Every finding on record at Sequoia Vista

Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) care plan was implemented when Resident 1 did not receive showers. This failure had the potential to place Resident 1 at risk for urinary tract infections (UTI- an infection of the bladder).Findings:During an interview on [DATE] at 11:57 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, facility's UTI prevention included routine showers.During an interview on [DATE] at 12:09 p.m. with Infection Preventionist (IP), IP stated, part of UTI prevention in the facility included increased showers.During a review of Resident 1's Daily Shower Schedule (DSS) dated [DATE], the DSS indicated Resident 1's shower days were Tuesday and Fridays.During a concurrent interview and record review on [DATE] at 1:23 p.m. with the Director of Staff Development (DSD), Resident 1's Shower Day Skin Inspection (SDSI) sheets dated [DATE] through [DATE] were reviewed. No documentation of SDSI sheets was found for the week of [DATE]-[DATE]. Resident 1's ADL (Activities of Daily Living): Bathing documentation dated [DATE] through [DATE] was reviewed. The ADL: Bathing indicated, no documentation of showers from [DATE]-[DATE]. DSD stated, Yeah, it [showering] didn't happen and showering is part of UTI prevention.During a concurrent interview and record review on [DATE] at 1:50 p.m. with Director of Nursing (DON), Resident 1's Care Plan Report (CPR) dated [DATE] was reviewed. The CPR indicated, FOCUS [Resident 1] has a history of recurrent Urinary Tract Infections. Interventions/Tasks. Good hygiene practices. DON stated showering is part of good hygiene practices and care plan was not followed.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans (undated), the P&P indicated, Policy Explanation and Compliance Guidelines.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to provide a bed bath as scheduled for one of three sampled residents (Resident 1). This failure resulted in Resident 1 missing multiple scheduled bed baths.Findings:During an interview on 8/13/26 at 12:13 p.m. with Resident 1, Resident 1 stated he went a week without getting a bed bath.During a review of Resident 1's Daily Shower Schedule (DSS) undated, the DSS indicated, All Residents should be showered on their shower days and Resident 1 was to receive a shower on Tuesday's and Friday's during pm shift.During a review of Resident 1's Bathing documentation (BD) dated 7/31/26-8/7/26, the BD indicated, 8/3/26, 8/4/26, 8/6/26, and 8/7/26 not applicable was documented.During an interview on 8/18/26 at 4:30 p.m. with Director of Nursing (DON), DON stated there was no evidence of Resident 1 receiving a bed bath 8/3-8/11. DON stated Resident 1 should have received a bed bath Tuesday and Friday's on pm shift.During a review of Resident 1's Policy and Procedure (P&P) titled, Resident Showers undated, the P&P indicated, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards or practice.Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Resident Personal Belongings for two of 51 sampled residents (Resident 26 and Resident 41) when Resident 26 and Resident 41's personal belonging were lost. This failure had the potential to negatively affect residents' dignity and quality of life.Findings:1. During an interview on 6/1/26 at 11:32 a.m. with Resident 41, Resident 41 stated, When I got here, my clothing went missing. This shirt [that I have on] isn't mine, but I wear it because it fit.During a review of Resident 41's Minimum Data Set (MDS-a resident assessment tool), dated 4/23/26, the MDS indicated, Resident 41 had a BIMS (Brief Interview for Mental Status-cognitive assessment) score of 14 (13-15 indicates normal thinking and memory).During a concurrent observation, interview, and record review on 6/3/26 at 2:47 p.m. with Licensed Vocational Nurse (LVN) 4 in Resident 41's room, Resident 41's Inventory of Personal Effects (IPE), dated 5/27/25 was reviewed. The IPE indicated, Resident 41 had a total of twenty personal belongings and there was no documentation of missing personal belongings. Resident 41 had 31 personal belongings in his closet. LVN 4 stated Resident 41 had five missing personal belongings that were not documented as missing in his IPE. LVN 4 stated Resident 41 had four belongings with no name and were not listed on the IPE. LVN 4 stated, Resident 41's belongings should have been labeled with his name. LVN 4 stated, The CNA [certified nursing assistant] or whoever is assigned to the resident [Resident 41] is supposed to update it [inventory list] and label clothing [personal belongings] with resident [Resident 41] name.During an interview on 6/4/26 at 8:31 a.m. with Housekeeping/Laundry Supervisor (HLS), HLS stated, Clothing goes to laundry with no name. It's CNA's responsibility to label it. HLS stated every month laundry had unclaimed resident personal belongings.During an interview on 6/4/26 at 8:59 a.m. with Social Service Director (SSD), SSD stated, all of Resident 41's clothing had been donated to him.2. During an interview on 6/2/26 at 3:13 p.m. with Resident 26, Resident 26 stated I am missing clothing. A whole bag of clothing. It [clothing] was never found.During a review of Resident 26's MDS, dated [DATE], the MDS indicated, Resident 26 had a BIMS score of 14.During a review of Resident 26's IPE, dated 9/18/25, the IPE indicated, Resident 26 had four items of clothing and no documented missing personal belongings. During a review of Resident 26's Theft and Loss Form (TLF), dated 4/6/26, the TLF indicated, Description of missing items: 1 red t-shirt with pocket, 1 navy shirt (t-shirt with pocket), 1 grey tank top, 1 grey shirt with collar.During a review of the facility's P&P titled, Resident Personal Belongings, undated, the P&P indicated, 1. All resident possessions, regardless of their apparent value to others, will be treated with respect. 4. Additional possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory listing.7. The facility will exercise reasonable care for the protection of the resident's property from loss or theft.

Based on observation, interview, and record review, the facility failed to ensure two of nine registered nurses (RN 2 and Director of Nursing [DON]) received education on use of an intravenous (IV- in the vein) pump (an electronic device that allows the nurse to program the rate and volume of the infusion), prior to the IV pumps being used. This failure had the potential for residents to have a delay in receiving their prescribed medications.Findings:During an observation on 6/3/26 at 9:15 a.m. in Resident 94's room, RN 2 was preparing to administer an IV antibiotic to Resident 94. Resident 94 asked RN 2, Do you know how to use the pump? The other day one of the nurses did not know how to use the pump.During an interview on 6/3/26 at 9:25 a.m. with DON, DON stated the pharmacy the facility recently contracted with uses a different model of IV pump than the prior pharmacy. DON stated she was not sure how to use the new pump and had to ask another nurse for assistance when she was going to administer IV antibiotics to Resident 94. DON stated when a resident had an IV medication order, the pharmacy would send an IV pump to the facility to be used to administer the medication. DON stated the pharmacy had not in-serviced RNs on the use of the new IV pumps. DON stated the pharmacist would provide an in-service, but no date had been set.During an interview on 6/3/26 at 10:55 a.m. with Administrator, Administrator stated her expectation would be for the nursing staff to be in-serviced on the use of the equipment before the equipment is used.During a concurrent interview and record review on 6/3/26 at 11:00 a.m. with DON and ADON, DON stated the facility began using the new pharmacy on 5/1/26. DON stated the new pharmacy provided an in-service on IV pumps that are now being used in the facility on 5/12/26. ADON provided a list of RNs employed by the facility, which showed nine RNs. The IV pump in-service sign-in sheet, dated 5/12/26, listed only three RNs who were in-serviced on use of the new IV pump. RN 2 was not listed on the IV pump in-service sign-in sheet.During a review of the IV pump manufacturers guidelines Service Manual (SM), (undated), the SM indicated, Parameter programming requires trained health care professional confirmation of limits and drug therapy to physician directive.During a review of the facility's policy and procedure (P&P) titled, Training Requirements dated 2025, the P&P indicated, It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 5. Training requirements should be met prior to staff and volunteers independently providing services to residents annually, and as necessary based on facility assessment.

Based on observation, interview, and record review, the facility failed to store over-the-counter medications (medication that does not require a prescription) in a clean and sanitary area. This failure had the potential for medications to become contaminated. Findings: During a concurrent observation and interview on [DATE] at 2:03 p.m. with Maintenance and Central Supply Personnel (MCSP), in the dirty utility area (a dedicated space used to store contaminated items and medical waste), there were four vital signs machines (an electronic assessment device) without covering. A sign by the wall indicated, Dirty Side. Two cabinets filled with over-the-counter medications in the dirty area. MCSP stated those are new medications and not expired. MCSP stated they have nowhere else to store the over-the-counter medications.During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 2026, the P&P indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on interview and record review, the facility failed to ensure competency evaluations were completed upon hire and annually for six of seven sampled employees (Certified Nursing Assistant [CNA] 2, CNA 3, CNA 1, Licensed Vocational Nurse [LVN] 1. LVN 2, and LVN 3). This failure resulted in the facility not being able to ensure staff possessed competency to provide care and services to meet resident needs. Findings:During an interview on 6/4/26 at 9:16 a.m. with CNA 2, CNA 2 stated she had been working at the facility since 2024. CNA 2 stated she had a competency evaluation upon hire but had not had another competency evaluation competed within the last year.During a concurrent interview and record review on 6/4/26 at 11:16 a.m. with Director of Staff Development (DSD), CNA 2's Employee Personnel File (EPF), (undated) was reviewed. The EPF indicated, CNA 2 had an orientation competency evaluation completed on 11/12/24. DSD stated CNA 2 did not have an annual competency evaluation since 11/12/24. DSD stated competency evaluations should be completed annually based off the hire date. DSD stated CNA 2 should have had an annual competency completed in November 2025.During a concurrent interview and record review on 6/4/26 at 11:35 a.m. with DSD, CNA 3's EPF, (undated) was reviewed. The EPF indicated, CNA 3 had an orientation competency evaluation completed on 11/1/24. DSD stated CNA 3 did not have an annual competency evaluation completed since 11/1/24. DSD stated CNA 3 should have had an annual competency completed in November 2025.During a concurrent interview and record review on 6/4/26 at 11:52 a.m. with DSD, CNA 1's EPF, (undated) was reviewed. The EPF indicated, CNA 1 had a hire date of 1/27/25 and there were no competency evaluations completed upon hire or annually. DSD stated CNA 1's orientation competency was blank and not completed. DSD stated CNA 1 should have had annual competency completed in January 2026.During a concurrent interview and record review on 6/4/26 at 2:12 p.m. with Director of Nursing (DON), LVN 1's EPF, (undated) was reviewed. The EPF indicated, LVN 1 had a hire date of 1/30/23 and there were no annual competency evaluations completed. DON stated there were no competencies completed for LVN 1 since 1/30/23. During a concurrent interview and record review on 6/4/26 at 2:21 p.m. with Human Recourses/ Payroll Manager (HR/PM), LVN 2's EPF, (undated) was reviewed. The EPF indicated, LVN 2 had a hire date of 10/20/25 and there were no orientation competency evaluations completed upon hire. HR/PM stated LVN 2 should have had an orientation competency completed.During an interview on 6/4/26 at 2:29 p.m. with DON, DON stated LVN 2 should have had an orientation competency completed upon hire. DON stated because LVN 2 did not have an orientation competency evaluation, she did not know LVN 2's skill set to provide care to residents.During a concurrent interview and record review on 6/4/26 at 2:30 p.m. with DSD, LVN 3's EPF, (undated) was reviewed. The EPF indicated, LVN 3 had a hire date of 5/11/26 and there were no competency evaluations completed upon hire. DSD stated LVN 3's orientation competency was not completed. DSD stated LVN 3 should have had an orientation competency completed prior to her completing the orientation process.During a review of the facility's policy and procedure (P&P) titled, Competency Evaluation, dated 2025, the P&P indicated, It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job.Initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified.Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations.

Based on observation, interview, and record review, the facility failed to ensure a recipe was followed when preparing a pureed (food blended to a pudding like consistency) diet. This failure had the potential for pureed food to not conserve its nutritive value, flavor, or the proper consistency for a pureed diet. Findings: During a concurrent observation and interview on 6/2/26 at 9:30 a.m. with [NAME] 1 in the kitchen, [NAME] 1 prepared to puree food for nine residents on pureed diets. [NAME] 1 stated the day's lunch menu was herb and spice roast beef with gravy, mashed potatoes, spinach au gratin, Caesar salad, fruit mix, and crumble cake. [NAME] 1 pureed the spinach and did not follow a recipe. [NAME] 1 pureed the roast beef and did not follow a recipe. [NAME] 1 was asked if he followed a pureed recipe. [NAME] 1 stated he had never seen a recipe book or binder for pureed diets and had not followed a recipe.During a concurrent interview and record review on 6/2/26 at 10:39 a.m. with Certified Dietary Manager (CDM), the recipe for pureed meats, dated 2025, was reviewed. The recipe indicated, Directions:1. Complete regular recipe. Measure out the total number of portions needed for pureed diet. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 5. The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. CDM stated [NAME] 1 did not follow a pureed recipe and he should have.During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, the P&P indicated, Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. The facility will use approved recipes, standardized to meet the resident census. 2. Recipes are specific as to portion yield, method or preparation.

Based on observation, interview, and record review, the facility failed to label and date three open boxes of food items in one of one freezer (Freezer 1) in the kitchen. This failure had the potential for residents to consume expired food. Findings: During a concurrent observation and interview on 6/1/26 at 9:32 a.m. in the facility kitchen with Certified Dietary Manager (CDM), Freezer 1 contained open, undated and unlabeled boxes of zucchini, french toast, and sausage. CDM stated all stored food items need to be labeled with a received by date and and open date. During a review of the facility's policy and procedure (P&P) titled, Labeling and dating of Foods, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. newly opened food items will need to be closed and labeled with an open date and used by date. produce is to be dated with received date.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Binding Arbitration Agreement (BAA - a way to resolve disputes between healthcare providers and residents) for three of three sampled residents (Resident 32, Resident 41, and Resident 80) when admission staff did not provide documentation and explanation in the residents' primary language. This failure had the potential for Resident 32, Resident 41, and Resident 80 to not be aware or fully understand the legal document they signed. Findings: 1. During a concurrent interview and record review on 6/3/26 at 9:37 a.m. with admission Coordinator (AC), Resident 32's BAA form, dated 9/9/25, was reviewed. AC stated the form was in English and it was not documented if the BAA was explained to Resident 32 in Spanish.During a concurrent interview and record review on 6/3/26 at 10:53 a.m. with Resident 32, Resident 32's BAA form, dated 9/9/25, was reviewed. Resident 32's BAA indicated, the form was written in English. Resident 32 stated he signed the BAA form written in English but does not know what he signed. Resident 32 stated his primary language was SpanishDuring a review of Resident 32's admission Record (AR), dated 6/3/26, the AR indicated, Resident 32's primary language was Spanish.During a review of Resident 32's Minimum Data Set (MDS-comprehensive assessment tool) dated 3/11/26, the MDS indicated, Resident 32 had a Brief Interview for Mental Status (BIMS-cognitive assessment tool) score of 8 (scores of 8-12 indicated moderately impaired cognition). 2. During a concurrent interview and record review on 6/3/26 at 9:39 a.m. with AC, Resident 41's BAA form, dated 3/12/25, was reviewed. AC stated the BAA form was in English and there was no documentation that indicated the BAA was explained to Resident 41 in Spanish.During a concurrent interview and record review on 6/3/26 at 10:44 a.m. with Resident 41, Resident 41's BAA form, dated 3/12/25, was reviewed. Resident 41's BAA indicated, the form was written in English. Resident 41 stated he signed the BAA form written in English but does not recall if the staff explained to him what he signed. Resident 41 stated the staff just asked him to sign it. Resident 41 stated his primary language was Spanish.During a review of Resident 41's AR, dated 6/3/26, the AR indicated, Resident 41's primary language was Spanish.During a review of Resident 41's MDS, dated [DATE], the MDS indicated, Resident 41 had a BIMS score of 14 (scores of 13-15 indicate intact cognition). 3. During a concurrent interview and record review on 6/3/26 at 9:41 a.m. with AC, Resident 80's BAA form, dated 8/18/25, was reviewed. AC stated the BAA form was in English and there was no documentation that indicated the BAA was explained to Resident 80 in Spanish.During a concurrent interview and record review on 6/3/26 at 11:03 a.m. with Resident 80, Resident 80's BAA form was reviewed. The BAA indicated, the form was written in English. Resident 80 stated the signature on the English form was his. Resident 80 stated no one from the facility had explained what was on the BAA form. Resident 80 stated that he just signed it. Resident 80 stated his primary language was Spanish.During a review of Resident 80's AR, dated 6/3/26, the AR indicated, Resident 80's primary language was Spanish.During a review of Resident 80's MDS dated [DATE], the MDS indicated, Resident 80 had a BIMS score of 14.During a review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreements, dated 2025, the P&P indicated, 1. When explaining the arbitration agreement, the facility shall. b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement.

Based on observation, interview, and record review, the facility failed to implement infection control practices when: The laundry room had two large plastic containers with colored liquid that were stored on the floor.The laundry room had an uncovered trash bin between two washing machines.Two of four sampled clean linen closets (CLC 2 and CLC 3) had dirty equipment stored and touching clean linen. Two of four sampled staff (Minimum Data Set Coordinator [MDSC] and Treatment Nurse [TN]) entered a contact isolation room (rooms where anyone entering must wear a protective gown and gloves, and wash their hands when entering and exiting the room to prevent the spread of infection) without wearing Personal Protective Equipment (PPE- wearable devices, clothing, or equipment to protect from infections.)The TN did not disinfect the surface before placing wound dressing supplies. The TN did not perform hand hygiene (cleaning hands by using soap and water or an alcohol based sanitizer) during wound dressing change for one of one sampled residents (Resident 41).The facility failed to implement effective infection control surveillance for 15 of 15 sampled residents (Resident 3, Resident 96, Resident 97, Resident 98, Resident 14, Resident 6, Resident 89, Resident 22, Resident 51, Resident 46, Resident 9, Resident 68, Resident 26, Resident 99, and Resident 62).Two of two sampled utility rooms (UR) were not separated into clean and dirty areas.Two of two sampled occupied isolation rooms contained residents on different types of isolation precautions (infection control measures used in healthcare settings to prevent the spread of germs). These failures had the potential to spread infectious diseases to residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 6/3/26 at 8:29 a.m. with Plant Operation Supervisor (POS), in the laundry room, there were two large plastic containers stored on the floor. One container contained a green colored liquid and the other contained a blue colored liquid. POS stated the two plastic containers on the floor were a kitchen degreaser and a cleaner. POS stated he did not know why the two plastic containers were on the laundry room floor and they should not have been there.During an interview on 6/4/26 at 8:42 a.m. with Housekeeping/Laundry Supervisor (HLS), HLS stated the degreaser should not have been on the floor, and it should have been stored on a shelf.2. During an observation on 6/3/26 at 8:30 a.m. in the laundry room, there was a large, uncovered trash bin that contained trash between two washing machines.During an interview on 6/4/26 at 8:42 a.m. with HLS, HLS stated the trash bin should have a lid at all times.During a review of the facility's policy and procedure (P&P) titled, Environmental Services Safety Procedures,(undated), the P&P indicated, It is the policy of this facility to ensure general safety procedures are followed in the course of performing housekeeping and/or laundry duties. Policy Explanation and compliance guidelines. 3. Staff will ensure equipment (e.g., cords, ladders, or chemicals) is properly stored and not left unattended in areas that are accessible to residents. When not in use, equipment will be stored in a locking closet, cabinet or storage area for safety.3. During an observation on 6/3/26 at 8:32 a.m. in CLC 2, there was a folded chair stored and leaning on the clean linens. During an observation on 6/3/26 at 8:32 a.m. in CLC 3, two wheelchair footrests were stored. During an interview on 6/4/26 at 8:42 a.m. with HLS, HLS stated the clean linen closets should not be used as a storage area for equipment. During a review of the facility's P&P titled, Handling Clean Linen, undated, the P&P indicated, It is the policy of the facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection.4. During an observation on 6/3/26 at 9:17 a.m. in Resident 3's and Resident 41's room, a sign by the door indicated, Contact Precautions. MDSC and TN entered the room without wearing a PPE. During an observation on 6/3/26 at 9:19 a.m. outside of Resident 41 and Resident 3's room, there were two signs by the door that indicated Contact Precautions (CP-measures used to stop the spread of germs that are passed by physical touch) and Enhanced Barrier Precautions (EBP-measures used to prevent the spread of resistant germs). CP sign indicated, Everyone must clean their hands including before entering and when leaving the room. Provider and staff must also put on gloves before room entry and discard gloves before room exit. Put on gown before room entry. Discard gown before exit. Do not wear the same gown and gloves for the care of more than one person. During a review of Resident 3's Order Details (OD), dated 6/1/26, the OD indicated, Contact precautions related to MRSA (Methicillin-resistant Staphylococcus aureus - a type of germ that is resistant to many common antibiotics [medicine to treat infections]) wound infection.During an interview on 6/3/26 at 9:25 a.m. with Infection Preventionist (IP), IP stated for contact precautions, PPE must be worn when entering the room. During a review of the facility's P&P titled, Transmission-Based (Isolation) Precautions, (undated), the P&P indicated, 10. Contact Precautions. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room.5. During a concurrent observation and interview on 6/3/26 at 9:40 a.m. with TN, in Resident 41's room, TN placed her wound dressing supplies on a barrier sheet (a protective layer of material). TN carried the barrier sheet and placed it on Resident 41's bedside table. Resident 41's bedside table was not cleaned or sanitized before the barrier sheet was placed. TN stated, I know I should have [sanitized the bedside table].During a review of the facility's P&P titled, Clean Dressing Change, (undated), the P&P indicated, 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application. a. If the table is soiled, wipe clean. 6. During a concurrent observation and interview on 6/3/26 at 9:40 a.m. with TN, in Resident 41's room, TN removed Resident 41's wound dressing, TN removed her gloves and put on a new pair of gloves without performing hand hygiene. TN cleansed the wound with wet gauze, removed her gloves, and applied a new pair of gloves and did not perform hand hygiene. TN applied a cream to Resident 41's wound then changed her gloves and did not perform hand hygiene prior to clean gloves being applied. TN stated she did not perform hand hygiene. During a review of the facility's P&P titled, Clean Dressing Change, (undated), the P&P indicated, 7. Wash hands and put on clean gloves.10. Remove gloves pulling inside out over the dressing. Discard into appropriate receptacle.11. Wash hands and put on clean gloves.During a review of the facility's P&P titled, Hand Hygiene, (undated), the P&P indicated, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. a. The use of gloves does not replace hand hygiene. if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 7. During a review of the facility's Infection Surveillance Report (ISR-the systematic collection and analysis of infection data, typically focusing on healthcare-associated infections (HAIs) and communicable diseases), dated January 2026, February 2026, March 2026, and April 2026, the ISR indicated, the following infections did not have documentation of signs and symptoms:a) On 1/19/26, Resident 3 had a diagnosis of sepsis (life threatening infection in the body).b) On 1/24/26, Resident 96 had a diagnosis of Bacteremia (bacteria in the blood stream).c) On 1/28/26, Resident 97 had a diagnosis of Bacteremia. d) On 1/22/26, Resident 98 had a diagnosis of Osteomyelitis (infection of the bone).e) On 1/16/26, Resident 14 had a diagnosis of Periodontitis (gum infection) and Otitis Media (ear infection).f) On 2/16/26, Resident 6 had a diagnosis of skin infection.g) On 2/16/26, Resident 3 had a diagnosis of skin infection. h) On 2/25/26, Resident 89 had a diagnosis of skin infection. i) On 2/26/26, Resident 22 had a diagnosis of Urinary Tract Infection (UTI-bladder infection).j) On 3/26/26, Resident 51 had a diagnosis of Pneumonia (lung infection).k) On 3/31/26, Resident 46 had a diagnosis of UTI.l) On 4/2/26, Resident 9 had a diagnosis of Bacteremia.m) On 4/20/26, Resident 68 had a diagnosis of Pneumonia.n) On 4/22/26, Resident 26 had a diagnosis of UTI.o) On 4/16/26, Resident 99 had a diagnosis of Cystitis (bladder infection).p) On 4/16/26, Resident 62 had a diagnosis of UTI.During an interview on 6/3/26 at 11:02 a.m. with Director of Staff Development (DSD), DSD stated she was the IP from January to April 2026. DSD stated she should have documented the signs and symptoms because it (documentation of signs and symptoms) was part of the ISR. During a review of the facility's P&P titled, Infection Surveillance, dated August 2024, the P&P indicated, The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: a. Data to be collected, including how often and the type of data to be documented, including. i. The infection site, pathogen (if available), signs and symptoms, and resident locations.8. During a concurrent observation and interview on 6/3/26 at 2:32 p.m. with IP, in UR1, there was line of red tape on the floor separating a portion of the room. UR 1 had a sign on the left side of the room that indicated, Dirty Side and a sign on the right side of the room that indicated, Clean Side. There was clean equipment on the left side of the red tape identified as the Dirty Side. IP stated the facility's clean and dirty utility area are combined in one room, with red tape dividing the clean and dirty sides. During a concurrent observation and interview on 6/3/26 at 2:34 p.m. with IP, in UR 2, there was a combination of clean and dirty equipment stored with no separation. IP stated the clean and dirty equipment should have been separated.9. During an observation on 6/1/26 at 9:51 a.m. outside of Resident 58's and Resident 89's room, a sign by the door indicated, Neutropenic Precaution (NP-infection prevention rules for people with severely low level of white blood cells [body's main defense against germs.]). The NP sign indicated, Everyone must: Perform hand hygiene before entering room and when leaving room. Put on gown before entering room and remove before leaving room. Put on gloves before entering room and remove before leaving room. Put on mask before entering room. Resident 58 was in the room with Resident 89 who was on neutropenic precautions. Resident 58 was not wearing a mask, gown, or gloves.During a review of Resident 89's OD, dated 6/1/26, the OD indicated, Neutropenic precautions related to neutropenia (low white blood cells).During an interview on 6/1/26 at 9:59 a.m. with IP, IP stated Resident 58 and Resident 89 should be in separate rooms.During an observation on 6/3/26 at 9:19 a.m. outside of Resident 41's and Resident 3's room, there were two signs posted on the wall indicated, Contact Precautions and Enhanced Barrier Precautions. During a review of Resident 41's Order Summary Report (OSR), dated 1/2/26, the OSR indicated, enhanced barrier precautions in place related to chronic [recurs over a long time] wounds.During a review of Resident 3's OD, dated 6/1/26, the OD indicated, Contact precautions related to MRSA wound infection.During an interview on 6/3/26 at 3:16 p.m. with IP, IP stated residents on contact isolation should be separated.During a review of the facility's P&P titled, Neutropenic Precautions, (undated), the P&P indicated, Policy Explanation: People that receive or have received chemotherapy or have other medical conditions that result in the decrease of the number of white blood cells are at risk for developing neutropenia. This places the person at greater risk of developing an infection. Neutropenic precautions are a mechanism to help protect the neutropenic person from the increased risk of infection. Compliance guidelines. 2. Staff, visitors, and other residents will adhere to guidance of the precautions to help protect the affected resident.During a review of the facility's P&P titled, Infection Prevention and Control Program, dated February 2025, the P&P indicated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 5. Isolation Protocol (Transmission-Based Precautions). b. Residents on transmission-based precautions should be placed into a private/single room if available/appropriate, or are cohorted with residents with the same pathogen, or share a room with a roommate with limited risk factors, in accordance with national standards.During a review of the facility's P&P titled, Transmission-Based (Isolation) Precautions, (undated), the P&P indicated, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Policy explanation and compliance guidelines.3. When implementing transmission-based precautions, the facility will consider the following. c. Cohorting residents with the same pathogen.

Based on interview and record review, the facility failed to ensure annual abuse prevention training was completed for three of nine sampled employees (Certified Nursing Assistant [CNA] 2, Dietary Aide [DA], and Housekeeping/Laundry Supervisor [HLS]). This failure had the potential to result in staff's inability to recognize, report, and respond appropriately to allegations or signs of abuse, placing residents at risk for harm.Findings:During an interview on 6/4/26 at 9:16 a.m. with CNA 2, CNA 2 stated she had not been provided with annual abuse training.During a concurrent interview and record review on 6/4/26 at 11:16 a.m. with Director of Staff Development (DSD), CNA 2's Employee Personnel File (EPF), (undated) was reviewed. The EPF indicated, CNA 2 did not have annual abuse training completed. DSD stated CNA 2 did not have annual abuse training. DSD stated abuse training should be completed upon hire and annually.During a concurrent interview and record review on 6/4/26 at 2:35 p.m. with Human Resources/Payroll Manager (HR/PM), DA's EPF, (undated) was reviewed. The EPF indicated, DA's last abuse training was completed on 4/19/24. HR/PM stated DA did not have an annual abuse training completed.During a concurrent interview and record review on 6/4/26 at 2:42 p.m. with HR/PM, HLS's EPF, (undated) was reviewed . The EPF indicated, HLS last abuse training was completed on 12/29/23. HR/PM stated HLS did not have an annual abuse training completed. HR/PM stated all facility staff should have annual abuse training. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 2025, the P&P indicated, Employee Training. A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services and as needed.

Based on interview and record review, the facility failed to notify the responsible party (RP) for one of 51 sampled residents (Resident 5) when a referral to a specialist (a medical doctor who has training in a specific field of medicine) was made . This failure had the potential for RP not being aware of Resident 5's treatment plan. Findings: During an interview on 6/3/26 at 3:45 p.m. with RP, RP stated she was not informed of Resident 5's referral to a urologist (a medical doctor who specializes in diagnosing and treating diseases of the kidneys). During a review of Resident 5's Order Details (PO-Physician's Orders), dated 4/1/26 the PO indicated, Urology consult ASAP [As soon as possible] per NP [Nurse practitioner - a registered nurse with advanced education and training] . During a review of Resident 5's Minimum Data Set (MDS - Comprehensive assessment tool), dated 4/8/26, the MDS indicated, Resident 5 had a Brief Interview for Mental Status (BIMS- cognitive assessment) score of 4 (score of 0-7 means cognitively impaired). During a concurrent interview and record review on 6/4/26 at 9:20 a.m. with Social Services Director (SSD), Resident 5's clinical record and was reviewed. SSD was unable to find documentation of notification to the RP. SSD stated she did not notify the RP of the referral to the Urologist. During a concurrent interview and record review on 6/4/26 at 10:57 a.m. with Director of Nursing (DON), Resident 5's clinical record was reviewed. DON stated she was unable to find documentation of notification to Resident 5's RP. DON stated the RP notification of Resident 5's referral to the urologist was the responsibility of the licensed nurses. During a review of the facility's policy and procedure (P&P) titled, Care Planning - Resident Participation, (undated), the P&P indicated, 3. The facility will notify the resident and/or resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care. During a review of the facility's P&P titled, Notification of Changes, (undated), the P&P indicated, Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include.3. Circumstances that require a need to alter treatment. This may include: a. New treatment.

Based on interview and record review, the facility failed to ensure care conferences were conducted at least quarterly for one of four sampled residents (Resident 6). This failure had the potential for care needs to go unmet.Findings:During a concurrent interview and record review on 6/3/26 at 11:24 a.m. with Assistant Director of Nursing (ADON) and Social Services Director (SSD), Resident 6's documented care conferences were reviewed. ADON stated Resident 6's last two care conferences were conducted on 3/8/24 and 10/22/25. SSD stated care conferences should be conducted quarterly and for Resident 6 they were not.A care conference policy was requested, and not was provided.

Based on observation, interview, and record review the facility failed to ensure medication was available to administer for one of four sampled residents (Resident 8). This failure had the potential for Resident 8 to experience symptoms of anxiety (a feeling of worry).Findings:During a review of Resident 8's physician orders (PO), the PO, dated 5/13/26, indicated, BusPIRone HCl [medication used to relieve the symptoms of anxiety and anxiety disorders] Tablet 5 MG [milligram]. Give 2 tablet [sic] by mouth two times a day for m/b [manifested by] inability to relax related to ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD 2 tablets = 10 mg.During a concurrent observation and interview on 6/3/26 at 9:42 a.m. with Licensed Vocational Nurse (LVN) 5, outside of Resident 8's room, LVN 5 prepared to give Resident 8 his morning medications. LVN 5 stated she was unable to find Resident 8's BusPIRone HCl in the medication cart.During a concurrent observation and interview on 6/3/26 at 9:44 a.m. outside of Resident 8's room, LVN 5 called the facility's pharmacy to re-order Resident 8's BusPIRone HCl. LVN 5 stated the pharmacy told her the medication would be delivered at noon on that day.During an interview on 6/3/26 at 10:38 a.m. with Director of Nursing (DON), DON stated medication refills can be requested using the facility's electronic medical record or by faxing a paper order form to pharmacy. DON stated the expectation is for nurses to re-order medication when there is still one to two days' worth of the resident's medication left and not wait until the medication is depleted.During a review of the facility's policy and procedure (P&P) titled, Medication Reordering dated, 2026, the P&P indicated, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting.

Based on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 20) received a diet as ordered by the physician. This failure had the potential to result in choking, difficulty chewing and swallowing, and inadequate nutritional intake.Findings:During a review of Resident 20's Order Summary Report (OSR), dated 6/3/26, the OSR indicated, on 5/8/26 Resident 20's physician ordered a no added salt, soft and bite sized diet. During a review of Resident 20's Care Plan Report (CPR), dated 3/23/26, the CPR indicated, [Resident 20] has nutritional problem or potential nutritional problem r/t [related to]. poor PO [by mouth] intake. Interventions. Licensed nurse to check trays for accuracy every meal. Provide and serve diet as ordered.During an observation on 6/1/26 at 12:28 p.m. in the dining room, Resident 20 was served a lunch plate that had a quesadilla (melted cheese in a toasted flour tortilla) cut into approximately 3-inch triangles. Resident 20 was not eating the quesadilla.During a concurrent observation and interview on 6/1/26 at 12:46 p.m. with Certified Dietary Manager (CDM) in the dining room, Resident 20's lunch plate had a quesadilla that was cut into approximately 3-inch triangles. CDM stated Resident 20 had received the quesadilla for lunch because she did not like beef and this was the alternative. CDM stated Resident 20's quesadilla should have been cut into smaller pieces than what she was served. CDM stated the quesadilla portions were too big of portions to be considered bite sized. CDM stated Resident 20 should not have been served a quesadilla as part of her soft diet.During an observation on 6/1/26 at 12:52 p.m. in the dining room, Resident 20 finished eating her lunch meal. Resident 20 had not eaten any of her quesadilla. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Orders, dated 2026, the P&P indicated, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.During a review of the International Dysphagia Diet Standardization Initiative Framework (IDDSIF), dated 2019, the IDDSIF indicated, Soft & [and] Bite-Sized. Bite-sized pieces as appropriate for size and oral processing skills. Adults, 15 mm [millimeter] = [equals] 1.5 cm [centimeter] pieces (no larger than). Biting is not required.When a sample the size of a thumb nail (1.5 cm x 1.5 cm) is pressed with the base of a spoon, the sample squashes and breaks apart, changes shape, and does not return to it original shape when the spoon is removed. No regular dry bread, sandwiches or toast of any kind. prepared bread that meets Level 6 Soft & Bite sized requirements. Pre-gelled soaked breads that are very moist and gelled through the entire thickness.

Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program (a coordinated healthcare initiative that ensures antibiotics are prescribed only when necessary and used correctly) for one of five sampled residents (Resident 35). This failure had the potential for Resident 35 to receive inappropriate antibiotics and had the potential for untreated infections.Findings: During a review of the facility's Infection Prevention and Control Surveillance Log (IPCSL), dated 4/18/26, the IPCSL indicated, Resident 35 had signs and symptoms. Dysuria [pain, burning, or discomfort during urination] .the organism on culture. not completed. treatment.Bactrim DS [antibiotic] twice a day for seven days. During a review of Resident 35's Lab [laboratory] Results Report (LRR), dated 4/17/26, the LRR indicated, 1) Please specify the test that was not performed: urine culture [a laboratory test that grows bacteria or yeast from a urine sample to diagnose urinary tract infections (UTIs). It identifies the exact type of germ causing the infection and determines which antibiotics will work best to treat]. 2) Please specify the reason the test was not performed: Improper Specimen Storage/Transportation issue. During a review of Resident 35's Medication Administration Record (MAR), dated April 2026, the MAR indicated, Resident 35 received Bactrim DS from 4/19/26 to 4/25/26 (for seven days). During an interview on 6/3/26 at 10:25 a.m. with Infection Preventionist (IP), IP stated there was no documentation the urine culture was re-done. IP stated, The urine specimen should have been re-collected and sent to lab. IP stated re-collection of urine specimen and monitoring lab results was the responsibility of the IP and licensed nurses to follow up. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, dated February 2025, the P&P indicated, b. Monitoring antibiotic use. i. Monitor response to antibiotics, and laboratory results when available, to determine the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out).

Based on interview and record review, the facility failed to develop a plan of care for the refusal of immunizations (the process by which a person's immune system becomes fortified against an infectious disease through vaccination) for one of five sampled residents (Resident 18). This failure had the potential for staff to be unaware of monitoring the risks for the Resident 18, who did not receive immunizations.Findings: During a review of Resident 18's Resident Vaccine Consent Form (RVCF), dated 3/25/26, the RVCF indicated, Resident 18 refused immunization for Pneumococcal (bacterial infection of the lungs), RSV (Respiratory Syncytial Virus-serious lung disease), and TDAP (Tetanus- a life-threatening bacterial disease that affects the nervous system, causing painful muscle contractions and spasms, and Diphtheria - a highly contagious, serious bacterial infection and Pertussis-contagious respiratory infection). During a concurrent interview and record review on 6/3/26 at 10:43 a.m. with Infection Preventionist (IP), Resident 18's Clinical Record (CR) was reviewed. IP stated she could not find a care plan for Resident 18's refusal of immunization. During a review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine (Series), dated February 2025, the P&P indicated, The resident/representative retains the right to refuse the immunization. The facility will document in the clinical record the reason for refusal or the medical contraindication of the immunization.

Based on observation, interview, and record review, the facility failed to ensure one of 51 sampled residents (Resident 7) call light system was functioning properly. This failure had the potential to place Resident 7 at risk for delayed staff response to urgent needs and medical emergencies.Findings:During a review of Resident 7's Minimum Data Set (MDS, a standardized assessment tool), dated [DATE]. The MDS, section GG functional abilities indicated, Resident 7 needed staff assistance with activities of daily living, including transfers and toileting.During a concurrent observation and interview on [DATE] at 11:23 a.m. with Resident 7 in Resident 7's room, Resident 7 stated that the call light system had not been working for months. Resident 7 stated that she had informed multiple staff of this issue. Resident 7 stated that she had to go out to the hallway to call for help. Resident 7 pushed the call light that was on her bed to call for assistance. The call light did not light up in the hallway and did not register any noise.During a concurrent observation and interview on [DATE] at 11:24 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 7's room, CNA 1 stated Resident 7 does not use her call light. CNA 1 stated Resident 7 rolls herself out to hallway to ask for assistance. CNA 1 pushed Resident 7's call light and stated Resident 7's call light was not working.During an interview on [DATE] at 11:26 a.m. with Activities Director (AD), AD stated Resident 7's call light was not lighting up in the hallway to indicate Resident 7 needed assistance.During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, dated 2025, the P&P indicated, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident bedside, toilet and bathing facility to allow residents to call for assistance. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.) 9. Ensure the call light system alerts staff members directly or goes to a centralized staff work area.

Based on interview and record review, the facility failed to verify one of four sampled respiratory therapists (RT 1) were licensed by the state, prior to hiring and performing respiratory care. This failure resulted in RT 1 providing respiratory care to residents without a state license and the potential to put residents at risk for harm. Findings:During a review of RT 1's New Hire Form (NHF) dated 7/14/25, the NHF indicated, Date of Hire.7/14/25.Position Title.RT.During a review of RT 1's Termination Form (TF) dated 4/14/26, the TF indicated, (RT 1) .termination date.4/14/26.failure to possess the licensure/certification required by the position.During an interview on 4/21/26 at 12:48 p.m. with Human Resources (HR), HR stated RT 1 was hired on 7/14/25 and worked as an RT. HR stated when an RT was hired their license was to be verified with the Department of Consumer Affairs prior to being employed. HR was unable to provide evidence of RT 1's state licensure being verified prior to hire. HR stated RT 1 did not have a state license prior to being hired or at time of termination. During a review of the Respiratory Therapist - Job Description (RTJD) undated, the RTJD indicated, Required Qualification.The respiratory therapist must possess.a valid, unrestricted license in his/her therapy discipline in the state.During a review of the facility's policy and procedure (P&P) titled, License Verification undated, the P&P indicated, The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure.

Based on interview and record review, the facility failed to notify the physician when one of three sampled residents (Resident 1) was refusing multiple doses of medications. This failure resulted in the physician being unaware of Resident 1's refusals and the potential for Resident 1 to experience adverse side effects.Findings:During a review of Resident 1's Order Summary Report (OSR-physician's orders) dated 4/1/26, the OSR indicated, buspirone (medication used to treat anxiety).give one tablet by mouth two times a day.start date 12/25/25.citalopram (medication used to treat depression).give one tablet by mouth one time a day.start date 3/4/26.Valporic acid (used to treat psychiatric disorders).give 10 ml (milliliters-unit of measurement) by mouth two times a day.start date 3/31/26.During a review of Resident 1's Medication Administration Record (MAR) dated 4/1/26-4/30/26, the MAR indicated, citalopram was refused on 4/1, 4/5, 4/7, 4/8 and buspirone and valproic acid were refused on 4/1, 4/2, 4/4, 4/5, 4/6, 4/7 and 4/8.During a concurrent interview and record review on 4/13/26 at 11:30 a.m. with Interim Director of Nursing (IDON), Resident 1's Progress Notes (PN) dated 4/1/26-4/8/26 were reviewed. IDON was unable to provide documentation of the physician being made aware of the medication refusals. IDON stated the physician should have been notified when Resident 1 refused the medications three times.During a review of the facility's policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directives undated, the P&P indicated, Should the resident refuse treatment of any kind, the facility will document the following in the resident's chart.a. What the resident refused. B. The reason for the refusal. C. How the resident was educated regarding the consequences of refusal.f. That the physician was notified of refusal and the resident's response to education/offering of alternatives.

Based on interview and record review, the facility failed to follow their policy and procedure for Medication Administration to administer medication at the right dosage and address a medication alert (automated notification feature designed to warn clinicians and staff about specific resident, clinical, or safety concerns) for one of three sampled residents (Resident 1) on methotrexate (medication that treats rheumatoid arthritis [RA - a disease that causes pain, stiffness, and swelling in the joints [the spots in your body where two or more bones meet] by decreasing the activity of your immune system [the body's complex, built-in defense network that works to keep germs and foreign substances out, while destroying any that get inside]). These failures resulted in a significant medication error (a preventable mistake in the medication process that causes a patient meaningful discomfort, jeopardizes their health, or leads to serious harm), caused bleeding to Resident 1's nose, gums, and bowel movement and resulted in acute hospitalization caused by methotrexate toxicity (when too much of the drug builds up in the body, turning a helpful medication into a dangerous one. Signs of methotrexate toxicity includes nausea, painful mouth sores/ulceration [open sore] in the mouth or throat), and caused Resident 1's body's immune system to not have the ability to fight off infection (the invasion and growth of germs [tiny living things that cause disease] in the body), damaged her kidneys (a pair of bean-shaped, reddish-brown organs located on either side of the spine) and resulted in Resident 1's death.Findings:During a review of Resident 1's acute hospital Discharge Instructions, Orders and Medications (DIOM), dated 11/19/25, the DIOM indicated, Resident 1 was to discharge from the acute hospital to the facility on [DATE] with an order for methotrexate 20 milligrams (mg - unit of measurement) by mouth every Friday (every seven days). The DIOM indicated Resident 1 had a diagnosis of RA.During a review of Resident 1s facility admission RECORD (AR), dated 1/14/26, the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including RA, shortness of breath, and difficulty walking.During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 11/26/25, under the section I (Active Diagnosis), Resident 1 had a diagnosis of RA.During a review of Resident 1's facility Physician's Order Sheet (POS), dated 11/19/25, the POS indicated Resident 1's was on methotrexate 20 mg by mouth every day (not every Friday as indicated in the acute hospital DIOM on 11/19/25). The POS indicated a medication alert note when the methotrexate order was inputted in the facility computer system. The POS medication alert indicated, This order is outside of the recommended dose or frequency . The dosing regimen (a prescribed course of medical treatment) of 2 tablets daily exceeds the usual dosing regimen of 0.25 (mg) to 2.5 (mg) tablets every 7 days. The frequency of daily exceeds the usual frequency of every 7 days.During a review of Resident 1's MEDICATION ADMINISTRATION RECORD (MAR), dated 11/2025 and 12/2025, the MAR indicated, methotrexate 20 mg by mouth every day. Resident 1 was administered methotrexate 20 mg daily by mouth on the following dates/times:a. 11/20/25 at 9 a.m.b. 11/21/25 at 8 a.m.c. 11/26/25 at 8 a.m.d. 11/27/25 at 8 a.m.e. 11/28/25 at 8 a.m.f. 11/29/25 at 8 a.m.g 11/30/25 at 8 a.m.h. 12/1/25 at 8 a.m.i. 12/2/25 at 8 a.m.j. 12/3/25 at 8 a.m.k. 12/4/25 at 8 a.m.l. 12/5/25 at 8 a.m.m. 12/6/25 at 8 a.m.n. 12/7/25 at 8 a.m.o. 12/8/25 at 8 a.m.p. 12/9/25 at 8 a.m.q. 12/10/25 at 8 a.m.r. 12/11/25 at 8 a.m.s. 12/12/25 at 8 a.m.t. 12/13/25 at 8 a.m.u. 12/14/25 at 8 a.m.v. 12/15/25 at 8 a.m.w. 2/16/25 at 8 a.m.During a review of Resident 1's Care Plan Report (CP - written, individualized document detailing a resident's health conditions, specific needs, and the tailored actions or services required to manage them) for methotrexate dated 11/19/25, the CP indicated, Resident 1 is on a medication (methotrexate) with a black box warning (the strictest, most serious safety alert required by the FDA [U.S. Food and Drug Administration] for prescription medications. It indicates risks of severe injury or death. It signifies that the drug has dangerous, potentially life-threatening side effects). The CP indicated methotrexate medication caused bone marrow (the soft, spongy, jelly - like tissue found in the hollow center of your bones, primarily acting as the body's main blood-cell factory. It produces red blood cells [RBC - for oxygen], white blood cells [WBC - to fight infection], and platelets [for clotting - the manner in which the body stops itself from bleeding]) suppression (the condition when the bone marrow stops producing new blood cells [cells produced in the bone marrow and found in the blood]). The CP indicated interventions for Resident 1 would be to have a monthly drug regimen review (DRR - a thorough, top-to-bottom check of all the medications a resident is taking) by a pharmacist (a healthcare professional and medication expert who ensures drugs are safe and effective).During a review of the facility document titled Rx (prescription) Order History ([NAME]) [documented by the facility pharmacist], undated, the [NAME] indicated, Resident 1's methotrexate 20 mg by mouth daily medication order was reviewed on 11/24/25 and 11/25/25 with no recommendations.During a review of the facility document titled Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations (DRR), dated 11/29/25, the DRR indicated, For Recommendation Created Between 11/1/2025 And 11/29/2025 .reviewed during the consultant pharmacist's visit but did not require any recommendations . (Resident 1).During a review of facility Resident 1's Progress Notes (PN), the PN indicated the following:a. On 12/16/25 at 9:12 p.m. - resident (1) . to be monitor for trouble swallowing . Resident (1) continues to have sore throat and difficulty with swallowing. Resident (1) noted with episode of epistaxis (nose bleeding) and bottom lip swelling. MD (medical doctor) . aware no new orders obtain at this time.b. On 12/17/25 at 7:46 a.m. - resident (1) continuing with epistaxis . Mouth is noted with dry blood around the bottom gums .CNAs (certified nursing assistants) alerted . of resident (1) having bloody stool. MD updated on status of resident (1) and gave the order to send resident out for further evaluation (at acute hospital) . Resident (1) picked up at approximately 1130 (a.m.).c. On 12/17/25 at 7:50 a.m. - LATE ENTRY . Resident (1) on monitoring for trouble swallowing . Resident (1) chin is swollen and red .Resident to have labs (laboratory) drawn 12/17/2025.d. On 12/17/25 at 8:36 a.m. - Resident (1) continues to have episodes of epistaxis . MD .notified at this time and advised with new orders for Afrin (nose medication for allergies . (for) 3 days. will continue to monitor for any changes r/t (related to) epistaxis at thistime (sic).e. On 12/18/26 at 3:47 a.m. - Resident (1) admitted to (acute hospital) .During an interview on 1/12/26 at 11:28 a.m. with Director of Nursing (DON), DON stated Resident 1 was admitted to the facility on [DATE], and around the middle of December (date not specified) Resident 1 started to have problems with swallowing and nose bleeding for approximately two days. DON stated Resident 1 was sent to the acute hospital due to continuing problems with nose bleeding. DON stated on approximately 12/31/25 she received a call from the hospital case manager stating Resident 1 appeared to have been getting her methotrexate daily instead of weekly. DON stated she checked Resident 1's MAR against the acute hospital discharge orders on 11/19/25 and validated the facility was not giving the appropriate dosage of methotrexate as ordered. DON stated Resident 1 was getting two 10 mg tablets of methotrexate (20 mg total) daily instead of the ordered 20 mg of methotrexate every Friday (per DIOM on 11/19/25). DON stated she called the facility (approximate date 12/31/25) pharmacy and spoke to a pharmacist regarding the medication error not being identified and the pharmacist response to the DON was, Oh my God. DON stated the methotrexate medication bubble pack (a type of pharmaceutical packaging where individual doses of medication are sealed in separate cavities or bubbles) provided by the pharmacy was labeled to give daily and not weekly.During an interview on 1/12/26 at 12:04 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated she admitted Resident 1 to the facility on [DATE]. LVN 1 stated she was the nurse who placed the acute hospital discharge orders into the facility computer system but could not remember how or why the order for methotrexate was changed from weekly to daily.During a review of Resident 1's acute hospital Emergency Documentation ([NAME]), dated 12/17/25, at 5:59 PM, the [NAME] indicated, The (Resident 1) presented with life-threatening cytopenias (Cytopenia means that you have low levels of red blood cells [anemia - a common condition characterized by a lack of healthy red blood cells or hemoglobin (an iron-rich protein in red blood cells that transports oxygen from the lungs to the body's tissues. Normal levels are generally 13.8 - 18.0) to carry sufficient oxygen to body tissues, resulting in fatigue, weakness, and pale skin], white blood cells [leukopenia] or platelets [thrombocytopenia]) and acute bleeding, evidenced by critical neutropenia (a condition characterized by an abnormally low count of neutrophils [a type of white blood cell essential for fighting bacterial infections. Neutrophils normally range from 1,500 to 8,000].) . WBC 0.24 [normal is 4,500 to 11,000] . neutrophil 0.00, thrombocytopenia (a condition characterized by a low blood platelet count, which is below 150,000. It can cause increased bruising [discoloration] and bleeding) . and anemia . hemoglobin 7.0 . along with organ (Body organs are specialized organized structures made of tissues that perform vital functions to keep us alive. An example would be the brain and lungs) dysfunction . Diagnosis is methotrexate toxicity with multi-organ involvement. admission to the hospital for critical care, transfusion support (when blood or blood products are placed into the body), and ongoing monitoring was required due to high risk of infection, bleeding, and further organ compromise. Acute bleeding manifested as epistaxis (bloody nose) required oxymetazoline nasal spray (medication that decreases blood vessels [structures in the body that circulate blood throughout your body]), tranexamic acid (medication to prevent heavy bleeding), and pending platelet transfusion (a procedure that injects donor platelets into a patient's vein to stop or prevent bleeding when their own platelet count is too low). Organ dysfunction is evidenced by acute kidney injury (a sudden, often reversible, drop in kidney function occurring within hours or days) . transaminitis (inflammation [the body's natural response to injury or infection] and/or damage to the liver [functions as a vital processing plant, filtering blood, breaking down toxins, producing bile for digestion, and storing energy]). Given the critical nature of the cytopenias, active bleeding, and multi-organ involvement, the patient requires admission to a monitored setting for ongoing critical care, transfusion support, and specialist consultation. The patient meets criteria for sepsis (a life-threatening reaction to an infection that causes your immune system to harm healthy tissues and organs) with suspected infection and systemic inflammatory response (SIRS - the body's massive, widespread alarm reaction to severe stress, such as infection and trauma. If left untreated, it can lead to organ failure). Critical Care Statement: Given that this (Resident 1's) symptoms presented the potential for a high probability of imminent deterioration in the patient's condition, I spent 47 minutes exclusive of other billable procedures involved in direct patient care of high-complexity medical decision making that required constant attendance, otherwise there was the likely sudden, significant deterioration in the patient's condition from respiratory failure (occurs when your lungs cannot get enough oxygen into your blood or cannot remove enough carbon dioxide from it, making it difficult to breathe). (Resident 1) requires inpatient admission for life-threatening cytopenias, including severe neutropenia (low levels of neutrophils) and thrombocytopenia (low level of platelets), with active bleeding and multi-organ dysfunction. Primary Diagnosis . Methotrexate toxicity . Secondary Diagnosis . Neutropenia . Thrombocytopenia . Anemia . Acute Kidney Failure (sudden decrease in kidney function).During a review of Resident 1's acute hospital History and Physical Reports (HPR), dated 12/17/25, at 10:12 PM, the HPR indicated, the acute hospital, Confirmed with nursing home, (Resident 1) was getting methotrexate . daily, suspect methotrexate overdose (happens when a toxic amount of a drug, or combination of drugs overwhelms the body).During a review of Resident 1's acute hospital Discharge Documentation (DD), dated 1/29/26, at 12:02 PM, the DD indicated, (Resident 1) had a prolonged hospital course . general, (Resident 1) was admitted for epistaxis found to have a suspected methotrexate toxicity with severe acute thrombocytopenia as well as pancytopenia (blood disorder defined by low counts of three blood types [red cells, white cells, platelets]. Hematology (medical study of blood) team was consulted and reversal agents (medications) were started immediately. (Resident 1) subsequently developed septic shock (a life-threatening medical emergency where a severe, widespread infection causes the immune system to overreact, leading to dangerously low blood pressure and poor blood flow) . (Resident 1) also developed acute renal failure (loss of kidney function) requiring dialysis (a life-sustaining medical treatment that filters waste products and excess fluid from the blood when the kidneys fail) . (Resident 1) . unfortunately developed respiratory failure . At this time (Resident 1) was transition to comfort care (approach focused on improving quality of life by relieving pain, symptoms, and stress when facing serious or terminal illness [a condition that cannot be cured or treated effectively leading to death]) will be discharged . on hospice (specialty that is used for end-of-life care).During a review of Resident 1's Certification of Vital Record (CVR - death certificate), the CVR indicated, Resident 1 passed away on 1/31/26 with the following diagnoses:a. Acute Renal Failureb. Methotrexate Toxicityc. Rheumatoid ArthritisThe CVR indicated, THE (Resident 1) INGESTED A TOXIC AMOUNT OF METHOTREXATE.During an interview on 3/11/26 at 11:33 a.m. with LVN 2, LVN 2 stated a medication alert means there is a contraindication or concern with the medication. LVN 2 stated staff are supposed to contact the facility pharmacy or the MD to see if it is safe to give the medication to Resident 1.During an interview on 3/11/26 at 11:35 a.m. with Registered Nurse (RN 1), RN 1 stated the purpose of a medication alert is to have staff make sure the medication is safe to give to the residents.During an interview on 3/11/26 at 11:41 a.m. with LVN 3, LVN 3 stated a medication alert is a notification for staff to call the pharmacy and the MD to clarify the medication order. LVN 3 stated a medication alert can come up for a resident if there is a dosage concern, a concern of the medication interacting with another medication, and/or if the medication order was inputted incorrectly in the computer system.During an interview on 3/12/26 at 3:34 p.m. with Assistant Director of Nurses (ADON), ADON stated I (ADON) feel like this could have been caught and not sure why the system failed.During a review of the Manufacturer's black box warning dated 3/18, the black box warning indicated under Warnings: .Methotrexate should be used only by physicians whose knowledge and experience include the use of antimetabolite (chemotherapy drugs that prevent cancer cells from making more cancer cells) therapy because of the possibility of serious toxic reactions (which can be fatal). Deaths have been reported with the use of Methotrexate in the treatment of malignancy (presence of cancerous cells), psoriasis (is a skin disease that causes a rash with itchy, scaly patches) and RA.During a review of the facility's policy and procedure (P&P) titled, Medication Administration, undated, the P&P indicated, Medication are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Ensure that the six rights of medication administration are followed . right dosage . right time . Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. If administering . immunosuppressant medications (medications that calm or weaken the immune system), follow pharmacy instructions for handling and administering of those specific medications. Report and document any adverse side effects . Correct any discrepancies and report to nurse manager.

Based on interview and record review, the facility failed to monitor and document whereabouts (the place where someone is) every hour according to the care plan (CP) for one of two sampled residents (Resident 1) when Resident 1 was a known high risk for elopement (occurs when a resident leaves the facility without authorization and/or any necessary supervision). This failure resulted in staff being unaware of Resident 1 leaving the facility unaccompanied, missing for approximately 10 hours, exposing Resident 1 to environmental dangers, experiencing exposure hypothermia (dangerous drop in body temperature), leukocytosis with left shift (higher-than-normal blood count of white blood cells in the blood), and metabolic acidosis (a serious condition where too much acid builds up in the body fluids, often because the kidneys cannot remove enough acid or the body produces too much), and requiring hospitalization.Findings:During a review of the admission Record (AR) dated 12/18/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of schizophrenia (chronic brain disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality through symptoms like hallucinations [hearing/seeing things] and delusions [false beliefs], anxiety disorder (mental condition characterized by excessive fear of or apprehension about real or perceived threats), major depressive disorder (serious mood disorder causing persistent sadness and loss of interest, affecting feelings, thoughts, and behavior).During a review of the facility's Investigation Follow Up (IFU) dated 6/23/25 (history of elopement, approximately six months prior to the 12/13/25 incident), the IFU indicated, Nurse on duty was notified by staff that Resident [1] is missing. Staff checked all the rooms at the facility and were still not found. At about 4 a.m. residents [Resident 1] were found by VPD [Police Department] next to the church.During a review of Resident 1's Care Plan (CP) dated 9/30/25, the CP indicated, [Resident 1] is an elopement risk/wanderer r/t [related to] history of attempts to leave facility unattended, impaired safety awareness. Elopement Risk Score: 14.0 High [risk]. Interventions: Monitor her whereabouts every hour.date initiated: 10/21/2025.During a review of the Minimum Data Set (MDS-resident assessment tool) dated 11/14/25, the MDS indicated Resident 1 had a BIMS (brief interview for mental status - cognitive screening) Summary Score of 9 (score of 8-12 means moderate impairment) and functional abilities: able to walk.During a review of Resident 1's POC (Point of Care) Response History (POCRH-used by staff to document Resident 1's monitoring and whereabouts), dated 12/13/25, the POCRH indicated Task: Monitor resident whereabouts every 1 hour. The POCRH indicated check marks on the following dates and times:a) On 12/13/25 at 5 a.m., 8:34 a.m., 11:31 a.m., 2:38 p.m., 5:48 p.m., and 7:04 p.m. (7:04 p.m. was the last documented time Resident 1 was checked before Resident 1 was discovered missing at 9:30 p.m.) b) On 12/12/25 at 5:09 a.m., 8:21 a.m., 1:02 p.m., 8:34 p.m., 9:03 p.m., and 11:51 p.m. c) On 12/11/25 at 5:01 a.m., 8:57 a.m., 10:47 a.m., 1:02 p.m., and 5:06 p.m.The document showed Resident 1's whereabouts were not monitored every hour. During a review of Resident 1's Progress Notes (PN) dated 12/14/25 at 2:34 a.m., the PN indicated, Resident [1] last seen at facility (12/13/24) around 8:40 p.m. by CNA [Certified Nursing Assistant]. They were [sic] [Resident 1] in room sleeping covered by blanket. Resident [1] was noticed missing around 9:30 p.m. CNA reported it to nurse at that time. All the facility was searched each bathroom and room, no sign of resident present inside. DON [Director of Nursing] .called at 9:53 p.m. to report that resident was unable to be found. Staff then continued to search outside and drive around neighborhood to see if they can find resident. Police were called around @ [at] 10:40 p.m. and report was filed. Police arrived to facility and took report from charge nurse and staff to get accurate description of resident [1]. Each staff member wrote statements. They [staff] then searched facility for possible exits resident may have taken. Police stated to charge nurse that door near resident's room was tested x3 [times three] and no alarm went off. Rp [responsible party] public guardian left message and Dr [doctor] made aware.During a review of the Ambulance Documentation (AD) dated 12/14/25 at 7:09 a.m., the AD indicated, Patient Condition hypothermia/cold injury.complaint.skin numbness.Per [name of town] PD [police department] the patient has been missing since approximately 8:00 p.m. last night.the patient was cold to the touch. EMS [emergency medical services] removed the patients wet socks once she was on the gurney and placed hot packs on her feet. EMS also gave the patient hot for her hands and armpits.EMS noted that the patient's heart rate was elevated at 142 sinus tachycardia [heart rate faster than normal, normal heart rate is 60-100].During a review of Resident 1's PN dated 12/14/25 at 9:28 a.m., the PN indicated, Investigator informed staff of resident being found around 7:00 a.m. and transferred to [hospital], writer spoke with ER [emergency room] nurse.he updated, resident has hypothermia, resident alert and conscious, vital heart rate fast/tachycardia [fast heart rate], right now she is on the warmer, resident is still under evaluation, MD [Medical Doctor] notified, family made aware.During a review of Resident 1's hospital's History and Physical (H&P) dated 12/14/25 at 2:29 p.m., the H&P indicated, Chief Complaint.Found down after eloping from facility.This is a [AGE] year-old female with past medical history of schizophrenia and major depression who presents to the Emergency Department for evaluation following eloping from [facility name]. The patient [Resident 1] was found this morning approximately 1 mile from her facility in a field after having eloped overnight. EMS reports that efforts were made to rewarm patient after she was found.Assessment and Plan 1. Exposure/Hypothermia.Elevated lactate [made in your muscles and red blood cells when they break down food for energy] and abnormal blood gas [shows how well your lungs are oxygenating blood] findings consistent with cold exposure.2. Leukocytosis with left shift.Assessment: Markedly elevated WBC [increased white blood cells] at 21.83 [normal range is 4,500-11,000 cells per microliter] with neutrophils [body's first responders to infection] at 91.5% [very high proportion of these infection-fighting white blood cells] and lymphopenia [too few lymphocytes- a type of white blood cell] in your blood, weakening your immune system and increasing infections risk). Concerning for infectious process versus stress response from exposure.3. Metabolic Acidosis.Assessment: Venous [vein] pH [a scale from 0 to 14 that measures how acidic or basic a substance is] 7.29 with elevated lactate at 3.8 [normal range is below 2 mmol/L [millimoles per liter-a unit of measurement], elevated anion gap [blood test calculation used to diagnose acid-base imbalances] at 21.3 [normal range is 10-18 mmol/L]. Likely secondary to cold exposure and possible tissue hypoperfusion [not enough oxygenated blood flowing to the body's tissues] .4. Facility elopement/neglect concern.Assessment: Second time patient has eloped from facility. Report filed for abuse and neglect per resident physician documentation.During an interview on 12/17/25 at 2 p.m. with DON, DON stated on 12/13/25 at approximately 9:52 p.m. the nurse called and reported Resident 1 was missing. DON stated Resident 1 was last seen by CNA 1 at approximately 8:45 p.m. DON stated the police were called and all staff were out looking for Resident 1. DON stated Resident 1 was found alive on 12/14/25 at approximately 7 a.m. a mile away in an empty lot. DON stated Resident 1 was found lying down and taken to the hospital and diagnosed with hypothermia.During an interview on 12/17/25 at 2:32 p.m. with Administrator, Administrator stated Resident 1 was reported missing on 12/13/25 at 9:15 p.m. Administrator stated Resident 1 was last seen by staff sitting on the edge of the bed at approximately 8:45 p.m. Administrator stated the police department found Resident 1 the next morning at 7:15 a.m. in a ravine hidden away approximately a mile from the facility. Administrator stated Resident 1 was missing approximately 10 hours and was admitted to the hospital for hypothermia. Administrator stated Resident 1 had a prior elopement attempt in June 2025.During an interview on 12/17/25 at 3 p.m. with DON, DON stated she did not know where Resident 1 exited the facility at but her best guess was the exit door closest to her room. [NAME] stated Resident 1 was wearing a gray shirt, knit shawl and socks. DON stated when Resident 1 was found she was wearing socks and had no shoes. DON stated the temperature was in the 40's (Fahrenheit, cold) the night Resident 1 went missing.During an interview on 12/17/25 at 3:19 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1 at the time she went missing. LVN 1 stated she was informed around 9 p.m. that Resident 1 was missing. LVN 1 stated staff looked for Resident 1 throughout the facility and were unable to locate her. LVN 1 stated she notified the DON and the police. LVN 1 stated she had last seen Resident 1 at approximately 6 p.m. walking in the hall towards the shower and Resident 1 was redirected back to her room. LVN 1 stated she did not know where Resident 1 exited the facility.During an interview on 12/17/25 at 4:01 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 1 at the time she was discovered missing. CNA 2 stated she last seen Resident 1 during last rounds at approximately 8:45 p.m. CNA 2 stated she had seen Resident 1's feet and she had a blanket over her sitting on the bed. CNA 2 stated shortly after that CNA 1 and her, went to Resident 1's room and noticed she wasn't there and immediately started looking for her. CNA 2 stated she did not know where Resident 1 exited the facility.During an interview on 12/18/25 at 1:48 p.m. with LVN 2, LVN 2 stated at times Resident 1 would peek out of her room to see who was in the hallway and wander in the facility looking at the doors exit seeking (attempt to leave). LVN 2 stated she last seen Resident 1 exit seeking four days prior to the 12/13/25 elopement.During an interview on 12/22/25 at 4:46 p.m. with CNA 1, CNA 1 stated she was assigned to Resident 1 on the night she went missing. CNA 1 stated she had last seen Resident 1 sitting on her bed with her feet on the floor around 7 p.m. CNA 1 stated she went to break around 8:40 p.m. and when she returned, she helped another CNA with her rounds and then went to check on her residents. CNA 1 stated when she noticed Resident 1 was missing, she notified the other staff and began looking for her. CNA 1 stated she did not know where Resident 1 exited the facility.During an interview on 1/9/26 at 9:11 a.m. with Administrator, Administrator stated every hour on the POCRH, the task would appear for the staff to document the hourly monitoring that was to be completed for Resident 1. Administrator stated in the POCRH, the time in the monitoring was done but did not contain the ability to enter the physical whereabouts of Resident 1. Administrator stated he expected staff to complete the task and document it (monitoring and whereabouts) every hour. During a review of the facility's policy and procedure (P&P) titled, Elopements andWandering Residents dated 3/2025, the P&P indicated, Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. The facility shall establish and utilize systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and managing residents at risk for elopement or unsafe wandering.residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.the interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan.interventions to increase staff awareness of the resident's risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff.adequate supervision will be provided to help prevent accidents or elopements.charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.the effectiveness of interventions will be evaluated, and changes will be made as needed.

Based on observation, interview and record review, the facility failed to ensure staff was not aggressive towards one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 threw a cup with water in it, at Resident 1 hitting him in the chest. This failure resulted in Resident 1 suffering abuse (improper treatment). Findings: During an observation on 3/21/22, at 2:59 PM, in Resident 1's room, Resident 1 was laying in bed asleep. Resident 1 was not interviewable. During a review of the facility's 5 Day Summary report, dated 3/24/21, the report indicated On 3/21/22, it was reported that on 3/20/22 at approximately 1:30 PM [Resident 1], was in the hallway.Charge Nurse [LVN 1], went to pass medication to [Resident 1]. [Resident 1] refused by putting his arm out. [LVN 1] waited and attempted again. Resident refused again and as he was extending his arm out, [LVN 1] was offering him the medicine cup and they made contact and the medication fell to ground. Medication was picked up and destroyed. [LVN 1] went around the staff assigned to [Resident 1] and took the cup that had water in it and tossed it in the direction of [Resident 1]. It made contact with his chest, wetting his shirt and the cup fell on the ground.Upon investigation, IDT feel that as this incident was witnessed it occurred During an interview on 3/21/22, at 1:12 PM, with Administrator, Administrator stated, on 3/20/21, at approximately 12 PM, LVN 1 was witnessed by Business Office Manager (BOM) throwing a cup with water in it at Resident 1, hitting him in the chest. During an interview on 3/21/22, at 2:14 PM, with BOM, BOM stated, on 3/20/22 between 12 PM and 1 PM, she was the assigned 1:1 for Resident 1. BOM stated, Resident 1 and [BOM] were sitting outside the therapy room when LVN 1 was attempting to administer Resident 1's medications. Resident 1 put his hand up to indicate no and turned away, in the process Resident 1 hit the pills out of LVN 1's hand and LVN 1 began walking away and then came from behind the BOM and told Resident 1, Everyone may be afraid of you but I'm not, and threw the cup with water in it at Resident 1's chest. The items hit the right side of Resident 1's chest and Resident 1 was wet. The cup fell to the floor, and LVN 1 stepped on the cup and said you are a bad man you deserve to be in jail. During a review of the facility policy and procedure (P&P) titled, Resident Rights dated 2011, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, interview, and record review, the facility failed to ensure resident safety for nine of nine residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9) that were an elopement risk (resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected), when a door alarm, that led to the smoke area with two unsecured gates that provided access off of facility grounds, was unarmed. This failure had the potential for the residents to sustain injury or suffer assault without staff being aware. Findings: During a review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 6/17/21, the SOC 341 indicated, Public Guardian received a call from Tulare County Crisis on 6/14 stating that [Resident 1] was in the ER [emergency room ]. [Resident 1] was placed on a 5150 [allows a person with a mental illness to be involuntarily detained for a 72-hour psychiatric hospitalization ] hold at approximately 11:30p.m on 6/13 after the Police Department received reports of her wheeling herself in traffic from 10-11 pm.I contacted [facility] at 8:30 am on 6/14 and spoke with SW [social worker] who stated she was not aware that [Resident 1] has eloped from the facility.I received a call from Administrator who reported she was attempting to speak with the night shift to get more details but at this time they were not aware of when she left the facility. They believe that [Resident 1] left through a side door. All doors have a buzzer to alert staff. The facility will be installing louder buzzers. During an interview on 6/17/21, at 4:43 PM, with Administrator, Administrator stated, on 6/14/21, at 8:30 AM, Social Service Director (SSD) received a phone call from Public Guardian informing the facility Resident 1 was found by VPD [Visalia Police Department] and taken to the acute care hospital on the night of 6/13/21. Administrator stated, the facility called the hospital and verified that Resident 1 had arrived via ambulance in the emergency roiagnom on [DATE] at approximately 11:30 PM. Administrator stated, during the facility's investigation it was discovered Resident 1 was last seen by a staff member on 6/13/21 between 9-10 PM. Resident 1 said she exited through an unalarmed door in dining room. During a review of Resident 1's Patient Care Plan: Elopement (CP), dated 6/15/21, the CP indicated, Actual elopement.Approaches/Plan.Secured doors with alarm. During an interview on 6/17/21, at 5:11 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 1 liked to go to the front of the building to the dining room and the dining room/activity room that lead to the smoke area. CNA 2 stated, Resident 1 would stay there sometimes all night. During a concurrent observation and interview on 6/17/21, at 6:17 PM, with DON, in the small dining room/activity room, there was a sliding glass door that led to a smoking area and a grassy area. There were two unlocked gates on each side of the grassy area, one that provided access to the parking lot in front of the building and one that provided access to the driveway behind the facility. When the slider door was opened, the alarm did not activate. The alarm was not turned on. DON confirmed the findings and stated the door alarm should have been reactivated immediately after entering/exiting the door by staff. During an interview on 6/17/21, at 6:26 PM, with Clinical Resource Consultant (CRC), CRC stated, the staff are responsible to reactivate the door alarms when entering/exiting the doors. During an interview on 6/17/21, at 7:16 PM, with Social Service Director (SSD), SSD stated, sometimes the residents remain outside after smoking. SSD stated, if the residents were out in the smoke area by themselves and exited through the gates staff would be unaware. Policy was requested from the facility on 6/17/21 and none was provided.

Based on interview and record review, the facility failed to ensure the safety of one of nine residents (Resident 1) when staff failed to provide supervision and were unaware Resident 1 had eloped (resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) from the facility for at least nine hours. This failure resulted in Resident 1 being located a block away from the facility by local law enforcement and transferred to the acute hospital. Findings: During a review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 6/17/21, the SOC 341 indicated, Public Guardian received a call from (Tulare) County Crisis on 6/14 stating that [Resident 1] was in the ER [emergency room ]. [Resident 1] was placed on a 5150 [allows a person with a mental illness to be involuntarily detained for a 72-hour psychiatric hospitalization ] hold at approximately 11:30 p.m. on 6/13 after the Police Department received reports of her wheeling herself in traffic from 10-11 pm.I contacted [facility] at 8:30 am on 6/14 and spoke with SW [social worker] who stated she was not aware that [Resident 1] has eloped from the facility.I received a call from Administrator who reported she was attempting to speak with the night shift to get more details but at this time they were not aware of when she left the facility. They believe that [Resident 1] left through a side door. All doors have a buzzer to alert staff. The facility will be installing louder buzzers. During a review of Resident 1's hospital Encounter Form (details of visit to medical facility), dated 6/13/21, the Encounter Form indicated, Enc [encounter] Start Date Time 6/13/21 Time 22:52 [10:52 PM]. During a review of Resident 1's hospital Emergency Documentation, dated 6/13/21, at 23:14 [11:14 PM], the Emergency Documentation indicated, BIBA [brought in by ambulance] for 5150 per VPD [Visalia Police Department, local law enforcement]. Pt [patient] unable to care for herself. During a review of Resident 1's Elopement Risk Assessment, dated 3/16/21, at 4:20 PM, the Elopement Risk Assessment indicated, Diagnoses.Dementia [loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life] in oth [other] diseases classd [classified] elswhr [elsewhere] w/o [with out] behavrl [behavioral] dis [disturbance].[CONDITION(S)] [psychiatric illness], unspecified.Major depressive disorder, single episode, unspecified.Anxiety disorder, unspecified.Moderate intellectual disabilities.Behaviors.Anger regarding facility placement.packing belonging.verbal statements about leaving.Contributing factors.Anxiety Disorder.Psychiatric Diagnosis.Evaluation Based on Assessment, does resident present an elopement risk? Yes. During a review of Resident 1's facility Progress Notes, dated 6/15/21, at 1:48 PM, the Progress Notes indicated, IDT [Interdisciplinary Team-professionals that plan, coordinate and deliver personalized care] team met to discuss the current plan of care for resident.staff was notified by Public Guardian, that resident was in the acute [hospital], picked up by VPD/American Ambulance.per acute report, no injuries admitted back to facility, on 6/14/21, @ [at] 1730 [5:30 PM]. During an interview on 6/17/21, at 4:43 PM, with Administrator, Administrator stated, on 6/14/21, at 8:30 AM, Social Service Director (SSD) received a phone call from Public Guardian informing the facility Resident 1 was found by local law enforcement and taken to the acute care hospital on the night of 6/13/21. Administrator stated, the facility called the hospital and verified that Resident 1 had arrived via ambulance in the emergency roiagnom on [DATE] at approximately 11:30 PM. Administrator stated, during the facility's investigation it was discovered Resident 1 was last seen by a staff member on 6/13/21 between 9-10 PM. Administrator stated, staff were expected to do rounds (visually check on resident) at least every two hours and should have set eyes on each resident. During an interview on 6/17/21, at 6:45 PM, SSD stated, on 6/14/21, at approximately 8:20-8:30 AM, she received a phone call from Public Guardian stating Resident 1 had been found on 6/13/21 by local law enforcement and transported to the acute hospital by ambulance. During an interview on 6/17/21, at 5:11 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 1 liked to go to the front of the building to the dining room and the small dining room/activity room that lead to the smoke area. CNA 2 stated, Resident 1 would stay there sometimes all night. CNA 2 stated, staff were responsible to check on each of the residents every one to two hours to make sure they are where they are supposed to be. During an interview on 6/17/21, at 5:28 PM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, she worked the AM shift (6:30 AM-3 PM) on 6/14/21 and was assigned to Resident 1. LVN 3 stated, when doing rounds with the off going shift (at approximately 6:30 AM) Resident 1 was not in her room and LVN 1 had told her that Resident 1 was wandering around the facility. LVN 3 stated, at approximately 7:45 AM she went to administer medications to Resident 1 and Resident 1 was not in her room, so she skipped Resident 1 and went to find her at the end of her medication pass (at approximately 8:20 AM). While looking for Resident 1 she was notified of Resident 1's elopement. During an interview on 6/17/21, at 5:57 PM, with CNA 3, CNA 3 stated, Resident 1 stayed in the hallway most of the time and only went to her room to use the bathroom. CNA 3 stated, the staff are expected to set eyes on the residents at least every two hours to ensure they are where they are supposed to be. During an interview on 6/17/21, at 6:01 PM, with Director of Nursing (DON), DON stated, all the facility doors had alarms except the dining room door. DON stated, Resident 1 left through the door in the dining room. During an interview on 6/17/21, at 6:03 PM, with LVN 4, LVN 4 stated, Resident 1 slept in her wheelchair and would go up front and hide, to avoid care. LVN 4 stated, Resident 1 exited the facility through an unalarmed door in the dining room that provided access from facility grounds. LVN 4 stated, staff are expected to check on the residents every 2 hours. During an interview on 6/21/21, at 8:55 PM, with LVN 2, LVN 2 stated, she was working the night Resident 1 eloped. LVN 2 stated, Resident 1 preferred to stay in the front hallway and only went to her room to use the bathroom. LVN 2 stated, she did not see Resident 1 during her shift. LVN 2 stated, the residents are supposed to be checked on every two hours and as needed. During an interview on 6/21/21, at 9:25 AM, with LVN 1, LVN 1 stated, she started her shift at 6:30 PM and was assigned to Resident 1 the night she eloped. LVN 1 stated, she last saw Resident 1 between 6 PM and 9 PM and no one reported Resident 1 was missing. LVN 1 stated, Resident 1 liked to sleep in the front of the facility in her wheelchair and she would normally not see Resident 1 through the night. LVN 1 stated, Resident 1 left the facility through the dining room door that provided access to the alley. LVN 1 stated, the dining room doors did not have alarms on them. During an interview on 6/21/21, at 1:40 PM, with CNA 4, CNA 4 stated, he last saw Resident 1 between 10:25 PM and 10:30 PM on the night she eloped from the facility. CNA 4 stated, staff are supposed to visually put eyes on the residents every two hours. During a review of the facility's policy and procedure (P&P) titled Routine Resident Checks dated 7/13, the P&P indicated, Staff shall make routine resident checks to help maintain resident safety and well-being.2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify and change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check.

Based on interview and record review, the facility failed to develop a comprehensive nutritional care plan in 14 days for one of 10 sampled residents (Resident 1) to address his risks of having nutrition-related health consequences, such as loss of appetite, difficult swallowing, and inability to use hands/fingers to eat independently. This failure resulted in Resident 1 losing 10 pounds, 4.7%, of his usual body weight, from [DATE] to [DATE], within eight days. Resident 1 died at an acute care hospital related to not eating or drinking. (RAI Manual 3.0, 2019 (a manual released by the Centers for Medicare & Medicaid Services (CMS) offers clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care to residents.) A comprehensive care plan is a patient-centered plan to care for an individual patient's needs. It contains all of the relevant information about a patient's diagnoses, the goals of treatment, the observations needed, actions must be performed, and a plan for evaluation. A comprehensive assessment is the first step in care planning. In the long- term care, the Minimum Data Set (MDS) is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS responses that indicate the need for additional assessment based on problem identification.) (The triggering of a care area indicates the facility needs to conduct more review to identify if additional assessment is needed. Then the staff reviews the information gathered through further review to determine whether the resident needs a new care plan or changes to an existing care plan. The decision to start a new care plan or revise an existing one is documented on the Care Area Assessment Summary. The comprehensive care plan should be developed within seven days after completion of the MDS, 14 days after admission.) Findings: Resident 1 was a [AGE] year-old male admitted to the facility on [DATE]. He had multiple medical conditions including: [DIAGNOSES REDACTED], heart failure, diabetes, and chronic pain, and other symptoms and signs concerning food and fluids intake. ([DIAGNOSES REDACTED] is caused by the body's immune system goes awry and attacks its own tissues - in this case, the muscles. The symptoms included weakness of the wrist and finger muscles, shrinking of the muscles of the forearms, weakness of the large muscles on the front part of the thighs, weakness of the lower leg muscles, and weakness of the [MEDICAL CONDITION] (muscular tube connecting the throat with the stomach which can cause difficulty swallowing) muscles. [DIAGNOSES REDACTED] patients with swallowing difficulties can suffer from poor nutrition as well as choking on food or drinks.) During a review of Resident 1's MDS, dated [DATE], indicated Resident 1 had problem in maintaining nutritional balance related to his contractures, inability to sit up, poor memory, anxiety, heart issues, digestive tract illness, and diuretics use. There was a note, under Analysis of Findings, read: res (resident) is mechanically altered with a very good po (oral) intake at this time ,[DATE]% continue to feed him self also have difficulty with swallowing as well. The comprehensive assessment triggered Nutritional Status as a concerned care area for Resident 1 and the interdisciplinary team decided to proceed with a care plan to address his risk for nutritional deficit. In the Care Area Assessment Summary of the same MDS, it indicated; New Care Plan Started for nutritional status. During a review of Resident 1's care plans, there was no care plan found in his medical records to address his nutritional status and risk of developing nutrition related problems such as dehydration or weight loss. During a review of the Registered Dietician's (RD) New Admission note, dated [DATE], Resident 1's usual body weight was around 210 pounds. During a review of Resident 1's Weight Data log, dated [DATE] thru [DATE], the log indicated Resident 1 weight 211 pounds on admission, [DATE]. On [DATE], he maintained his weight at 211 pounds. On [DATE], Resident 1 weight 201 pounds, a 10-pound loss. During a more in-depth review of Resident 1's Meal Percentage log, dated [DATE], indicated the resident, from [DATE] to [DATE], was able to take at least 25 percent of the meals served. From [DATE] to [DATE], the meal intakes are listed below: [DATE]-only took 25% of dinner. No documentation for breakfast and lunch. [DATE]-took 100% breakfast and 50% dinner. No documentation for lunch. [DATE]-took 25% breakfast, 50% lunch, and 50% dinner. [DATE]-took 25% breakfast, refused lunch, and took 100% dinner. [DATE]-took 25% breakfast, 10% lunch, and no documentation for dinner. [DATE]-took 50% breakfast, 25% lunch, and 100% dinner. [DATE]-took 25% breakfast, no documentation for lunch, and 100% dinner. [DATE]-did not eat breakfast, refused lunch, and no documentation for dinner. [DATE]-no documentation for meals entire day. [DATE]-no documentation for breakfast and lunch, refused dinner. [DATE]-no documentation for breakfast, refused lunch and dinner. [DATE]- no documentation for breakfast and lunch, refused dinner. [DATE] and [DATE]-refused breakfast and no documentation for lunch and dinner. [DATE]-no documentation of any meal intake. [DATE]-refused breakfast and dinner, no documentation for lunch. [DATE]-took 10% breakfast, no documentation for lunch, refused dinner. [DATE]-no documentation on meal intake. [DATE]-refused breakfast, no documentation for lunch and dinner. During a review of [DATE] ADL (Activities of Daily Living) FLOW SHEET ADDITIONAL NOTES, completed by a certified nursing assistant (CNA), it indicated on [DATE], at 1:35 PM, nurse and therapy notified that resident hasn't been eating right complains of taste. Offer alternate or pudding. At 6 PM, another CNA documented: R (Resident) ate 25% dinner alt (alternate) offered and ref (refused), c/n (charge nurse) notif (notified). On [DATE], another CNA documented; R (resident) refused breakfast, charge nurse notified. The Activities of Daily Living (ADL) flow sheet from [DATE] to [DATE] was reviewed. There were 36 meals served, Resident ate 25% of breakfast on [DATE] and 25% lunch on [DATE]. The rest of 34 meals, Resident 1 refused 25 meals, and facility staff did not document nine meal intakes. There were a few notes on the ADL FLOW SHEET ADDITIONAL NOTES section: On [DATE], at 7:30 AM, the note indicated; (Resident 1) refusing to eat or drink. He keeps spitting out food and drinks, nurse notified. On the same day, at 12:30 PM, the note indicated; (Resident 1) is refusing to eat lunch or drink he keeps spitting it out nurse notified. The third note was entered on [DATE], no time, indicated; (Resident 1) refused dinner, tried feeding him, but he would yell continue to spit everything out. On [DATE], at 7 AM, a CNA documented: CNA (Certified Nursing Assistant) fed resident he couldn't chew and started spitting food out C/N (Charge Nurse) aware. On the same documentation, five hours later, another CNA documented the facility transferred Resident 1 to an acute care hospital. The admitting physician at the hospital Emergency Department assessed Resident 1 with severely dehydrated (not enough water in the body), with hemoconcentration (concentrated blood or thickened blood usually resulting from loss of fluid to the tissues from blood vessels). During a concurrent interview and record review on [DATE], at 11:04 AM, with Minimum Data Set Coordinator Assistant (MDSCA), MDSCA reviewed Resident 1's meal percentage log for [DATE] thru [DATE]. MDSCA confirmed the log had missing documentation and Resident 1 had refused meals. During a concurrent interview and record review, on [DATE], at 10:34 AM, with Dietary Supervisor (DS), DS reviewed Resident 1's Weight Data log. DS confirmed Resident 1 had weight 211 pounds on ,[DATE] and 201 pounds on ,[DATE], indicating Resident 1 had lost 10 pounds in eight days. DS stated Resident 1 had a weight loss, and the weight loss was not a planned weight loss. During a concurrent interview and record review, on [DATE], at 11:26 AM, with the Director of Nursing (DON) and Chief Nursing Officer (CNO), both the DON and CNO confirmed Resident 1's weight loss may be related to the poor meal intake and stated, There should have been an intervention, and SBAR (situation, background, assessment, and recommendation; a communication form used to identify a residents change of condition before calling the physician) It just got missed. During a concurrent interview and record review on [DATE], at 11:19 AM, with the DON, DON reviewed Resident 1's medical records and was unable to find any care plan developed by staff to address Resident 1's nutritional risk factors or poor oral intake. DON stated, He (Resident 1) doesn't have a nutritional care plan. (There was) No baseline either (comprehensive care plan). He should have had one. There should have been a baseline (care plan) on admission and an updated care plan when he (Resident 1) started to lose weight. During a review of the facility's policy and procedure (P&P) on Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, revised [DATE], subtitled Monitoring indicated: 1. The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals; (1) Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status; for example, stabilization of weight, laboratory values, or food/fluid intake. During a review of the facility's P&P titled, Care Plans-Comprehensive, revised [DATE], it indicated, 7. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 8. Assessment of residents are ongoing and care plans are revised as information about the resident's condition change. The facility staff did not develop a comprehensive nutritional care plan for Resident 1 in 21 days after his admission to intervene or minimize the risks for weight loss, nor did the facility initiate a care plan when the resident started to eat poorly. During a review of Resident 1's hospital's medical records, the Discharge Documentation, dated [DATE], indicated Resident 1 expired at 8:43 AM. His discharge [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) when the resident was left unattended in the bathroom. This failure resulted in Resident 1 falling and sustaining a dens fracture (a break in the second bone of the spine), bilateral nasal bone fracture (a break on both sides of the nasal bone), and fractures involving the lateral wall of the right orbit (cavity which contains the right eye) and right maxillary sinus (nasal bone area). Findings: During an observation and interview with Resident 1 and Family Member 1 (FM 1), on 11/16/18, at 12:55 PM, in Resident 1's hospital room, Resident 1 was observed to have purple discoloration over her chin, nose, and under both eyes. Resident 1 was wearing a cervical collar (a device used to keep the neck from moving) restricting the movement of Resident 1's neck and head. Resident 1 stated she did not want to talk. FM 1 was at the bedside and stated she believes her mother was in pain and that was the reason Resident 1 did not want to talk. During a review of the clinical record for Resident 1, the Admissions Record dated 9/13/17, indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. degeneration (wear of the discs between each vertebrae) of the lower spine, and a history of falling. Resident 1's MDS (Minimum Data Set- an assessment tool), dated 9/22/18, indicated Resident 1 required extensive assistance from the facility staff to transfer, dress, use the toilet, and perform personal hygiene tasks. The MDS assessment indicated Resident 1 has had two or more falls since her admission to the facility on [DATE]. Resident 1's care plan titled, At risk for falls related to: impaired balance, use of medications, history of femur fracture, . and poor safety awareness initiated on 9/9/18 and revised on 10/15/18, indicated Do not leave unattended in bathroom. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 11/16/18, at 3:35 PM, LVN 1 described Resident 1 as Spanish speaking only. LVN 1 stated Resident 1 required assistance from one staff to assist the resident with transferring. She stated the resident was alert, oriented, and impulsive. LVN 1 stated at approximately 2 PM on 11/14/18, Resident 1 was sitting at the nurse's station. LVN 1 stated Resident 1 requested assistance to use the restroom. LVN 1 stated Resident 1's assigned Certified Nursing Assistant 1 (CNA 1) was busy showering another resident, so CNA 2 was asked to assist Resident 1 to the restroom. CNA 2 assisted Resident 1 to the restroom and stepped out. LVN 1 stated about 10 to 15 minutes later, CNA 1 and CNA 2 were walking down the hall when CNA 1 stated Resident 1 was observed on the bathroom floor. LVN 1 stated Resident 1 was found on the bathroom floor and complained of pain to her nose and eyes. She stated Resident 1 had blood coming from her nose. During an interview with CNA 2 and review of the clinical record for Resident 1, on 11/30/18, at 12:05 PM, CNA 2 stated he was not assigned to Resident 1 on the day of the occurrence but worked with her often. He stated Resident 1 had hip problems, she could kind of stand and he believes she has a history of falls. CNA 2 confirmed he assisted Resident 1 to the restroom. CNA 2 stated, We (CNAs) stand right outside the door normally, . but I was the only CNA on the floor and call lights were going off. I did not think it would be an issue and she (Resident 1) was taking quite a long time. CNA 2 stated he got tired of waiting and answered some call lights. When he returned back he stated he saw Resident 1 on the floor in the bathroom with a pool of blood around her. CNA 2 stated he learns about residents by working with the residents. Resident 1's care plan titled, At risk for falls . revised on 10/15/18, indicated under interventions Do not leave unattended in bathroom, was reviewed with CNA 2, he stated he was never told about that intervention. During an interview with CNA 1 and review of the clinical record for Resident 1, on 11/30/18, at 12:21 PM, CNA 1 confirmed she was assigned to Resident 1 but was giving another resident a shower at the time of the fall. CNA 1 stated, I never left her (Resident 1) alone in the bathroom by herself, she will try to stand up. I always get a second CNA. I know from previous experience with her she is impatient. CNA 1 stated she learns about the residents needs from a binder at the nurses' station or she will ask the nurse. She stated she was not sure if Resident 1 had fallen in the past. Resident 1's care plan titled, At risk for falls . revised on 10/15/18, indicated under interventions Do not leave unattended in bathroom, was reviewed with CNA 1. CNA 1 stated she was not aware of that intervention. During an interview with the Director of Staff Development (DSD) and review of the clinical record for Resident 1, on 11/30/18, at 2:55 PM, the DSD confirmed the Resident Profile (a document used by the facility staff which indicates the type of care/precautions each resident requires) for Resident 1 undated, did not contain documentation related to a history of falls or an intervention which indicated Resident 1 should not be left unattended in the bathroom. During an interview on 12/11/18, at 4:27 PM, with Housekeeper 2 (HK 2), HK 2 stated on 11/14/18 she was cleaning a room two doors down from Resident 1's room. She stated Resident 1 was taken to the bathroom by CNA 2 and ten minutes later the call light came on for Resident 1's room. HK 2 stated the call light was on for about 20 minutes before they found Resident 1 on the floor in the bathroom. The facility policy and procedure titled Care Planning Process dated 12/11/17, indicated 3. The comprehensive care plan will be developed by the interdisciplinary team that includes the attending physician, a member of the nutritional services, an RN and a CNA with the responsibility for the patient/resident. The facility policy and procedure titled Fall Prevention and Fall Related Injury Management dated 4/11/17, indicated 2. The licensed nurse and/or Interdisciplinary Team (IDT) will develop an initial fall/injury prevention care plan based on the patient/resident specific risk factors that will be communicated to the staff.

Based on interview and record review, the facility failed to develop and follow a comprehensive plan of care for two or more person assistance during transfer for one of one sampled resident (1) which resulted in Resident 1 sustaining a broken leg. Findings: The clinical record for Resident 1 was reviewed and contained the following: The Admission Record dated 8/16/15, indicated Resident 1 had a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A Nursing Evaluation/Data Collection form dated 8/16/15, indicated Resident 1 had a weight of 232 pounds and was 64 inches tall with a body mass index (BMI) of 39.8 (a person with a BMI over 30 is considered obese). This form indicated when Resident 1 was transferred between surfaces and moved to a standing position, she was totally dependent on staff and required two or more persons physical assistance. Resident 1's care plan for assistance in daily living dated 8/16/15, indicated she was dependent on staff with transfers and toileting and required maximum assistance. The area under approach indicating how many persons would be required to assist the resident was checked but the actual area for how many persons required was left blank. A Balance Assessment Tool dated 8/18/15 indicated Resident 1 was unable to rise from a chair without help, had unsteady balance and was unsafe to sit back down. Nurse's notes dated 8/18/15 at 10:30 PM, indicated CNA (certified nursing assistant) went into room . to answer resident's bathroom call light. Resident was in the bathroom. At 1645 (4:45 PM), CNA stood resident up and resident's knee buckled up. CNA guided resident to floor. CNA notified CN (charge nurse) immediately. Nurse's notes dated 8/19/15 at 5:15 PM, indicated: Resident had x-ray of knees done due to complaint of pain. X-ray results showed fracture to left femur (thigh bone), Resident 1's x-ray report dated 8/19/15 at 3:15 PM indicated: Acute oblique displaced [MEDICAL CONDITION] femoral diaphysis and metaphysis. (Recent slanted [MEDICAL CONDITION] bone head and shaft where the bone is not aligned.) During an interview on 8/28/15 at 9:30 AM, the Administrator stated Resident 1 was in the restroom and felt weak. She started going down and CNA 1 called for help. During an interview on 8/31/15 at 4:48 PM, CNA 1 verified she was the only staff member assisting Resident 1. CNA 1 stated: It was around 4:45 PM, I stood her up and she was holding on to the sink . Her left knee buckled and I guided her to the floor. She went down on both knees. I got someone to help me get her into the wheelchair. I told (Licensed Vocational Nurse (LVN)) 1 what happened. During an interview on 9/2/15 at 12:30 PM, LVN 1 stated: When I was called, (CNA 1) said she eased her to the floor. She was leaning toward the sink . I ran and got (another CNA) and we lifted her onto the toilet chair seat and we put oxygen on her. She didn't have oxygen on at the time. We took her to bed. She said her left knee was hurting. I don't know who put her in the bathroom. She was a two-lift person. She's heavy and not strong and has to have oxygen on all the time. The facility policy and procedure titled Duties and Responsibilities undated, read Developing a comprehensive care plan for each resident . Reviewing care plans to assure that: They reflect the resident's medical and nursing assessment, They are oriented toward preventing declines in functioning and/or functional levels. They attempt to manage risk factors . They reflect and interdisciplinary approach to maintain or improve functional abilities.

Based on observation, interview, and record review the facility failed to protect one of one sampled resident (1) from abuse when Certified Nursing Assistant (CNA) 1 hit Resident 1 with a closed fist and then CNA 1 came back into the room five minutes later, slapped Resident 1 in the face and swore at him which violated the resident's rights and resulted in Resident 1 looking like he was going to cry and then staying very quiet afterwards. Findings: An unannounced visit was made to the facility on [DATE] at 12:01 PM to investigate an allegation of resident abuse by staff. Resident 1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 6/30/15 at 12:30 PM, CNA 2 stated she was in Resident 1's room with CNA 1, CNA 3, and CNA 4 and Resident 1 became combative on 6/24/15 at 2:40 PM. CNA 2 stated He (Resident 1) cornered her (CNA 1) in the corner and he grabbed her arm. She (CNA 1) hit him in the back of the neck with a closed fist. He looked like he was going to cry. We finished with him and I left. It happened so fast, we were all in shock. A statement written on 6/30/15 at 12:35 PM by CNA 2 indicated: I went into the room to help my co-worker (CNA 3) change (Resident 1). I put gloves on and so did she. (CNA 1) and (CNA 4) walked in the room and put on gloves to help us. As soon as we started pulling down his pants to change him, he became combative and his merry chair (a walker with a seat constructed of plastic pipe) cornered (CNA 1) against the wall. He then started to swing his arms and he managed to grab onto (CNA 1)'s arms with his hands and nails. She then made a fist and hit him on the back of the neck, upper back. She managed to get away after that and walked out of the room. The incident happened at 2:15 PM. During an interview on 7/1/15 at 8:30 AM, CNA 1 stated He grabbed my arm and I pulled my arm away. I may have hit him because he was trying to bite me. CNA 1 stated she had not been trained on how to handle a combative resident. During an interview on 7/1/15 at 12:05 PM, CNA 3 stated He (Resident 1) was in his merry walker. He was in the corner and (CNA 1) was against the wall. He got agitated and clawed her arm. She hit his neck with a closed fist and shoved him in the corner. She left the room and then came back and slapped him saying, 'I hope you die, motherf---ker.' I was the only person in the room when she came back and slapped him. A statement written on 7/1/15 at 12:10 PM by CNA 3 indicated: It was about 2:20 PM, when me and (CNA 2) were getting ready to change (Resident 1). During that time, (CNA 4) and (CNA 1) walked in and saw that we were getting ready to change (Resident 1) so they put on gloves to help us. When we started changing (Resident 1) he started getting combative and started to dig his fingernails on (CNA 1)'s arms, he was also trying to bite her arm. (CNA 1) got mad and hit (Resident 1) with a closed fist behind (his) neck. We pulled his pants up and (CNA 1) shoved him in his chair. About five minutes later, she came back into the room, closed the door, went up to him and slapped him on the cheek. She then told him 'I hope you die motherf---ker.' After the incident I noticed (Resident 1) was shocked because he just sat on his chair still and .he stayed quiet afterwards. During an interview on 7/1/15 at 12:20 PM, CNA 4 stated He (Resident 1) didn't want to stand and (CNA 1) yanked him up by the arm. He grabbed her left arm and dug his nails in. She pushed his head away with open hand. She pushed him back in the chair and pushed his head again. A statement written on 7/1/15 at 12:40 PM, by CNA 4 indicated: Around 2:10 PM, I went to go in and check to see if the other aid, (CNA 1) needed help.but saw that she was changing (Resident 1) for CNA 3 and went over to help. (Resident 1) wasn't wanting to stand up so (CNA 1) pulled him up by his left arm quick and in a hard motion, which agitated (sic) the resident. (Resident 1) then tried to bite her while grabbing her left arm and digging his nails into her arm. When the resident was doing that (CNA 1) got mad and pushed his left temple enough to make his whole head move, which made the resident even more angry. Then, he grabbed his side table and tried pushing it into her side while she was changing him. By the time I got the table from him (CNA 1) was done changing him and had his pants back up. She pushed (his) left temple again after she got done changing him and pushed him back down into his chair and pushed him once more in his left temple and then left the room angrily(sic). During a concurrent interview and observation on 6/30/15 at 2 PM, Resident 1 was seated in the merry walker next to his bed. His eyes were closed and his hands were on his lap. CNA 5 was seated several feet away from him and stated Yes, he's tried to hit me a couple of times. You just need to stay out of his reach. The facility policy titled Reporting Abuse to Facility Management, undated, indicated: Our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friend, or other individuals.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for one resident (1) when, on 2/6/12, at 3:15 PM, Resident 1 was sitting in a wheelchair at the nurses' station, and was handed a cup of hot coffee and left unsupervised. Resident 1 dropped the cup of coffee, spilling the hot liquid on her lap, which resulted in deep burns to both of her thighs, and required surgical treatment. According to emedicinehealth (www.emedicinehealth.com), "all thermal burns cause an injury to the different layers of the skin. The type of burn and the severity of the burn depends on the number of layers of skin affected." A "Partial thickness burn or second degree burn...involves the epidermis (outermost layer of skin) and some portion of the dermis, the second layer of skin. This type of burn may be further categorized as superficial or deep, depending on how much of the dermis is involved. A Full thickness burn or third degree burn...is the most severe burn. The burn involves all of the epidermis and dermis, the first two layers of the skin. Nerve endings...blood vessels, hair follicles, and...sweat glands are all destroyed." Findings: On 3/15/12, at 12:45 PM, a review of Resident 1's record, at Facility 1, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred to another facility (SNF 2) per the responsible party's and resident's request on 2/8/12. The record for Resident 1 was reviewed on 3/15/12. The "Nurse's Notes", dated 2/6/12, at 3:15 PM, indicated "Resident was sitting in w/c (wheelchair) in hallway near nurse's station and dropped a cup of coffee in her lap." She was taken to her room, where her clothing was removed and first aid treatment was provided. The Nurse's Notes indicated, she "has reddened skin (burns) on upper inner bilateral (both) thighs with some blisters. Reddened skin area on right upper inner thigh (measured) 23 centimeter (cm - a unit of measure) by 9.5 cm. and 30 cm by 7.5 cm. on left upper inner thigh." On 2/7/12, at 4 AM, the Nurse's Notes indicated "superficial burns on upper inner bilateral thighs with some blistering and loose skin from broken blisters." At 4 PM, the Nurse's Notes indicated "wound specialist in to see burns to bilateral upper thighs (groin). Partial to full thickness burns, wound bed is yellow/red. Periwound (around the wound) blistered...20 percent slough (dead tissue)." According to an article from the Journal of American Medicine Association (Katcher, L.K. (1981). Scald Burns from Hot Tap Water. Journal of AM Med Assoc., 246(11), 1219-1222), and Table 1 of Time and Temperature Relationship to Serious Burns (Mortiz, A.R., Henriques F.C. Jr. (1947). Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-729), burns related to hot liquids may be due to spills. "Many residents in long-term facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility...decreased cognition...decreased mobility, and decreased ability to communicate." Table 1 indicated at a water temperature of 133 degrees F. a third degree burn can occur in 15 seconds. 100 degrees F is considered a safe temperature for bathing. "Burns can occur even at water temperatures below those identified in the table depending on an individual's condition and the length of exposure." The "Resident-Data Collection", (admission nursing assessment), form, dated 2/2/12, indicated she had left sided weakness and was dependent for eating and all personal hygiene and grooming activities. A Minimum Data Set (MDS-a resident assessment tool), dated 2/8/12, indicated Resident 1 required a one person physical assistance for eating and personal hygiene activities, and extensive assistance with a two person assist for transfers and toilet use. The Plan of Care Report from Physical Therapy (PT), dated 2/3/12, indicated the resident was referred to PT for a left ankle fracture. "The patient complains of pain, weakness and decreased functional ability to perform bed mobility, transfers and ambulation..." The medical history indicated the resident also had Diabetic neuropathy (damage to nerves that can affect sensation). The "Patient Care Plan for Functional Rehabilitation/ADLs", dated 2/3/12, indicated a problem area for her [DIAGNOSES REDACTED]. The "Resident Care Plan for Cognitive Status/Communication," dated 2/3/12, indicated facility staff interventions included "obtain resident's full attention prior to any conversation, allow time to respond, and provide cues as needed for safety awareness and visual aid." The Physical Therapy treatment care plan identified left sided neglect (lack of awareness of the left side of the body) as a problem for potential concern. During an interview with the Director of Nurses, on 3/15/12, at 1:40 PM, she stated a Certified Nursing Assistant (CNA) 1, brought a cup of coffee to the resident from the kitchen on 2/6/12. The resident spilled the coffee, sustained burns to both thighs and received treatment for [REDACTED]. During an interview with CNA 2, on 3/15/12, at 1:55 PM, she stated she had taken care of Resident 1 prior to the date of her burn. She described the resident as "she had one side paralyzed but fed herself with her good hand." When asked if the resident was able to hold her own cup and drink, CNA 2 stated "Yes, with steadying assistance." She stated the resident was very alert and could make requests for what she needed or wanted. During an interview with CNA 1, on 3/15/12, at 2:30 PM, she stated she was the CNA who brought the coffee to Resident 1 on 2/6/12. CNA 1 stated she was not assigned to Resident 1 that day, but was working in the back hallway where the resident resided. She stated the resident was sitting in her wheelchair across from the nurse's station and the Charge Nurse instructed her to get some coffee for the resident. CNA 1 stated the beverage/snack cart had already been around to deliver beverages or snacks to the residents that afternoon, so she "went to the kitchen, poured a cup (from the coffee maker), put 2-3 ice cubes in it, brought the cup to the resident and handed it to her. The resident took the cup and I returned to my assigned residents." "About four minutes later, the Charge Nurse screamed for help (for the CNA assigned to Resident 1) to take the resident to her room." CNA 1 stated the Charge Nurse was at the nurse's station and "should know the patients...I just did what my Charge Nurse told me to do." During an interview with the staff that delivered the beverage/snack cart (CS), on 3/15/12, at 2:15 PM, when asked about obtaining coffee from the kitchen she stated "Out of the tap? I'd be careful" regarding the temperature. At 2:30 PM, an interview with the Administrator was conducted. He stated CS worked in central supply but often helped with the distribution of the snack cart and other tasks as needed. During an interview with the CS, at 2:50 PM, she stated she assisted with snack and beverage distribution. She stated she makes sure the coffee is not too hot by feeling the temperature of the outside of the cup, and if the cup was too warm she pours some in a little cup and checks it herself. On 3/15/12, at 1:45 PM, an interview with the Dietary Supervisor (DS) was conducted. He stated the facility used an institutional coffee maker that has the hot water "piped into (the coffee maker from) the wall. He stated the manufacturer indicated the coffee out of the tap was 180 degrees Farenheit (F). He was unable to produce documentation of the manufacturer guidelines and stated "the serving temperature (of coffee) is usually lower." At 2:15 PM, the DS was observed pouring a cup of coffee directly from the coffee machine tap. The DS temped (checked the temperature) the beverage at 166 degrees F. The CS had just returned to the kitchen from distributing beverages and snacks to the residents. Coffee was poured from the carafe on the beverage cart and was temped by the DS at 138 degrees F. The DS stated he did not temp coffee or any hot beverages prior to serving to the residents. The dietary department tray line temperature logs did not record beverage temperatures. The DS could not locate a Dietary Department policy for beverage temperature practices, and stated they did not check the temperatures of beverages. During an observation and interview with Resident 1, on 3/20/12, at 3:20 PM, at SNF 2, she was observed sitting up in a wheelchair in Physical Therapy. Her left arm was observed hanging off the side of the wheelchair, with minimal movement noted. Her right hand and arm were observed to have good movement that included thumb to finger movement and a moderately firm handshake. When asked about the incident with the coffee at Facility 1, she stated she was handed the cup of coffee and took it. "Then I don't know what happened, it (coffee) just spilled in my lap and I screamed." She stated the burn to her thighs still hurts and "is what causes me pain." "I really don't remember exactly what happened... but the other day I was holding a cup of jello in my right hand and it just spilled in my lap." During an interview with Resident 1 and her family member, on 4/4/12, at 4:25 PM, she stated she had surgery for [REDACTED]. "They zipped up the wound with all the burn removed." The record for Resident 1's stay at SNF 2 was reviewed on 4/5/12. She was admitted on [DATE] with [DIAGNOSES REDACTED]. The "History and Physical", dated 2/9/12, included an additional [DIAGNOSES REDACTED]. On 3/2/12, the resident was sent to Hospital A for evaluation of her burns, which were described as partial thickness burns. The Hospital A "Physician Documentation" form, dated 3/2/12, indicated the resident was sent for an "evaluation of thermal burns to bilateral inner thighs after spilling hot coffee onto her lap." The skin was examined with notation of "burns to bilateral anterior thighs, second to third degree...left leg appears deeper, full thickness...refer pt to Burn center for evaluation for possible grafting." The wound log (SNF 2) for Resident 1, was reviewed on 4/5/12. The measurements of her burns indicated the left inner thigh burn measured 4 X 9.5 cm on 2/29/12 and 3.5 X 21.5 cm on 3/6/12. The right inner thigh burn measured 3 X 5.5 cm on 2/29/12 and 2 X 5 cm on 3/6/12. The records for Resident 1, from Hospital B, were reviewed on 4/19/12. The "Notes Report" form, dated 3/13/12, indicated the resident "sustained a scald burn from hot coffee to bilateral thigh on 2/6/12, which had been treated by her PMD (private medical doctor) with silvadene (an ointment used to treat burns)...for about five weeks..." "Bilateral groin left worse than right, full thickness, with thin layer of yellow eschar to left." "Plan to take patient to OR (operating room) for burn excision (to cut out) and primary closure left groin....less than 1% TBSA (total body surface area) scald burn full thickness to left groin." The "Notes Report", dated 3/20/12, indicated SNF 2 "had been treating this burn for over a month..." "The burn on her inner thigh was in a drip pattern going down her inner thigh in a strip type...was amenable to excision and primary closure." The "Notes Report", dated 4/5/12, indicated the resident went to the Operating Room on 3/20/12 for a burn excision and primary closure of the left groin burns less than 1 % of total body surface. Resident 1 had follow up visits at Hospital B on 3/23/12 and 4/5/12.