy and procedure (P&P) titled Care Plans-Baseline, revised 3/2022, the P&P indicated, . resident and or representative are provided a written summary of the baseline care plan.provision of the summary to the resident and or resident representative is documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure one out of twenty sampled residents (Resident 28) was provided the Restorative Nursing Assistant Program (RNA-P, a program which provides exercise and a range of motion activities to the residents), when Resident 28's physician's orders, person-centered care plan, and resident's choice to participate in the RNA-P was not being followed.This failure had the potential to result in Resident 28's decline in physical abilities and decreased muscle strength.Findings:A review of Resident 28's admission record indicated he was originally admitted to the facility in November 2023 with diagnoses including lung disease and the absence of right leg, below the knee. A review of Resident 28's Minimum Data Set (MDS- a federally mandated assessment tool), dated 8/22/25, indicated Resident 28 had an ability to express ideas and wants.A review of Resident 28's Care Plan Report, dated 12/8/23 with no resolved date, titled Restorative Nursing- Range of Motion indicated, RNA PROGRAM FOR AROM [active range of motion] BUE [bilateral upper extremity] RESISTIVE EXERCISE 3x15 for each exercise. Encourage to engage in UE [upper extremity] exercises for bicep/triceps curls, chest press, and overhead press as tolerance. May also engage in omnicycle [exercise equipment] for BUE at level 1-2 for approx. [approximately] 15 minutes. MWF [Mondays, Wednesdays, and Fridays]. A review of Resident 28's Order Summary Report, for active orders, indicated RNA PROGRAM FOR AROM BUE RESISTIVE EXERCISE 3x15 for each exercise. Encourage to engage in UE exercises for bicep/triceps curls, chest press, and overhead press as tolerance. May also engage in omnicycle for BUE at level 1-2 for approx. 15 minutes. every day shift every Mon, Wed, Fri.A review of Resident 28's Nursing - RNA Weekly Summary/Restorative Progress Notes, dated 7/20/25, the Restorative Nursing Assistant (RNA) documented we just see him twice this week, resident do bicycle and no complain of pain. During an observation and interview on 9/9/25 at 4 p.m., with Resident 28 in his room, Resident 28 voiced concerns that he was no longer getting RNA-P. He stated he does not know why it stopped; he was going three days a week and was doing well. Resident 28 said he liked going to the activity outings and wanted to be strong enough to participate. During a concurrent interview and record review on 9/12/25 at 10:40 a.m., with Director of Staff Development (DSD), DSD stated she is responsible for the RNA-P, and for scheduling the RNA staff meetings to review the residents' progression. DSD said meetings had not been scheduled in a while. DSD presented a spreadsheet named RNA Program - January 2025, with 32 residents listed, including Resident 28, for Active and Passive ROM [range of motion] for BLE [bilateral lower extremity] and BUE, scheduled for Mondays, Wednesdays, and Fridays. DSD said this was an old list and acknowledged she did not have current spreadsheets, or meeting notes. The DSD confirmed there was no physician's order to discontinue Resident 28's RNA-P. DSD stated it was important to have an accurate rehabilitation treatment care plan for residents to maintain their level of mobility. During a concurrent interview and record review on 9/12/25 at 2 p.m., with Director of Nursing (DON) and RNA, DON and RNA acknowledged Resident 28 had not been evaluated since 7/20/25, and meetings had not been scheduled. They both confirmed Resident 28 started the RNA-P in December 2023, and there were no physician's orders to end the program. DON and RNA stated the RNA-P was important to prevent decline, continue mobilization, and prevent contractures (a condition in which muscles and tissues become abnormally tight, restricting movement. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, revised July 2017, the P&P stipulated, Residents will receive restorative nursing care.to help promote optimal safety and independence.Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. 4. The resident.will be included in determining goals and the plan of care. 5. Restorative goals may include,.maintaining or strengthening his/her physiological and psychological resources; c. maintaining his/her dignity, independence and self-esteem; and d. participating in the development and implementation of his/her plan of care.

Based on observation, interviews and record reviews, the facility failed to ensure the call light (a communication tool used in healthcare settings to allow patients to request assistance from staff) was within reach for one out of five sampled residents (Resident 102), when her call light was found coiled around her lower bed post away from her reach.This failure put Resident 102 at risk for delayed provision of care and accidents.Findings:A review of Resident 102's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission to the facility in April 2020 with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).During a concurrent observation and interview on 09/09/2025 at 11:47 AM, in Resident 102's room, Resident 102's stated she had been using the pressure pad to call for help and no staff responded because she believed it was not working. Resident 102 stated earlier in the morning her normal call light had been changed to the pressure pad call button. Resident 102 stated it was very frustrating to have a call light that was not working because the call light was the way to call staff when help was needed. During a concurrent observation and interview on 09/09/2025 at 12:08 AM, Licensed Nurse (LN) C verified Resident 102's pressure pad call button was not working but pointed out there was a call button that was working, however, it was coiled on the lower bed post which was too far for Resident 102 to reach. LN C stated a call light must always be in working condition and must always be within a resident's reach. LN C stated not having a working call light and not having a call light within reach put the residents' safety at risk as it placed them at high risk for accidents.During an interview on 09/12/2025 at10:35 AM, the Director of Staff Development (DSD) stated call lights were meant to be used by the resident to call the staff's attention if they needed help. The DSD stated that a call light wrapped on the lower bed post was unacceptable and was not within a residents' reach. The DSD stated if the call light wasn't within residents' they might fall or have an accident when they tried to get up on their own.A review of the facility's policy and procedure (P&P) titled Answering Call lights, undated, indicated, .when resident is in bed or confined in a chair be sure the call light is within easy reach of the resident.

Based on observation and interview, the facility failed to maintain the kitchen's drain in working order when the sewage drainpipe was observed disconnected and leaking outside the kitchen. This decreased the facility's potential to maintain sewer lines in proper working order and containment.Findings:During a concurrent observation and interview on 9/9/25 at 11:27 a.m. with the Maintenance Director (Maint Dir) outside the kitchen near the wall corresponding to the kitchen's food preparation sink. A black plastic sewer pipe was observed coming off the wall down to the top of the ground. The pipe was observed disconnected at one of the joints with light-colored solid particles scattered in the direction of the slope of the ground from the pipe's opening. Maint Dir confirmed that the pipe is not supposed to be disconnected. During an interview on 9/12/25 at 1:47 p.m. with the Dietary Supervisor (DS), DS acknowledged that a leaky drainpipe could attract pests, and it should have been fixed. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised December 2009, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interviews and record review, the facility failed to ensure one resident out of 20 sampled residents (Resident 87) was provided with a safe and sanitary environment when the commode (portable toilet designed for individuals with limited mobility) was covered with a blanket.This failure has the potential to spread germs and cause illness among residents.Findings:A review of Resident 87's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date to the facility in July 2025 with a diagnoses of muscle weakness and difficulty walking.During a concurrent observation and interview on 09/09/2025 at 12:34 PM, in Resident 87's room, a commode was covered with a blanket. Resident 87 stated staff have used a blanket to cover the commode for about two months.During a concurrent observation and interview on 09/09/2025 at 1:18 PM, Licensed Nurse (LN) C verified Resident 87's commode bucket was covered with a blanket. LN C verified the commode had always been covered that way. LN C stated it was not acceptable, and it was the facility's responsibility to ensure commode was covered with the appropriate lid. LN C stated covering the commode bucket with a blanket was unhygienic and unsanitary. During an interview on 09/11/2025 at 11:57 AM, the Infection Preventionist (IP) it was not acceptable to cover the commode with a blanket as it was an infection control issue. The IP stated cloth traps and harbor bacteria, so it becomes a contaminated surface, and could increase the risk of spreading germs and bacteria that could make the resident sick.A review of the facility's policy and procedure (P&P) titled Policies and Practices-Infection Control, revised 9/2023, indicated, .this facility's infection control practices are intended to help support a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infection.

Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of practice for administering medications as ordered by the physician (MD) for three residents (Resident 1, Resident 2, and Resident 3) of three sampled residents when: 1. Resident 1 did not receive her heart failure medication, antidepressant medication, and ointment for skin redness;2. Resident 2 did not receive a dose of his anti-fungal powder; and,3. Resident 3 did not receive her medication to alleviate pain and itching and medication for her thyroid. These failures decreased the facility's potential to ensure residents received medications that prevented a decline in their health status or prolonged discomfort due to their health diagnoses. Findings:1. A review of Resident 1's admission record indicated she was admitted on [DATE] with a diagnosis of congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and adjustment disorder with depressed mood (a mental health condition characterized by significant and persistent feelings of sadness and hopelessness).A review of Resident 1's Medication Administration Record (MAR), dated August 2025, indicated the following MD orders:a. Sacubitril/Valsartan (medication used to treat heart failure), 24-26 milligrams (mg- a unit of measurement) tablet, one tablet by mouth two times a day for heart failure with a start date of 8/12/25 at 5 p.m. The MAR indicated Resident 1 had not been given the evening dose of the medication on 8/12/25 nor the morning and evening doses on 8/13/25 at 9 a.m. and 5 p.m.b. Sacubitril/Valsartan, 24-26 mg. tablet, one-half tablet by mouth two times a day for heart failure with a start date of 8/26/25 at 6 p.m. The MAR indicated Resident 1 had not been given the evening dose of the medication on 8/30/25 at 6 p.m. and 8/31/25 at 6 p.m.c. Trazadone (used to treat depression), 50 mg. tablet, two tablets by mouth, at bedtime for depression with a start date of 8/12/25 at 8 p.m. The MAR indicated Resident 1 had not been given the dose on 8/12/25 at 8 p.m.d. Menthol Zinc Oxide ointment 0.44 -20.6% (%- a unit of measurement), apply to effected area topically every 8 hours for redness of skin with a start date of 8/12/25 at 5 p.m. The MAR indicated Resident 1 had not been given the evening dose on 8/12/25 at 5 p.m. and the morning dose on 8/13/25 at 1 a.m.2. A review of Resident 2's admission record indicated he was admitted on [DATE] with the diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).A review of Resident 2's MAR, dated August 2025, indicated the following MD orders:a. Nystatin (anti-fungal) Powder, 100000 UNIT/Gram (UNIT/GM.- a unit of measurement), apply to groin topically every shift for moisture-associated skin damage (MASD) with a start date of 8/20/25 at 2:30 p.m. The MAR indicated Resident 2 had not been given the night shift dose (NOC) of the medication on 8/20/25. 3. A review of Resident 3's admission record indicated she was admitted on [DATE] with the diagnosis of a recurring dislocation of the left shoulder and psoriasis (a chronic skin condition characterized by itchy and sometimes painful red, scaly plaques that can appear anywhere on the body). A review of Resident 3's MAR, dated August 2025, indicated the following MD orders:a. Lidocaine (medication used to alleviate pain) external patch, 4%, apply to effected area topically one time a day for pain with a start date of 8/27/25 at 9 a.m. The MAR indicated Resident 3 had not been given the medication on 8/27/25 nor 8/28/25 at 9 a.m. b. Betamethasone Dipropionate external cream 0/05%, apply to affected area topically every 8 hours for psoriasis with a start date of 8/26/25 at 5 p.m. The MAR indicated Resident 3 had not been given the evening dose on 8/26/25 at 5 p.m., the morning and mid-day dose on both 8/27/25 and 8/28/25 at 1 a.m. and 9 a.m.c. Levothyroxine Sodium oral tablet, 50 micrograms (mcg. - a unit of measurement), give 50 mcg by mouth in the morning for hypothyroidism (when the thyroid gland is unable to meet the body's needs) with a start date of 8/31/25 at 6 a.m. The MAR indicated Resident 3 had not been given the medication on 8/31/25 at 6 a.m. During a concurrent interview and record review on 9/2/25 at 11:24 a.m., the Infection Preventionist (IP) reviewed Resident 1's, Resident 2's, and Resident 3's August 2025 MARs and confirmed all three residents had missed doses of their medications.During a second interview and concurrent record review on 9/2/25 at 12:10 p.m., the IP stated licensed nurses are expected to check the facility's emergency medication stock for the ordered medication. The licensed nurses are also expected to call the pharmacy to confirm a delivery date and time, then call the physician to notify him of the issue. The physician can then decide whether to order a substitute or confirm that the delay of medication administration is okay. Lastly, the licensed nurses are then expected to document what they did and any instructions they were given in the resident's chart. The IP also stated the pharmacy was located close by so most medications could be delivered the same day; however, if the order is placed at night, the medication would be delivered the following morning. The IP reviewed Resident 1, Resident 2, and Resident 3's progress notes and confirmed there was no documented evidence the pharmacy nor the physician was called. The IP also reviewed the list of medications available in the facility's emergency medication stock and found only the lidocaine patch was available. The IP stated the nurse could have administered the lidocaine from the facility's emergency medication stock.During an interview with the acting Director of Nursing (DON) and the Administrator (ADM) on 9/2/25 at 2:36 p.m., the DON confirmed if a medication was missed then it is considered a medication error and could have negatively affected the health of the residents. A review of the facility's policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to protect a census of 94 residents from sexual abuse when the facility allowed an alleged perpetrator, Certified Nursing Assistant 1 (CNA 1), to enter the facility on 4/4/25 after conducting an incomplete investigation per facility policy for a census of 94 residents. This failure granted CNA 1 access to Resident 1 and had the potential to place Resident 1 and other residents at risk for further harm. Cross-reference F610. Findings A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of cardiomegaly (a condition when the heart becomes larger than normal) and dementia (a progressive state of mental decline). A review of Resident 1's progress note dated 4/4/25 at 9:38 p.m. indicated, Spoke to this [Resident 1] at approximately 12:40 p.m. today due to .reporting to a CNA that [Resident 1] experienced sexual abuse at the facility .This [Resident 1] reported that a male cleaned her in her room after a bowel movement .He then took the [Resident 1] to the shower room where he provided a shower .The [Resident 1] states that it was in her room that the male exposed himself to her and asked her to touch him . A review of CNA 1's time sheet dated 4/1/25 to 4/8/25, indicated CNA 1 clocked in for work on 4/4/25 at 3:31 p.m. and clocked out for the shift at 6:07 p.m. During an interview on 4/9/25 at 1:29 p.m., the Director of Nursing (DON) stated she became aware of the sexual abuse allegation against CNA 1 at approximately 12:30 p.m. on 4/4/25. The DON stated was able to identify the alleged abuser based on Resident 1's description of him. The DON then questioned other female residents in the same hallway as Resident 1's room and altered CNA 1's schedule to exclude Resident 1. The DON interviewed CNA 1 about the alleged incident after he clocked in for his shift on the afternoon of 4/4/25 at 4 p.m. The DON stated CNA 1 admitted to providing Resident 1 showers three times per week but documented them under another CNA's name. The DON then placed CNA 1 on suspension following her interview with him on 4/4/25. During an interview on 4/14/25 at 1:16 p.m., the Director of Staff Development (DSD) stated she was also made aware of the sexual abuse allegation at approximately 12:30 p.m. on 4/4/25. A review of facility policy titled Abuse Prevention Program , dated 2001, indicated, Our residents have the right to be free from abuse .This includes but is not limited to freedom from .sexual .abuse. As part of the resident abuse prevention, the administration will .protect residents during abuse investigations. A review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating , dated 2001, indicated, The administrator ensures that the resident .are protected from retaliation or reprisal by the alleged perpetrator.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse for one resident (Resident 1) of eight sampled residents when Resident 1 alleged a male Certified Nursing Assistant (CNA) matching the identity of CNA 1 exposed himself to Resident 1 and forced Resident 1 to touch his genitals. This failure decreased the facility's potential to protect Resident 1 and a facility census of 94 residents at the facility from harm. Findings: A review of CNA 1's employee file indicated he was hired at the facility on 8/31/21. A review of Resident 1's admission record indicated admission to the facility on [DATE] with a diagnosis of cardiomegaly (a condition when the heart becomes larger than normal), dementia (a progressive state of mental decline), delirium due to known physiological condition, adult failure to thrive (a condition where older adults experience a significant decline in their overall health and well-being, often due to a combination of physical, psychological, and social factors), and the need for assistance with personal care. A review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated 3/3/25, indicated Resident 1: - had a Brief Interview for Mental Status (BIMS-an assessment tool) score of 11, which indicated moderate cognitive (relating to processes of thinking and reasoning) impairment, - had no signs and symptoms of delirium (a disturbed state of mind characterized by symptoms such as confusion, disorientation, agitation, and hallucinations (a mental state in which a person's senses makes them believe a situation is real but it is not), - required substantial assistance (the helper does more than half the effort) from staff to shower/bathe. A review of Resident 1's untitled facility documents referred to by nursing staff as shower sheets (documentation of residents' skin conditions during showers), dated 2/27/25, 3/10/25, 3/27/25 and 4/3/25 indicated a wet signature (a handwritten signature made with ink on a physical document) by CNA 1 which indicated he provided Resident 1 showers. A review of a facility document faxed to the California Department of Public Health (CDPH) on 4/4/25 at 3:18 p.m., indicated, DSD [Director of Staff Development] approached [Resident 2] at approximately 12:30 p.m DSD asked [Resident 2] to bring her to the allegedly abused resident .[Resident 1] began to explain that there is a male that is approximately 6 feet, Latin, dark, with black hair, and a muffled voice .The male told her that she needed a bath. The male got bath supplies and returned. After returning, the male cleaned her bowel movement with peri-wipes [disposable wipes designed to clean the area between the anus and the genitals] and cleaned her vagina. He then took her to the shower room, undressed her and gave her a shower with warm water .After returning to the room, the male exposed his chest then unzipped his pants, and asked [Resident 1] to touch him. [Resident 1] states that this occurred within the last month. [Resident 1] also states that she could point out this male because he looks exactly like an ex-boyfriend that she had [AGE] years ago .[Resident 1]'s diagnoses and chart were reviewed. Diagnoses include dementia, delirium, mild cognitive impairment. Review of the resident chart revealed that the resident has only had showers from female staff for the last 30 days. The facility's investigation points to no substantiated abuse. A review of Resident 1's document titled POC [Plan of Care] Response History printed on 4/4/25 at 8:59 p.m. indicated a shower/bath had been provided to Resident 1 by CNA 4 on 3/27/25 and 4/3/25. A review of Resident 1's progress note dated 4/4/25 at 9:38 p.m., indicated, .The facility did not find the abuse allegation substantiated following its investigation, including interviews of various residents. In an interview on 4/8/25 at 12:20 p.m., the Long-Term Care (LTC) Ombudsman stated she interviewed Resident 1 and Resident 2 and found their details of the incident matched. The LTC Ombudsman also stated she believed Resident 1 was a good witness for herself despite her diagnosis of dementia. A review of a facility document faxed to CDPH on 4/8/25 at 2:49 p.m. indicated, Subject: 5-day follow up investigation from reported abuse from 04-04-25 .The [Resident 1] reported a different version of the story to another resident on 04/03/25 .Other female residents were interviewed of the same hallway were interviewed to assess if they have ever been made to feel uncomfortable or if any staff members were inappropriate in anyway, including someone verbalized to them [sic]. Each female resident interviewed stated that there have been no inappropriate words or actions by male staff members directed at them or witnessed by them. The residents interviewed include [four residents which did not include Resident 1's roommate] .At this time the facility is concluding the investigation and does not find this allegation substantiated. The inconsistencies in the stories as well as the inability to find any female residents who could identify the CNA as a danger to any residents brought us to the conclusion that there was no harm committed .Facility Immediately intervened upon receiving report from the resident to ensure that she was safe .The incident was investigation and reported to CDPH, LTC Ombudsman, and .[the] Police Department. A review of the facility's census dated 4/9/25 at 8:28 a.m. indicated Resident 7's room was located next door to Resident 1 on the same hallway. In an interview on 4/9/25 at 12:01 p.m., CNA 2 stated Resident 1 told her she did not want CNA 1 caring for her because he was rude to her roommate. The CNA 2 stated Resident 1 had not used CNA 1's name, but had described him as, a big man. The CNA 2 then suggested the Surveyors interview three specific residents because they would have stories to tell them about CNA 1. The CNA 2 added when the Surveyor had been at the facility on 4/4/25 the staff who were working did not feel comfortable talking about CNA 1 because his wife (CNA 4) was working at the facility on the same shift. A review of Resident 7's MDS dated [DATE] indicated a BIMS score of 11 which indicated moderate cognitive impairment. In an interview on 4/9/25 at 1:04 p.m., Resident 7 stated she had been living in the facility for 2 years and 3 months. Resident 7 also stated, One guy [CNA 1] used to touch me on the leg. He used to give me showers, but I won't let him do that anymore. He touched my leg and said, ' Come on baby.' I told the Administrator [ADM] who asked me if I wanted him to get rid of him. He said he would call the police [but they] haven't come yet .Touching like rubbing. [He] almost touched my private parts, but I pushed his hand away and said, ' No.' In an interview on 4/9/25 at 1:29 p.m., the Director of Nursing (DON) stated she became aware of Resident 1's sexual abuse allegation against CNA 1 at approximately 12:30 p.m. on 4/4/25. The DON stated was able to identify the alleged abuser based on Resident 1's description of him. The DON then questioned other female residents in the same hallway as Resident 1's room and altered CNA 1's schedule to exclude Resident 1. The DON stated she had not found any other residents who complained or had issues with CNA 1's care. The DON interviewed CNA 1 about the alleged incident after he clocked in for his shift on the afternoon of 4/4/25 at 4 p.m. The DON stated CNA 1 admitted to providing Resident 1 showers three times per week but documented them under another CNA's name. The DON then placed CNA 1 on suspension following her interview with him on 4/4/25. The DON stated CNA 1 had been placed on suspension from 4/4/25 to 4/7/25. In an interview on 4/11/25 at 10:25 a.m., Resident 7 stated the incident with CNA 1 occurred around 3 weeks ago. Resident 7 stated, I didn't tell anyone [other staff] about it- only the guy in charge. Resident 7 confirmed the guy in charge was the [ADM]. Resident 7 added she told her nurse she did not want CNA 1 caring for her anymore. In an interview on 4/11/25 at 10:36 a.m., LN 3 stated, [Resident 7] mentioned a while ago, ' There was a guy that gave me a shower and he washed my vagina- really washed it. The LN 3 stated when she asked Resident 7 whether she felt it was sexual or made her feel uncomfortable, Resident 7 stated she did not know and asked if it was weird that his wife was in the room also. The LN 3 told Resident 7 it was not necessarily weird if the wife was trying to help. The LN 3 stated Resident 7 often made [NAME] comments about male genitals and if LN 3 felt it was misconduct of sexual connotation, the LN 3 would report it to the DON and refer to the facility's binder titled Mandated Reporting Binder. In an interview on 4/14/25 at 12:28 p.m., CNA 4 stated CNA 1 has always had a problem obtaining access to the facility's Electronic Documentation System (EDS). CNA 4 stated she and CNA 1 had started working at the facility as on-call or per diem (called to work when needed) staff. When CNA 4 and CNA 1 became full-time staff, CNA 1's inability to log into the EDS became a real problem. CNA 4 gave CNA 1 her password so CNA 1 could document under her name. CNA 4 stated CNA 1 had notified the DSD on several occasions about his inability to log into the EDS, but they never fixed it until now. CNA 4 stated, I know it was wrong, but [CNA 1] couldn't document so I did it. In an interview on 4/14/25 at 1:16 p.m., the DSD acknowledged she was made aware of Resident 1's sexual abuse allegation against CNA 1 at approximately 12:30 p.m. on 4/4/25. The DSD stated she interviewed Resident 1 then reviewed Resident 1's shower documentation and did not see CNA 1 listed as a person who gave Resident 1 a shower/bath. The DSD then left the facility around 2 p.m. The DSD stated she returned to the facility around 6 p.m. after the DON informed her CNA 1 had stated he had given Resident 1 showers/baths and had been documenting under CNA 4's name. The DSD interviewed female residents whom CNA 1 would have showered. The DSD confirmed these female residents were not in CNA 1's old or new assignment. The DSD also stated she interviewed three staff members but was only able to name one of the staff members as she was unable to remember the names of the other two. The DSD acknowledged she had not included the staff interviews in her report because she did not think it mattered. The DSD left the facility again at 8:30 p.m. and considered the investigation concluded. The DSD stated Resident 1's story kept changing so the investigation concluded quickly. The DSD acknowledged she interviewed Resident 1 once and thought Resident 1 may have had a urinary tract infection, indicating Resident 1 may have a common side effect of confusion from it. The DSD stated she had been working at the facility for 4 months and had not been trained on how to investigate abuse allegations. The DSD further stated she did not follow the facility's Abuse Investigation Protocol. In an interview on 4/14/25 at 1:53 p.m., the Director of Nursing (DON) stated CNA 1 told her he did not usually touch female residents near their private parts or will have his wife accompany him when he provides a female resident a shower/bath. The DON further stated she had interviewed CNA 1 and one other male staff member who worked the same shift as CNA 1. The DON also stated, [It was] absolutely wrong [CNA 1] documented under [CNA 4's] name .I did not assist [the DSD] in the investigation, write up or conclusion. In an interview on 4/14/25 at 2:24 p.m., the ADM denied Resident 7's report of having been inappropriately touched by CNA 1. The ADM stated he would have reported it. The ADM confirmed he was the Abuse Coordinator and named the DON and DSD as his designees. The ADM further stated, If I am here, I will help [with the investigation]. The ADM acknowledged he had not gone to the facility on [DATE]. The ADM also acknowledged he had read the 5-day follow up investigation report but had not noticed it did not include any staff interviews. The ADM stated he did not, formally train anyone on the correct procedure for investigating abuse allegations . The ADM stated he could not confirm the investigation was thorough. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating , dated 2001, indicated, All reports of resident abuse .[are] thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse .is suspected, the suspicion must be reported immediately to the administrator .The administrator of the individual making the allegation immediately reports his or her suspicion .Upon receiving any allegations of abuse .the administrator is responsible for determining what actions .are needed for the protection of residents .The administrator initiates investigations. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation .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 by the facility. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The individual conducting the investigation as a minimum .interviews the resident's attending physician as needed to determine the resident's condition .interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .interviews the resident's roommate .interviews other residents to whom the accused employee provides care or services .reviews all events leading up to the alleged incident; and documents the investigation completely and thoroughly .The investigator consults daily with the administrator concerning the progress/findings of the investigation .

Based on interview and record review, the facility failed to implement its abuse and change of condition policy for two residents (Resident 1 and Resident 2) of four sampled residents when the facility staff did not: Notify the residents' family representatives and physicians, Document an Interdisciplinary Team (IDT- a multidisciplinary team who ensures a comprehensive and coordinated approach to patient care) note, and Initiate care plans to provide person-centered care for both residents for an allegation of resident-to-resident abuse. This failure decreased the facility's potential to prevent recurrence of abuse between Resident 1 and Resident 2. Findings: A review of a investigation summary report sent to the California Department of Public Health (CDPH) on 4/14/25 indicated, On 4/9/25, the [Resident 1] reported to the staff that her roommate [Resident 2], came to her bed around midnight, tore the blankets off the bed, began commanding that she go to the bathroom, and then struck her on the face and chest several times. During an interview on 4/25/25 at 9:10 a.m., the Administrator stated the permanent Director of Nursing (DON) was on leave and not currently working at the facility. A review of an electronic-mail sent to the Surveyor on 4/25/25 at 12:41 p.m. from the Director of Medical Records (DMR) indicated there was no documented evidence of family representative notifications, physician notifications, Special Incident Reports (SIR- a form that documents critical and unexpected events that could impact a patient's health or safety), or IDT notes found in Resident 1 or Resident 2's charts regarding the allegation of abuse on that was reported on 4/9/25. During an interview on 4/25/25 at 2:40 p.m., the Director of Staff Development (DSD) stated licensed staff were expected to notify residents' representatives and physicians of resident-to-resident abuse allegations. The DSD also stated staff were also required to complete a SIR of the allegation and document an IDT note in each residents' chart. During a phone interview on 4/25/25 at 2:48 p.m., Licensed Staff A (LS A) stated Resident 1 notified her of the resident-to-resident abuse allegation on 4/9/25 at around 6 a.m. LS A stated she wrote a nursing progress note about it but did not complete a SIR. LS A stated she was unsure if she had notified the residents' family members or the physician of the allegation. LS A stated Resident 1 was moved to another room after the allegation. During an interview on 4/25/25 at 2:58 p.m., the DMR acknowledged there were no care plans in Resident 1 and Resident 2's medical charts regarding the abuse allegation reported on 4/09/25. During a phone interview on 4/28/25 at 9:22 a.m., the DSD stated care plans were expected to be initiated after an abuse allegation for the residents involved. During a phone interview on 5/7/25 at 2:15 p.m., the DSD stated Charge Nurses were responsible for notifying the residents' representatives and physicians about any allegations of abuse when they were notified. The DSD also stated licensed nurses were expected to monitor residents involved in the alleged abuse for 72 hours and document their assessments in the residents' charts. The DSD further stated care plans regarding abuse allegations were expected to be initiated by the IDT. During a review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 9/22, indicated, .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies .The resident's representative .The resident's attending physician; and .The facility medical director .The administrator is responsible for keeping the resident and his/her representative .informed of the progress of the investigation. Record review of the facility's policy titled, Change in a Resident's Condition or Status, revised 2/21 indicated, .The nurse will notify the resident's attending physician or physician on call when there has been an .incident involving the resident .A ' significant change' of condition is a major decline .in the resident's status that .requires interdisciplinary review and/or revision to the care plan .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR [Situation, Background, Assessment, Recommendation] Communication Form .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when .there is a significant change in the resident's physical, mental, or psychosocial status .there is a need to change the resident's room assignment.

Based on interviews and record reviews, the facility failed to provide resident-centered care to one resident (Resident 1) of four sampled residents when Licensed Nurses administered Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions combined with artificial breathing in an effort to manually preserve brain function to restore blood circulation and breathing in a person whose heart unexpectedly stops beating) against Resident 1 ' s decision not to be resuscitated (rescued). This failure resulted in physical, psychosocial (involving both psychological and social aspects), and financial harm to Resident 1 after she had survived the medical emergency. Findings: A review of Resident 1 ' s admission record indicated an initial admission to the facility on [DATE]. The admission record also indicated Resident 1 was her own responsible party (a person in charge of making healthcare decisions). A review of Resident 1 ' s Physician Orders for Life Sustaining Treatment (POLST, a portable medical order that document ' s a person ' s decisions regarding end-of-life care), prepared on [DATE] indicated, .First follow these orders, then contact Physician .A copy of the signed POLST form is a legally valid physician order .Cardiopulmonary Resuscitation (CPR): If patient has no pulse and is not breathing .[check marked as choice] Do Not Attempt Resuscitation/DNR (Allow for Natural Death) .Medical Interventions: If patient is found with a pulse and/or is breathing .[check marked as choice] Comfort-Focused Treatment- primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location .Information and Signatures: Discussed with .[check marked as choice] Patient (Patient has Capacity) . [check marked as choice] No Advanced Directive .Signature of Physician .My signature below indicates to the best of my knowledge that these orders are consisted with the patient ' s medical condition and preferences [signed by Physician on] XXX[DATE] .Signature of Patient .I am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of this form .[signed by Resident 1] on XXX[DATE]. A review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15 which meant her cognition was intact. A review of Resident 1 ' s Care Plan initiated on [DATE] indicated, [Resident 1] has a POLST for DNR Status [with] the goal [that Resident 1 ' s] POLST/DNR status will be followed through [the] target date [of [DATE]] or till change of order .[interventions staff were expected to implement included] DNR POLST form will be in the medical records at all times .Staff will recognize [Resident 1 ' s] wishes and follow as indicated. A review or Resident 1 ' s Order Summary Report which indicated active orders as of [DATE] at 3:50 p.m. indicated, DNR Code .Active [order as of] [DATE] .Pt [Patient] has capacity to make healthcare decisions: Yes .Active [order as of] [DATE] .I have approved these orders for [Resident 1] .[Orders signed by Physician on] [DATE]. A review of Resident 1 ' s Progress Note dated [DATE] at 12:28 p.m. documented by Licensed Nurse A indicated, Called to patients [sic] room by CNA [Certified Nursing Assistant]. [Resident 1] noted to be slumped over in wheelchair and unresponsive. Pallor [abnormal paleness of the skin] noted, sternal rub [the most common painful stimulus practiced in the field by Emergency Medical Technicians and paramedics] attempted without response, carotid pulse [a wave of blood pressure felt on either side of the neck] absent. Initiated CPR after transfer to bed .Another nurse [Licensed Nurse B] took over CPR. Chart checked and noted to be DNR. [Resident 1] began crying out in pain. Paramedics responded and transferred to ED [Emergency Department] . A review of Resident 1 ' s Hospital Discharge Summary dated [DATE] indicated, Principle Diagnosis: Syncope [a temporary loss of consciousness that occurs when the brain does not receive enough blood flow] .NSTEMI (non-ST elevated myocardial infarction) [a type of heart attack where involving a partial blockage of one of the coronary arteries, causing reduced flow of oxygen to the heart muscle] .[Resident 1] had a CPR for few minutes at the [facility] when they did not find a pulse over there. [Resident 1] woke up after 5 minutes . During an interview on [DATE] at 12:32 p.m. Resident 1 stated could not recall going to the hospital. Resident 1 stated she was told her heart stopped beating and was resuscitated by Licensed Nurse A. Resident 1 stated when she came back to the facility, Licensed Nurse A apologized to her for performing CPR when her code was DNR. Resident 1 stated she now must live in an assisted living facility where she has had to pay $6,000 per month just to sit in a wheelchair, unable to do things independently. Resident 1 stated, I did not wish to live in this situation. During an interview on [DATE] at 1:35 p. m. with the Director of Nursing (DON), she stated it was her expectation for nurses to verify the resident ' s code status before initiating CPR. The DON stated Licensed Nurse A became aware of Resident 1 ' s DNR code status after she had already provided CPR. During an interview on [DATE] at 1:42 p.m. Licensed Nurse B confirmed she went to Resident 1 ' s room and saw Licensed Nurse A performing CPR on Resident 1. Licensed Nurse B stated she assisted Licensed Nurse A with the CPR and took over the chest compressions. Licensed Nurse B stated while she was performing chest compressions on Resident 1, another nurse informed her Resident 1 ' s code status was DNR, so she stopped performing the chest compressions. During an interview on [DATE] at 9:58 a.m., Resident 1 stated because she was resuscitated, she is now experiencing a financial burden because she is having to spend her money for people to take care of her since she is physically unable to care for herself. Resident 1 stated she is anxious because she is running out of money, and she is unsure of where she will go when her money runs out. Resident 1 also stated she is depressed and, .would not wish her current situation on anybody. A review of the facility ' s policy and procedure titled Resident Rights, dated 2001, indicated, Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident ' s right to .self-determination .be supported by the facility in exercising his or her rights .participate in, his or her care planning and treatment . A review of the facility ' s policy and procedure titled Do Not Resuscitate Order, dated 2001, indicated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect .Do not resuscitate (DNR) orders will remain in effect until the resident .provides the facility with a signed and dated request to end the DNR order .

Based on observation, interviews and records review, the facility failed to assess and provide necessary treatment and services for two of two sampled residents (Resident 1, and Resident 2) when: 1. Resident 1 was not properly assessed for symptoms of scabies (an itching skin irritation caused by the microscopic human itch mite, which burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic rash) when she developed skin rashes to her arms, legs, and abdomen and the facility did not administer Permethrin cream (medication used to treat scabies) and Ivermectin (an anti-parasitic drug) to Resident 1 according to the dermatologist ' s order. This failure resulted in: a. Delayed diagnosis scabies causing Resident 1 to suffer for over two months from severe itching and skin eruptions; and b. The potential risk for scabies outbreak due to lack of timely interventions to prevent the spread of scabies to other residents and staff. 2. Resident 2 did not receive her scheduled Ertapenem Sodium (used to treat certain serious infections) and Daptomycin (used to treat certain serious bacterial infections) intravenously (delivered into a vein by injection or through a catheter) for the treatment of wound infection. This failure had the potential for increased risk of organ failure or death due to untreated infection. Findings: Resident 1 During a telephone interview with Family Member A on 10/20/22 at 9:13 a.m., Family Member A stated around last week of July 2022, Family Member A found rashes to Resident 1's legs when she lifted Resident 1's pants and found more rashes to Resident 1's arms and chest when checked other parts of Resident 1's body. Family Member A stated she reported about the rashes to the nurse and was told they were going to get a treatment order from the doctor. Family Member A stated the facility told her they would arrange the dermatology appointment for Resident 1 when she told them she would take Resident 1 to a dermatologist; however, the dermatology appointment did not happen immediately. Family Member A stated Resident 1 suffered from severe itching, clawing her skin for more than two months before she saw dermatologist. Family Member A stated she took Resident 1 to the dermatologist on 10/10/22 and she was told Resident 1 had scabies. Family Member A stated the doctor gave a prescription for Permethrin and Ivermectin. Family Member A stated she informed the Director of Nursing (DON) about Resident 1's diagnosis of scabies; however, the DON did not believe Resident 1 had scabies and told Family Member A she did not have the staff to provide the treatment and shower and she was not going to follow the treatment according to the doctor ' s order. Family Member A stated she personally purchased the Permethrin cream from outside pharmacy and applied the first treatment of Permethrin cream to Resident 1 on the night of 10/10/22 at around 8 p.m. and personally gave shower to Resident 1 the next morning. Family Member A stated she gave the second treatment of Permethrin to Resident 1 after one week. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Idiopathic Peripheral Neuropathy (damage to the nerves located outside of the brain and spinal cord); and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for Resident 1, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 9/23/22 indicated Resident 1 had a BIMS score of 11 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). During a record review for Resident 1, the document titled Progress Note dated 7/29/22 at 10:32 a.m. indicated Resident 1 requested to see a dermatologist for her rash. During a record review for Resident 1, the document titled Progress Note dated 8/4/22 at 12:20 a.m. indicated Resident 1 had a small red raised rash on her upper and lower extremities for two weeks; some were scabbed from itching. The Progress Note indicated Family Member A requested for Resident 1's Primary Care Physician (PCP) to see Resident 1 to address the rash. During a record review for Resident 1, the document titled Progress Note dated 8/19/22 at 8:29 a.m. indicated, Scattered itchy rash reported. Affected areas include arms, legs, and abdomen. During a record review for Resident 1, the Treatment Administration record (TAR) for August 2022 indicated Resident 1 was started on Triamcinolone Acetonide Cream (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) on 8/24/22 to be applied to Resident 1's arms, legs, and abdomen. During a record review for Resident 1, the document titled Progress Note dated 9/07/22 at 1:20 p.m. indicated, Rash to arms and abdomen resolved but now presents on legs. During a record review for Resident 1, the document titled Progress Note dated 9/14/22 at 12:42 p.m. indicated, Ongoing topical skin care for rash/itchy eruptions on legs, arms, and abdomen. During a record review for Resident 1, the document titled Progress Note dated 9/27/22 at 8:18 a.m. indicated, Resident 1 had scattered itchy rash which was treated twice. The Progress Note indicated a Dermatology referral was sent. During a record review for Resident 1, the Dermatology report dated 10/10/22 indicated Resident 1 was seen for, rash located on whole body. The Dermatology report indicated Resident 1 had Scabies to her trunk, right upper extremity, left upper extremity, right lower extremity, and left lower extremity. The report indicated a comment, this has been going on for two months. With expected duration over one year if there is no treatment. Patient describes extreme pruritis. The dermatology report indicated an order for: - Ivermectin 3 mg oral tablet (Take 4 pills by mouth, then take 4 pills two weeks later). - Permethrin 5% topical cream (Apply at night from the neck down and then repeat 7 days later). During a record review for Resident 1, the Treatment Administration Record (TAR) for October 2022 indicated a doctor ' s order written on 9/07/22 for, [NAME] lotion (used to relieve itching and pain from certain skin conditions) to itchy skin TID (three times a day) PRN (as needed). The TAR indicated from 10/1/22 to 10/19/22, Resident 1 received [NAME] lotion treatment on 10/3, 10/4 and 10/14. The TAR did not indicate an order for Permethrin 5% topical cream. During a record review for Resident 1, the Medication Administration Record (MAR) for October 2022 did not indicate an order for Ivermectin. During an observation and concurrent interview with Resident 1 in her room on 10/20/22 at 1:36 p.m., Resident 1 was wearing long sleeved blouse and long pants. When Resident 1 was asked if she had rashes on her body, Resident 1 stated she did not have rash at the moment; however, Resident 1 stated, rashes comes and goes. During an interview with Unlicensed Staff B on 10/20/22 at 1:38 p.m., Unlicensed Staff B stated Resident 1 was confused but she was independent with ADL care (Activities of Daily Living - the tasks of everyday life like eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). Unlicensed Staff A stated Resident 1 had rashes on her body over a month ago and verbally reported this issue to the treatment nurse. During an interview with the Licensed Staff C on 10/20/22 at 2:03 p.m., Licensed Staff C stated Resident 1 had a rash for a while and was treated with Hydrocortisone (medication used to treat a variety of skin conditions) and Triamcinolone which worked for a while; however, Licensed Staff C stated Resident 1was always itchy. Licensed Staff C verified Resident 1 had an appointment with the dermatologist and was diagnosed to have scabies. Licensed Staff C stated the dermatologist ordered Permethrin cream. Licensed Staff C stated Family Member A applied the Permethrin cream brought from the dermatology appointment to Resident 1 on the evening of 10/20/22. Licensed Staff C stated Family Member A gave Resident 1 a shower next day. When Licensed Staff C was asked who provided the second treatment of Permethrin cream to Resident 1, Licensed Staff C stated Family Member A provided the treatment and the CNA (Certified Nursing Assistant) showered Resident 1 the next day. Licensed Staff C verified the application of Permethrin cream was not documented in Resident 1's TAR. During an interview with the DON on 10/20/22 at 2:12 p.m., The DON stated she was not sure when Resident 1's body rash started. The DON stated Resident 1 was treated with different cream. The DON stated Family Member A took Resident 1 to a dermatologist and was told Resident 1 had scabies; however, the DON stated she did not think it was scabies. She stated the doctor just looked at Resident 1, gave a diagnosis of scabies without skin scraping (to obtain a sample of skin in order to check for parasites or fungus under the microscope) and ordered Permethrin cream. The DON stated Family Member A applied the Permethrin cream to Resident 1 in the evening on 10/20/22 and showered Resident 1 in the morning. During an interview with Licensed Staff D on 3/01/23 at 10:07 a.m. Licensed Staff D stated new orders obtained from a doctor's appointment were transcribed to the MAR either by the DON or the ADON (Assistant Director of Nursing). When Licensed Staff D was asked if resident ' s family members were allowed to administer medications or ointments. Licensed Staff D stated no because they might not give the right amount of medication needed. Licensed Staff D stated if the MAR had no licensed nurse initial/ signature, the medication was not given. During an interview with the ADON on 3/01/23 at 10:33 a.m., the ADON stated all doctor ' s order that came with the resident from a doctor ' s appointment would be transcribed in the resident's MAR. The ADON stated resident's family members could apply ointments or administer medications to resident with the supervision of a licensed nurse then the licensed nurse would document in resident ' s MAR or TAR immediately that medication was given. The ADON verified the order for Permethrin cream from the dermatologist was not written on the TAR. The ADON concurred if the medication was not documented in the MAR or TAR, the medication was not given. During an interview and concurrent record review with the DON on 3/01/23 at 11:26 a.m. The DON stated all doctor ' s order that came with the resident from a doctor ' s appointment would be transcribed in the resident's MAR or TAR. The DON verified the dermatology report for Resident 1 dated 10/10/22 indicated an order for, Ivermectin 3 mg oral tablets (Take 4 pills by mouth, then take 4 pills two weeks later. The DON verified the October 2022 MAR for Resident 1 did not have an order written for Ivermectin. When the DON was asked how would she know if the Ivermectin was administered to Resident 1, she stated she did not know there was an order for Ivermectin. The DON also verified the Permethrin order was not transcribed in Resident 1's TAR. She stated the Family Member A was very involved with Resident1 ' s care and preferred to apply the ointment for Resident 1. The DON stated Family Member A was allowed to apply the ointment with the licensed nurse ' s supervision. The DON stated the nurse should have documented in Resident 1 ' s TAR that the medication was given. Review of the Facility policy and procedure titled Scabies Identification, Treatment and Environmental Cleaning revised in on 8/2016 indicated, The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei (also known as the itch mite - a parasitic mite that burrows into skin and causes scabies) and to prevent the spread of scabies to other residents and staff. The policy ' s general guidelines indicated, Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment followed without scrapings. Resident 2 On 10/14/22, the California Department of Public Health Filed Operations Branch received an anonymous complaint via voicemail involving Resident 2. Review of the document titled Intake Information dated 10/14/22 indicated Resident 2 was admitted to the facility for antibiotic therapy; however, Resident 2 did not receive her dose of antibiotic on 10/13/22 because the facility did not have any RNs (Registered Nurse) to do it. The document indicated this was the second time this incident had happened, and Resident 2 was afraid she would die from missing her antibiotic. During a record review for Resident 2, the Face sheet indicated Resident 2 was admitted on [DATE] with diagnoses including but not limited to Infection of the Skin and Subcutaneous Tissue (the layer of tissue that underlies the skin) and Stage 4 (the deepest, extending into the muscle, tendon, ligament, cartilage or even bone) Pressure Ulcer (also known as bedsore - damage to an area of the skin caused by constant pressure on the area for a long time) of the sacral region (the triangular bone just below the lumbar vertebrae (series of small bones forming the backbone). During a record review for Resident 2, the MDS dated [DATE] indicated Resident 2 had a BIMS score of 15 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). During an interview with Resident 2 on 10/20/22 at 12:44 p.m., Resident 2 stated she had bone infection and was in the facility for IV antibiotics. Resident 2 stated she was supposed to receive two IV antibiotics in the afternoon; however, Resident 2 stated she missed her dose a few times. Resident 2 stated sated she was worried because her doctor told her she could not miss a dose of the antibiotic or her condition could get worse, and she could die. During a record review for Resident 2, the document titled Order Summary Report indicated a doctor ' s order written on 9/29/22 for Ertapenem Sodium (used to treat certain serious infections) 1 gram intravenously (delivered into a vein by injection or through a catheter) every 24 hours for purulent (full of, containing, forming, or discharging pus) skin/soft tissue infection until 10/31/22. During a record review for Resident 2, the document titled Progress Note dated 10/01/22 at 1:16 p.m. indicated the infectious diseases doctor (expert in the diagnosis and treatment of infectious diseases) added an order for Daptomycin antibiotic to be given to Resident 2 for 42 days. During a record review for Resident 2, the MAR for October 2022 indicated a doctor's order for Daptomycin (used to treat certain serious bacterial infections) 1000 milligram intravenously every 24 hours to start on 10/02/22 for wound infection. During an interview with Licensed Staff D on 3/01/23 at 10:04 a.m., Licensed Staff D stated RNs administer IV medications to the residents. Licensed Staff D stated if there was no RN in the evening, either the DON or on-call RN would come in to administer the IV medications. Licensed Staff D stated the RN who administered the IV medication should sign the MAR immediately. Licensed Staff D stated if the MAR had no licensed nurse initial or signature, the medication was not given. During an interview and concurrent record review (of MAR) with the ADON on 3/01/23 at 10:29 a.m. The ADON stated RNs administers IV medications to the residents. When the ADON was asked about their process when no RN was available in the evening to administer IV medications, the ADON stated either the DON or the on-call RN would come in to administer. The ADON stated the RN who administered the IV medication should document in the MAR immediately. The ADON verified Resident 2's MAR for October 2022 indicated that no licensed nurses' initials or signature for the Daptomycin order on 10/5; 10/08; 10/10; 10/13 and 10/14. The MAR indicated no licensed nurses ' initials or signature for the Ertapenem order on 10/3; 10/5; 10/6; 10/12 and 10/13. The ADON concurred if the medication was not documented in the MAR, the medication was not given. Review of the Facility policy and procedure titled Documentation of Medication Administration revised on 4/17 indicated the following: - The facility shall maintain a medication administration record to document all medications administered. - A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). - Administration of medication must be documented immediately after (never before) it is given. - Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; f. Signature and title of the person administering the medication;

Based on interview and record review, the facility failed to ensure resident safety when staff did not implement adequate supervision and assistance for 2 of 19 sampled residents (Resident 22 and 83). Resident 22 had poor safety awareness and a history of wandering at home, which led to harm. This failure contributed to Resident 22 falling on 9/21/18 and wandering outside on 10/10/18, falling and fracturing her right hand. Resident 24 had stated call lights takes forever to answer, and she had the potential for dizziness and disorientation related to her treatment for [REDACTED]. (Cross Reference F657) Findings: A review of Resident 22's Admission Record, dated 9/19/18, indicated she had a [DIAGNOSES REDACTED]. functioning), symptoms and signs involving cognitive (an intellectual process by which one becomes aware of, perceives, or comprehends ideas; it involves all aspects of perception, thinking, reasoning, and remembering) and awareness, etc. A review of Resident 22's Admission MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 10/2/18, indicated: 1. Resident 22 had a BIM (Brief Interview of Mental Status) score of 2 (severely cognitively impaired), 2. needed 2 person physical assist with bed mobility (how a resident moves to and from lying position and turns side to side), 3. 1 person physical assist with transfer (how a person moves between surfaces, including to or from bed, chair, wheelchair, and standing position), walking, eating, dressing, and personal hygiene (combing hair, brushing teeth ), 4. needed extensive two person physical assist with toilet use, 5. total dependence on bathing with one person physical assist, 6. was not steady and could only stabilize with human assistance when in a standing position, and 7. had a behavior of wandering, which occurred 4 to 6 days, but not every day. A review of Resident 22's Baseline Care Plan, dated 9/20/18, indicated she was at Risk for Falls due to poor impulse control and an Elopement Risk due to she had a behavior of wandering at home, a WanderGuard was placed on Resident 22 due to she was an elopement risk, and she enjoyed such activities as working in the garden, reading, watching television, and frequent visits with family. Resident 22's Comprehensive Care Plan did not include an Activities care plan, which included stimulating and meaningful activities, which would occupy her time. A review of Resident 22's clinical record titled, PACS: Nursing - Wandering Risk Observation/Assessment - V2, dated 9/19/18, indicated Resident 22 had a wandering evaluation score of 9 (At risk to wander). A review of Resident 22' clinical record titled, PACS: Nursing - Fall Risk Observation Assessment - V2, dated 9/19/18, indicated Resident 22 had a fall risk evaluation score of 14 (moderate risk for falling). Fall 1 A review of Resident 22's PACS: Rehab - status [REDACTED]. No injuries noted. A review of Resident 22's Elopement Secondary to Confusion/Wandering care plan, initiated 9/21/18, interventions included: 1. Distract Resident 22 when wandering, bringing her to activities or group events, 2. Redirect from doors, and 3. Roam alert protocol. A review of Resident 22's At Risk for Fall or Injury care plan due to generalized weakness, initiated 9/23/18, interventions included: 1. Announce self when entering resident area, 2. Call light within reach and answered promptly, 3. During activities keep close observation to minimize potential falls, 4. Keep environment free of hazards: small objects on floor, hot liquids, and toxic liquids, 5. Orient to environment, and 6. Notify physician and responsible party for all fall incidents. There was no updated plan of care interventions indicating how often staff would frequent rounds to ensure safety, no indication room supervision was provided and no indication bed was in low position and fall safety mats were on floor next to bed. Elopement & Fall 2 A review Resident 22's Nurses' Progress Notes, dated 10/11/18 at 12:23 a.m., indicated CNA (Certified Nursing Assistant) heard the door alarm sound and when he went to check, CNA found Resident 22 at the back parking lot lying flat on the ground. Resident 22 sustained scratches at the back of her right shoulder, abrasion on her right check and a big bump on her right forehead and complaining of pain on her forehead. Resident 22 was transferred to the acute care ED (Emergency Department) per physician's instructions for further evaluation. A review of Resident 22's acute care facility Patient Visit Information report, dated 10/11/18 at 2:26 a.m., the Radiology Results Report, dated 10/22/19, and Nurse's Progress Notes, dated 10/11/18, indicated Resident 22 sustained a Boxer's [MEDICAL CONDITION] hand at the fifth metacarpal (the pinky finger) and returned to the facility on [DATE] at 3:40 a.m. with a splint, which she would not keep on. Resident 22's hand was swollen and discolored. Review of Resident 22's Elopement Secondary to Confusion/Wandering care plan, initiated 9/21/19, and Fall Risk care plan, initiated 9/23/18, was not revised after the fall with injury. There was no updated plan of care interventions indicating how often staff would frequent rounds to ensure safety, no indication room supervision was provided, and a WanderGuard had been implemented prior to the fall with injury. Resident 22, who has a [DIAGNOSES REDACTED]. During an interview on 3/27/19 at 5:20 p.m., Manager M was asked about Resident 22's Fall Risk care plan and post falls, and what he looked at to develop care plans for Resident 22, who was at risk for falls, wandering and elopement. Manager M stated he assessed the resident, looked at progress notes, physician notes, the Fall Risk Assessment completed upon the resident's admission to the facility, Post Fall Assessment, the medications the resident was on, pain levels, interviews with resident and clinical staff, and family. Manager M stated he did not talk to Resident 22's family because the family was not very familiar with Resident 22; she had come from another facility. Surveyor pointed out to Manager M Resident 22's daughter had taken care of her for 7 years prior to her being admitted to the facility and was very familiar with her mom's care. Manager M stated he must have got her confused due to it was near the time of the fires and transfers were occurring. When Manager M was asked if he thought Resident 22's Fall Risk and Wandering care plan had sufficient interventions and if it should have been revised after her fall with injury, Manager M would not comment. During an interview on 3/28/19 at 9:15 a.m., Unlicensed Staff KK stated Resident 22 did need assistance with dressing and transferring to her wheelchair. Unlicensed Staff KK stated Resident 22 did wear a WanderGuard on her wrist, but she was mainly wheelchair bound now. Unlicensed Staff KK stated she had not seen Resident 22 try to get up on her own. Unlicensed Staff KK stated Resident 22 would stand-up using her walker to assist with transferring from the bed to the wheelchair. Unlicensed Staff KK stated Resident 22 was a Room Alert Elopement because she wore a WanderGuard. Unlicensed Staff KK stated if a resident got within 10 feet from an Exit door, the WanderGuard would go off. During a concurrent interview and record review at 3/28/19 at 9:40 a.m., DON was asked if Resident 22's elopement and fall, which took place on 10/10/18 per Nurse's Progress Notes had been investigated and if there had been a SBAR and PACS: Rehab status [REDACTED]. DON stated she wrote an IDT note, dated 10/15/18, as a clarification of the Nurse's Progress Note, dated 10/11/18, to clarify what occurred on 10/10/18 because Resident 22 was not found out on the back patio. The IDT note indicated, Resident 22 was self-ambulating (walking) throughout the facility when she was stepping out the rear entrance when noted to lose balance and fall just outside of rear entrance of building. The Nurse's Progress Note indicated Resident 22 had an unwitnessed fall. DON stated Resident 22's Fall Risk and Wander care plans should have been revised and there should have been a Short Term Post Fall care plan after Resident 22 returned from the acute care ED. During an interview on 3/28/19 at 11:35 a.m., MR C and DON were asked several times by surveyor for the SBAR, PACS: Rehab status [REDACTED]. MR C and DON could not find any of the documents to indicate a Post Fall investigation had taken place. The policy/procedure titled, Falls - Clinical Protocol, revised 3/18, indicated: 1. The staff and practitioner will review each resident's risk factors for falling and document in the medical record: a. Examples of risk factors for falling include gait and balance disorder, cognitive impairment, weakness, confusion, etc., 2. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall, 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is correctable, 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling .and also reconsider the current interventions, etc. Elopement 2 A review of Resident 22's Nurse's Progress Note, dated 10/14/18 at 4:22 p.m., indicated Resident 22 was found wandering outside the facility, the DON and daughter were notified about incident, activity people were to provide one on one supervision, and will continue to monitor for further evaluation. Resident 22's Wandering care plan, initiated 9/21/18, had no updated plan of care interventions indicating how often staff would frequent rounds to ensure safety, and no indication one on one supervision was provided, and if a WanderGuard was in place. The policy/procedure titled, Elopements, revised 12/07, indicated: 1. The attending physician, should be notified and Report of Incident/Accident should be completed and filed. Nurse's Note only indicated the DON and Resident 22's daughter was notified. There was no note of a Report of Incident/Accident was completed. A review of Resident 22's Nurse's Progress Notes, dated 10/14/18 at 9:29 p.m. indicated Resident 22 had a difficult day and had attempted several times on the PM shift to leave the facility. A review of Resident 22's Social Service Note, dated 10/15/18 at 12:14 p.m., indicated Social Services (S/S) talked to Resident 22's daughter, who let S/S know things Resident 22 enjoyed, such as sitting outside in the sun. Daughter used to give Resident 22 small projects at home to do in the backyard like separating leaves or twigs to keep her occupied, and she enjoyed solitaire. S/S indicated staff would provide 1:1 visits with the offering of the materials Resident 22's daughter suggested. Resident 22's care plan was not updated to include an Activities plan of care with the interventions recommended by Resident 22's daughter nor did the care plan indicate Resident 22 would receive 1:1 visits from the Activities staff. A review of Resident 22's Quarterly MDS, dated [DATE], indicated Resident 22 had a BIM score of 2 (severely cognitively impaired), had 1 fall with major injuries, and needed extensive assistance with transfer, walking, and toilet use A review of Resident 22's PACS: Nursing - Fall Risk Observation/Assessment - V2, dated 1/17/19, and PACS: Nursing - Wandering Risk Observation/Assessment - V2, dated 1/17/19, both completed by Manager M, indicated Resident 22 was at Moderate Risk for falling and at High Risk to wander, but there were no revisions done on Resident 22's Fall Risk care plan, initiated 9/23/18, and Resident 22's Elopement Secondary to Confusion/Wandering, care plan, initiated 9/21/18. The facility document titled, Job Description MDS Nurse, 7/18, indicated: 1. A primary function of the MDS nurse is to assess resident care needs, direct and supervise staff to meet the resident's needs, coordinate with other members of the IDT develop and implement a plan of care that meets the needs of the resident, 2. Conduct observations and interviews as well as evaluations required for MDS and/or care plan preparations, 3. Review orders with the appropriate nurse daily or more frequently if necessary, 4. Review accidents/accidents and critically ill/unstable residents, 5. Ensure all areas, which are triggered on the resident Assessment Protocol Summary, are included on the resident's plan of care The policy/procedure titled, Care Plans, Comprehensive Person-Centered, revised 12/16, indicated: 1. Care plan interventions are chosen 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: a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms of triggers, b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident, 2. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change, 3. The IDT must review and update the care plan: a. When desired outcome is not met, etc. During an interview with Resident 83 on 3/25/19 at 9:27 a.m., she stated it took a long time for staff to answer call lights, and her family helped her up to the bathroom and she fell . A review of her Medical Data Sheet (MDS) (An MDS, or minimum data set, assessment is used by nursing homes to assess and plan care for patients.) information indicated her BIMS (Brief Interview for Mental Status) indicated a score of 9 (Residents with a BIMS score of 8-12 or a CPS score of 0-2 were considered to be mildly impaired. Residents were considered cognitively intact if they were able to complete the BIMS and scored between 13 and 15). During a review of Resident 83's medical record, a document titled Progress Notes, dated 3/23/19 at 12:51 p.m., signed by Licensed Staff (LS) 00indicated Pt fell in shower room with husband and daughter. Daughter stated pt's husband was behind pt and went to close the door, tripped, and grabbed pt down with him. Pt and daughter stated no one hit their head and denied and pain/discomfort. VSS. Will continue to assess. On 3/23/19 at 21:39 (9:39 p.m.) a progress note signed by LS UU indicated Addendum: Pt has a small dry abrasion and bruise on left knee r/t the fall. WCTM. On 3/24/19 at 3:18 (a.m.) a progress note signed by LS VV, indicated S/P witness fall day one: Pt is alert and oriented to baseline. No c/o pain. No new injuries to note. Continuing to monitor left knee bruising and small abrasion. A review of Resident 83's medical record, a document titled Care Plan, indicated Falls: At Risk for Fall or injury Due to: Generalized weakness r/t recent hospitalization , initiated 3/5/19, indicated Goal Will be free from fall or injury .Notify MD and RP promptly for all fall incidents. During an interview with the Director of Nursing (DON) on 03/25/19 11:09 AM, she stated she was aware of a non-injury fall by Resident 83. She stated family was with the Resident. The DON stated she did not document the injury and did not follow the facility P&P because it was a non-injury fall and she assessed no harm. The DON stated she would not be able to find anything because she didn't document anything. She stated it facility P&P to assess for non-injury and witnessed versus un-witnessed. She stated she would have to review the rest of the P&P for details. A review of the facility P&P titled Falls - Clinical Protocol, indicated 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury .c. Musculoskeletal function .f. Pain; .Precipitating factors, details on how fall occurred; i. All current medications .j. All active [DIAGNOSES REDACTED]. The physician will identify medical conditions affecting fall risks (for example, a recent stroke or medications that cause dizziness or [MEDICAL CONDITION]) and the risk for significant complications of falls ( .increased risk of bleeding in someone taking anticoagulants). 5. The staff will evaluate and document falls that occur while the individual is in the facility: for example, when and where they happen, any observation of the events, etc.

Based on interview and record review, the facility failed to update care plans for 3 of 19 sampled residents (Resident 22, 79, and 83) when: 1. Resident 22's care plan was not revised after she wandered outside unsupervised, had an unwitnessed fall and sustained a fractured right hand. 1b. Resident 79 had multiple falls. 1c. Resident 83 experienced a fall witnessed by her family and there was no documentation in the medical record. 2. Resident 83's care plan for [MEDICAL TREATMENT] was not revised to accurately reflect the resident's care needs or [MEDICAL TREATMENT] protocol of the facility. This failure of not revising resident's care plans resulted in harm for Resident 22 and had the potential for harm for Resident 79 and 83 as follows: 1 a. Resident 22 to continue not to be adequately assisted and supervised which resulted in a fall with a fracture and which could lead to her falling again, causing harm, and in severe cases death. (Cross Reference F689) 1b. Resident 79's repetition of the same behavior that lead to the original fall, which could result in another fall resulting in harm and potential serious injury. 1c. Resident 83's risk of re-hospitalization from a serious injury was increased when assessment of current interventions was not revised and updated. 2. Resident 83 to return from [MEDICAL TREATMENT], not to be adequately assessed, which could lead to renal shutdown, re-hospitalization , and in severe cases death. Findings: 1a. A review of Resident 22's Admission Record, dated 9/19/18, indicated she had a [DIAGNOSES REDACTED]. functioning), symptoms and signs involving cognitive function (an intellectual process by which one becomes aware of, perceives, or comprehends ideas; it involves all aspects of perception, thinking, reasoning, and remembering) and awareness, etc. A review of Resident 22's Admission MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 10/2/18, indicated: 1. Resident 22 had a BIM (Brief Interview of Mental Status) score of 2 (severely cognitively impaired), 2. needed 2 person physical assist with bed mobility (how a resident moves to and from lying position and turns side to side), 3. 1 person physical assist with transfer (how a person moves between surfaces, including to or from bed, chair, wheelchair, and standing position), walking, eating, dressing, and personal hygiene (combing hair, brushing teeth ), 4. needed extensive two person physical assist with toilet use, 5. total dependence on bathing with one person physical assist, 6. was not steady and could only stabilize with human assistance when in a standing position, and 7. had a behavior of wandering, which occurred 4 to 6 days, but not every day. A review of Resident 22's Baseline Care Plan, dated 9/20/18, indicated she was at Risk for Falls due to poor impulse control and an Elopement Risk due to she had a behavior of wandering at home, a WanderGuard was placed on Resident 22 due to she was an elopement risk, and she enjoyed such activities as working in the garden, reading, watching television, and frequent visits with family. Resident 22's Comprehensive Care Plan did not include an Activities care plan, which included stimulating and meaningful activities, which would occupy her time. A review of Resident 22's clinical record titled, PACS: Nursing - Wandering Risk Observation/Assessment - V2, dated 9/19/18, indicated Resident 22 had a wandering evaluation score of 9 (At risk to wander). A review of Resident 22' clinical record titled, PACS: Nursing - Fall Risk Observation Assessment - V2, dated 9/19/18, indicated Resident 22 had a fall risk evaluation score of 14 (moderate risk for falling). Fall 1 A review of Resident 22's PACS: Rehab - status [REDACTED]. No injuries noted. A review of Resident 22's Elopement Secondary to Confusion/Wandering care plan, initiated 9/21/18, interventions included: 1. Distract Resident 22 when wandering, bringing her to activities or group events, 2. Redirect from doors, and 3. Roam alert protocol. A review of Resident 22's At Risk for Fall or Injury care plan due to generalized weakness, initiated 9/23/18, interventions included: 1. Announce self when entering resident area, 2. Call light within reach and answered promptly, 3. During activities keep close observation to minimize potential falls, 4. Keep environment free of hazards: small objects on floor, hot liquids, and toxic liquids, 5. Orient to environment, and 6. Notify physician and responsible party for all fall incidents. There was no updated plan of care interventions indicating how often staff would frequent rounds to ensure safety, no indication room supervision was provided and no indication bed was in low position and fall safety mats were on floor next to bed. Elopement & Fall 2 A review Resident 22's Nurses' Progress Notes, dated 10/11/18 at 12:23 a.m., indicated CNA (Certified Nursing Assistant) heard the door alarm sound and when he went to check, CNA found Resident 22 at the back parking lot lying flat on the ground. Resident 22 sustained scratches at the back of her right shoulder, abrasion on her right check and a big bump on her right forehead and complaining of pain on her forehead. Resident 22 was transferred to the acute care ED (Emergency Department) per physician's instructions for further evaluation. A review of Resident 22's acute care facility Patient Visit Information report, dated 10/11/18 at 2:26 a.m., the Radiology Results Report, dated 10/22/19, and Nurse's Progress Notes, dated 10/11/18, indicated Resident 22 sustained a Boxer's [MEDICAL CONDITION] hand at the fifth metacarpal (the pinky finger) and returned to the facility on [DATE] at 3:40 a.m. with a splint, which she would not keep on. Resident 22's hand was swollen and discolored. Review of Resident 22's Elopement Secondary to Confusion/Wandering care plan, initiated 9/21/19, and Fall Risk care plan, initiated 9/23/18, was not revised after the fall with injury. There was no updated plan of care interventions indicating how often staff would frequent rounds to ensure safety, no indication room supervision was provided, and a WanderGuard had been implemented prior to the fall with injury. Resident 22, who has a [DIAGNOSES REDACTED]. During an interview on 3/27/19 at 5:20 p.m., Manager M was asked about Resident 22's Fall Risk care plan and post falls, and what he looked at to develop care plans for Resident 22, who was at risk for falls, wandering and elopement. Manager M stated he assessed the resident, looked at progress notes, physician notes, the Fall Risk Assessment completed upon the resident's admission to the facility, Post Fall Assessment, the medications the resident was on, pain levels, interviews with resident and clinical staff, and family. Manager M stated he did not talk to Resident 22's family because the family was not very familiar with Resident 22; she had come from another facility. Surveyor pointed out to Manager M Resident 22's daughter had taken care of her for 7 years prior to her being admitted to the facility and was very familiar with her mom's care. Manager M stated he must have got her confused due to it was near the time of the fires and transfers were occurring. When Manager M was asked if he thought Resident 22's Fall Risk and Wandering care plan had sufficient interventions and if it should have been revised after her fall with injury, Manager M would not comment. During an interview on 3/28/19 at 9:15 a.m., Unlicensed Staff KK stated Resident 22 did need assistance with dressing and transferring to her wheelchair. Unlicensed Staff KK stated Resident 22 did wear a WanderGuard on her wrist, but she was mainly wheelchair bound now. Unlicensed Staff KK stated she had not seen Resident 22 try to get up on her own. Unlicensed Staff KK stated Resident 22 would stand-up using her walker to assist with transferring from the bed to the wheelchair. Unlicensed Staff KK stated Resident 22 was a Room Alert Elopement because she wore a WanderGuard. Unlicensed Staff KK stated if a resident got within 10 feet from an Exit door, the WanderGuard would go off. During a concurrent interview and record review at 3/28/19 at 9:40 a.m., DON was asked if Resident 22's elopement and fall, which took place on 10/10/18 per Nurse's Progress Notes had been investigated and if there had been a SBAR and PACS: Rehab status [REDACTED]. DON stated she wrote an IDT note, dated 10/15/18, as a clarification of the Nurse's Progress Note, dated 10/11/18, to clarify what occurred on 10/10/18 because Resident 22 was not found out on the back patio. The IDT note indicated, Resident 22 was self-ambulating (walking) throughout the facility when she was stepping out the rear entrance when noted to lose balance and fall just outside of rear entrance of building. The Nurse's Progress Note indicated Resident 22 had an unwitnessed fall. DON stated Resident 22's Fall Risk and Wander care plans should have been revised and there should have been a Short Term Post Fall care plan after Resident 22 returned from the acute care ED. During an interview on 3/28/19 at 11:35 a.m., MR C and DON were asked several times by surveyor for the SBAR, PACS: Rehab status [REDACTED]. MR C and DON could not find any of the documents to indicate a Post Fall investigation had taken place. The policy/procedure titled, Falls - Clinical Protocol, revised 3/18, indicated: 1. The staff and practitioner will review each resident's risk factors for falling and document in the medical record: a. Examples of risk factors for falling include gait and balance disorder, cognitive impairment, weakness, confusion, etc., 2. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall, 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is correctable, 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling .and also reconsider the current interventions, etc. Elopement 2 A review of Resident 22's Nurse's Progress Note, dated 10/14/18 at 4:22 p.m., indicated Resident 22 was found wandering outside the facility, the DON and daughter were notified about incident, activity people were to provide one on one supervision, and will continue to monitor for further evaluation. Resident 22's Wandering care plan, initiated 9/21/18, had no updated plan of care interventions indicating how often staff would frequent rounds to ensure safety, and no indication one on one supervision was provided, and if a WanderGuard was in place. The policy/procedure titled, Elopements, revised 12/07, indicated: 1. The attending physician, should be notified and Report of Incident/Accident should be completed and filed. Nurse's Note only indicated the DON and Resident 22's daughter was notified. There was no note of a Report of Incident/Accident was completed. A review of Resident 22's Nurse's Progress Notes, dated 10/14/18 at 9:29 p.m. indicated Resident 22 had a difficult day and had attempted several times on the PM shift to leave the facility. A review of Resident 22's Social Service Note, dated 10/15/18 at 12:14 p.m., indicated Social Services (S/S) talked to Resident 22's daughter, who let S/S know things Resident 22 enjoyed, such as sitting outside in the sun. Daughter used to give Resident 22 small projects at home to do in the backyard like separating leaves or twigs to keep her occupied, and she enjoyed solitaire. S/S indicated staff would provide 1:1 visits with the offering of the materials Resident 22's daughter suggested. Resident 22's care plan was not updated to include an Activities plan of care with the interventions recommended by Resident 22's daughter and/or indicated Resident 22 would receive 1:1 visits from the Activities staff. A review of Resident 22's Quarterly MDS, dated [DATE], indicated Resident 22 had a BIM score of 2 (severely cognitively impaired), had 1 fall with major injuries, and needed extensive assistance with transfer, walking, and toilet use A review of Resident 22's PACS: Nursing - Fall Risk Observation/Assessment - V2, dated 1/17/19, and PACS: Nursing - Wandering Risk Observation/Assessment - V2, dated 1/17/19, both completed by Manager M, indicated Resident 22 was at Moderate Risk for falling and at High Risk to wander, but there were no revisions done on Resident 22's Fall Risk care plan, initiated 9/23/18, and Resident 22's Elopement Secondary to Confusion/Wandering, care plan, initiated 9/21/18. The facility document titled, Job Description MDS Nurse, 7/18, indicated: 1. A primary function of the MDS nurse is to assess resident care needs, direct and supervise staff to meet the resident's needs, coordinate with other members of the IDT develop and implement a plan of care that meets the needs of the resident, 2. Conduct observations and interviews as well as evaluations required for MDS and/or care plan preparations, 3. Review orders with the appropriate nurse daily or more frequently if necessary, 4. Review accidents/accidents and critically ill/unstable residents, 5. Ensure all areas, which are triggered on the resident Assessment Protocol Summary, are included on the resident's plan of care The policy/procedure titled, Care Plans, Comprehensive Person-Centered, revised 12/16, indicated: 1. Care plan interventions are chosen 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: a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms of triggers, b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident, 2. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change, 3. The IDT must review and update the care plan: a. When desired outcome is not met, etc. 1b. During an interview, and concurrent record review, on 3/27/19, at 3:48 p.m., Manager M reviewed the electronic medical record for Resident 79 and confirmed there was a pattern of multiple falls. Manager M confirmed there was an unwitnessed fall on 9/12/18. Manager M was unable to provide a post fall assessment. The only documentation found was nursing progress notes. Review of the Interdisciplinary Team (IDT) meeting note, dated 9/24/18, indicated Resident 79 had another unwitnessed fall. During a review of the clinical record for Resident 79, the Care plan, indicated Resident 79 was at moderate risk for falls related to deconditioning and balance problems. The Goal for Resident 79 was to be free of falls through the review date. The date initiated was 8/8/18 and it was revised on 2/14/19. There were no changes made to the interventions for Resident 79 when though he had multiple falls. During a review of the clinical record for Resident 79, the Care plan, indicated Resident 79 had an actual fall with no injury on 2/13/19. The goal for Resident 79 was to resume usual activities without incident. The intervention was to continue the interventions from the at risk for falls section of the Care Plan. During an interview, on 3/27/19, at 3:55 p.m., Manager M confirmed that there were no changes to the Care Plan to reduce the risk for falls for Resident 79 even after three documented falls had occurred. Findings: 1c. During an interview with Resident 83 on 3/25/19 at 9:27 a.m., she stated it took a long time for staff to answer call lights, and her family helped her up to the bathroom and she fell . During a review of Resident 83s medical record, no fall was documented or care planned. A review of her Medical Data Sheet (MDS) (An MDS, or minimum data set, assessment is used by nursing homes to assess and plan care for patients.) information indicated her BIMS (Brief Interview for Mental Status) indicated a score of 9. (Residents with a BIMS score of 8-12 were considered to be mildly impaired. Residents were considered cognitively intact if they were able to complete the BIMS and scored between 13 and 15.) During an interview with the DON on 03/27/19 11:09 AM, she stated she was aware of a non-injury fall by Resident 83. She stated family was with the Resident. The DON stated she did not document the injury and did not follow the facility P&P because it was a non-injury fall. During an interview and record review with the DON, a review of Resident 83's medical record indicated there was no documentation about Resident 83's fall. The DON stated she would not be able to find anything because she didn't document anything. She stated it facility P&P to assess for non-injury and witnessed versus un-witnessed. She stated she would have to review the rest of the P&P for details. A review of the facility P&P titled Falls - Clinical Protocol, indicated 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, .c. Musculoskeletal function, .f. Pain; .Precipitating factors, details on how fall occurred; i. All current medications, .j. All active [DIAGNOSES REDACTED]. The physician will identify medical conditions affecting fall risks (for example, a recent stroke or medications that cause dizziness or [MEDICAL CONDITION])and the risk for significant complications of falls ( .increased risk of bleeding in someone taking anticoagulants). 5. The staff will evaluate and document falls that occur while the individual is in the facility: for example, when and where they happen, any observation of the events, etc. 2. During an interview with Resident 83 on 3/25/19 at 9:27 a.m., she stated was going to go to [MEDICAL TREATMENT] today. She pointed to her lunch bag and said they gave me a lunch to take with me. During an interview and document review with Manager M on 3/28/19 at 11:40 a.m., in his office, he stated he utilized the documentation in the medical record, physician orders [REDACTED]. He stated the DON and licensed staff also participate in the care plan process, and the Inter Disciplinary Team (IDT) complete an assessment upon Resident admission. Manager M stated the DON included care plans relevant to her assessment for Resident 83. A review of Resident 83's care plan for [MEDICAL TREATMENT] indicated Resident needs [MEDICAL TREATMENT] [MEDICAL TREATMENT] related to [MEDICAL CONDITION] dated 3/5/19. The care plan indicated in the section titled Interventions Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Manager M stated he did not know what the [MEDICAL TREATMENT] protocol was. During review of the [MEDICAL TREATMENT] Binder located at the nursing desk, there was only one document, and it was dated 3/27/19. The document was titled [MEDICAL TREATMENT]/OBSERVATION COMMUNICATION FORM Golden Living Center - Santa Rosa. Manager M stated the form was observed to be completed by the [MEDICAL TREATMENT] unit and it was supposed to be filled out by the Licensed Nurse before Resident 83 went to [MEDICAL TREATMENT] to communicate to the [MEDICAL TREATMENT] Nurses. Manager M stated there is nothing documented before or after treatment by the facility and it appeared staff at the facility were not consistently using the form to communicate and document to the [MEDICAL TREATMENT] center staff before and after Resident 83 had [MEDICAL TREATMENT] treatment. Manager M reviewed the care plan and he stated there was no documentation describing the type of [MEDICAL TREATMENT] catheter, side or site. A review of the care plan did not indicate when and how often to do vital signs before and after [MEDICAL TREATMENT]. Manager M reviewed the vital signs records on the [MEDICAL TREATMENT] days of Monday, Wednesday and Friday and stated staff are taking vital signs only once a day, and not before or after [MEDICAL TREATMENT]. He stated vital signs should be taken more often after returning from [MEDICAL TREATMENT] and stated the risk to resident care of not monitoring vital signs of a resident receiving [MEDICAL TREATMENT] is harm or death from complications post [MEDICAL TREATMENT]. Manager M was unable to provide a facility P&P for [MEDICAL TREATMENT] care. During a review of Resident 83's medical record, a document titled ADMISSION RECORD indicated she was admitted [DATE] from an acute care hospital. She was a 76-year female with [DIAGNOSES REDACTED]. A review of the facility P&P titled Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), 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. In the section titled Policy Interpretation and Implementation, the P&P indicated 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: a. Include measurable objective and timeframe; .g. Incorporate identified problem areas; .h. Incorporate risk factors associated with identified problems; .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. A review of the facility P&P titled Goals and Objective, Care Plans, revised (MONTH) 2009, indicated Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem .4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. A review of a facility document titled Job Description: Registered Nurse, dated 9/2018, indicated in the section titled Care Plan and Assessment Functions, Participate in the development of a written plan of care that identified the problems/needs of the resident, indicates the care to be given, goals to be accomplished .Review nurses's notes to determine if the care plan is being followed .Review resident's medical and nursing treatments to ensure that they are provided in accordance with the resident's care plan and wishes. A review of a facility document titled Job Description: Minimum Data Set (MDS) Nurse, dated 9/2018, indicated A primary function of the MDS nurse is to assess resident care needs, .coordinate with other members of the Inter-Disciplinary Team (IDT) develop and implement a plan of care that meets the individual needs of each resident. A review of a facility document titled [MEDICAL TREATMENT] Protocol, not dated, indicated in the section titled Documentation - The general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter 2. Condition of dressing (interventions if needed). 3. If [MEDICAL TREATMENT] was done during shift. 4. Any part of report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given. 5. Observations post-[MEDICAL TREATMENT]. A review of a facility document titled [MEDICAL CONDITION], Care of a Resident with, revised (MONTH) 2019, indicated Resident with [MEDICAL CONDITIONS] will be cared for according to currently recognized standards of care .1. Staff caring for residents with [MEDICAL CONDITION], including residents receiving [MEDICAL TREATMENT] care outside the facility, shall be trained in the care and special needs of these residents 5. The resident's comprehensive care plan will reflect the resident's needs related to [MEDICAL CONDITION]/[MEDICAL TREATMENT] care.

Based on interview and record review, the facility failed to address the redness of Resident 1's coccyx (tailbone), who was at risk for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), by not notifying the physician when it was first observed on 3/30/17. When Resident 1's sacral (relating to the sacrum a large, triangular bone at the base of the spine) wound was seen by the physician six days later, Resident 1 was sent out to the acute hospital for complicated sacral pressure ulcers. Findings: Review of the facility Admission Record (summary of important information about a patient) indicated Resident 1 was readmitted to the facility from an acute hospital on [DATE], with [DIAGNOSES REDACTED]. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion), urinary tract infection (is an infection in any part of your urinary system, kidneys, ureters, bladder and urethra), weakness, dementia (general term for a decline in mental ability severe enough to interfere with daily life) and severe protein-calorie malnutrition (refers to a form of malnutrition where there is inadequate calorie or protein intake). Review of Resident 1's Nursing Admission assessment dated [DATE], indicated Resident 1's skin was intact/clear. Resident 1's Braden score (a scale for predicting pressure ulcer) was 15 (15-18 at risk; 13-14 moderate risk; 10-12 high risk and less than 9 is severe risk). Review of Resident 1's Admission MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) an assessment tool dated 3/27/17, indicated severely impaired cognition (understanding, comprehension), requiring extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene; always incontinent (having no or insufficient voluntary control over urination or defecation ) of bladder and bowel and no unhealed pressure ulcers. Review of Resident 1's Physician order [REDACTED]. Review of Resident 1's Care Plan initiated on 3/5/17 indicated ulcer actual or at risk due to: assistance required in bed mobility, Braden score 18 or less, PCM (protein calorie malnutrition), [MEDICAL CONDITION] ([MEDICAL CONDITION], an umbrella term used to describe progressive lung diseases including [MEDICAL CONDITION], chronic [MEDICAL CONDITION]), PEG (percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate), HOB (head of bed) elevated increasing skin breakdown risk, Kyphosis (can be called roundback, abnormally excessive curvature of the spine as it occurs in the cervical (neck), [MEDICATION NAME] (relating to the chest) and sacral), [DIAGNOSES REDACTED] (redness) to coccyx/discoloration noted upon admit, sluggish to blanch (lose color briefly when you press your finger on it and then remove your finger) Updated 4/3/17. Poor compliance with positioning, restless. Interventions listed: Complete Braden Scale per facility policy; conduct weekly skin inspection; do not massage over bony prominence (areas where bones are close to the surface); encourage frequent repositioning and heel flotation; provide air mattress; provide pressure reducing wheelchair cushion; skin assessment to be completed per facility policy. Review of Resident 1's Progress Notes dated 3/30/17 at 9:16 a.m., indicated that the Treatment Nurse performed a skin check and documented Mild blanchable (redness should fade, when the skin is touched and released) [DIAGNOSES REDACTED] (redness) to coccyx. Fragile . Review of Resident 1's Progress Notes dated 4/3/17 at 1:35 p.m., indicated that Licensed Staff A documented a change of condition for Resident 1. [DIAGNOSES REDACTED] noted to bilateral (relating to two sides; affecting both sides) coccyx with encapsulated (as if in a capsule) tissue and multiple pustules (small bumps on the skin that contain fluid or pus). Resident 1 reported pain as a 10 (based on a pain scale of 1-10 with 0 being no pain, 1-3 as mild pain, 4-6 as moderate pain, and 7-10 as severe pain). The resident's representative and physician were notified. Review of Resident 1's Progress Notes dated 4/4/17 at 7:20 a.m., Licensed Staff B documented open area on sacrum. Review of Resident 1's Progress Notes dated 4/4/17 at 11:44 a.m., the Treatment Nurse documented, Pustules are no longer present. Confluent (flowing together or merging) [DIAGNOSES REDACTED] with satellite (surrounding) [MEDICAL CONDITION] remains but resolving. L (left) and R (right) coccyx continues to present with firm encapsulated tissue 3 cm (centimeter) long which is tender. R side which has a small raised, fleshy, draining area that was preeuptive (sic) looking yesterday. Review of Resident 1's Progress Notes dated 4/4/17 at 3:23 p.m., Licensed Staff A documented Resident 1's pustules are opened. Review of the Social Service Note dated 4/4/17 at 6:03 p.m., indicated the DPOA (durable power of attorney) was concerned about the opened area of Resident 1's bottom and requested that Resident 1 be sent out to the hospital. Social Service explained to the DPOA that the nurses are taking care of it and if Resident 1 needed to go out to the hospital the staff would contact him. Review of Progress Notes dated 4/4/17 at 10:43 p.m., Licensed Staff C documented that Resident 1 was seen by the physician for her sacral wound and Resident 1 ordered to be sent to the acute hospital by ambulance. Review of the physician progress notes [REDACTED]. Complicated sacral decubitus ulcers with abscess development. Pt (patient) will be transferred to acute hospital for I+D (incision and drainage), wound care and likely necessity for IV (intravenous) ABX (antibiotic), suggest wound culture . During an interview on 5/18/17 at 2:05 p.m., the Treatment Nurse when asked what prompted her to do a skin check, stated, A CNA (certified nurse assistant) reported. The Treatment Nurse was also asked if she informed the physician of her observation on 3/30/17 of Resident 1's redness to her buttocks, stated, No. I don't believe it was necessary, there was no need to. The Treatment Nurse when asked further why a change of condition was not initiated, stated, I didn't think it triggered a change of condition. The Treatment Nurse also stated she applied barrier cream, a skin protectant in individual tubes not requiring a physician order. Review of Resident 1's Weekly Skin Review indicated one skin assessment dated [DATE]. No other weekly skin assessment since readmission on 3/14/17. During an interview on 5/18/17 at 3:18 p.m., the Assistant Director of Nursing when shown the Skin assessment dated [DATE], stated It's the only one. Review of Resident 1's acute hospital's ED (Emergency Department) Provider Notes dated 4/4/17 indicated evidence of inflammation/phlegmon (a spreading diffuse [MEDICAL CONDITION] process with formation of purulent exudate consistent with more severe infections, and is commonly referred to as pus) over the sacrum and gluteal (gluteal muscles are a group of three muscles which make up the buttocks) area but no obvious drainable abscess. Resident 1 was admitted to the hospital. Review of the acute hospital's History and Physical dated 4/5/17 indicated that Resident 1 was noted to have a deep tissue injury and signs of early sacral wound. The wound was quite extensive and severe and Resident 1 was complaining of pain and was kept for pain control and wound care. Surgical debridement (removal of unhealthy tissue from a wound to promote healing using scalpels, forceps, scissors and other instruments) under MAC (Monitored Anesthesia Care, often referred to as twilight sleep) was recommended. Review of the acute hospital's Discharge Summary dated 4/24 17, indicated Resident 1 had necrotic (death of cells or tissues from severe injury or disease) pressure ulcer stage 4 (the pressure ulcer is very deep, reaching into muscle and bone and causing extensive damage) and underwent debridement and skin substitute graft (skin substitutes contain cells that promote healing) procedures. Review of facility document tilted Change in a Resident's Condition or Status revised November 2015, under Policy Statement indicated the facility shall promptly notify the resident, his/her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, .).Under Policy Interpretation and Implementation1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .b. A discovery of injuries of an unknown source; . d. A significant change in the resident's medical physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; . g. A need to transfer the resident to a hospital/treatment center; 2. A significant change of condition is a decline .in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self -limiting); . c. requires interdisciplinary review and/or revision to the care plan; Review of an undated facility Skin Integrity Guideline indicated: Purpose: to provide a comprehensive approach for monitoring skin conditions; to decrease pressure ulcer and/or wound formation by identifying those patients/residents who are at risk, and implementing appropriate interventions; to promote healing of wounds of any etiology, whether admitted or acquired. Objectives: decrease the prevalence and incidence of patients/residents who develop pressure ulcers; provide a guideline for optimal care to promote healing to patients with all identified alterations in skin integrity (surgical incisions, skin tears, bruising etc.). Documentation of Weekly Skin Evaluation/Observations: Licensed Nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review; Licensed Nurse to document progress weekly.

Based on observation, interview and record review, the facility failed to develop and implement effective interventions to prevent multiple falls and did not consistently update the nursing plan of care after each fall, per facility policy and procedure, for 1 of 19 sampled residents (Resident 3). These failures contributed to Resident 3 falling 10 times in a seven-month period (4/2016 through 11/2016). Resident 3 fractured his hip after his ninth fall (9/7/16) which required surgical repair. Resident 3 continued to have pain in his hip almost 5 months after surgery. Resident 3's tenth fall (11/15/16) placed him at risk for damage to his surgically repaired hip and additional injury. Findings: Review of Resident 3's medical record revealed he had [DIAGNOSES REDACTED]. His BIMS (brief interview for mental status), dated 12/21/16, indicated he had a score of 7 (severe cognitive impairment). Resident 3's fall risk assessment dated [DATE], revealed Resident 3 had a score of 12 (ten or greater indicates a high fall risk). The assessment indicated Resident 3 had intermittent confusion, had one to two falls in the previous three months, was chair bound (needed to stay in a chair), had balance problems while standing and walking, had lower extremity (legs) weakness, and required the use of an assistive device (wheel chair). Resident 3's nursing plan of care for fall risk, updated 9/7/16, indicated that Resident 3 was at risk for falls related to medication, history of falls, [DIAGNOSES REDACTED]. The Fall Risk care plan's goal was no serious fall related injuries. Care plan interventions to address fall risk were to assess pain, put bed in low position, put call light/personal items within easy reach, encourage resident to allow staff assistance with toileting and transfers, frequent reminders/encouragement to use call light for assistance, and grab bar in bathroom, verbally ask resident to toilet after meals and prior to going to bed, well lit/clutter free environment, labs as ordered by physician, fall mat beside bed, room close to nurses station, and observe medication side effects (fainting, low blood pressure, sedation, dizziness, increased confusion and impaired psychomotor function (origination of movement in conscious mental activity)), offer restroom every 1 to 2 hours and as needed, program for lower extremity exercises, therapy referrals, transfer pole in bathroom and trial at bedside, and use of alarms and pull-up briefs (diaper). The interventions indicated Resident 3 refused a Hipster (hip pad worn to protect hip in the event of a fall). First Fall: Review of Resident 3's Change of Condition progress note, dated 4/4/16 at 11:25 p.m., indicated Resident 3 got out of bed to go to the bathroom and the alarm sounded. Licensed Nurse B documented that Resident 1's knees and legs buckled, and she gently lowered him to the floor, a guided sit down assist to the floor. Resident 3's physician was notified. Review of Resident 3's Interdisciplinary Team Note (IDT), dated 4/5/16, indicated the team met due to resident fall. The IDT note indicated Resident 3 had a history of [REDACTED]. The IDT note indicated the team recommended continuing with scheduled toileting, medication review request, rehabilitation post fall evaluation as needed, and (staff) anticipation of needs, as able. Review of Resident 3's Post Fall Analysis/ Plan (dated 4/5/16) indicated Resident 3 fell on [DATE] at 11 p.m. The plan indicated Resident 3 had a history of [REDACTED]. The plan indicated Resident 3 had voided (urinated) one hour before the fall, was attempting to self transfer, and lost strength. The box under Possible Causal/Contributing Factors and Observations was blank. The box under, Specify Recommendations/Interventions taken to Prevent Reoccurrence was blank. The document indicated Resident 3's care plan was not revised after this fall. Second Fall: Review of Resident 3's Change of Condition progress note, dated 5/3/16 at 8:11 a.m., indicated Resident 3 got out of bed on his own and walked into the bathroom, where he had an unwitnessed fall. The note indicated while in the bathroom, Resident 3 lost his balance when lowering himself to the toilet and ended up on the floor. Review of the Post Fall Analysis Plan, dated 5/3/16 at 7:30 p.m., revealed the box under, Specify Recommendations/Interventions taken to Prevent Reoccurrence was blank. Third Fall: Review of Resident 3's Change of Condition progress note, dated 5/3/16 at 8:22 p.m. (twelve hours after his last fall), indicated, heard wheelchair alarm but too late. Found patient on the floor next to his wheelchair in his room. Patient attempted to transfer himself to bed but too weak . Review of the Post Fall Analysis Plan, dated 5/4/16, indicated Resident 3 was a high fall risk with poor safety awareness. The box under Specify Recommendations/Interventions taken to Prevent Reoccurrence indicated cont (continue) with use of alarm. The document indicated the care plan had not been revised after the third fall. Fourth Fall: Review of Resident 3's Change of Condition progress note, dated 5/4/16 at 7:30 a.m., indicated Resident 3 got out of bed in the middle of the night, to take self to bathroom, alarms sounding, but pt (patient) had already landed on buttocks in front of bathroom. Fifth Fall: Review of Resident 3's Change of Condition progress note, dated 5/12/16 at 7:25 p.m., indicated Resident 3 was found in sitting position next to his bed. Assessed for any injuries; no injuries noted related to unwitnessed fall . Review of the Post Fall Analysis Plan, dated 5/12/16, indicated Resident 3 attempted to transfer himself to the wheelchair but slipped to the floor. The box under Specify Recommendations/Interventions taken to Prevent Reoccurrence indicated reassure bed alarm and wheelchair in (sic) placed with proper function. Other interventions included wheel chair evaluation, pain management evaluation, and continue toileting schedule. Sixth Fall: Review of Resident 3's Change of Condition progress note, dated 5/15/16 at 1:30 a.m., indicated Resident 3 was found on the floor next to bed, alarm sounding, but pt (patient) transferred self before staff could asst (assist) . Review of the Post Fall Analysis Plan, dated 5/15/16, revealed box under Specify Recommendations/Interventions taken to Prevent Reoccurrence indicated cont (continue) bed in low position and alarms to chair and floor mat. Additional recommendations included medication review and physical therapy. Seventh Fall: Review of Resident 3's Change of Condition progress note, dated 6/2/16 at 9:26 p.m., indicated Resident 3 had an unwitnessed fall and staff found patient on the floor with small amount of bleeding near top of his heads with skin tear measured 1.2 cm (centimeters) Review of the Post Fall Analysis Plan, dated 6/2/16, indicated facility would recommend referral to a behavioral program and monitor every 15 minutes by staff. Eighth Fall: Review of Resident 3's Change of Condition progress note, dated 8/20/16 at 1:38 p.m., indicated Resident 3 had an unwitnessed fall and was found on the floor of the bathroom. Review of the Post Fall Analysis Plan, dated 8/20/16, revealed the identified recommendations and interventions after Resident 3's eighth fall had previously been implemented by the facility after his prior falls. The box under Specify Recommendations/Interventions taken to Prevent Reoccurrence indicated On Q15 min (every 15 minute) checks already for observation to help prevent falls. Resident receives regularly (sic) reinforcement teaching regarding the use of call light and need to ask for help when needed to transfer or use restroom. Resident verbalizes understanding but continues to be non compliant. Other previously implemented interventions included scheduled toileting plan and re-orient/redirect at all times as needed. The document indicated the Care Plan had not been updated after Resident 3's eighth fall. Ninth Fall: Review of Resident 3's Change of Condition progress note, dated 9/7/16 at 3:59 a.m., indicated Resident 3 was found on the bathroom floor, was screaming get me up off the floor, and stated his butt hurts. Review of the Post Fall Analysis Plan, dated 9/7/16, revealed Resident 3 tried to walk to the bathroom, was found by staff, and was screaming my butt hurts. Staff documented found plug to alarm was disconnected, (Resident 3) may have disconnected, has done this before, when he gets irritated with noise from alarm. The document indicated Resident 3 was transferred to an acute care hospital for further evaluation. Review of a hospital operative note, dated 9/7/16, indicated Resident 3 sustained a left femur fracture and underwent hip fracture surgery with nail insertion. A hospital discharge note, dated 9/12/15 (five days after admission), indicated Resident 3 was admitted for a hip fracture and had surgery to place a nail (for stability). During an interview with Administrator D and the Director of Nursing (DON) on 10/11/16 at 1:45 p.m., the DON stated Resident 3 had fallen approximately ten times. She stated he had an ORIF (open reduction, internal fixation - surgery to fix a broken bone) about one week earlier. She stated Resident 3 had behavior issues and was oriented only to himself (disoriented to time and place) and required extensive assistance from staff to transfer. 10th Fall: Review of Resident 3's Change of Condition progress note dated 11/15/16 at 11:04 p.m. (two months after his hip fracture and surgery) indicated Resident 3 had an unwitnessed fall in the bathroom. The note indicated Resident 3 suffered left arm and hand skin tears and bruising. Review of care plan titled Recent Fall (dated 11/16/16) indicated actual fall, unwitnessed, fall in the bathroom. The approach plan indicated frequent visual check . and more frequent rounds. Review of the Post Fall Analysis Plan, dated 11/15/16, revealed Resident 3 was attempting to get on the toilet. The box under Specify Recommendations/Interventions taken to Prevent Reoccurrence indicated ensure quiet environment, redirect, offer snacks/fluids. During an observation and interview on 2/1/17 at 11:25 a.m. (almost five months after his hip fracture and surgery), Resident 3 was lying in bed and able to talk. When asked if he had ever fallen he stated, Yes. I broke my butt. When asked how it was now feeling, Resident 3 stated, terrible and said he had pain. During an interview and review of Resident 3's medical record on 2/1/17 at 1:15 p.m., the DON reviewed the ten falls that occurred between 4/4/16 and 11/15/16. The DON was asked to describe the supervision Resident 3 received after his three falls between 5/3/16 and 5/4/16 (two-day period). She stated Resident 3 was closely monitored. When asked to describe the monitoring, she stated staff performed visual checks and they would walk by and look at him. During the same interview, the DON stated that Resident 3 had visual checks every fifteen minutes from 5/15/16 through 6/3/16 (to help prevent falls). The DON stated the next step would be one to one monitoring (a designated staff member that would stay with the resident at all times) but this was not yet required per (facility) evaluation. During the same interview on 2/1/17, the DON was asked to describe Resident 3's fall on 8/20/16. She stated Resident 3 was on visual checks every fifteen minutes at the time of the fall. When asked if that intervention was effective, she agreed frequent visual checks were not working (Resident 3 fell on [DATE] and on 8/20/16 while he had visual checks every fifteen minutes). The DON stated staff reinforced teaching but Resident 3 was noncompliant. She stated Resident 3's insurance provider would not give one to one (pay for one to one monitoring). During the same interview on 2/1/17, the DON was asked to describe Resident 3's fall on 9/7/16 (that caused his hip fracture). She stated Resident 3 was being visually monitored very fifteen minutes, the CNA (certified nursing assistant) had just seen him less than five minutes (earlier), and the alarm sounded. When asked if his monitoring and supervision (by staff) had been adequate, she stated Resident 2 needed constant redirection. The DON stated she could not say if the monitoring was enough or not enough and stated we accommodated his needs. The facility's policy and procedure titled, Fall Management Guideline (undated) indicated following a resident fall, appropriate interventions are implemented and care plan is updated. Review of facility policy titled, Fall Prevention (undated) indicated it was the policy of the facility to prepare a plan of care to reduce the potential for future falls. The document indicated, 16 the Post Fall Assessment . will be used to improve the resident's fall prevention plan ., 18. The care plan will be updated, post fall, identifying the fall and goals and approaches to reduce the potential of future reoccurrence, 19 Recommendations to reduce the potential for future falls will be care planned as appropriate.

Based on interview and record review, the facility failed to ensure safe and orderly transfer for 1 of 20 sampled residents (Resident 19) when the facility did not: confirm Resident 19's acceptance to an out-of-state skilled nursing facility, provide the receiving facility with Resident 19's medical records, and confirm the availability of a continuous oxygen supply, breathing treatments every four hours as needed, and physical assistance for eating and toileting for Resident 19. This failure resulted in Resident 19 experiencing physical discomfort during travel, prolonged psychological stress, and an avoidable emergency department treatment, with the potential to result in Resident 19's rapid decline in physical well-being including death. Findings: Review of Resident 19's "Admission Record" dated 10/3/13, reflected the need for skilled nursing care following a fall and surgery, a recent venous embolism and [MEDICAL CONDITION] and infection, plus a medical history of [REDACTED]. Review of Resident 19's Minimum Data Set (MDS), a resident assessment tool, dated 10/10/13, reflected a staff assessment for mental status indicating that Resident 19 had moderately impaired thinking and short-term and long-term memory problems. It also, indicated moderately impaired daily decision-making, meaning that Resident 19 made poor decisions and required cues/supervision. In addition, Resident 19 needed assistance with all activities of daily living, including meal set-up and incontinence care, medications, and supplemental oxygen Review of the "Medication Administration Record" dated 1/1/14, reflected physician's orders [REDACTED]. 1. Oxygen by nasal cannula, titrate to keep oxygen saturation greater than 92 percent. 2. [MEDICATION NAME] (medication used for shortness of breath or wheezing) every 4 hours as needed. During a telephone interview on 2/20/14 at 12:50 p.m., Administrative Staff R of the receiving facility stated that Resident 19 arrived unexpectedly at the facility on 1/15/14 at 4:30 p.m., 1800 miles from the discharging facility. Administrative Staff R stated the facility received initial paperwork about Resident 19 on 1/3/14, and requested additional information from the discharging facility on 1/6/14. The discharging facility did not contact the receiving facility again. Administrative Staff R stated she spoke with Resident 19's family member regarding the need for additional information before confirming acceptance, but never received a call back. Administrative Staff R stated that no one from the receiving facility accepted Resident 19 for placement. During an interview on 2/1/14 at 2:10 p.m., Administrative Staff C (of the discharging facility) stated she received an email from Administrative Staff U that Resident 19 was accepted for placement, but she did not confirm that information with the receiving facility or have any involvement with the transfer. During an interview on 2/1/14 at 3 p.m., and concurrent review of the facility's "Social Services Coordinator" job description dated 9/30/04, Administrative Staff C acknowledged her failure to assist Resident 19's family during her out-of-state transfer. A review of Resident 19's clinical record at the discharging facility, included a note dated 1/6/14, that the family had provided a list of possible skilled nursing facilities for Resident 19's relocation. The note further indicated that the discharging facility staff would "provide necessary paperwork for possible discharge to a (skilled nursing facility in another state)...." The next note regarding Resident 19's discharge date d 1/14/14 reflected that Resident 19 "has been accepted by (the receiving facility) and will discharge there on 1/15/14...." The record contained no documentation of communication with the receiving facility. During a telephone interview on 3/5/14 at 8:35 a.m., a family member of Resident 19 (Family S) stated she and another family member picked Resident 19 up at the airport and drove her to the receiving facility. Family S stated that Resident 19 was soaked with urine, hungry, and anxious when she got off the plane. The receiving facility told Resident 19 and Family S that they did not have a confirmation of admission. Family S stated the receiving facility told her, "We talked to someone (at the discharging facility) about a week ago, but we haven't heard anything since." Family S stated, "We didn't know what to do. I would have taken her home with me, but I'm disabled, too." The receiving facility suggested taking Resident 19 to the local emergency room . A review of Resident 19's out-of-state emergency department medical records, dated 1/5/14, reflected a [DIAGNOSES REDACTED]. In addition, Resident 19's pulse was high as 113 (A normal resting heart rate for adults ranges from 60 to 100 beats a minute anything above or below that may signal a problem) and oxygen saturation was as low as 90%. Resident 19 remained in the emergency department for 20 hours as a "social" admission until acceptance and placement in a skilled nursing facility. Further review of Resident 19's out-of state emergency department history and physical, dated 1/15/14, reflected that Resident 19 required oxygen and breathing treatments upon arrival. During a telephone interview on 2/20/14 at 12:50 p.m., Family S stated, "This whole thing has been a nightmare." A review of the discharging facility Interdisciplinary Discharge Summary, incorrectly dated 1/14/13 (correct date 1/14/14) reflects Resident 19 required assistance with ambulation, transfers, toileting, dressing, bathing and grooming, and required set up for eating. Resident 19 required a puree (ground to pudding consistency) diet with thick nectar liquids. The section of Resident 19's Interdisciplinary Discharge Summary titled "Post Discharge Plan of Care: Care and Services Required (include treatments/procedures)" indicates "Resident discharging to SNF in (another state) to be closer to daughter. (F)amily will take to airport." Resident 19's Discharge Summary has no entries in the areas designated for "Pre-discharge preparation of resident/family" and "Aid provided to resident/family in arranging post-discharge services." Resident 19's Discharge Summary also did not refer to use of supplemental oxygen. No documentation of collaboration with Resident 19's family regarding arrangements for supplemental oxygen, appropriate food, or required personal assistance during travel could be located in her clinical record. A review of the facility Social Services Policies and Procedures Manual, "Section 2: Assessment, Evaluation, and Documentation, Subject: SS-206 Discharge Plan," dated July 2006, revised October 2009, indicates that "Social services staff...will participate in the development of a discharge plan for residents with a potential for discharge...to another nursing facility or skilled nursing facility....The discharge plan is used...to address continuing care needs after discharge."