Every finding on record at Seaview Rehabilitation & Wellness Center, LP

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect during the provision of incontinent care when Certified Nursing Assistant A (CNA A) interacted with Resident 1 in a rude and disrespectful manner, causing Resident 1 to repeatedly call for help and request that CNA A be removed from the room.This finding had the potential to result in diminished dignity, trust, and emotional well-being for Resident 1 during personal care, as well as increased anxiety, reluctance to seek assistance, and a negative perception of the facility's caregiving environment. A review of the admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including left hemiplegia (paralysis [inability to move] one side of the body) following cerebral infarction (the death of brain tissue caused by a blocked blood vessel), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, leading to problems with memory, planning, and judgment), and anxiety disorder (mental health condition involving excessive, persistent fear, worry, and physical symptoms that interfere with daily life).A review of the Minimum Data Set (MDS), dated 06/2026, indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 14. Section E documented no hallucinations, delusions, psychosis, rejection of care, wandering, or behavioral symptoms directed toward others.During an interview conducted on 7/21/26, Resident 1 stated CNA A was rude while providing incontinent care and attempted to turn her onto her left side after she repeatedly stated she could not tolerate that position. Resident 1 stated she repeatedly called for help and requested CNA A be removed from the room. Resident 1 stated another CNA entered the room, CNA A left the room, and the resident's care was completed. Resident 1 stated she did not want CNA A to provide her care again.During an interview conducted on 7/22/26 at 10:15 a.m., CNA B stated he heard Resident 1 repeatedly calling for help and calling for Licensed Nurse B. CNA B stated he entered the room and heard Resident 1 state, Get this woman off of me and describe CNA A as rude and mean. CNA B stated he completed Resident 1's incontinent care after CNA A left the room.During an interview conducted on 7/22/26 at 10:30 a.m., Licensed Nurse B stated Resident 1 had been at her normal baseline prior to the incident. Licensed Nurse B stated Resident 1 later reported CNA A had been rough during incontinent care.During an interview conducted on 7/22/26 at 10:38 a.m., the Social Services Director stated Resident 1 normally communicated her needs appropriately and did not typically make complaints regarding staff.A review of the Situation, Background, Assessment, Recommendation (SBAR), dated 7/06/26 at 3 p.m., indicated Resident 1 reported CNA A had been rough while providing incontinent care.A review of the facility policy titled, Resident Rights, revised 1/01/12, indicated residents have the right to be treated with kindness, respect, and dignity and have the right to make choices regarding their care and daily routines.A review of the facility policy titled, Dressing the Resident, revised 1/01/12, indicated staff were to introduce themselves, explain the procedure before providing care, address the resident by name, encourage resident participation, observe resident tolerance, provide reassurance, and promote resident dignity and self-esteem throughout personal care.A review of the facility policy titled Resident Rights - Quality of Life, revised March 2017, indicated residents were to receive care that promoted dignity, individuality, respect, and quality of life. The policy further indicated staff were expected to communicate respectfully, explain care before providing services, encourage resident participation, and provide person-centered care consistent with resident preferences.

Based on interview and record review, the facility failed to ensure timely completion of a physician ordered psychological evaluation for one (1 ) of three (3 ) sampled residents (Resident 1).This failure resulted in an 11 month delay in needed mental health services, with potential exacerbation in Resident 1's continued confusion, agitation, and psychological distress.A review of Resident 1's Face Sheet (a facility demographic) indicated she was admitted on [DATE] with diagnoses including depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), age related cognitive decline (difficulty with thinking, memory, concentration beyond what is typically expected due to aging), and cognitive communication deficit (an impairment in communication caused by disrupted brain function, rather than a primary speech or language issue ).A review of the Minimum Data Set (MDS, resident assessment tool to evaluate each resident's physical, mental, and functional status), dated 2/25/26, indicated Resident 1 had severe cognitive impairment (a score in the 0-7 range points to serious challenges with cognitive tasks, such as repeating words, recalling items, and recognizing the current month or year) and had exhibited problematic behavior symptoms directed toward others, including threatening, yelling at, or cursing at staff.A review of the Order Summary Report, dated 6/23/26, indicated an order dated 7/30/25 for a Psychology/Psychiatry consult, with follow up treatment as indicated. There was no evidence the ordered consult had been completed at any time during the 11 month period.A review of facility Progress Notes, dated 3/09/26 at 6 a.m., indicated, [Resident 1] has increased agitation in evening. She has had multiple outbursts towards staff.is afraid for staff to the leave the room.[Facility MD] notified with request for tele psych referral.A review of facility Progress Notes, dated 4/02/26 at 2:43 p.m. indicated, [Resident 1] noted refusing CNA [Certified Nursing Assistant] to allow care.began to yell and wave her hand aggressively stating I don't want any of you bitches to touch me.A review of facility Progress Notes, dated 4/04/26 at 7:28 p.m., indicated [Resident 1] called police to make complaint.refused care.claimed she was being held captive.A review of facility Progress Notes, dated 6/18/26 at 3:04 p.m., indicated [Resident 1] became unhappy with the way a CNA was providing care for her.she was displeased with him and started to yell out loudly abuse.During an interview on 6/22/26 at 3:10 p.m., Resident 1 stated the 6/18/26 incident she reported as abuse was due to the CNA rushing her.During an interview on 6/23/26 at 11:30 a.m., the Director of Nursing (DON) stated the psychology/psychiatry consult order was an automatic admission order and acknowledged that, based on Resident 1's documented behaviors, the consult should have been arranged and completed. The DON further stated the facility's psychology/psychiatry provider had been on maternity leave and the covering provider failed to show up, resulting in no service being provided.A review of facility Policy and Procedure (P & P) titled, Referral to Outside Services, dated 12/01/13, indicated, The Director of Social Services is responsible for locating agencies and programs to meet the need of residents, facilitating the execution of service provider contracts, and referring residents to existing contracted providers.For clinical services, a nursing designee will assist the Director of Social Services in locating a provider.The Director of Social Services or his or her designee will coordinate with Nursing Staff to ensure that the Attending Physician's order and referral to outside provider is documented in the resident's medical record.

Based on interview and record review the facility failed to ensure a resident and the resident's family members were notified and invited to participate in care conferences (a collaborative meeting between a resident, their family, and the healthcare team to discuss the resident's health status, treatment progress, and update or establish a personalized care plan) for one resident (Resident 1) of three sampled residents.This failure decreased the facility's potential to ensure the resident and resident's family were given the opportunity to make decisions regarding Resident 1's healthcare goals and treatment.Findings:A review of Resident 1's Face Sheet indicated admission to the facility on 5/21/25 with diagnoses that included Chronic Atrial Fibrillation (a continuous, irregular, and often rapid heartbeat), Cervical Disc Disorders (a variety of neck conditions related to the breakdown of the spinal discs [the cushions between your neck vertebrae]), Bilateral Cystoid Macular Degeneration (an eye condition in which fluid accumulates in the central part of the eye) with blindness in both eyes, and Muscle Weakness.A review with the Minimum Data Set ( MDS, a resident assessment and care screening tool) dated 5/26/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, a standardized cognitive screening tool used to assess short-term memory, recall, and temporal orientation) score was 14 which meant her processes of thinking, remembering, and learning were intact.A review of the facility's census dated 6/3/26 indicated Resident 1 was no longer at the facility.A review of the facility's Interdisciplinary Team (IDT, a group of healthcare professionals who collaborate to provide personalized care to each resident) Care Conference notes on 6/3/26 indicated care conference meetings were held on 11/24/25, 2/16/26, and 5/16/26. The notes indicated a Registered Nurse/Licensed Vocational Nurse, Dietary staff, Social Worker and the Activity Department were in attendance. There was no indication Resident 1 and/or Resident 1's family members were invited or attended any of the meetings.During an interview on 6/3/26 at 11:46 a.m., the Social Service Director (SSD) acknowledged she was part of the IDT and stated Resident 1 and her family were always invited to the meetings. The SSD also stated Resident 1 always attended the meetings. The SSD further stated the attendees would be documented on the IDT notes. The SSD was asked to verify the attendees at each of the IDT meetings held on 5/16/26, 2/16/26 and 11/24/25 but was unable to provide any documented evidence to support Resident 1 and her family members had been invited and attended the care plan meetings.During a telephone interview on 6/16/26 at 11:10 am, Resident 1's Family Member (FM) stated he had not attended any care conferences for Resident 1 while she was at the facility. Resident 1's FM stated he was always invited and attended some of the care conferences at Resident 1's previous facility, but not at this facility.A review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, revised 4/24/25 indicated, Care Planning Conference.The facility must provide the resident and representative.reasonable notice of care planning conferences to enable resident and representative participation.The care planning meeting will be documented in the resident's clinical record.

Based on interview and record review the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week for a census of 39.This failure had the potential for residents to have unmet care needs and services.Findings:A review of the facility's third quarter (4/1/25-6/30/25) Payroll Based Journal (PBJ) Staffing Data Report, printed on 9/15/25, indicated the facility did not have RN coverage on 4/5/25, 5/16/25, 5/23/25, 5/26/25 and 6/20/25.A review of the facility's Daily Staffing Sheet dated 4/5/25, 5/16/25, 5/23/25, 5/26/25 and 6/20/25, indicated no RNs were scheduled.During an interview with the Administrator (ADM) on 9/24/25 at 1:57 p.m. the ADM confirmed there had been several days when no RN had worked eight consecutive hours and stated it was important to have an RN for the supervision and clinical assessment of residents.During a review of the facility's policy and procedure (P&P) titled, Nursing Department- Staffing, Scheduling & Postings, dated 7/18, the P&P indicated, To ensure than (sic) adequate number of nursing personnel are available to meet resident needs.

Based on observation, interview, and record review, the facility failed to ensure accurate reconciliation, accountability and disposition (the process of returning and/or destroying unused medications) of controlled medications (medications with high potential for abuse or addiction) and medication administration for a census of 39 residents when:Random controlled medication audits for two residents (Resident 20, and Resident 36) did not reconcile. The medications were signed out of Individual Narcotic Record (INR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents; and,The Controlled Substance Disposition Log was not provided for medications that were destroyed on 7/17/25 and 8/21/25.These failures resulted in the facility not having an accurate accountability of controlled substances and increased the potential for diversion.Findings:1.The controlled medication record for two random residents (Resident 20 and Resident 36) who received as needed controlled medications were requested for review during the survey.A review of Resident 20's Order Summary Report [OSR], dated 4/10/25, indicated, Hydrocodone- Acetaminophen Tablet 5-325 mg: Give 1 tablet by mouth every 6 hours as needed for pain.A review of Resident 20's INR for Hydrocodone-Acetaminophen Tablet 5-325mg, indicated nursing staff had removed the following from the medication cart and documented on the INR without documenting the respective administration on the MAR: One tablet on 9/15/25 at 7:30 p.m., one tablet on 9/18/25 at 6:45 p.m., one tablet on 9/20/25 at 5:30 a.m., and one tablet on 9/22/25 at 6:30 p.m.A review of Resident 36's OSR dated 6/21/24, indicated, oxycodone HCI Oral Tablet 5 mg: Give 1 tablet by mouth every 4 hours as needed.A review of Resident 36's INR for Oxycodone 5 mg, indicated the nursing staff had removed the following from the medication cart and documented on the INR without documenting the respective administration on the MAR: One tablet on 9/1/25 at 8 p.m., one tablet on 9/3/25 at 5 p.m., one tablet on 9/15/25 at 8:12 a.m., and one tablet on 9/16/25 at 8 p.m. The MAR indicated one tablet was given to the resident on 9/21/25, but this medication was not removed from the medication cart.In an interview on 9/23/25 at 1:40 p.m. Licensed Nurse 2 (LN 2) stated when narcotics are given, they are signed out in the INR and documented in the MAR.During a concurrent interview and record review on 9/23/25 at 1:45 p.m. of Resident 20 and Resident 36's narcotic documentation with the Director of Nursing (DON), the DON confirmed the INR did not match the MAR. The DON stated she expected staff to follow the policy and document the narcotic in the MAR, If they [nurses] take it, they have to say what they did with it.A review of the facility's policy and procedure (P&P) titled, Medication- Administration, dated 6/25, indicated, .The time and dose of the medication or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administered the medication or treatment.2. During a review of a facility provided document titled, CONTROLLED SUBSTANCE DISPOSITION LOG, the log indicated, Instructions: Upon receipt of the Narcotic Medication from the licensed nurse.the DON will complete this disposition log. The DON will also sign the Narcotic Bound Book. This log is maintained in a binder inside the Narcotic Drawer in the DONs office.A concurrent interview and record review on 9/24/25 at 9:17 a.m. of the narcotic disposition binder was conducted with the DON. The Controlled Substance Disposition Log for July and August were not in the binder. The DON confirmed the logs for both 7/17/25 and 8/21/25 were missing from the binder and stated it was important to keep an accurate account of narcotics. The DON stated, We need to know what comes in and what goes out and that nothing was taken. The DON stated she expected to see an accurate disposition record.In an interview on 9/24/25 at 12:18 p.m. the Regional Quality Management Consultant (RQMC) confirmed the logs were unable to be located. The RQMC stated it was important to have the Controlled Substance Disposition Logs so the facility would have a chain of custody of the narcotics. The RQMC stated she expected the log to be accurate, filled out by the DON and co-signed by the pharmacist.

Based on observations and interviews, the facility failed to protect the health of nine residents (Resident 37, Resident 38, Resident 35, Resident 3, Resident 14, Resident 34, Resident 1, Resident 21 and Resident 22) out of a census of 36 residents when:1. Hand hygiene was not performed prior to dining; and,2. Toilet plungers were placed directly on resident bathroom floors without being in receptacles.These failures decreased the facility's potential to prevent resident illness.Findings: 1. During an observation on 9/22/25 at 1:03 p.m. in Resident 37's room, Resident 37 was provided with his lunch tray without offering hand hygiene prior. There was no hand wipes were noted on Resident 37's lunch tray. During an observation on 9/22/25 at 1:05 p.m., in Resident 38's room, Resident 38 was provided with his lunch tray without offering hand hygiene prior. There was no hand wipes were noted on Resident 38's lunch tray. During an observation in Resident 3's room on 9/22/25 at 1:08 p.m., Certified Nursing Assistant 2 (CNA 2) donned (put on) Personal Protective Equipment (PPE) without first performing hand hygiene to feed Resident 3. The CNA intermittently assisted Resident 3's roommate on three separate occasions, failing to change gloves or perform hand hygiene between interactions with the residents. During an observation in Resident 14's room on 9/22/25 at 1:12 p.m., CNA 1 positioned Resident 14 in a seated position while in bed. CNA 1 started to feed Resident 14 without performing hand hygiene prior. During an observation in Resident 34's room on 9/22/25 at 1:14 p.m., Minimum Data Set Coordinator (MDSC) entered Resident 34's room. The MDSC assisted Resident 34 to eat without offering hand hygiene prior. During an interview on 9/22/25 at 1:29 p.m., the Infection Preventionist (IP) recommended hand hygiene for both residents and staff prior to eating or feeding. The IP stated, The hands are the dirtiest things on our bodies. They [Residents and staff] touch things, then they put the germs right in their mouths. The IP stated hand hygiene is the most important practice to follow to mitigate the spread of illness. A record review of the facility's policy titled Hand Hygiene dated 1/1/12 indicated, The facility considers hand hygiene the primary means to prevent the spread of infection.Facility staff follow the hand hygiene procedure to help prevent the spread of infections to other staff, residents, and visitors. 2. During a concurrent observation and interview on 9/22/25 at 9:36 a.m., CNA 4 verified a toilet plunger was sitting directly on the floor of the bathroom without a container to prevent contamination from bowel and bladder contamination and said, It should be stored in a container. They're supposed to have a receptacle to put it in. [Resident 21 and Resident 22] use that bathroom. During an observation on 9/22/25 at 10:05 a.m. there was a plunger observed sitting directly on the floor of the bathroom shared by Resident 1 and Resident 35 with no receptacle to catch the toilet drippings. During a concurrent observation and interview on 9/22/25 at 10:12 a.m. the IP verified a toilet plunger was placed directly on the floor of the bathroom shared by Resident 1 and Resident 35 and said, The plunger should not be directly on the floor. In an interview on 9/22/25 at 10:18 a.m. the Housekeeping Supervisor (HS) said, All plungers should be covered with a fresh plastic bag to keep the bacteria off the floor. The policy for storage of plungers in resident bathrooms was requested but not provided.

Based on interview and record review, the facility failed to ensure person centered, comprehensive care for seven residents (Resident 7, Resident 6, Resident 3, Resident 39, Resident 24, Resident 34, and Resident 10) out of a census of 36 when the Interdisciplinary Team (IDT-a group of healthcare professionals collaborating to develop and implement a resident centered treatment plan) did not plan quarterly care conferences or involve residents and/or Responsible Party (RP, a person or entity responsible for making healthcare decisions).These failures resulted in lost opportunities for the residents to be included in decisions regarding their care, treatment and interventions.Findings: A review of Resident 7's Multidisciplinary Care Conference (MCC), dated 9/10/24, indicated a quarterly care conference was held without Resident 7's RP present. A further review of Resident 7's medical chart indicated Resident 7 had no quarterly care conference held for the 4th quarter of 2024. A review of Resident 6's MCC, dated 10/23/24, indicated a quarterly care conference was held without Resident 5 nor Resident 5's RP present. A further review of Resident 5's medical chart indicated Resident had no quarterly care conferences for the first or second quarter of 2025. A review of Resident 3's MCC, dated 3/4/25, indicated a quarterly care conference was held without Resident 3 nor Resident 3's RP present. A further review of Resident 3's medical chart indicated Resident 3 had no quarterly care conference held in the 4th quarter of 2024. During an interview on 9/22/25 at 8:42 a.m., the Ombudsman (OMS) stated she had not attended any care conferences recently due to turnovers in leadership. During an interview on 9/22/25 at 11:12 a.m. Resident 39 said, I usually get care conferences where they discuss my care but not lately. During a concurrent record review and interview on 9/25/25 at approximately 12:30 p.m., evidence of Resident 39's last care conference was requested. The Social Services Director (SSS) verified Resident 39 had no care conference since 9/20/24. During a concurrent interview and record review on 9/22/25 at 2:46 p.m., Resident 6's daughter stated she was his RP. She stated she had not been invited to participate in a care conference in almost a year. She stated this concerned her because she wanted to speak with his physician and the team about Resident 6's health status. A review of Resident 6's medical chart indicated no quarterly care conference was held in the 4th quarter of 2024. During a record review on 9/23/25 of Resident 24's chart, MCC forms indicated no quarterly care conferences were held for Resident 24 during the 2nd and 3rd quarters of 2025. During a record review on 9/23/25 of Resident 34's chart, the MCC forms indicated an initial care conference was not held for Resident 34. During a record review on 9/23/25 of Resident 10's chart, the MCC forms indicated an initial care conference was not held for Resident 10. During an interview on 9/23/25 at 10:54 a.m., the SSD stated she was responsible for coordinating quarterly care conferences. The SSD stated prior to her accepting this position, quarterly care conferences were not completed for approximately one year. A review of the facility's policy titled Comprehensive Person-Centered Care Planning, dated November 2018 indicated, It is the policy of this facility to provide person-centered.interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.The IDT team will include.the resident and the resident's representative(s). An explanation must be included in a resident's medical record if participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.

Based on observation, interview and record review the facility failed to provide treatment and service to maintain or improve mobility for one resident (Resident 38) out of a census of 36 when Resident 38 did not receive Restorative Nurse Assistance (RNA-program designed to help residents maintain or regain maximum physical potential) sessions as ordered and was not evaluated for proper wheelchair height.This failure decreased the facility's potential to ensure Resident 38's ability to do activities of daily living (ADL, basic self-care tasks that are typically performed independently daily, i.e. dressing, bathing, toileting) did not diminish.Findings:A review of Resident 38's admission record indicated Resident 38 was admitted to the facility on [DATE] with a primary diagnosis of infection and inflammatory (part of the body becoming red, swollen, hot and often painful) reaction due to internal right hip prosthesis (artificial body part).A review of Resident 38's Section F-Preferences for Customary Routine and Activities of the Minimum Data Set (MDS-a federally mandated assessment tool) dated 6/26/25 indicated Resident 38 thought it was very important for him to participate in his favorite activities. A further review of this assessment indicated Resident 38 thought it was somewhat important for him to get fresh air when the weather was good and to participate in group activities with people.A review of Resident 38's Order Details, dated 7/18/25, indicated the RNA program was ordered for Resident 38 as follows, Active Range of Motion [resident moving joints through full range of motion without therapist assistance] to bilateral [both] extremities, ambulating with front rolling walker; 3 episodes per week.A review of Resident 38's progress note dated 7/29/25 at 4:18 p.m., indicated Resident 38 had joined the RNA program. A review of Resident 38's RNA documentation from 7/31/25 to 9/23/25 indicated Resident 38 did not receive RNA services three times per week as ordered.During a concurrent observation and interview on 9/22/25 at 9:23 a.m., Resident 38 was lying in bed with a hospital gown on with a healed amputation to Resident 38's right leg and partial hip area. Resident 38 stated he did not get out of bed much; however, would get out of bed and participate in more activities if his wheelchair was not so low. Resident 38 stated the wheelchair belonged to his sister-in-law, but it (the wheelchair) was too low for him to safely transfer out of his bed and propel himself out of the room. A wheelchair was observed folded and propped up against the wall. Resident 38 stated he was bored at times.During an interview on 9/23/25 at 11:30 a.m., the Administrator (ADM) stated the Physical Therapist (PT) was shared between three buildings and would come to the building when needed. The ADM further stated he cannot estimate how often PT worked at the facility. During an interview on 9/23/25, at 11:35 a.m., the PT stated evaluations for wheelchair height could be determined after the resident's weight, height and cognitive (relating to processes of thinking and reasoning) impairment was assessed. The PT further stated not having a wheelchair at the proper height posed a safety hazard for residents to fall and accidents occurred. During an interview on 9/24/25 at 12:50 p.m., the RNA stated she would try to work with Resident 38 two or three times per week but was occasionally pulled from her RNA duties to perform Certified Nursing Assistant (CNA) duties. RNA stated Resident 38's wheelchair is too low for him, and the PT was the only discipline who could determine a safe wheelchair height. The RNA further stated if a wheelchair was too low, a resident can get their legs caught up in the wheels or it would cause the resident to sit funny which would cause discomfort after sitting for a while.A review of the facility's document titled Restorative Nursing Program Guidelines, dated September 2019, indicated, Restorative care implies that the possibility for progress exists and that improvement can be expected.This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.

Based on observation, interview, and record review the facility failed to follow physician orders for one of 14 sampled residents (Resident 22) when the oxygen order did not match the amount of oxygen the resident was administered.This failure caused Resident 22 to receive the incorrect amount of oxygen.Findings:A review of an admission record indicated Resident 22 was admitted to the facility in early 2022 with diagnosis which included chronic respiratory failure with hypercapnia (condition where the body fails to adequately remove carbon dioxide from the blood) and hypoxia (low levels of oxygen in your body tissues).A review of Resident 22's physician order dated 7/17/25 indicated, PRN [as needed] Oxygen @2L [liters]/min Via NC [nasal cannula] .A review of Resident 22's care plan initiated 1/10/24 indicated, [Resident 22] has oxygen therapy r/t [related to] Ineffective gas exchange.OXYGEN SETTINGS: O2 [oxygen] via NC @ 1-2L PRN.During an observation on 9/22/25 at 8:23 a.m. of Resident 22's oxygen concentrator, the oxygen was set to deliver 4L/min. A picture was taken of the oxygen concentrator with the resident's permission.During a concurrent observation and interview on 9/23/25 at 11:43 a.m. of Resident 22's oxygen concentrator setting with Licensed Nurse (LN 1), LN 1 confirmed the oxygen setting was at 4L/min. LN 1 reviewed the physician order in the electronic health record (EHR) and stated the order was for 2L /min. LN 1confirmed staff was not following the physician order for oxygen and stated it was important to follow the physician's order.During an interview and record review on 9/23/25 at 1:58 p.m., the Director of Nursing (DON) was shown a picture of Resident 2's oxygen concentrator set at 4L/min. The DON confirmed the physician order was for 2L/min. The DON stated nurses should follow the physician order and nurses were responsible to ensure what the patient received matched the order.A review of the facility policy and procedure (P&P) titled, Oxygen Therapy, dated 11/17, indicated, .Administer oxygen per physician orders.

Based on observation, interviews and record reviews, the facility failed to ensure staff followed the facility's enhanced barrier precautions (EBP, an infection control intervention, that involves the use of gowns and gloves during high-contact care activities to reduce the transmission of Multidrug-Resistant Organisms [MDROs, bacteria, that have become resistant to multiple antibiotics]) for one out of two sampled residents (Resident 2) when staff did not wear gown while changing Resident 2's incontinence brief (a type of absorbent undergarment, similar to an adult diaper). This failure could result in a higher risk of transmitting MDROs to residents and could make residents sick. Findings A review of Resident 2's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 2 was admitted to the facility in September 2017 with diagnoses including Neuromuscular Dysfunction of Bladder (neurogenic bladder-a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). A review of Resident 2's care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed), dated 1/2025, indicated Resident 2 had an Indwelling Catheter (IC-a hollow tube inserted into the bladder to drain or collect urine). During a concurrent observation and interview on 6/18/25 at 2:58 p.m., Resident 2 was noted to have an IC. Unlicensed Staff E and Unlicensed Staff F was observed not wearing gowns while changing Resident 2's incontinence brief. Resident 2's room had a document by the door titled Enhanced Barrier Precautions (EBP). The EBP document indicated staff should wear gown and gloves when changing incontinence briefs. During an interview on 6/18/25 at 3:00 p.m., Unlicensed Staff E and Unlicensed Staff F verified they did not wear gowns when they changed Resident 2's incontinence brief. Unlicensed Staff E verified Resident 2 had an IC and they should have worn gowns when changing Resident 2s incontinence brief. Unlicensed Staff E stated following the EBP, such as wearing gown when changing incontinence briefs, was for infection prevention and to prevent cross contamination (when bacteria or other microorganisms are unintentionally transferred from one object to another). During an interview on 6/18/25 at 3:05 p.m., Resident 2 verified Unlicensed Staff E and Unlicensed Staff F did not wear gowns when they changed her incontinence brief earlier. Resident 2 stated she was surprised to learn that staff should be wearing a gown whenever they changed her incontinence brief and added, staff had never wore a gown when they were changing her incontinence brief. During an interview on 6/18/25 at 3:17 p.m., Licensed Nurse (LN) G stated residents with ICs were placed on EBP and staff should wear gowns when they were changing incontinence briefs as an infection control measure, to prevent cross contamination and getting others sick. During an interview on 6/18/25 at 3:25 p.m., the Infection Preventionist (IP) stated all residents who had an IC were placed on EBP. The IP verified Resident 2 had an IC and staff should wear gown when they were changing Resident 2's incontinence brief. The IP stated if staff did not wear a gown while changing Resident 2's incontinence brief, it meant the EBP was not followed. The IP stated it was important to follow the EBP as an infection prevention measure and to prevent cross contamination. A review of the document from California Department of Public Health (CDPH, licensing) titled Enhanced Barrier Precaution (EBP) indicated, .anyone participating in any of these six moments must also: [NAME] [put on] gown and gloves .toileting and changing incontinence briefs . A review of the facility's policy and procedure (P&P) titled Enhanced Barrier Precautions, revised 6/7/24, it indicated, . EBP applies for all residents with any of the following: .wounds or indwelling medical devices such as urinary catheter and to wear gown and gloves when changing briefs .

Based on interviews and record reviews, the facility failed to ensure: 1. staff were knowledgeable of the abuse reporting guidelines: whom to report abuse allegations and the time frame for reporting abuse allegations, and 2.an abuse allegation was reported within the two-hour reporting time frame. These failures could put all facility residents at risk to experience abuse without timely reporting to the designated agencies. Findings: 1. During an interview on 6/18/25 at 10:54 a.m., Unlicensed Staff A stated abuse allegations should be reported to the state (California Department of Public Health or CDPH) and the Administrator (ADM) within 24 hours. Unlicensed Staff A stated it was important for abuse allegations to be reported to the right agencies and at the appropriate time frame so the allegations could be investigated while the details were still clear for the safety and wellbeing of the residents. During an interview on 6/18/25 at 12:57 a.m., Licensed Nurse (LN) B stated abuse allegations were expected to be reported to the state and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). LN B stated the police should be notified depending on type of abuse. LN B stated it was important to know the correct agency to report abuse allegations to ensure residents safety. During an interview on 6/18/25 at 1:21 p.m., Unlicensed Staff C stated was expected to report abuse allegations only to the ombudsman and the state. Unlicensed Staff C stated as far she knew, abuse allegations should be reported within 24 hours to get the story straight and to get the alleged abuser away to protect the resident. During an interview on 6/18/24 at 2:04 p.m., the Minimum Data Set assessment Coordinator (MDSC, a licensed nurse, often an RN, who manages the assessment process for residents in long-term care facilities using the MDS system) stated was expected to report abuse allegations to the ombudsman and then asked, was there more? The MDSC stated it was important to report abuse allegations to the right agencies to protect the resident. During an interview on 6/18/25 at 3:19 p.m., Unlicensed Staff D stated was expected to report abuse allegations within 24 hours only to law enforcement and the Ombudsman. Unlicensed Staff D stated it was important abuse allegations were reported to the right agencies to protect residents' rights and to snip the abuse in the bud really quick. During an interview on 6/18/25 at 3:25 p.m., the Infection Preventionist (IP) stated was expected to report abuse allegations only to the ombudsman and law enforcement to protect the resident. A review of the All Facilities Letter (AFL, information contained may include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) 21-26, dated 7/26/21, indicated, . Pursuant to Title 42 CFR section 483.12(c)(1) . facilities must report any instance of suspected or alleged abuse, neglect, exploitation, and/or mistreatment of elders or dependent adults to their local law enforcement agency, LTC ombudsman, and [CDPH]. When to Report . for incidents that involve abuse or result in serious bodily injury, facilities must: Call local law enforcement immediately, but no later than two hours after the allegation is made. File a written or electronic report to the LTC ombudsman, local law enforcement, and [CDPH] within two hours . for any other reasonable suspicion that does not result in abuse or serious bodily injury, facilities must: Call local law enforcement as soon as possible, but no later than 24 hours after the allegation is made. File a written or electronic report to the [Ombudsman], local law enforcement and [CDPH] within 24 hours . 2. During a review of the Report of suspected dependent adult/elder abuse, dated 5/24/25, indicated an allegation abuse occurred on 5/23/25 when, .observe [Certified Nursing Assistant] holding a sheet over [Resident's] head and pushing her down . A review of the facility's fax confirmations, for date 5/24/25, indicated the Report of suspected dependent adult/elder abuse was faxed to the Ombudsman on 5/24/25 at 9:43 a.m. and the Humboldt Sheriff Department (HSD) on 5/24/25 at 11:39 a.m. During a concurrent interview and record review on 6/18/25 at 3:56 p.m., with the ADM, Report of suspected dependent adult/elder abuse and email and fax confirmation receipts, dated 5/24/25, were reviewed. The ADM confirmed the abuse allegation occurred on 5/23/25 and all abuse allegations should be reported to the state, the Ombudsman and law enforcement within 2 hours. The ADM verified the facility did not meet the two hour reporting time frame requirement when the abuse allegation was reported to the Ombudsman on 5/24/25 at 9:43 a.m. and the HSD on 5/24/25 at 11:39 a.m.

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin potentially resulting from abuse to the Department within two hours. This failure delayed the Department's investigation of the injury and potential abuse. The facility further failed to ensure staff were trained on reporting abuse allegations. This failure placed residents at risk of abuse. During an interview on 5/21/24 at 2:00 PM, the Administrator in Training (AIT) stated injury of unknown origin for Resident 1 was reported on 5/17/24. During an interview on 5/21/24 at 2:35 PM, Unlicensed Staff A stated she entered Resident 1's room on 5/17/24 to assist him with getting dressed. Unlicensed Staff A helped Resident 1 remove his shirt and she observed bruising on his left upper chest and going into his left armpit. The bruising was all shades - purple, blue, yellow, and green. Unlicensed staff A asked Resident 1 what happened. Resident 1 stated it happened last night when a guy came in and roughed me up. Unlicensed Staff A immediately reported the bruising to Licensed Nurse B. During an interview on 5/21/24 at 3:00 PM, Licensed Nurse B stated she reviewed a shower sheet (a record of resident's skin condition observed during shower time) for Resident 1, dated 5/13/24. The shower sheet had a drawing of a body and the unlicensed staff who showered Resident 1 marked skin conditions on the drawing. The drawing showed Resident 1 had bruising on his chest, left upper arm, and left underarm. Licensed Nurse B stated Licensed Nurse C looked at the bruising after it was documented on the shower sheet on 5/13/24. During an interview and record review on 5/21/24 at 3:28 PM with Licensed Nurse C, Licensed Nurse C verified the shower sheet for Resident 1, dated 5/13/24, showed bruising on chest, left upper arm, and left arm pit. Licensed Nurse C stated no one reported bruising to her on 5/13/24. Licensed Nurse C further stated she looked at Resident 1's bruising on his left chest and left arm pit when it was reported to her on 5/17/24. Licensed Nurse C requested an order for a chest x-ray for Resident 1 on 5/17/24. Licensed Nurse C stated shower sheets were reviewed the day of the shower or the next day by a licensed nurse. During an interview on 5/21/24 at 4:35 PM, Unlicensed Staff H stated she had 24 hours to report abuse but reported as soon as possible. During an interview and observation on 5/21/24 at 4:40 PM, with Unlicensed Staff D, Resident 1 was lying in his bed. Unlicensed Staff D held up Resident 1's shirt and he had multicolored (blue, purple, green, and yellow) bruising on his left chest and left armpit. Unlicensed Staff D stated she reported suspected abuse immediately, but we have 24 hours. During an interview on 5/21/24 at 4:55 PM, Licensed Nurse B stated we reported abuse immediately and we had 24 hours to report to the state. During an interview on 5/21/24 at 4:56 PM, Unlicensed Staff E stated she provided a shower to Resident 1 on 5/13/24. Unlicensed Staff E stated she observed bruising on Resident 1's left chest and left armpit during his shower on 5/13/24. Unlicensed Staff E documented the bruising on the shower sheet and reported to the charge nurse on the same day. During an interview on 5/21/24 at 5:25 PM, Licensed Nurse F stated he did not recall if Unlicensed Staff E reported Resident 1's bruising on 5/13/24. During an interview on 5/21/24 at 5:35 PM, the Director of Nursing (DON) stated Licensed Nurse F worked a double shift on 5/13/24 and was the charge nurse for both AM and PM shifts. Record review of documents for Resident 1 titled Weekly Assessment Worksheet , with instructions to be completed by CNA and given to charge nurse on bath/shower day . , the following was indicated: 4/22/24 bandage on right hip with bruising 4/26/24 no new skin conditions 4/27/24 no new skin conditions 4/29/24 refused 3 times 5/2/24 resident refused because he was sleeping 5/6/24 no new skin issues 5/9/24 shower offered and refused 3 attempts 5/13/24 scab left lower arm and right wrist, bruising on chest, left upper arm, and armpit 5/16/24 resident refused shower and/or bed bath 5/20/24 scab right hand, bruising on chest left upper body and left arm Record review of policy titled Abuse Reporting and Investigations , policy indicated as the purpose, To protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of unknown source .are promptly reported . The policy also indicated, Administrator or designated representative will also notify .CDPH by telephone and in writing (SOC 341) within two (2) hours of initial report. Record review of a document titled, SOC 341 Report of Suspected Dependent Adult/Elder Abuse indicated the document was completed on 5/17/24. Record review of a document titled, Fax Cover Sheet indicated the SOC 341 was faxed to the Department on 5/17/24 at 1:40 PM.

Based on observation, interview, and record review the facility failed to provide behavioral management care according to the care plan of one of two sampled residents (Resident 1) when staff argued with Resident 1, who had a known behavior of verbal and physical aggression towards staff, and staff did not remove or redirect Resident 1 from the source of agitation. This failure resulted in Resident 1's behavior escalating and to continue his aggression for 10 to 20 minutes. Findings: During an observation and concurrent interview on 2/7/24 at 11:15 a.m., Resident 1 was sitting in his bed in his room directly across from the nurses' station. Resident 1 stated that on 1/28/24 he was in bed and called for assistance to the bathroom. He stated he waited an hour for his aide, and another aide finally came and got him to the bathroom. Resident 1 stated that later that day he saw his aide, Unlicensed Staff A, and told her the other aides can't do all your work for you, you need to pick it up. Resident 1 stated, She (Unlicensed Staff A) got all mad. I told her to quit being so lazy, she said ' you're the one who's lazy, that's why you're in that wheelchair.' When asked how that made him feel, Resident 1 stated, It made me mad. I'm like a ticking time bomb. During an interview on 2/22/24 at 9:21 a.m., Licensed Nurse B stated she remembered the incident with Resident 1 and Unlicensed Staff A on 1/28/24. Licensed Nurse B stated she was at the nurses' station, Resident 1 was in the hallway in his wheelchair, and Unlicensed Staff A was in a room helping a resident. Licensed Nurse B stated Resident 1 started yelling at Unlicensed Staff A, and Unlicensed Staff A responded, If you would just let me finish helping your roommate, I could help you. Licensed Nurse B stated Resident 1 told Unlicensed Staff A, You need to get the fuck out of my room. Licensed Nurse B stated Resident 1 did that a lot, he gets in a mood and goes off on whoever. Licensed Nurse B stated Unlicensed Staff A could have stopped it (Resident 1's behavior) by not responding, but since she said that, it escalated it. It was an ugly scene. During an interview on 2/22/24 at 2:21 p.m., Unlicensed Staff C stated that on 1/28/24 she helped Unlicensed Staff A put a resident back to bed. Unlicensed Staff C stated that when they came out of the resident's room, Unlicensed Staff A had her hands full of dirty laundry and Resident 1's call light was on, so she (Unlicensed Staff C) went to help Resident 1 while Unlicensed Staff A took care of the laundry. Unlicensed Staff C stated Resident 1 started yelling and cussing at Unlicensed Staff A for not helping him, she told him she had been busy and apologized. Unlicensed Staff C stated Unlicensed Staff A went into another resident's room to help him and Resident 1 followed her and continued yelling and cussing at her. During an interview on 2/22/24 at 3:10 p.m., Unlicensed Staff D stated he remembered that on 1/28/24 Unlicensed Staff A called him to Resident 1's room and asked for a mop because there was poop on the floor. Unlicensed Staff D stated he started mopping and Resident 1 started yelling at Unlicensed Staff A, He was talking crap to her asking why didn't she do her job, why did she call him (Unlicensed Staff D) to come do her job? Unlicensed Staff D stated Resident 1 got really aggressive and moved towards Unlicensed Staff A, acting like he was going to hit her, he was verbally calling her names and stuff. Unlicensed Staff D stated Unlicensed Staff A asked Resident 1, What are you going to do, [Resident 1 named]? Are you going to hit me? During an interview on 2/26/24 at 9:02 a.m., Licensed Nurse E stated she remembered that on 1/28/24 she heard Resident 1 and Unlicensed Staff A arguing, and then two nurses came to her office to inform her Resident 1 was in the hall and Unlicensed Staff A was in Resident 1's room and they were yelling at each other. Licensed Nurse E stated Resident 1 had this behavior of yelling and cussing at staff. Licensed Nurse E stated she heard Unlicensed Staff A tell another aide that Resident 1's behavior was like a toddler within ear shot of Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A swearing and yelling at Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A say to Resident 1 that she needed to take care of your roommate in your fucking room. Licensed Nurse E stated she did not intervene during these interactions between Resident 1 and Unlicensed Staff A. During an interview on 3/13/24 at 2:12 p.m., Licensed Nurse E stated that when Resident 1 and Unlicensed Staff A were arguing on 1/28/24, nobody did anything. Licensed Nurse E stated that Resident 1 was yelling at Unlicensed Staff A for approximately 15 to 20 minutes before eventually Licensed Nurse F told Unlicensed Staff A she needed to walk away. Licensed Nurse E stated Resident 1 was pretty good about being redirected, but if you engage, he gets worse. Licensed Nurse E verified she was the management in the facility on 1/28/24. Licensed Nurse E stated she took Resident 1 down to file a grievance just to remove him from the situation and that finally stopped it. When asked how the staff should have responded to Resident 1's behavior, Licensed Nurse E stated the charge nurse should have told them to stop and separated them. During an interview on 3/13/24 at 2:51 p.m., Unlicensed Staff A stated she remembered that on 1/28/24 Resident 1 was upset, verbally abusing me, displeased that he didn't get help going number two. Unlicensed Staff A stated that she looked at her nurse while this was happening, but she didn't do anything. Unlicensed Staff A stated Unlicensed Staff C helped her get a resident back to bed, then she helped Resident 1's roommate with his shower, and, [Resident 1] followed me, verbally abusing me. She stated Unlicensed Staff D came to clean up poop in Resident 1's room, and Resident 1 called her lazy for having Unlicensed Staff D do her job. Unlicensed Staff A stated she explained to Resident 1 that she cleaned it up, Unlicensed Staff D was just going over the area with a bleach mop, and then [Resident 1] shook his fist at me and threatened to punch me. Unlicensed Staff A verified Unlicensed Staff D was in the room at that time. Unlicensed Staff A stated she looked at the nurses sitting at the nurses' station (across from Resident 1's room) and they were all looking away. When asked if there was any management in the facility at the time of the incident, Unlicensed Staff A stated Licensed Nurse E was the management that day. Unlicensed Staff A stated she did not ask Licensed Nurse E to help with Resident 1 as she had not helped in the past. Unlicensed Staff A stated Licensed Nurse E sat at the nurses' station and watched the whole thing. Unlicensed Staff A stated that when Resident 1 wanted to file a grievance, Licensed Nurse E jumped in and offered to take Resident 1 to file the grievance. When queried, Unlicensed Staff A denied she had gotten training on how to manage Resident 1's behavior. Unlicensed Staff A stated she really believed he would have hit her, and I'm really scared of him, and I don't know whatto do. Unlicensed Staff A stated she had cared for him for one year without training on how to manage his aggression. When queried, Unlicensed Staff A stated for 10 to 15 minutes Resident 1 yelled at her (on 1/28/24) and followed her from the linen closet to his room and down to the other end of the hall to another resident's room. Unlicensed Staff A stated that at one point she heard Unlicensed Staff C ask the nurses, Aren't you going to do anything? (about his aggression towards Unlicensed Staff A) and they said, No. During an interview on 3/14/24 at 3:53 p.m., Director of Nursing (DON) stated that unfortunately the staff were afraid Resident 1 would target them if they intervened when he got aggressive. DON stated her expectation was that staff would de-escalate him when he was aggressive towards staff. DON verified that Resident 1's care plan indicated management would intervene and stated that normally if she was there, she would go talk to him. DON verified Licensed Nurse E was the management staff in the facility on 1/28/24 and stated Licensed Nurse E did take Resident 1 to her office to file the grievance. Review of Resident 1's face sheet revealed an admitted [DATE] with medical diagnoses including left-sided weakness and paralysis following a stroke (a blood clot or bleed in the brain), heart failure, chronic kidney disease, depression, and a blood clot in the lung, among others. Review of Resident 1's care plan indicated a focus area, initiated 7/13/23, The resident is verbally aggressive towards staff [related to] Ineffective Coping Skills, Mental/Emotional Illness, Poor impulse control. Interventions for this focus area, dated 7/13/23, included, The resident's triggers for verbal aggression are unpredictable. The resident's behaviors is [sic] de-escalated by speaking to management 1 to 1 and When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later among others. Further review of Resident 1's care plan indicated a focus area initiated on 7/13/23, The resident has potential to be physically aggressive towards staff [related to] Anger, Depression, Poor impulse control. Interventions, also initiated on 7/13/23, included, The resident's triggers for physical aggression are unpredictable. The resident's behaviors is [sic] de-escalated by speaking to management, food and When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later among others. Review of facility policy and procedure Behavior Management, last revised 1/2020, indicated, Purpose: To ensure the facility provides the necessary behavioral healthcare and services to residents in accordance with their comprehensive assessment and person-centered plan of care. Policy: The facility will ensure that when a resident displays a mental disorder, psychosocial adjustment difficulties (e.g. crying, yelling, hitting, etc.) . they will receive appropriate treatment to address the problem or attain the highest practicable mental and psychosocial wellbeing. Procedure: . C. In an effort to manage the behavioral problem(s) the IDT (interdisciplinary team) will: . iii. Use effective verbal and non-verbal communication techniques . vi. Avoid arguing or debating with the resident.

Based on observation, interview, and record review, the facility failed to report potential abuse timely when a nurse witnessed a certified nursing assistant yell and cuss at a resident, Resident 1, and facility staff did not report the incident, or Resident 1's grievance about the incident, to the Department for three days. This failure resulted in a delayed suspension of a potentially abusive staff member and a delayed investigation into an allegation of abuse of a vulnerable resident. Findings: On 1/31/24, the Department received a report from the facility that indicated, During a meeting on 1/31/24 @ 3:30 pm the ombudsman had reported that they had received a report of potential abuse between this resident and a staff member. Immediately initiated an investigation and staff member suspended immediately. During an observation and concurrent interview on 2/7/24 at 11:15 a.m., Resident 1 was sitting in his bed in his room. Resident 1 stated that on 1/28/24 he waited an hour for his aide to help him with toileting, and another aide finally came and got him to the bathroom. Resident 1 stated that later when he saw his aide, Unlicensed Staff A, he told her the other aides can't do all your work for you, you need to pick it up. Resident 1 stated, She (Unlicensed Staff A) got all mad. I told her to quit being so lazy, she said ' you're the one who's lazy, that's why you're in that wheelchair.' When asked how that made him feel, Resident 1 stated, It made me mad. I'm like a ticking time bomb. During an interview on 2/26/24 at 9:02 a.m., Licensed Nurse E stated she remembered that on 1/28/24 she heard Resident 1 and Unlicensed Staff A arguing, and she sent a text to the Director of Nursing to inform her of the argument. Licensed Nurse E stated two nurses also came to her office to inform her Resident 1 was in the hall and Unlicensed Staff A was in Resident 1's room and they were yelling at each other. Licensed Nurse E stated that she heard Unlicensed Staff A tell another aide that Resident 1's behavior was like a toddler within ear shot of Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A swearing and yelling at Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A say to Resident 1 that she needed to take care of your roommate in your fucking room. Licensed Nurse E stated she did not intervene during these interactions between Resident 1 and Unlicensed Staff A. During an interview on 3/13/24 at 2:12 p.m., Licensed Nurse E stated that when Resident 1 and Unlicensed Staff A were arguing on 1/28/24, nobody did anything. Licensed Nurse E stated usually no one intervened when Unlicensed Staff A started yelling because it did not help (she would continue to yell). When asked if staff yelling and cussing at a resident was potential verbal abuse, Licensed Nurse E stated, Yes. When queried, Licensed Nurse E stated she should have reported it to the Director of Nursing and filled out an SOC 341 (official document used to report alleged elder abuse, which is sent to the Department and the ombudsman's office). Licensed Nurse E stated she took Resident 1 down to her office to file a grievance to remove him from the situation, and that finally stopped the argument. During an interview on 3/14/24 at 4:35 p.m., Administrator verified he was the abuse coordinator. When queried about his expectation for reporting abuse, Administrator stated that in the case of the incident involving Unlicensed Staff A and Resident 1, they did not have the information about what happened (the alleged abuse) until the ombudsman told them about it, but if they do have the information, it should be reported that day. Administrator verified that if a staff witnessed another staff yelling and cussing at a resident, that should have been reported. Review of facility document Resident Grievance/Complaint Investigation Report, dated 1/28/24, indicated Resident 1's name at the top and Licensed Nurse A's name as the staff member completing the form. Section titled Subject of Grievance/Complaint indicated, . when up in chair he came out and told [Unlicensed Staff A] she wasn't doing her job. This turned into an argument. He told her she was lazy. She told him he was lazy too and that's why he's stuck in a [wheelchair]. Review of facility policy and procedure Abuse - Reporting & Investigations, last revised 3/2018, indicated, The Facility will report all allegations of abuse . as required by law and regulations to the appropriate agencies. The Facility promptly reports and throroughly investigates all allegations of resident abuse, mistreatment . If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facilities [sic] policies. Subsection titled, Notification of Outside Agencies of Allegation of Abuse with No Serious Bodily Injury indicated, A. The Administrator or designated representative will notify within two (2) hours notify [sic], by telephone, CDPH, the Ombudsman and Law Enforcement. B. The Administrator or designated representative will send a written SOC341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours.

Based on observation, interview, and record review, the facility failed to implement its abuse prevention policy for one of two sampled residents, Resident 1, when staff did not implement Resident 1's care plan for a behavior that put him at high risk for conflict, and staff were not trained on how to respond to his aggression. This resulted in Resident 1 arguing aggressively with a staff member while no staff intervened for approximately 10 to 20 minutes. Findings: During an observation and concurrent interview on 2/7/24 at 11:15 a.m., Resident 1 was sitting in his bed in his room directly across from the nurses' station. A transfer pole (a floor-to-ceiling grab bar used for transferring between the bed and wheelchair) was noted at his bedside. Resident 1 stated that on 1/28/24 he was in bed and needed to go bad, I needed to have a BM (bowel movement). He stated he waited an hour for his aide, and another aide finally came and got him to the bathroom. Resident 1 stated that later when he saw his aide, Unlicensed Staff A, he told her the other aides can't do all your work for you, you need to pick it up. Resident 1 stated, She (Unlicensed Staff A) got all mad. I told her to quit being so lazy, she said ' you're the one who's lazy, that's why you're in that wheelchair.' When asked how that made him feel, Resident 1 stated, It made me mad. I'm like a ticking time bomb. During an interview on 2/22/24 at 9:21 a.m., Licensed Nurse B stated she remembered the incident with Resident 1 and Unlicensed Staff A on 1/28/24. Licensed Nurse B stated she was at the nurses' station, Resident 1 was in the hallway in his wheelchair, and Unlicensed Staff A was in a room helping a resident. Licensed Nurse B stated Resident 1 started yelling at Unlicensed Staff A, and Unlicensed Staff A responded, If you would just let me finish helping your roommate, I could help you. Licensed Nurse B stated Resident 1 told Unlicensed Staff A, You need to get the fuck out of my room. Licensed Nurse B stated Resident 1 did that a lot, he gets in a mood and goes off on whoever. Licensed Nurse B stated Unlicensed Staff A could have stopped it (Resident 1's behavior) by not responding, but since she said that, it escalated it. It was an ugly scene. During an interview on 2/22/24 at 2:21 p.m., Unlicensed Staff C stated that on 1/28/24 she helped Unlicensed Staff A put a resident back to bed. Unlicensed Staff C stated that when they came out of the resident's room, Unlicensed Staff A had her hands full of dirty laundry and Resident 1's call light was on, so she (Unlicensed Staff C) went to help Resident 1 while Unlicensed Staff A took care of the laundry. Unlicensed Staff C stated Resident 1 started yelling and cussing at Unlicensed Staff A for not helping him, she told him she had been busy and apologized. Unlicensed Staff C stated Unlicensed Staff A went into another resident's room to help him and Resident 1 followed her and continued yelling and cussing at her. During an interview on 2/22/24 at 3:10 p.m., Unlicensed Staff D stated he remembered that on 1/28/24 Unlicensed Staff A called him to Resident 1's room and asked for a mop because there was poop on the floor. Unlicensed Staff D stated he started mopping and Resident 1 started yelling at Unlicensed Staff A, He was talking crap to her asking why didn't she do her job, why did she call him (Unlicensed Staff D) to come do her job? Unlicensed Staff D stated Resident 1 got really aggressive and moved towards Unlicensed Staff A, acting like he was going to hit her, he was verbally calling her names and stuff. Unlicensed Staff D stated Unlicensed Staff A asked Resident 1, What are you going to do, [Resident 1 named]? Are you going to hit me? During an interview on 2/26/24 at 9:02 a.m., Licensed Nurse E stated she remembered that on 1/28/24 she heard Resident 1 and Unlicensed Staff A arguing, and then two nurses came to her office to inform her Resident 1 was in the hall and Unlicensed Staff A was in Resident 1's room and they were yelling at each other. Licensed Nurse E stated Resident 1 had this behavior of yelling and cussing at staff. Licensed Nurse E stated she heard Unlicensed Staff A tell another aide that Resident 1's behavior was like a toddler within ear shot of Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A swearing and yelling at Resident 1. Licensed Nurse E stated she heard Unlicensed Staff A say to Resident 1 that she needed to take care of your roommate in your fucking room. Licensed Nurse E stated she did not intervene during these interactions between Resident 1 and Unlicensed Staff A. During an interview on 3/13/24 at 2:12 p.m., Licensed Nurse E stated that when Resident 1 and Unlicensed Staff A were arguing, nobody did anything. Licensed Nurse E stated that Resident 1 was yelling at Unlicensed Staff A for approximately 15 to 20 minutes before eventually Licensed Nurse F told Unlicensed Staff A she needed to walk away. Licensed Nurse E stated Resident 1 was pretty good about being redirected, but if you engage, he gets worse. Licensed Nurse E stated she took Resident 1 down to her office to file a grievance just to remove him from the situation, and that finally stopped it. When asked how the staff should have responded to Resident 1's behavior, Licensed Nurse E stated the charge nurse should have told them to stop and separated them. During an interview on 3/13/24 at 2:51 p.m., Unlicensed Staff A stated she remembered that on 1/28/24 Resident 1 was upset, verbally abusing me, displeased that he didn't get help going number two. Unlicensed Staff A stated that she looked at her nurse while this was happening, but she didn't do anything. Unlicensed Staff A stated Unlicensed Staff C helped her get a resident back to bed, then she helped Resident 1's roommate with his shower, and, [Resident 1] followed me, verbally abusing me. She stated Unlicensed Staff D came to clean up poop in Resident 1's room, and Resident 1 called her lazy for having Unlicensed Staff D do her job. Unlicensed Staff A stated she explained to Resident 1 that she cleaned it up, Unlicensed Staff D was just going over the area with a bleach mop, and then [Resident 1] shook his fist at me and threatened to punch me. Unlicensed Staff A verified Unlicensed Staff D was in the room at that time. Unlicensed Staff A stated she looked at the nurses sitting at the nurses' station (across from Resident 1's room) and they were all looking away. When asked if there was any management in the facility at the time of the incident, Unlicensed Staff A stated Licensed Nurse E was the management that day. Unlicensed Staff A stated she did not ask Licensed Nurse E to help with Resident 1 as she had not helped in the past. Unlicensed Staff A stated Licensed Nurse E sat at the nurses' station and watched the whole thing. Unlicensed Staff A stated that when Resident 1 wanted to file a grievance, Licensed Nurse E jumped in and offered to take Resident 1 to file the grievance. When queried, Unlicensed Staff A denied she had gotten training on how to manage Resident 1's behavior. Unlicensed Staff A stated she really believed he would have hit her, and I'm really scared of him, and I don't know what to do. Unlicensed Staff A stated she had cared for Resident 1 for one year without training on how to manage his aggression. When queried, Unlicensed Staff A stated for 10 to 15 minutes Resident 1 yelled at her (on 1/28/24) and followed her from the linen closet to his room and down to the other end of the hall to another resident's room. Unlicensed Staff A stated that at one point she heard Unlicensed Staff C ask the nurses, Aren't you going to do anything? (about his aggression towards Unlicensed Staff A) and they said, No. During an interview on 3/14/24 at 3:53 p.m., Director of Nursing (DON) stated that unfortunately the staff were afraid Resident 1 would target them if they intervened when he got aggressive. DON stated her expectation was that staff would de-escalate him when he was aggressive towards staff. DON verified that Resident 1's care plan indicated management would intervene and stated that normally if she was there, she would go talk to him. DON verified Licensed Nurse E was the management staff in the facility on 1/28/24 and stated Licensed Nurse E did take Resident 1 to her office to file the grievance. DON verified his behavior put him at risk for abuse. When asked what the facility had done to address that risk, DON stated staff got abuse trainings, in-services, and videos. Documentation of staff trainings regarding Resident 1's behavior of verbal aggression was requested. DON stated she would look. Review of electronic correspondence from DON dated 3/26/24 indicated she was unable to find documentation of staff trainings specific to managing Resident 1's behavior prior to the 1/28/24 incident. Review of Resident 1's face sheet revealed an admitted [DATE], he was his own responsible party, and he had medical diagnoses including left-sided weakness and paralysis following a stroke (a blood clot or bleed in the brain), heart failure, chronic kidney disease, depression, and a blood clot in the lung, among others. Review of Resident 1's care plan indicated a focus area, initiated 7/13/23, The resident is verbally aggressive towards staff [related to] Ineffective Coping Skills, Mental/Emotional Illness, Poor impulse control. Interventions for this focus area, dated 7/13/23, included, The resident's triggers for verbal aggression are unpredictable. The resident's behaviors is [sic] de-escalated by speaking to management 1 to 1 and When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later, among others. Further review of Resident 1's care plan indicated a focus area initiated on 7/13/23, The resident has potential to be physically aggressive towards staff [related to] Anger, Depression, Poor impulse control. Interventions, dated 7/13/23, included, The resident's triggers for physical aggression are unpredictable. The resident's behaviors is [sic] de-escalated by speaking to management, food and When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later, among others. Review of facility policy and procedure Abuse - Prevention, Screening, & Training Program, last revised 7/2018, indicated, The facility does not condone any form of resident abuse . and develops Facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse . and mistreatment. Subsection titled Prevention indicated, The Facility assists or may rotate staff working with challenging or aggressive residents and allows staff to express frustration with their job or in working with behaviorally challenging residents. The Facility identifies, corrects, and intervenes in situations in which abuse . and/or mistreatment is more likely to occur. The Facility conducts resident . ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict .

Based on interview and record review, the facility failed to provide the resident and/or their responsible party with a summary of the resident's Baseline Plan of Care for two of 24 sampled residents (Resident 21 and 102). This failure had the potential to limit communication with the resident and/or their responsible party on how the facility planned to manage the resident's needed services and treatments while at the facility, which could have led to the resident feeling stressed, uneasy and lack of trust with the staff providing care, leading to negatively affecting the resident's physical and psychosocial well-being. Findings: 1. A review of Resident 21's Admission Record, indicated Resident 21 was admitted to the facility on [DATE], with a diagnosis including CHF (Congested Heart Failure: long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply), Non-Stemi Myocardial Infarction (Partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle), Atrial Fib (extremely fast and irregular beats from the upper chambers of the heart), abnormalities of gait (person's manner of walking) and mobility, muscle weakness, cellulitis of the groin (a bacteria infection that develops in your skin), amongst others. A review of Resident 21's Progress Note - MD (Doctor of Medicine) History and Physical, date 12/28/23, indicated: History of Present Illness: CHF, COPD (Chronic Obstructive Pulmonary Disease: is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), tobacco dependence, and history of colon cancer, who presented at the hospital with shortness of breath and weakness and was treated for acute CHF and failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) . During his hospitalization the patient was declining a lot of medications, so he was educated about the importance of medication compliance . Assessment/Plan: . He had been in atrial fib at the hospital secondary to CHF. Returned to a normal sinus rhythm (rhythm of a healthy heart) after diuresis (increase urine output) . He was on Eliquis (Apixaban: blood thinner medicine that reduces blood clotting) although no longer is on and unclear details why: Continue Apixaban as ordered, monitor for sign/symptoms of bleeding, continue monitoring heart rate and rhythm with vital signs specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), and with each visit, weigh benefits versus risks of chronic anticoagulation . A review of Resident 21's Admitting 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 12/25/23, indicated Resident 21s BIMS (Brief Interview of Mental Status) of 13 (cognitively intact: the ability to clearly think, learn, and remember). A review of Resident 21's Baseline Care Plan - V2, signed and dated by DON (Director of Nursing) on 12/20/23, indicated Resident 21 wanted to return to the community, occasionally incontinent of urine and bowel, on a diuretic and anticoagulant (blood thinner to prevent clots from forming), on Black Box medications (added to the labeling of drugs or drug products by the Food and Drug Administration when serious adverse reactions or special problems occur, particularly those that may lead to death or serious injury), medication list provided to Resident 21, admitted with two UTDs (Unstageable Full Thickness Skin or Tissue Loss - Depth Unknown) on right buttocks, physical therapy and occupational therapy to improve functional status, amongst other information and goals. Under 5. Baseline Care Plan Summary and Signatures: B.: Resident Signature and Date, Resident 21's name was typed in and no date. There was no indication Resident 21 received a copy of his Baseline Care Plan. During an interview on 1/9/24 at 8:48 a.m., Resident 21 could not recall if he received a copy of his Baseline Care Plan indicating his goals and if he signed the care plan. Resident 21 stated he did get a list of the medications he was being administered. 2. A review of Resident 102's Admission Record, indicated Resident 102 was admitted to the facility on [DATE], with a diagnosis including pneumonia caused by streptococci (infection of the lungs caused by a bacteria), COPD, acute duodenal ulcer with hemorrhage (bleeding open sore located in the first part of the small intestines), abnormalities with gait and mobility, depression, moderate protein-calorie malnutrition (lack of proper nutrition), chronic CHF, Type Two Diabetes (blood sugar to high), amongst others. A review of Resident 102's Baseline Care Plan - V2, signed and dated by DON on 1/6/23, indicated Resident 102's vision was impaired, preferred a shower, family or significant other involvement in care discussions, initial discharge goals: return to the community, substantial/maximal assistance with oral care, dependent on toilet hygiene, shower, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and mobility, history of falls prior to admission, stage three pressure ulcer (deep, crater-like wound in the skin extend through the skin into deeper tissue and fat but does not reach muscle, tendon, or bone) on right buttocks, amongst other information and goals. Under 5. Baseline Care Plan Summary and Signatures: B.: Resident Signature and Date, Resident 102's name was typed in and no date. There was no indication Resident 102 received a copy of his Baseline Care Plan. During an interview on 1/10/24 at 2:49 p.m., the Director of Nursing (DON) stated the resident Baseline Care Plan was an IDT (Interdisciplinary Team: brings together knowledge from different health care disciplines to help people receive the care they need) effort. The DON stated the appropriate staff and disciplines based on the resident's needs such as nursing, dietary, activities, social services, physical therapy and so on, would meet with the resident and go over their part of the resident's Baseline Care Plan, which included goals and interventions. The DON stated a copy of the resident's medication list was given to the resident. When the DON was asked how one would know if the various disciplines met with the resident and/or their responsible party and went over the resident's immediate healthcare treatment/interventions and goals if the resident or responsible party did not sign, date and receive a copy the resident's Baseline Care Plan, the DON stated she thought the resident just needed to be provided their medication list. The facility Policy/Procedure titled, Comprehensive Person-Centered Care Planning, revised 11/2018, indicated: . Ill. Baseline Care Plan Summary: . b. A copy of the baseline care plan summary will be provided to the resident and/or resident representative .

Based on interview and record review the facility failed to offer COVID-19 ( an infectious disease caused by the SARS-CoV-2 virus and those infection could experience mild to moderate or severe respiratory illness) immunizations (a process by which a person becomes protected against a disease through vaccination.) as appropriate to four (Confidential Resident 30, Confidential Resident 34, Confidential Resident 2 and Confidential Resident 3) out of 12 sampled residents. This failure had the potential for residents to acquire COVID-19 and suffer a more serious illness without the added benefit of having the vaccine in their system. Findings: During a concurrent interview on 1/10/24 at 2:26 p.m. with Confidential Resident 30, Confidential Resident 34, Confidential Resident 2 and Confidential Resident 3 all indicated they had wanted to COVID-19 vaccine but were denied by the facility. Resident 30 indicated the facility had indicated the resident would be vaccinated after training for the nurses had taken place but that was back in October of 2023. Confidential Resident 30 indicated the residents were in waiting mode to hear further information about when they would receive the vaccine. Confidential Resident 30 indicated there was fear and concern about the delay in obtaining the vaccine since the facility had just had an outbreak of COVID-19. Confidential Resident 34 indicated there was agreement about the concern and fear of not having the COVID -19 vaccine. Confidential Resident 2 indicated there was frustration and anger about having to wait so long and it didn't make sense that training the nurses would take so long. Confidential Resident 3 indicated frustration about waiting for the COVID-19 vaccine as well. During an interview on 1/11/24 at 2:09 p.m. with Infection Preventionist (IP), IP stated the residents had not been offered the COVID-19 booster due to the corporation requiring testing for the nurses on how to handle and store the vaccine appropriately. IP indicated there was no time frame with regards to training and had no idea when the training would take place. IP indicated there could be a vaccine clinic through multiple agencies who would come and administer the COVID-19 vaccine but that was not put in place due to the pending training. IP confirmed there was no scheduled training or plan to administer the COVID-19 vaccine. During a review of the facility's policy and procedure, titled, COVID-19 Vaccination Program, dated 3/15/22, indicated, Support the safe and efficient distribution of COVID-19 vaccines to Residents and Health Care Personnel .A vaccine administration clinic may be held when there are multiple Residents or Health Care Personnel who require vaccination .COVID-19 vaccine and booster doses of vaccine will be provided by the Facility free of charge .

Based on staff interview and facility document review, the facility staff failed to treat six residents (Resident 6, Confidential Resident 30, Confidential Resident 34, Confidential Resident 2, Confidential Resident 3 and Confidential Resident 202.) out to 12 sampled residents with dignity when staff would assist a resident to the bathroom and then leave for an extended period of time, answer a call light and then not return to provide care. These failures resulted in residents feeling like they were worthless or invisible. Findings: During an interview on 1/9/24 at 8:45 a.m., Resident 6 stated that when she pressed her call light for assistance, sometimes her aid would come in and tell her they had three residents they needed to help before her and she would have to wait. Resident 6 stated she thought to herself, I hope they don't forget about me. During an interview on 1/9/24 at 9:36 a.m., with Confidential Resident 202, Confidential Resident 202 indicated some of the staff were disrespectful when providing care. Confidential Resident 202 indicated an occurrence where a staff member assisted him to the toilet and then left him for an extended period of time. Confidential Resident 202 indicated when he voiced his displeasure that the staff member forgot about him, the staff member shouted at him that he could not speak to him in that manner. Confidential Resident 202 indicated some staff would get very upset if their work was criticized and indicated the staff providing care could be arrogant like the residents were lucky to have care provided them. Confidential Resident 202 was very concerned about retaliation and wanted to ensure their privacy would be protected. During a concurrent interview on 1/10/24 at 2:26 p.m., with Confidential Residents 3, 30, 34 and 2, all described instances where the staff were being disrespectful when providing resident care. Confidential Resident 3 indicated on a weekend, when he put on his call light as staff member came in and turned the call light off and left. Confidential Resident 3 indicated it took approximately seven hours for a staff member to return and change his brief. Confidential Resident 3 indicated he felt worthless when being treated that way. Confidential Resident 34 indicated a staff member answered her call light, then proceeded to tell the resident she would find the unlicensed staff who had been assigned but no one ever came back. Confidential Resident 34 indicated she was on the commode and proceeded to stay on there for the next 45 minutes and would have called 911 if she had her phone with her. Confidential Resident 34 indicated she felt stiff, and her bottom ached from sitting on the commode that long. Confidential Resident 30 indicated there were many times when she put her call light on and the staff member would come to the door, stated they were not the assigned staff but would find the staff to help and then on one came. Confidential Resident 30 indicated she got angry and felt forgotten. Confidential Resident 2 indicated again, a staff member would answer the call light but not help the resident, stating, they didn't know who was assigned to that resident and then just left without any explanation. Confidential Resident 2 indicated that made her feel like a non-person, almost invisible. Confidential Resident 2 indicated when she wanted to be put back in bed it was also a challenge as staff would again indicate they needed help or didn't know who was assigned and then leave without following up to ensure her needs were met. During an interview on 1/12/24 at 12:06 p.m., with Director of Nursing (DON), DON indicated there had been measures put in place to better answer the resident call lights and provided an example that during mealtimes, the department managers were expected to answer call lights. DON indicated this would result in a staff member indicating the assigned staff member would be contacted but had thought there would have been follow up with the residents. DON referenced the Call Light Pledge document which all department managers were to sign and agree to adhere to its contents. DON indicated she was not aware of call lights being answered but no follow up regarding the resident needs not being addressed. DON indicated she had not been made aware of staff not being respectful to residents. A review of the facility's, Call Light Pledge Team Approach, not dated, indicated, if you are unable to address the resident's need, inform the resident that you will get someone to help them, the call light should remain on while you find the appropriate staff member responsible for the need. If they are busy and unable to attend the needs, ask someone else.

Based on observation, interview, and record review, the facility failed to: 1. Replace the roof which had been leaking for at least three years, and 2. Had shower doors which locked and were not easily accessed by staff. These failures resulted in residents living in an environment that was visibly in need of repair and upkeep. Findings: 1. During a phone interview on 1/9/24 at 11:09 a.m., a confidential family member stated she felt the facility looked neglected and could use a good cleaning and paint job. She stated whenever she came here to visit her mom she wanted to bring her gardening gloves and pruning sheers and go to work on the grounds. During an observation on 1/10/24 at 8:25 a.m., while rain was falling on the roof of the facility, the rain gutter and eave midway toward the entrance of the facility looked broken/rotten. Rain water was pouring over the gutter like a waterfall in front of a resident's window as the rain was coming down. Note: a photo was taken of the rotten gutter and eave. During an observation on 1/10/24 at 9:54 a.m., heavy rain was falling on the roof of the facility. A trash can was noted in the lobby of the facility in the middle of the floor outside the billing office with a yellow caution cone next to it. The trash can had water dripping into it from the ceiling and had approximately one to two inches of water inside. During an interview on 1/11/24 at 11:35 a.m., the Maintenance Director was asked about the broken/rotten gutter and eave midway toward the entrance of the facility and the water pouring over the gutter like a waterfall in front of a resident's window as the rain was coming down. The Maintenance Director stated the facility had quotes for the roof and gutters. The Maintenance Director stated he had to go up and clean the gutters during the fall to winter (2.5 months) daily because of the wind and debris from the surrounding trees. During an interview on 1/11/24 at 11:55 a.m., Director of Nursing (DON) stated she had been working at the facility for five years and the roof of the facility had been leaking for the past three years. DON verified the roof was leaking into the lobby, and had also been leaking when one of the surveyors was at the facility in November 2023. DON stated they had had five to seven roofing companies come out to the facility recently to make bids on replacing the facility roof. DON stated some of the roofing companies that came out had told them, We already gave you bids, and she was hoping that with the new administrator, they will finally accept one of the bids and get the new roof. During an interview on 1/11/24 at 4:20 p.m., Administrator stated he had two bids from the five companies that came out to evaluate the roof. Administrator stated he was expecting three more bids and once they were all in, he would pick one to do the job. When queried, Administrator stated he had the roofing companies come out because the roof just looked like it needed to be replaced and it looked like it had needed to be done for a while. He stated he did not understand why it was not done a long time ago since some of these roofing companies already came out before and gave bids but the job was never done. Review of provided roof replacement bids indicated one roofing company provided their proposal on 12/27/23 and a second company provided their proposal on 12/6/23. Review of facility policy Resident Rooms and Environment, last revised 1/1/12, indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment. 39792 2. During an interview on 1/10/24 at 2:26 p.m. Confidential Resident 34 indicated there had been at least three separate instances where the staff assisting in showering a resident had to leave and the resident had been locked in the shower and the key to unlock the door was not readily available. Confidential Resident 34 indicated the first instance occurred when a staff member was assisting a resident in the shower and had to leave for a second to grab something and the door going into the shower was locked so when the staff left the shower room, the door remained locked. The staff member could not get back into the shower room and the resident in the shower could not manage to independently open the door from the inside. Confidential Resident 34 indicated the door to the shower room had a lock on the outside for which a key would open the door and from the inside there was button type device to unlock the door from the inside. The room was large with multiple showers and room for wheelchairs and to leave the shower staff would require navigating multiple feet to access the door to then open it. Residents, who would be wheelchair bound and seated in a shower chair would not be able to navigate a wet slippery floor or residents who do not use assistive devices would find it dangerous to navigate a slippery floor to open the door or risk falling. Confidential Resident 34 indicated there was a scramble to find the key and then open the shower door to finish showering the resident. Confidential Resident 34 indicated it happened at another time where the resident was able to open the door from the inside after the key to access the door was not readily available. Confidential Resident 34 indicated the third time the same scenario occurred, the staff had determined the key to open the shower door was taken home by management and they had to come back to the facility open the door. Confidential Resident 34 indicated that since the issue had occurred multiple times and the facility was aware of the issue; there was no reason for this to keep happening and it would be scary to be locked in the shower room. During an interview on 1/10/24 at 4:30 p.m., with Licensed Staff G, Licensed Staff G indicated she was not sure who had the key to shower room and thought the unlicensed staff members would have the key. Licensed Staff G indicated she had just asked an unlicensed staff member for the shower key and that person did not have key to the shower room. Licensed Staff G indicated a key ring from the nursing station which had many keys on it, none of which were labeled and thought the key might be one of those, but she would have to check each key to see if one of the keys would open the lock. During an interview and concurrent observation on 1/10/24 at 4:36 p.m., with Licensed Staff H, Licensed Staff H indicated she had the key for the shower and then proceeded to attempt to unlock the door. The key was able to be inserted into the locked door but the key did not unlock the door after multiple attempts. During a concurrent observation and interview with Licensed Staff G, Licensed Staff H and Maintenance Director in front of the East Shower room door, Maintenance Director compared his key to the shower room door with Licensed Staff H's key and the markings were observed to be identical. Maintenance Director proceeded to use Licensed Staff H's key to unlock the shower room door and again the key would enter the lock but not unlock the door. Maintenance Director further examined the key and observed there was a light bend in the tip of the key, indicating that's why the key did not unlock the door. Licensed Staff G attempted to find the shower key on the key ring and found the key to unlock the door after multiple attempts with other keys on the key ring. Maintenance Director indicated he had made numerous copies of the shower keys for the licensed and unlicensed staff but had asked an unlicensed staff prior to the interview and the staff member did not have the shower key on their person. During an interview on 1/10/24 at 4:51 p.m., with Director of Nursing (DON) indicated she was not aware of the issue with the shower keys. DON indicated there could be a large safety concern if a resident was locked inside the shower and the key could not be accessed readily. DON indicated the Administrator should be included in the conversation. During a concurrent interview on 1/10/24 at 4:56 p.m., with Administrator and DON, Administrator indicated there could be a serious safety harm situation if a resident was locked in the shower room and the key was not readily available. Administrator indicated he was going to have a conversation with the Maintenance Director to come up with a safer plan with regards to the shower room doors. During an observation and interview on 1/10/24 at 6:03 p.m., with Administrator, he was observed to place a shower key which was attached to a large green label placed in a plastic sleeve, Shower Key on a hook hanging next to the shower room. Administrator indicated each shower room had the same key, meaning each key would fit all the shower doors and each shower room had the same key and identifier so any resident who might get locked into the shower room would have readily available access to enter the shower room. The key was placed high enough so residents would not be able to enter the shower room while someone was in the shower but low enough that all staff would able to access the room in an emergency. During a review of the facility's policy and procedure titled, Residents Rooms and Environment, dated 1/1/12, Purpose to provide residents with a safe, clean, comfortable and homelike environment.

Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to : 1. Identify failure of staff to follow hand hygiene procedure (Cross Reference F880), 2. Identify failure to provide new residents and families with baseline care plans (Cross Reference F655), 3. Identify the failure of staff to respond to residents' requests for help (Cross Reference F550). These failures prevented the QAPI committee from developing, implementing, and evaluating action plans to correct systematic deficient practices. Finding: During an interview on 1/12/24 at 11:30 a.m. with Administrator and Director of Nursing (DON), Administrator stated the QAPI committee found projects through surveys, complaint investigations, things come up at the meetings, inspections rounds, and floor staff could bring projects. Administrator stated once the committee identified it (a project) we work to fix it. DON stated hand hygiene and baseline care plans were not projects they were currently working on. Administrator stated the committee was not tracking residents' perception of staff response to requests for assistance. Review of facility document 2024 Quality Assurance and Performance Improvement (QAPI) Plan for [facility named], not dated, indicated, The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners . The QAPI team at [facility named] will decide what data to monitor routinely. Areas to consider may include, but not limited to the following examples: Clinical care areas (i.e. pressure ulcers, falls, infections) . Resident satisfaction . Care plans . The document further indicated the committee had two Focus Items: Re-opening the 49 suspended beds and falls.

Based on interview and record review, the facility failed to honor Resident 1's rights when a Licensed Nurse cut Resident 1's hair without permission. This failure decreased the facility's potential to ensure residents' rights and respect residents' different cultures. Findings: A review of Resident 1's admission record indicated admission to the facility on [DATE] with diagnosis which included left-sided weakness as a result of a stoke, lupus (an autoimmune disease which can affect tissue and organs), and depression. A review of a Minimum Data Set (MDS, an assessment tool), dated 2/15/23, indicated Resident 1 had mild memory problems. A review of a progress note dated 3/2/23 at 8 p.m., indicated, .Resident [1] is disappointed that his hair was cut without his consent . In an interview on 3/17/23 at 9:45 a.m., Resident 1 confirmed a nurse cut his hair without asking his permission. Resident 1 stated he felt the LN was disrespectful because he was Native American and hair was an important, sacred, and significant representation of his culture. Resident 1 stated he kept his braid and still had it in his personal possessions. In an interview on 3/17/23 at 10:15 a.m., the Administrator verified the LN should not have cut Resident 1's hair without his consent as it was against the facility policy and procedure for resident rights. In an interview on 3/17/23 at 10:30 a.m., the Director of Nurses (DON) stated Resident 1's rights were not respected. In an interview on 3/21/23 at 3:49 p.m., Certified Nurse Assistant C (CNA C) stated she witnessed Resident 1 tell the LN, No when she stated she was going to cut his hair. The CNA C also stated, [Resident 1] reached up to feel his hair and [the LN] said [it was] too late .[Resident 1] was upset .He was about to cry .[The LN] showed no regret .She asked me to lie and tell him to say it was OK. He was embarrassed and ashamed. After it happened, he pulled his hoodie up so no one could see his hair. A review of the facility's policy and procedure titled Resident Rights, revised 1/1/12, indicated, .Resident's [sic] have freedom of choice .about how they wish to live their everyday lives and receive care .Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights .

Based on observation, interview and record review, the facility failed to ensure 3 of 3 residents sampled for pain (Resident 94, Resident 146, and Resident 24) received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan, the resident's preference, and facility policy. Licensed nurses did not notify Resident 94's physician (Physician P) for approximately seven days when her pain was routinely high (#7-9 out of 10 on the pain scale; Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable), despite pain medication administration; Nursing staff did not notify Resident 146 or Resident 24's physicians of ineffective pain control; Nursing staff did not assess, reassess, or document Resident 94, Resident 146 and Resident 24's pain consistently and accurately; and Nursing staff did not develop, and revise when needed, person-centered care plans addressing pain for these three residents. These failures: 1) Contributed to Resident 94 experiencing moderate to severe pain, described as excruciating and screeching, for a timeframe of approximately seven days and to Resident 94 crying and moaning in pain when being repositioned; 2) Potentially prevented Resident 94, Resident 146 and Resident 24's physicians from knowing interventions ordered for them were ineffective and affording them the opportunity to make changes to the resident's plan of care; 3) Contributed to Resident 146 experiencing several days of severe pain described as, excruciating; and 4) Contributed to Resident 24 experiencing moderate pain that made her feel helpless, made her feel as if she were suffering, and prevented her from participating in activities other that watching television. Findings: 1) Review of Resident 94's medical record from her hospital stay (4/20/22 - 4/26/2022) indicated Resident 94 was a, pleasant [AGE] years (sic) old female with a . past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 94 was admitted to the hospital where she was diagnosed with a fracture of her right humerus (upper arm), left humerus (located near the elbow), and a questionable fracture of the left calcaneus (heel). Resident 94 had a surgical repair of her left elbow on 4/20/22 and was transferred to the facility on [DATE] (approximately six days after surgery). Review of Resident 94's facility medical record revealed physician orders, dated 4/26/2022, that indicated, Patient is capable of making informed choice and decisions .Patient is capable of participating in their plan of treatment. During an observation and concurrent interview on 5/03/2022 at 10:08 a.m., Resident 94 was lying on her back in bed. Resident 94's left arm was in an immobilization device (splint), her right arm was in a sling, and her the left side of her face had a yellow bruise. Resident 94 stated she did not remember how she injured her arms and stated she had, screeching pain in her elbow. Review of Resident 94's facility medical record revealed physician orders, dated 4/26/2022 (her admitted to the facility), that included: Assess for pain every shift and chart intensity of pain using 1-10 pain scale. 0= no pain, 1-4= mild pain, 5-7= moderate pain, 8-9= severe pain, 10= excruciating pain. every (sic) shift Non-Pharmacological interventions: A-Heat, B-Re-positioning . G-Immobilization of Joints, H-Other (document in Nurses note) . Pain medication ordered on 4/26/2022 included [MEDICATION(S)] (a narcotic pain killer) 5-325 mg (milligram), one tablet every four hours as needed for moderate pain or two tablets every four hours as needed for severe pain and [MEDICATION(S)] (a narcotic pain killer), one tablet every four hours as needed for severe pain. Review of Resident 94's MAR (medication administration record; document where nurses chart various interventions and medications given) indicated from 4/26/2022 through 4/29/2022 (Physician P's initial visit with her), Resident 94's nurses assessed her pain every shift to be between #7-9 on the pain scale (moderate to severe pain). During the same three day period, Resident 94's nurses documented giving her [MEDICATION(S)] two tablets (for severe pain) approximately seven times: the pain was documented as a #7 on one occasion, #8 on three occasions, and #9 on three occasions. During the same timeframe, Resident 94's nurses also documented giving her [MEDICATION(S)] approximately nine times: nurses documented the pain as a #7 on two occasions, #8 on three occasions and #9 on four occasions. Nurses documented the medications to be E (effective) and intermittently documented the decrease in the pain (reflected in a lower pain-scale number) after the medication was given (from zero to #3). Resident 94's medical record did not contain documentation that nursing staff contacted Physician P to inform him Resident 94's pain was ranging from #7-9 despite narcotic pain medication. Review of Resident 94's facility medical record revealed a physician admission note written by Physician P on 4/29/2022, three days after admission. Physician P documented, Patient is being seen today via telemed (Telemedicine allows health care professionals to evaluate, diagnose and treat patients at a distance using telecommunications technology - computers, video, phone, messaging). Physician P documented Resident 94's history of present illness (fall with fractures and mild dementia), vital signs (temperature, heart rate, blood pressure, oxygen level, etc.), his physical exam, and assessment diagnosis. Documentation of Resident 94's pain was not located in the Physician P's note. Review of Resident 94's facility medical record revealed a changed physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] 5-325 mg, 1-2 tablets every four hours was changed to [MEDICATION(S)] 10-325 mg tablet every six hours as needed for severe pain. No changes were made to the [MEDICATION(S)] order. Review of Resident 94's MAR (from 4/30/2022 through 5/4/2022) revealed conflicting pain assessments by nursing staff. On 4/30/2022, the night nurse documented Resident 94's pain as a zero, but also documented her pain was a #8 at 3:32 a.m. (when [MEDICATION(S)] was given) and a #9 at 6:13 a.m. (when [MEDICATION(S)] was given). On 5/2/2022, the day and evening nurses documented her pain as a zero, but also documented her pain was a #8 (when [MEDICATION(S)] was administered). On 5/3/2022, the day shift nurse documented her pain was #3, but also documented her pain was #7 (when [MEDICATION(S)] was given) . On 5/4/2022, an evening shift nurse documented her pain as a zero, but also documented her pain was #8 (when [MEDICATION(S)] was given). The remainder of the nurse's MAR's pain scale documentation (from 4/26/2022 through 5/4/2022) indicated Resident 94's pain was between #7-9. Review of Nursing Progress Notes located in Resident 94's medical record revealed nursing staff did not document they notified Physician P when Resident 94's pain medication was ineffective in pain control. On 4/30/3033 at 5:44 a.m., LN Q documented [MEDICATION(S)] was given at 3:32 a.m. for severe pain (#8 on the pain scale). LN Q documented the [MEDICATION(S)] was ineffective by charting, Follow-up Pain Scale was: 4 (on the pain scale) . PRN (as needed) Administration was: Ineffective. At 7:48 a.m., LN Q documented [MEDICATION(S)] was given at 6:13 a.m. for severe pain (#9). She documented the [MEDICATION(S)] was ineffective by charting Follow-up Pain Scale was: 7 .PRN Administration was: Ineffective. Documentation that LN Q notified Physician P that both [MEDICATION(S)] and [MEDICATION(S)] were ineffective in controlling Resident 94's pain was not located in the medical record. Review of facility policy titled, Pain Management, subtitled, Procedure, further subtitled, II. Pain Management (Revised 11/2016) indicated, E. If .the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician. During an observation and interview on 5/05/22 at 9:14 a.m., Unlicensed Staff I went into Resident 94's room. When she exited the room, Staff I stated Resident 94 was in pain. Staff I stated Resident 94 had told her she (Resident 94) would rather be dead than have that much pain. Staff I stated the nurse had already given Resident 94 pain medication and said she would tell her again that Resident 94 was in pain. During an observation 5/05/22 at 9:16 a.m., a nurse gave Staff I ice to put on Resident 94's arm. Staff I entered Resident 94's room with the ice. During an observation and concurrent interview on 5/05/22 at 9:28 a.m., Resident 94 was lying on her back in bed. Resident 94 was covered by a sheet (a blanket was on a nearby chair), the patio door was open (letting in a breeze), and her room was chilly. Ice packs were on the bed next to her. Resident 94's left arm (in a splint) was on one pillow, but her arm was below the level of her heart. Her left hand had 3-4 plus [CONDITION(S)] (moderate swelling). Resident 94's right arm was in a sling. When asked if she was in pain, Resident 94 stated her pain was, excruciating and stated she had tingling pain in her hand (left), going up to her elbow. When asked what number her pain was, Resident 94 stated, nine or ten.When asked why the ice was on the bed and not on her arm, Resident 94 stated she was in too much pain to also be cold. During an interview on 5/05/22 at 09:47 a.m., the DSD (director of staff development) stated she was familiar with Resident 94 and had helped admit her (on 4/26/2022). The DSD stated Resident 94 had fractured her left elbow and right humerus at home. The DSD stated Resident 94 was taking [MEDICATION(S)] and [MEDICATION(S)] alternately for the pain but it had not been working, so the [MEDICATION(S)] was increased to 10 mg (in the past). The DSD stated Resident 94's pain was now up to a #7 or #8 and stated the medication takes the pain down to a zero, but it didn't last long. The DSD stated Resident 94's pain stayed at a zero for about an hour (after the pain medication was given). The DSD stated staff called the doctor to increase the pain medication, days ago. When asked if nursing staff had called the physician recently about Resident 94's pain control, the DSD stated, no and stated the doctors are sometimes reluctant to order narcotics. When informed Resident 94 had described her pain as a #9 or #10 and verbalized it was excruciating and tingling, the DSD stated it might be nerve pain and she may need [MEDICATION(S)] (a medication that treats nerve pain). During the same interview on 5/05/22 at 09:47 a.m., the DSD was informed that Resident 94's left hand had [CONDITION(S)]. The DSD stated her arm was, on a pillow. The DSD was informed Resident 94's arm was on a pillow but her arm was still below the level of her heart. The DSD was asked where Resident 94's left arm should be in order to help decrease the [CONDITION(S)] in her hand, and the DSD stated, above her heart. The DSD stated she would elevate Resident 94's left arm and agreed elevating the arm to decrease [CONDITION(S)] would likely help the pain. When asked why she was not using ice (on her left arm), the DSD stated Resident 94 did not like the ice. When asked why Resident 94 did not like the ice, the DSD stated she thought it was because the ice fell off. The DSD was informed Resident 94 had verbalized the ice made her cold and she didn't want to be cold on top of being in pain. The DSD was informed Resident 94 was covered only by a sheet, her patio door was open, and the room was chilly. The DSD stated she was not aware Resident 94 was complaining of being cold. Review of facility policy titled, Pain Management, subtitled, Procedure, further subtitled, II. Pain Management (Revised 11/2016) indicated, J. Nursing staff will also utilize non-pharmacological interventions to address possible issues contributing to pain. Interventions include . Resident is cold . Apply warm blankets, adjust room temperature . Resident has swelling .Provide apply ice packs or cold compress . During an observation and concurrent interview on 5/05/22 at 10:18 a.m., Resident 94's daughter was at her bedside. Resident 94's left arm was elevated above her heart and she was covered by a blanket. Resident 94 stated she was warm. Resident 94's daughter stated she thought her mother was receiving enough pain medication and stated she was not too groggy (from the medication). During an interview on 5/05/22 at 10:20 a.m., Unlicensed Staff I was asked what she had done earlier to address Resident 94's pain. Staff I stated, I tried everything (but) she didn't want it. Staff I stated she tried to elevate Resident 94's arm above her heart but it hurt her shoulder. Staff I stated Resident 94 did not want ice on her arm because the ice was cold. When informed that Resident 94's patio door was open and the she was covered only by a sheet, Staff I stated, I guess I should have put a blanket on her. When asked if she was able to turn (reposition) Resident 94, Staff I stated, no because it was too painful to turn her side to side. Staff I stated it took two CNA's (certified nursing aides) to turn Resident 94. Staff I stated when they turned her to change her diaper, Resident 94 cried from the pain. During an observation and concurrent interview on 5/05/22 at 3:18 p.m., Resident 94 was lying on her back in bed. Her left arm was elevated above her heart. When asked how her pain was, Resident 94 stated it was a #6 or 7. When reminded her pain had been #8-9 that morning, Resident 94 stated she thought it was a little improved. When reminded it had been excruciating, Resident 94 stated her pain was no longer excruciating, but it would be if she moved her elbow. When asked if her pain was a little lower, Resident 94 stated she thought it was. During an interview on 5/05/22 at 3:24 p.m., Unlicensed Staff R stated she had first worked with Resident 94 on Monday, three days earlier, and had taken care of her on Tuesday as well. When asked about Resident 94's pain (on Monday and Tuesday), Staff R stated Resident 94 could not move her arms and could not turn side to side due to pain. When asked what her pain level was on Tuesday, the last day she took care of Resident 94, Staff R stated, 10 (excruciating, per the MAR). When asked if the nurses had given Resident 94 pain medication at the time, Staff R stated, yes. When asked how she changed Resident 94's diaper, Staff R stated, two of us lifted her bottom using a bridge technique (feet flat on the bed with knees bent, legs used to lift hips off the bed). When asked how Resident 94 tolerated the bridge technique to change her diaper, Staff R state she tolerated it okay and did not cry. When asked if staff were able to reposition Resident 94 every two hours (to prevent pressure ulcers - skin breakdown), Staff R stated they were not able to turn her due to her pain. Staff R stated they elevated her arm on pillows and intermittently applied ice. During an interview on 5/05/22 at 3:38 p.m., Licensed Nurse Q stated she was Resident 94's nurse that evening. Nurse Q stated she had been Resident 94's nurse the prior evening as well and stated she had pain issues at that time, but the pain medication had taken her pain down to a tolerable level. Nurse Q stated the [MEDICATION(S)] and [MEDICATION(S)] worked okay yesterday and Resident 94's pain, at #8, was brought down to zero. Nurse Q stated some days Resident 94 was still hurting after her pain medication and, there's nothing else I can give. When asked if she had called Resident 94's doctor on those occasions to inform him the pain medication was not providing adequate pain control, Nurse Q stated she had, sent a message but stated she had not sent any messages recently. Nurse Q stated she applied hot packs and stated ice packs did not work. When asked about repositioning Resident 94, Nurse Q stated it required two staff to turn Resident 94 but she was not comfortable during the process. When asked how she knew Resident 94 was not comfortable during repositioning, Nurse Q stated, she moans a little. During an interview 05/05/22 at 4 p.m., the DON (Director of Nursing) and ADON (Assistant Director of Nursing) were asked about Resident 94's pain that day. The ADON stated she had called Physician P earlier in the day and her [MEDICATION(S)] was changed to a scheduled dose (rather than as needed) and the [MEDICATION(S)] was unchanged. The ADON stated they would wait, a few days to assess the benefits of the interventions. The ADON stated if Resident 94 was still in pain (after a few days), they would make a second call to Physician P to get the pain under control. The DON stated Resident 94's pain should have been managed, a long time ago by notifying the physician about her pain. Review of Resident 94's medical record revealed no documentation in the nurse progress notes that nursing staff had called to notify Physician P of Resident 94's high pain levels. Review of Resident 94's medical record revealed a Social Service progress note written by Staff S on 5/5/2022 at 5:23 p.m. Staff S documented, Resident stated 'Id (sic) rather die than be in this pain' Resident is on q-15 checks (every 15 minute checks by staff). Notified daughter . Will continue to monitor. Staff S documented a note on 5/6/2022 at 9:16 a.m. that indicated, Room visit with resident. She in in (sic) bed comfortable. Writer asked resident about statement she made yesterday Resident stated 'They just changed me and I was in a lot of pain and at that brief second I felt like that but it passed. I have no intentions ofhurting (sic) myself I just don't want to be in pain anymore'. During a telephone interview 05/06/22 at 9 a.m., Physician P was asked about Resident 94's admission and pain control while at the facility. Physician P stated he provided telemedicine services and Resident 94 had been seen via televisit (on 4/29/22) only. Reviewed observations, interviews, and record review regarding Resident 94's pain with Physician P including: Resident 94's description of screeching and excruciation pain, pain levels frequently between #7-9 despite pain medication, ice inconsistently applied by staff, limited repositioning secondary to pain, and left arm not elevated above the heart. Physician P stated Resident 94's [MEDICATION(S)] was increased from 5 to 10 on the day of the televisit (4/29/2022, approximately seven days earlier). Physician P stated nursing staff called him yesterday (5/5/2022) and he made changes to the [MEDICATION(S)] (changed it to routine, versus as needed) and added [MEDICATION(S)] (medication for nerve pain). Physician P stated they had been trying to meet Resident 94's needs but they did not want to overmedicate her. Physician P was asked if nursing staff had notified him of Resident 94's uncontrolled pain from the time the [MEDICATION(S)] was increased (4/29/2022) until yesterday (a timeframe of approximately seven days), Physician P stated nursing did not notify him. Physician P was asked if any changes to Resident 94's pain medication had occurred between 4/29/2022 and yesterday (seven days), Physician P stated he was not aware of any changes. When asked if he would have wanted to know about Resident 94's poor pain control, Physician P stated, of course. He stated they were there to help patients. He stated if a medication regime was not working, they would make changes. Physician P stated if Resident 94 had severe pain despite being routinely medicated, she may need additional imaging studies. Physician P stated Resident 94 was at risk for a DVT ([CONDITION(S)], blood clot) and she may need to return to the hospital for an ultrasound to rule out a blood clot. During a telephone interview on 5/09/22 at 12:17 p.m., the DON was asked about Resident 94's status. The DON stated Resident 94 had been sent to the emergency room at the hospital where it was determined she was negative for a DVT (she did not have a clot). The DON stated Resident 94 was sent back to the facility (after her hospital visit) and was doing good. The DON stated Resident 94's pain was improved, she was started on [MEDICATION(S)], and her pain had decreased to #5 out of 10. Review of Resident 94's care plan for Acute Pain (dated 4/26/2022) indicated the goal of care was, Resident will be free of pain/discomfort. The care plan indicated interventions included, Administer ice packs as ordered Administer pain medication per order, if non-medication interventions are ineffective . Evaluate the effectiveness of pain-relieving interventions (non-medication and medication) .Evaluate non-verbal indicators of pain .Evaluate pain . The Acute Pain care plan did not identify non-medication interventions and did not indicate the physician should be notified if interventions were unsuccessful at controlling pain. Review of facility policy titled, Pain Management, subtitled, Policy (Revised 11/2016) indicated, Facility staff will help the resident attain or maintain their highest level of well-being whole working to prevent or manage the resident's pain to the extent possible. Under subtitle, Procedure, further subtitled, I. Pain Assessment the policy indicated, D. The Interdisciplinary Team will develop a resident centered care plan for pain management, including non-pharmacological interventions . i. Goals for pain management and the acceptable level of pain relief will be determined in conjunction with the resident when possible. Review of the RN (registered nurse) Staff Nurse Job Description, subtitled General Duties and Responsibilities: further subtitled, Clinical (undated) indicated, Conducts daily resident rounds to assess and evaluate the resident's physical, medical and emotional status and to implement or revise nursing interventions to the resident plan of care .Evaluates the patient's progress toward specific goals and adjusts the nursing plan of care, as necessary . 2) Record review indicated Resident 146 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 5/03/22 at 10:48 a.m., Resident 146 was observed in bed, in a hospital gown. He stated he had been in a lot of pain for several days. Resident 146 stated the night of 5/02/22, he pressed the call light because he needed pain medicine. Resident 146 stated his pain level was 8 out of 10. Resident 146 stated Unlicensed Staff A responded to the call light, and he requested pain medication. Resident 146 stated Unlicensed Staff A came back and told him the Licensed Nurse (Licensed Nurse B) assigned to him stated he was not due for his pain medication (indicating it was not time for him to receive pain medication). Resident 146 stated no interventions were attempted to relieve his pain, and eventually he fell asleep in excruciating pain. During an interview on 5/03/22 at 3:29 p.m., Unlicensed Staff A confirmed being assigned to Resident 146 the night of 5/02/22. Unlicensed Staff A also confirmed Resident 146 requested pain medication, and she notified Licensed Nurse B, who was Resident 146's assigned Licensed Nurse, about his request. Unlicensed Staff A stated Licensed Nurse B told her Resident 146 was not due for his pain medication, so she went back to Resident 146's room and provided him with that information. Record review of Resident 146's MAR and Nursing Notes did not mention Resident 146's episode of pain the night of 5/02/22 mentioned by Resident 146 and Unlicensed Staff A, or described any type of pain assessment. During a phone interview on 5/06/22 at 10:26 a.m., Licensed Nurse B confirmed being the assigned Licensed Nurse for Resident 146 the night of 5/02/22. When asked about Resident 146's request for pain medication during her shift, Licensed Nurse B stated she could not remember. Licensed Nurse B stated she checked on Resident 146 during that shift, but could not remember if she documented anything related to pain. Record review of Resident 146's care plan for acute and chronic pain did not include any specific interventions to manage his pain, and no non-pharmacological interventions other than hot or cold packs for comfort. Some of the interventions in the care plan indicated, Administer prescribed medication before activity and therapy .Determine Resident's satisfactory pain level .Establish a pain management treatment plan. During an interview on 5/05/22 at 2:47 p.m., the DON confirmed creating Resident 146's care plan for pain. The DON stated she did not ask Resident 146 if hot and cold packs were effective in relieving his pain, and confirmed these were the (only) non-pharmacological interventions written in the care plan. The DON confirmed the care plan was generalized. When asked to provide Resident 146's pain management treatment plan (documented in the care plan), she stated this plan had not been documented. Record review of Resident 146's MAR indicated he had received 6 doses of [MEDICATION(S)] Acetaminophen (A combination medicine used to treat moderate to severe pain) 10-325 mg (Milligrams) tablets as needed, from 5/01/22 through 5/04/22 for pain levels of 7 out of 10. The pain reassessments after the administration of this medication were documented as 0 out of 10 after every administration. Yet, during an interview on 5/06/22 at 11:17 a.m., Resident 146 stated his pain level was never 0, even with medication, and stated the lowest level it reached, even after taking pain medication was 6 out of 10. Resident 146 stated he could tolerate pain levels of 4 out of 10 but it never reached that level. Resident 146 stated on 5/06/22, he pushed the call button three to four times to request pain medication, but nobody had provided him with it. Resident 146 stated his pain management system was not working out, and confirmed he was suffering. Resident 146 stated facility staff were not doing enough for him, and stated non-pharmacological interventions had never been attempted for him at this facility. Resident 146 stated the pain was on his left hip area, and it was dull in quality when immobile, but sharp when he moved. Record review of a physician order dated 4/22/22 at 3:00 p.m. indicated, Assess for pain every shift and chart intensity of pain using 1-10 numeric pain scale. Resident 146's MAR indicated his pain level from 5/01/22 through 5/05/22 reached a level of 8 out of 10 on five occasions, and 7 out of 10 on one occasion. The DON was asked on 5/06/22 at 10:01 a.m., to provide pain reassessment documentation of these pain levels documented on Resident 146's MAR from 5/01/22 through 5/05/22. During an interview with the DON on 5/06/22 at 11:01 a.m., she stated there was no documentation these pain levels were reassessed. During an interview with the DON on 5/06/22 at 12:44 p.m., the DON stated if a Resident's pain management plan was not effective, the doctor had to be notified for a revision, and this notification was required to be documented. The DON stated non-pharmacological interventions should be attempted, and pain reassessed after documenting high levels of pain. The DON was asked what was the expectation of a Licensed Nurse after unlicensed personnel notified her a Resident was requesting pain medication for high levels of pain. The DON stated the Licensed Nurse was supposed to assess the pain, medicate appropriately and try non-pharmacological interventions if pain was not relieved. The DON also stated the physician had to be notified if the pain was not relieved to a comfortable level. 3) Record review indicated Resident 24 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/03/22 at 10:36 a.m., Resident 24 stated she was frequently in pain, mostly in her feet, and her pain level at the moment was about a 9 from a scale from 1 to 10. Record review of a physician order dated 1/20/22 at 7:00 a.m. indicated, Assess for pain every shift and chart intensity of pain using 1-10 numeric pain scale. Resident 24's MAR indicated her pain level from 5/01/22 through 5/04/22 reached a level of 5 out of 10 on one occasion. The DON was asked on 5/06/22 at 10:01 a.m., to provide pain reassessment documentation of this pain level documented on 5/03/22 for morning shift. During an interview with the DON on 5/06/22 at 11:01 a.m., she confirmed there was no documentation this pain level was reassessed. Record review of Resident 24's care plan for chronic pain did not include any specific interventions to manage her pain, and no non-pharmacological interventions at all. Some of the interventions in the care plan indicated, Administer pain medications per order .determine Resident's satisfactory pain level .Evaluate pain During an interview on 5/05/22 at 2:47 p.m., the DON confirmed creating Resident 24's care plan for pain. The DON confirmed the care plan was generalized and did not include any non-pharmacological interventions. Record review indicated Resident 24 was administered [MEDICATION(S)] (A medication used to treat moderate to severe pain), in different doses, on 4 occasions from 5/01/22 through 5/05/22 for pain levels of 7 out of 10. Reassessments of these pain levels after the administration of [MEDICATION(S)] were documented as 0 out of 10, which indicated the medication was effective in relieving pain. Yet, during an interview on 5/06/22 at 11:33 a.m., Resident 24 stated that with pain medication, her pain level went down to 5 or 6 out of 10, but it was not always effective. Resident 24 stated her pain level was never a 0 out of 10. During the interview on 5/06/22 at 11:33 a.m., Resident 24 was asked if there were times when she requested pain medication and was denied the medication for not being due for it. Resident 24 responded, Yes, often. When asked how she felt about it, she stated, Like I am helpless, there's nothing I can do. Resident 24 confirmed she was suffering. When asked if the facility had attempted non-pharmacological interventions to relieve her pain, Resident 24 stated they had not. When asked if her medication regimen for pain control was effective, Resident 24 stated it was not. Resident 24 was observed showing facial expressions of pain. When asked if she was involved in any activities, Resident 1 stated, I hurt too much to do any other activities than TV. During an interview on 5/06/22 at 11:49 a.m., Licensed Nurse C confirmed being the assigned nurse for Resident 24 and Resident 146 the morning of 5/06/22. Licensed Nurse C confirmed being aware both residents had very high levels of pain frequently. When asked if the physician had been called in regards to these residents high pain levels, Licensed Nurse C stated, Not that I'm aware of. Record review of the facility policy titled, Pain Management, last revised in November of 2016, indicated, Facility Staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible .A Licensed Nurse will assess each resident for pain upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is significant change in status .The Interdisciplinary Team will develop a resident centered care plan for pain management, including non-pharmacological interventions .The Licensed Nurse will administer pain medication as ordered and document medication administered on the medication Administration Record (MAR) .After medications/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour .If there is an onset of pain , if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician.

Based on interview and record review, the facility failed to ensure one out of 3 residents (Resident 1) was free from one unnecessary drugs when Resident 1 received [MEDICATION NAME] (a non-steroidal anti-[MEDICAL CONDITION] drug, NSAID- use for pain relief and inflammation) for 25 days after it was discontinued. This failure resulted to Resident 1's hospitalization with Gastrointestinal (GI- stomach and intestines) bleeding as one of the diagnoses. Findings: On 1/20/17, the facility admitted Resident 1 with multiple [DIAGNOSES REDACTED]. On 1/21/17, the Physician order [REDACTED]. The Medication Administration Record (MAR) for 1/17 indicated [MEDICATION NAME] was discontinued. Without new order from the physician, the MAR for 2/17 indicated Resident 1 received [MEDICATION NAME], together with Celecoxib (another type of NSAID), from 2/1/17 to 2/25/17. On 2/25/17, the facility sent Resident 1 to the hospital. Review of the facility clinical records for Resident 1 indicated the following: The Black Box Warning Medications Care Plan for [MEDICATION NAME], initiated on 1/20/17 and discontinued on 1/21/17, indicated, .May also cause increased risk of serious GI adverse events; inlc. (including) GI bleed, ulcers, and perforation (hole in the GI wall). With similar warning, Care Plan for [MEDICATION NAME]/Celecoxib was initiated on 1/20/17, no discontinuation date. On 1/21/17, the Physician order [REDACTED]. The Medication Administration Record (MAR) for 1/17 indicated [MEDICATION NAME] and [MEDICATION NAME] were discontinued on 1/21/17. The Physician order [REDACTED]. [MEDICATION NAME] was not in this document indicating the medical record personal received the physician order [REDACTED]. This document was reviewed by the nurse on 1/27/17, physician on 2/1/17, and pharmacist on 2/9/17. The Nurse's Notes dated 2/25/17 at 5:30 p.m. indicated nurse could not palpate (feel) the pulse, could not check blood pressure, apical pulse (listening to heart beat with stethoscope place above the chest) was 11 beats per minute (bpm) (normal range is 60-100 bpm). The nurse's note indicated Resident 1 was unresponsive and diaphoretic (excessive sweating). The nurse's note indicated the staff called 911 (Emergency hotline) and the paramedic arrived and transported Resident 1 to the hospital. Review of the hospital clinical records for Resident 1 indicated the following: The Emergency Department (ED) Report dated 2/25/17, at 8:46 p.m. indicated, When I (Physician) performed a rectal examination (physical examination of the rectum), I found bleeding around a large fecal globule (round particle made of feces). On palpation to this mass, fecal fluid (liquid of feces substance) and significant amount of blood began draining as pressure from the mass was released. Patient (Resident 1) found to have a massive most likely upper GI bleed . I (Physician) reviewed her medication with our Pharmacist. She (Resident 1) is prescribed duplicate NSAIDs which likely to be the cause of her symptoms . NG tube (Nasogastric tube- tubing inserted through the nose into the stomach use to give medicine and/or remove the stomach content) was placed and over 400 CCs (millimeter) of coffee-ground emesis (vomitus, a sign of upper [MEDICAL CONDITION]) produced. Patient (Resident 1) required multiple blood pressure re-evaluations as her pressures initially were quite low. Patient (Resident 1) was started on levo fed ([MEDICATION NAME]- medicine use to control blood pressure in certain acute hypotensive (low blood pressure) states), fluids, [MEDICATION NAME](Antibiotic) (sic) she (Resident 1) was also given Versed (used to produce sleepiness or drowsiness and to relieve anxiety before surgery or certain procedures) which helped somewhat. Blood pressure started to respond well and we (Healthcare professionals) back off on the pressors (substance that tends to cause a rise in blood pressure). Patient (Resident 1) was admitted in critical condition . During this critical care time, the patient (Resident 1) was at high risk of life threatening or organ threatening decompensation The ED Cares assessment dated [DATE], at 9:50 p.m. indicated Resident 1 received 2nd unit of blood transfusion. The History and Physical Report dictated date on 2/25/17, at 11:08 p.m. indicated, Assessment: .potentially upper GI bleed with dehydration . Plan 2. Upper GI bleed: Potentially fairly significant large amount (of ground-coffee colored emesis) was taken out of her GI tract via NG when she (Resident 1) arrived . Plan 6. Reflux, on several NSAIDs: she likely does have a gastritis or [MEDICAL CONDITION] ulcer disease and as mentioned will be treated. The Consultation Report with transcription date of 2/16/17, at 12:07 p.m. indicated, PAST MEDICAL HISTORY: Daughter indicates history of bleeding ulcer [AGE] years ago .IMPRESSION: The patient with upper [MEDICAL CONDITION] with positive NG tube for coffee-grounds, likely on the basis of anti-[MEDICAL CONDITION] usage . The Operative Report for upper endoscopy (a procedure performed on individuals to examine the esophagus, stomach, and duodenum-the first portion of the small bowel) dictated date on 2/26/17, at 1:18 p.m. indicated, Large [DIAGNOSES REDACTED] ulcer (sore in the lining of the small intestine). The Progress Note dictated date on 2/27/17, at 4:39 p.m. indicated, Impression: Large [DIAGNOSES REDACTED] ulcer and difficult to access position. She (Resident 1) is still at significant risk of rebleeding, though this risk decreases with every day. We (Healthcare professionals) will continue her on high-dose PPIs (Proton pump inhibitors- medications used in treating and preventing NSAID-associated ulcers). She should absolutely avoid antiinflammatories (sic) in the future . The Hospitalist Progress Note dated 3/19/17, at 4:07 p.m., indicated GI bleed- likely 2/2 (secondary to) NSAID use .Discussed discontinuation of all NSAIDs . During an interview on 3/28/17, at 12:29 p.m., Licensed Staff A verified there was a physician ordered to discontinue [MEDICATION NAME] on 1/21/17, and there was no new order from the physician for [MEDICATION NAME] afterwards. During an interview on 3/28/17 at 7:55 p.m., Licensed Staff A stated the [MEDICATION NAME] order in the Physician order [REDACTED]. During an interview on 4/14/17, at 10:37 a.m., when asked why Resident 1 was on Celecoxib and [MEDICATION NAME], the Primary Physician stated, I don't believe they are together. If they are, it's an oversight. The Primary Physician stated his last notes indicated not to give any NSAIDs due to [DIAGNOSES REDACTED] ulcer. The Primary Physician stated, My record 2/17 prescription history, I don't see [MEDICATION NAME] on my records. I don't know how the [MEDICATION NAME] got there. The Primary Physician stated [MEDICATION NAME] could put people at high risk for [DIAGNOSES REDACTED] ulcer while people [MEDICATION NAME] (Celecoxib) have lower risk. The Primary Physician stated [MEDICATION NAME] and [MEDICATION NAME] combination is not recommended due to duplicate therapy (refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication). During an interview on 4/14/17 at 3 p.m., the DON stated she did not see any recommendation from the pharmacist for Resident 1's February 2017 Medication Regimen Review (a thorough evaluation of the medication regimen by a pharmacist, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities in collaboration with other members of the interdisciplinary team). During an interview on 4/26/17, at 10:20 a.m., Licensed Staff A stated, the facility process for physician orders [REDACTED]. Also, Licensed Staff A stated the facility process for MAR review was for the nurse to compare the physician orders [REDACTED]. Licensed Staff A stated the nurse who performed the recapitulation did not catch that [MEDICATION NAME] was discontinued on 1/21/17, yet, it showed up on the Physician order [REDACTED]. During an interview on 4/26/17, at 10:50 a.m., the Consultant Pharmacist stated, there shouldn't be NSAIDs at the same time. Consultant Pharmacist stated one of the side effects of [MEDICATION NAME] and Celecoxib was GI bleed-more serious situations. As to why the [MEDICATION NAME] order showed in 2/17 MAR and Physician order [REDACTED]. During an interview on 4/26/17, at 11:15 a.m., Unlicensed Staff B, the person who enters physician order [REDACTED]. Unlicensed Staff B stated after printing out the MAR, he provided notification to nurses indicating, Recaps have been printed out. Any new order or changed orders please place in the current month's MAR and oncoming month's MAR. The facility policy and procedure titled Medication Administration dated 1/1/12 indicated, Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. The facility policy and procedure titled Drug Regimen Review dated 12/16 indicated, Purpose. To identify clinical irregularities during monthly regimen review by pharmacist and promptly bring them to the attention of the medical director, attending physician and director of nursing. Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- A. In excessive dose (including duplicate drug therapy). Beginning of CITATION The facility failed to 1. Follow physician order [REDACTED]. 2. Identify duplicate therapy of [MEDICATION NAME] and Celecoxib (another type of NSAID). 3. Follow the resident care plan regarding Black Box warning for [MEDICATION NAME] and Celecoxib. Findings: Clinical record review on 3/27/17, revealed that Resident 1 was a [AGE] year-old female who was admitted to the facility on [DATE] for skilled nursing care. Resident 1 had [DIAGNOSES REDACTED]. Resident 1 was described in the unit, as being confuse and screams for assistance. On 1/21/17, the Physician order [REDACTED]. The Medication Administration Record (MAR) for 1/17 indicated [MEDICATION NAME] was discontinued on 1/21/17, yet, it appeared on the Physician order [REDACTED]. The MAR for 2/17 indicated Resident 1 received [MEDICATION NAME], together with Celecoxib, from 2/1/17 to 2/25/17. The Black Box Warning Medications Care Plan for [MEDICATION NAME] and Celecoxib indicated, .May also cause increased risk of serious GI adverse events; inlc. (including) GI bleed, ulcers, and perforation (hole in the GI wall). The care plan for [MEDICATION NAME] indicated it was discontinued on 1/21/17, and the care plan for Celecoxib was not. Further clinical record review indicated that on 1/21/17, the physician ordered to discontinue [MEDICATION NAME] and [MEDICATION NAME]. The Physician Recapitulation order revealed [MEDICATION NAME] was not in the order indicating the medical record processed the order sheet. On 2/25/17 at 5:30 p.m., the Nurse's Notes indicated the nurse could not palpate (feel) the pulse, could not check blood pressure, apical pulse (listening to heart beat with stethoscope place above the chest) was 11 beats per minute (bpm) (normal range is 60-100 bpm). The nurse's note indicated Resident 1 was unresponsive and diaphoretic (excessive sweating). The nurse's note indicated the staff called 911 (Emergency hotline) and the paramedic arrived and transported Resident 1 to the hospital. Review of the hospital clinical records for Resident 1 indicated the following: The Emergency Department (ED) Report dated 2/25/17, at 8:46 p.m. indicated, When I (Physician) performed a rectal examination (physical examination of the rectum), I found bleeding around a large fecal globule (round particle made of feces). On palpation to this mass, fecal fluid (liquid of feces substance) and significant amount of blood began draining as pressure from the mass was released. Patient (Resident 1) found to have a massive most likely upper GI bleed . I (Physician) reviewed her medication with our Pharmacist. She (Resident 1) is prescribed duplicate NSAIDs which likely to be the cause of her symptoms . NG tube (Nasogastric tube- tubing inserted through the nose into the stomach use to give medicine and/or remove the stomach content) was placed and over 400 CCs (millimeter) of coffee-ground emesis (vomitus, a sign of upper [MEDICAL CONDITION]) produced. Patient (Resident 1) required multiple blood pressure re-evaluations as her pressures initially were quite low. Patient (Resident 1) was started on levo fed ([MEDICATION NAME]- medicine use to control blood pressure in certain acute hypotensive (low blood pressure) states), fluids, [MEDICATION NAME](Antibiotic) (sic) she (Resident 1) was also given Versed (used to produce sleepiness or drowsiness and to relieve anxiety before surgery or certain procedures) which helped somewhat. Blood pressure started to respond well and we (Healthcare professionals) back off on the pressors (substance that tends to cause a rise in blood pressure). Patient (Resident 1) was admitted in critical condition . During this critical care time, the patient (Resident 1) was at high risk of life threatening or organ threatening decompensation The ED Cares assessment dated [DATE], at 9:50 p.m. indicated Resident 1 received 2nd unit of blood transfusion. The History and Physical Report dictated date on 2/25/17, at 11:08 p.m. indicated, Assessment: .potentially upper GI bleed with dehydration . Plan 2. Upper GI bleed: Potentially fairly significant large amount (of ground-coffee colored emesis) was taken out of her GI tract via NG when she (Resident 1) arrived . Plan 6. Reflux, on several NSAIDs: she likely does have a gastritis or [MEDICAL CONDITION] ulcer disease and as mentioned will be treated. The Consultation Report with transcription date of 2/16/17, at 12:07 p.m. indicated, PAST MEDICAL HISTORY: Daughter indicates history of bleeding ulcer [AGE] years ago .IMPRESSION: The patient with upper [MEDICAL CONDITION] with positive NG tube for coffee-grounds, likely on the basis of anti-[MEDICAL CONDITION] usage . The Operative Report for upper endoscopy (a procedure performed on individuals to examine the esophagus, stomach, and duodenum-the first portion of the small bowel) dictated date on 2/26/17, at 1:18 p.m. indicated, Large [DIAGNOSES REDACTED] ulcer (sore in the lining of the small intestine). The Progress Note dictated date on 2/27/17, at 4:39 p.m. indicated, Impression: Large [DIAGNOSES REDACTED] ulcer and difficult to access position. She (Resident 1) is still at significant risk of rebleeding, though this risk decreases with every day. We (Healthcare professionals) will continue her on high-dose PPIs (Proton pump inhibitors- medications used in treating and preventing NSAID-associated ulcers). She should absolutely avoid antiinflammatories (sic) in the future . The Hospitalist Progress Note dated 3/19/17, at 4:07 p.m., indicated GI bleed- likely 2/2 (secondary to) NSAID use .Discussed discontinuation of all NSAIDs . During an interview on 3/28/17, at 12:29 p.m., Licensed Staff A verified there was a physician ordered to discontinue [MEDICATION NAME] on 1/21/17, and there was no new order from the physician for [MEDICATION NAME] afterwards. During an interview on 3/28/17 at 7:55 p.m., Licensed Staff A stated the [MEDICATION NAME] order in the Physician order [REDACTED]. During an interview on 4/14/17, at 10:37 a.m., when asked why Resident 1 was on Celecoxib and [MEDICATION NAME], the Primary Physician stated, I don't believe they are together. If they are, it's an oversight. The Primary Physician stated his last notes indicated not to give any NSAIDs due to [DIAGNOSES REDACTED] ulcer. The Primary Physician stated, My record 2/17 prescription history, I don't see [MEDICATION NAME] on my records. I don't know how the [MEDICATION NAME] got there. The Primary Physician stated [MEDICATION NAME] could put people at high risk for [DIAGNOSES REDACTED] ulcer while people [MEDICATION NAME] (Celecoxib) have lower risk. The Primary Physician stated [MEDICATION NAME] and [MEDICATION NAME] combination is not recommended due to duplicate therapy (refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication). During an interview on 4/14/17 at 3 p.m., the DON stated she did not see any recommendation from the pharmacist for Resident 1's February 2017 Medication Regimen Review (a thorough evaluation of the medication regimen by a pharmacist, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities in collaboration with other members of the interdisciplinary team). During an interview on 4/26/17, at 10:20 a.m., Licensed Staff A stated, the facility process for physician orders [REDACTED]. Also, Licensed Staff A stated the facility process for MAR review was for the nurse to compare the physician orders [REDACTED]. Licensed Staff A stated the nurse who performed the recapitulation did not catch that [MEDICATION NAME] was discontinued on 1/21/17, yet, it showed up on the Physician order [REDACTED]. During an interview on 4/26/17, at 10:50 a.m., the Consultant Pharmacist stated, there shouldn't be NSAIDs at the same time. Consultant Pharmacist stated one of the side effects of [MEDICATION NAME] and Celecoxib was GI bleed-more serious situations. As to why the [MEDICATION NAME] order showed in 2/17 MAR and Physician order [REDACTED]. During an interview on 4/26/17, at 11:15 a.m., Unlicensed Staff B, the person who enters physician order [REDACTED]. Unlicensed Staff B stated after printing out the MAR, he provided notification to nurses indicating, Recaps have been printed out. Any new order or changed orders please place in the current month's MAR and oncoming month's MAR. The facility policy and procedure titled Medication Administration dated 1/1/12 indicated, Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. The facility policy and procedure titled Drug Regimen Review dated 12/16 indicated, Purpose. To identify clinical irregularities during monthly regimen review by pharmacist and promptly bring them to the attention of the medical director, attending physician and director of nursing. Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- A. In excessive dose (including duplicate drug therapy). Therefore, the facility failed to 1. Follow physician order [REDACTED]. 2. Identify duplicate therapy of [MEDICATION NAME] and Celecoxib (another type of NSAID). 3. Follow the resident care plan regarding Black Box warning for [MEDICATION NAME] and Celecoxib. These violations presented either imminent danger that death or serious hard would result or a substantial probability that death or serious physical injury would result. End of CITATION

Beginning of CITATION (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; The facility failed to maintain an accurate medical records. Findings: Clinical record review on 3/27/17, revealed that Resident 1 was a [AGE] year-old female who was admitted to the facility on [DATE] for skilled nursing care. Resident 1 had [DIAGNOSES REDACTED]. On 1/21/17, the Physician order [REDACTED]. The Medication Administration Record (MAR) for 1/17 indicated [MEDICATION NAME] was discontinued on 1/21/17, yet, it appeared on the Physician order [REDACTED]. The Physician order [REDACTED]. The (MONTH) (YEAR) orders were reviewed and signed by the nurse on 1/27/17, physician on 2/1/17, and pharmacist on 2/9/17. Celecoxib was also noted on the (MONTH) (YEAR) Physician order [REDACTED]. The MAR indicated Resident 1 received Celecoxib on (MONTH) (YEAR). The Black Box Warning Medications Care Plan for [MEDICATION NAME] and Celecoxib indicated, .May also cause increased risk of serious GI adverse events; inlc. (including) GI bleed, ulcers, and perforation (hole in the GI wall). The care plan for [MEDICATION NAME] indicated it was discontinued on 1/21/17, and the care plan for Celecoxib was not. On 2/25/17 at 5:30 p.m., the Nurse's Notes indicated the nurse could not palpate (feel) the pulse, could not check blood pressure, apical pulse (listening to heart beat with stethoscope place above the chest) was 11 beats per minute (bpm) (normal range is 60-100 bpm). The nurse's note indicated Resident 1 was unresponsive and diaphoretic (excessive sweating). The nurse's note indicated the staff called 911 (Emergency hotline) and the paramedic arrived and transported Resident 1 to the hospital. Review of the hospital clinical records for Resident 1 indicated the following: The Emergency Department (ED) Report dated 2/25/17, at 8:46 p.m. indicated, When I (Physician) performed a rectal examination (physical examination of the rectum), I found bleeding around a large fecal globule (round particle made of feces). On palpation to this mass, fecal fluid (liquid of feces substance) and significant amount of blood began draining as pressure from the mass was released. Patient (Resident 1) found to have a massive most likely upper GI bleed . I (Physician) reviewed her medication with our Pharmacist. She (Resident 1) is prescribed duplicate NSAIDs which likely to be the cause of her symptoms . NG tube (Nasogastric tube- tubing inserted through the nose into the stomach use to give medicine and/or remove the stomach content) was placed and over 400 CCs (millimeter) of coffee-ground emesis (vomitus, a sign of upper [MEDICAL CONDITION]) produced. Patient (Resident 1) required multiple blood pressure re-evaluations as her pressures initially were quite low. Patient (Resident 1) was started on levo fed ([MEDICATION NAME]- medicine use to control blood pressure in certain acute hypotensive (low blood pressure) states), fluids, [MEDICATION NAME](Antibiotic) (sic) she (Resident 1) was also given Versed (used to produce sleepiness or drowsiness and to relieve anxiety before surgery or certain procedures) which helped somewhat. Blood pressure started to respond well and we (Healthcare professionals) back off on the pressors (substance that tends to cause a rise in blood pressure). Patient (Resident 1) was admitted in critical condition . During this critical care time, the patient (Resident 1) was at high risk of life threatening or organ threatening decompensation The ED Cares assessment dated [DATE], at 9:50 p.m. indicated Resident 1 received 2nd unit of blood transfusion. The History and Physical Report dictated date on 2/25/17, at 11:08 p.m. indicated, Assessment: .potentially upper GI bleed with dehydration . Plan 2. Upper GI bleed: Potentially fairly significant large amount (of ground-coffee colored emesis) was taken out of her GI tract via NG when she (Resident 1) arrived . Plan 6. Reflux, on several NSAIDs: she likely does have a gastritis or [MEDICAL CONDITION] ulcer disease and as mentioned will be treated. The Consultation Report with transcription date of 2/16/17, at 12:07 p.m. indicated, PAST MEDICAL HISTORY: Daughter indicates history of bleeding ulcer [AGE] years ago .IMPRESSION: The patient with upper [MEDICAL CONDITION] with positive NG tube for coffee-grounds, likely on the basis of anti-[MEDICAL CONDITION] usage . The Operative Report for upper endoscopy (a procedure performed on individuals to examine the esophagus, stomach, and duodenum-the first portion of the small bowel) dictated date on 2/26/17, at 1:18 p.m. indicated, Large [DIAGNOSES REDACTED] ulcer (sore in the lining of the small intestine). The Progress Note dictated date on 2/27/17, at 4:39 p.m. indicated, Impression: Large [DIAGNOSES REDACTED] ulcer and difficult to access position. She (Resident 1) is still at significant risk of rebleeding, though this risk decreases with every day. We (Healthcare professionals) will continue her on high-dose PPIs (Proton pump inhibitors- medications used in treating and preventing NSAID-associated ulcers). She should absolutely avoid antiinflammatories (sic) in the future . The Hospitalist Progress Note dated 3/19/17, at 4:07 p.m., indicated GI bleed- likely 2/2 (secondary to) NSAID use .Discussed discontinuation of all NSAIDs . During an interview on 3/28/17, at 12:29 p.m., Licensed Staff A verified there was a physician ordered to discontinue [MEDICATION NAME] on 1/21/17, and there was no new order from the physician for [MEDICATION NAME] afterwards. During an interview on 3/28/17 at 7:55 p.m., Licensed Staff A stated the [MEDICATION NAME] order in the Physician order [REDACTED]. During an interview on 4/14/17, at 10:37 a.m., when asked why Resident 1 was on Celecoxib and [MEDICATION NAME], the Primary Physician stated, I don't believe they are together. If they are, it's an oversight. The Primary Physician stated his last notes indicated not to give any NSAIDs due to [DIAGNOSES REDACTED] ulcer. The Primary Physician stated, My record 2/17 prescription history, I don't see [MEDICATION NAME] on my records. I don't know how the [MEDICATION NAME] got there. The Primary Physician stated [MEDICATION NAME] could put people at high risk for [DIAGNOSES REDACTED] ulcer while people taking [MEDICATION NAME] (Celecoxib) have lower risk. The Primary Physician stated [MEDICATION NAME] and [MEDICATION NAME] combination is not recommended due to duplicate therapy (refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication). During an interview on 4/14/17 at 3 p.m., the DON stated she did not see any recommendation from the pharmacist for Resident 1's (MONTH) (YEAR) Medication Regimen Review (a thorough evaluation of the medication regimen by a pharmacist, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities in collaboration with other members of the interdisciplinary team). During an interview on 4/26/17, at 10:20 a.m., Licensed Staff A stated, the facility process for physician orders [REDACTED]. Licensed Staff A stated the nurse who performed the recapitulation did not catch that [MEDICATION NAME] was discontinued on 1/21/17. During an interview on 4/26/17, at 10:50 a.m., the Consultant Pharmacist stated, there shouldn't be NSAIDs at the same time. Consultant Pharmacist stated one of the side effects of [MEDICATION NAME] and Celecoxib was GI bleed-more serious situations. As to why the [MEDICATION NAME] order showed in 2/17 MAR and Physician order [REDACTED]. During an interview on 4/26/17, at 11:15 a.m., Unlicensed Staff B, the person who enters physician order [REDACTED]. Unlicensed Staff B stated after printing out the MAR, he provided notification to nurses indicating, Recaps have been printed out. Any new order or changed orders please place in the current month's MAR and oncoming month's MAR. During an interview on 4/26/17, at 4:07 p.m., the DON stated, There's a medical error supported by the paper trail which were the MAR for 1/12 and 2/12. When asked if there was a transcription (transfer of information from the hand written physician order [REDACTED]. The facility policy and procedure titled Medication Administration dated 1/1/12 indicated, Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. The facility policy and procedure titled Drug Regimen Review dated 12/16 indicated, Purpose. To identify clinical irregularities during monthly regimen review by pharmacist and promptly bring them to the attention of the medical director, attending physician and director of nursing. Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- A. In excessive dose (including duplicate drug therapy). Therefore, the facility failed to maintain an accurate medical records. These violations presented either imminent danger that death or serious hard would result or a substantial probability that death or serious physical injury would result. End of CITATION

Based on observation, interview and record review, the facility failed to provide adequate supervision for one resident (Resident 1) and ensure her environment was free of accident hazards when she fell while one staff member, instead of the required two staff, attempted to transfer her using a Hoyer lift (patient lift that utilizes a sling to transfer residents). Resident 1 had a history of [REDACTED]. This failure caused Resident 1 to sustain multiple rib fractures, a hemothorax (blood accumulation in the space between the chest wall and the lung which can interfere with normal breathing; most common cause is chest trauma) and a skin tear. Resident 1's injuries caused her to have increased pain and to experience fear when she was subsequently moved with the Hoyer lift. Findings: Review of Resident 1's facility face sheet (medical information), dated 8/31/16, indicated Resident 1 had generalized muscle weakness and her physician progress notes [REDACTED]. Review of her MDS dated [DATE] (three months before her fall from the lift) indicated Resident 1 was unsteady, had impaired balance during transfers, and had a recent fall at the facility. Review of Resident 1's MDS's dated 5/16/16 and 8/16/16 (prior to her fall) revealed she had no pain. Review of Resident 1's medical record document of monthly vital signs, weights, and pain assessment indicated Resident 1 had no pain from January, 2016 through August 3, 2016. Review of Resident 1's Medication Record Administration (MAR) indicated she had no pain from August 1 through August 26, 2016 but was given Norco (narcotic pain reliever) for generalized discomfort. Review of Resident 1's nursing care plan (direction for the nursing care an individual may need) dated 8/26/16 indicated Resident 1 fell to the floor while being transferred by staff and complained of pain to her right arm and right elbow. The care plan indicated Resident 1 would be sent to a local hospital emergency room for a post fall evaluation. Review of Resident 1's SBAR notes (facility document where nurses document the situation, background, appearance and review/notification of an incident), dated 8/26/16, revealed Resident 1 had fallen and had sustained a right arm skin tear and complained of increased pain in her right shoulder and elbow. The document indicated Resident 1's pain was 7 out of 10 (pain assessment scare where 1 was no pain and 10 was worst pain imaginable) and she grimaced when her right arm and shoulder were touched. The document indicated Resident 1 was sent to the local hospital's emergency room for evaluation of possible right arm fracture. Review of the Emergency Department Report dated 8/26/16 at 9:24 p.m. (documented by Physician K) indicated Resident 1's chief complaint was right elbow pain after fall. Review of the History & Physical Report, documented by Physician G (dated 8/27/16, no time) indicated the reason for Resident 1's hospital admission was fall. Physician G documented that Resident 1 was being transported in some type of lift mechanism and she fell . Physician G indicated Resident 1 was taken in for further evaluation. Review of hospital radiology (x-ray imaging) report dated 8/26/16 at 8:26 p.m. indicated Resident 1 had a chest x-ray from one view (XR Chest 1V). The report indicated Resident 1 was status [REDACTED]. Under subtitle Impression, the report revealed Resident 1 had multiple right rib fractures with associated minor right hemothorax . The report was electronically signed by Physician H on 8/27/16 at 4:58 p.m. Review of Resident 1's hospital physician progress notes [REDACTED]. The physician progress notes [REDACTED]. Review of Resident 1's medical record nurse's notes revealed she was transferred back to the facility via ambulance on 8/30/16. Review of an Interdisciplinary Team (IDT) conference record dated 8/31/16 indicated Resident 1 was status [REDACTED]. An IDT conference record dated 9/1/16 indicated Resident 1 had fractures to her right fifth through eighth ribs, as noted on x-ray report from the hospital. The report indicated the facility notified Physician I of the x-ray results. During an observation on 8/31/16 at 2:05 p.m., Resident 1 was lying in her bed. During an interview at 2:10 p.m., Resident 1 had difficulty expressing herself verbally and nodded or shook her head in response to questions. When asked if she had fallen recently, Resident 1 nodded her head up and down, indicating yes. When asked where she fell , Resident 1 used her left hand to point to her right shoulder. After that movement, she made a facial grimace. When asked if she was in pain, Resident 1 nodded her head up and down, indicating yes. When asked if she had pain before she had fallen, she shook her head side to side, indicating no. When asked if she had pain after she fell , she nodded yes. At that time, she moved slightly and again grimaced. When asked if she wanted pain medicine from the nurse, she shook her head to indicate no. During an interview on 8/31/16 at 2:25 p.m., Licensed Nurse B stated Resident 1 was alert and oriented (aware of person, place and time; not disoriented) but had problems with speech. He stated she was able to tell you yes and no and was able to answer well that way. He stated he had medicated her for pain earlier that day. When asked how her pain compared to her pain before her fall, he stated normally she went to the dining room to eat her meals but she wanted to stay in bed that day, which was unusual for her. He stated she usually smiled more but she was not smiling that day. During an interview on 8/31/16 at 2:45 p.m., Certified Nursing Assistant C (CNA C) stated she had worked with Resident 1 approximately two weeks earlier. She stated Resident 1 required maximum assistance from staff but had gotten up for breakfast and lunch at that time. When asked if she had pain when she got her up two weeks ago, CNA C stated Resident 1 was, perfectly fine and had not had pain. CNA C stated she had fed Resident 1 that morning (8/31/16) in bed because she had not gotten up. She stated Resident 1 was in pain during breakfast and the elevated head of the bed had caused Resident 1 pain. During an interview on 8/31/16 at 3:00 p.m., CNA D stated he knew Resident 1 and had taken care of her in the past. He stated it was hard to communicate with her but she could say water and light and was able to shake her head to indicate yes and no. CNA D stated Resident 1 required maximum assistance from staff and they used a Hoyer lift to move her. He stated two staff moved her in the Hoyer lift. He stated Resident 1 got up in the wheel chair for all meals but she was now in pain and did not want to get up. During an interview on 8/31/16 at 3:20 p.m., Licensed Nurse E stated she was Resident 1's nurse the evening she fell from the Hoyer lift and she had gotten a stat (respond immediately) call to her room. She stated Resident 1 was lying on the floor, had a skin tear, and had complained of pain on her right side. She stated Resident 1 used her fingers to communicate that her pain was 7 out of 10 (on the pain scale). She stated CNA F was alone (no other staff were present) and he told her the Hoyer lift dropped Resident 1. She stated CNA F had gotten Resident 1 up in the Hoyer by himself. She stated CNA F was sent home after the incident (he did not finish working his shift). During an interview on 8/31/16 at 1:30 p.m., the Director of Nursing stated Resident 1 fell while CNA F was transferring her using a Hoyer lift. She stated Resident 1 had been injured and she had right shoulder pain and a skin tear. During an interview with Administrator A and the Director of Nursing (DON) on 8/31/16 at 3:45 p.m., Administrator A stated the root cause of Resident 1's fall was the CNA had not followed facility policy and procedure. She stated two staff members, not one, were required to transfer residents using a Hoyer lift. She stated facility maintenance staff had assessed the Hoyer's sling after the incident. She stated the sling was okay but it had not been hooked right. Review of Resident 1's nurse's note dated 8/31/16 at 2:50 p.m. (after she returned from the hospital) indicated Resident 1 was given Norco (narcotic pain reliever) for moaning and groaning. Review of Resident 1's Medication Administration Record (MAR) indicated she received additional Norco later that day for moaning/groaning. Review of Resident 1's night shift nurse's note dated 9/1/16 indicated she was given Oxycodone (narcotic pain reliever stronger that Norco) for, severe pain, a lot of facial expressions . and for hands clutching and tightening up. Review of Resident 1's nurse's note dated 9/3/16 at 10:25 a.m. indicated Resident 1 complained of right sided chest pain and staff gave her Norco for pain relief. The note further indicated Resident 1 was very guarded while in Hoyer sling. A nurse's note dated 9/4/16 at 11:10 a.m. indicated Resident 1 complained of right arm/shoulder and right side chest pain and staff gave her Norco with good results. The note further indicated Resident 1 was still afraid of using lift to get in and out of bed. During a telephone interview and concurrent record review on 10/4/16 at 10:20 a.m., Physician I (Resident 1's primary physician) stated she was Resident 1's doctor. She stated Resident 1 was totally dependent on staff for her care and only one CNA was assisting her at the time she fell from the Hoyer lift. When asked if Resident 1's radiology results, dated 8/26/16, (that indicated Resident 1 had multiple right rib fractures with a right hemothorax) was caused from her fall from the Hoyer lift, Physician I responded, yes. She stated that Physician J's progress note, dated 8/29/16 at 12:39 p.m., (that indicated Resident 1 had not sustained rib fractures) was not correct. Review of facility policy titled Total Mechanical Lift (revised 1/1/12) indicated a mechanical lift would be used appropriately to facilitate transfers of residents. The policy indicated II. At least two people are present while resident is being transferred with the mechanical lift.