Every finding on record at Shasta Healthcare

Based on observation, interview, and policy review, the facility failed to ensure food safety and sanitation guidelines were followed when:There was an undated gallon of milk in the refrigerator that was partially used, undated bags of bread in the dry goods storage area, an undated box of individual jelly packets in the dry goods storage area.There was a box of potatoes stored on the floor of the dry goods storage area, and a box of paper dining napkins stored on the floor of an outdoor storage area.There was brown crusty debris on baking pans, and the red and green cutting boards had cuts in the surfaces.The ice machine had a pale brown substance in the internal ice chute (where the ice comes down from the storage bin).These failures had the potential to cause foodborne illnesses for all residents of the facility who ate food prepared by the kitchen and used ice.Findings:During a tour of the kitchen on 4/21/26 at 9:58 am, the Dietary Aid (DA) confirmed there was a gallon of milk in the refrigerator which was not dated upon opening and that it should have been dated.During a tour of the kitchen on 4/21/26 at 10:07 am the Certified Dietary Manager (CDM) confirmed:There was an undated bag of bread in the dry goods storage area, and an undated box of individual jelly packets in the dry goods storage area, and they should have been dated.There was a box of potatoes stored on the floor of the dry goods storage area, and a box of paper dining napkins stored on the floor of an outdoor storage area, and they should not have been stored on the floor.There was brown crusty debris on baking pans, and the red and green cutting boards had cuts in the surfaces, and that the pans should not have crusty brown debris on them and the cutting boards should not have cuts in the surfaces.During a concurrent observation, interview, and record review on 4/24/26 at 10:08 am, the Maintenance Director (Maint) confirmed there was a pale brown substance observed on a clean white paper towel used to wipe the inside of the ice machine's ice chute. Maint confirmed that the inside of the ice storage bin was not clean. Maint indicated that he had just started the job and did not know how to clean the ice machine, and review of the facility's records titled, Preventative Maintenance Log Quarterly Ice Machine Service indicated that the ice machine had last been cleaned on 11/21/25, and that the previous cleanings were done on 8/23/25, 5/22/25, and 2/20/25.A review of the USDA Food Code 2022, section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) .Ready-to-eat, time/temperature control for safety food .shall be clearly marked to indicate the date. (D) (3) Marking the date or day the original container is opened in a food establishment.A review of the USDA Food Code 2022, section 3-305.11 Food Storage. (A) .Food shall be protected from contamination by storing the food: (1) In a clean, dry location, (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.A review of the USDA Food Code 2022, section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.A review of the USDA Food Code 2022, section 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-Contact Surfaces shall be: smooth.A review of the USDA Food Code 2022, section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) .single-service and single-use articles shall be stored: (3) At least 15 cm (6 inches) above the floor.A review of a facility policy titled, Kitchen Sanitation reviewed 1/16/26 indicated, The facility is committed to maintaining a clean, sanitary, and safe kitchen environment in compliance with all applicable federal, state, and local regulations, including California Department of Public Health (CDPH) guidelines and Title 22 requirements. Proper sanitation practices are essential to prevent foodborne illness and ensure the health and safety of residents, staff, and visitors. And 8. Cleaning Schedules A written cleaning schedule must be maintained, specifying: Daily, weekly, and monthly tasks, responsible staff, verification/sign-off logs. Supervisors must monitor compliance and document completion.Review of a facility policy titled, Food Receiving and Storage dated 11/1/22 indicated food in dry storage areas are kept at least 6 inches off the floor.

Based on observation, interview, and record review, the facility failed to ensure the most recent recertification survey (an evaluation of the facility to ensure they are compliant with federal regulations, and clinical quality) was available to the residents of the facility.This failure resulted in a violation of resident rights. Findings:During a confidential interview of facility Resident Council (a group of residents who regularly meet to advocate for their right) on 4/23/26 at 10:01 am, the attendees of the meeting indicated that they did not know where in the facility to find the results of surveys conducted at the facility.During a concurrent observation and interview on 4/23/26 at 10:37 am the Director of Nursing (DON) confirmed that the survey results binder was in the foyer (an entrance hall or entryway that acts as a transitional space between the outdoors and the main areas of a building, in which there is an outdoor entrance, followed by a room, and then another set of doors leading into the main area of the building) where any resident who could not open the interior doors to the foyer would be unable to access the survey results stored in an unlabeled binder on a shelf in the foyer without asking for help.

Based on observations, interviews, and record reviews, the facility did not ensure one out of 12 sampled residents (Resident 46) was able to safely self-administer medication when Resident 46's Albuterol inhaler (a fast-acting medication that opened the airways in the lungs and made breathing easier) was stored at the bedside and available for use. This had the potential for overdosing or incorrect usage which could lead to a decline in health status. Findings: A review of the facility's policy and procedure (P&P) titled, Medication, Storage at Bedside, dated 1/16/26, indicated, that medications could only be kept at a resident's bedside if there was a Physician's order and the Interdisciplinary Team (IDT, a group of medical professionals who met to discuss residents' care) had evaluated and approved the safety of self-administration A review of Resident 46's admission Record, dated 4/14/26, indicated admission to the facility on 4/14/26 with the diagnoses of atrial fibrillation (top part of the heart shakes instead of beating effectively causing an irregular heartbeat) and hypertension (high blood pressure). During a concurrent observation, interview, and record review, on 4/23/26 at 9:09 am, located in Resident 46's room, with Licensed Nurse (LN) A, an Albuterol inhaler was observed on the bedside table. LN A confirmed the observation and reviewed Resident 46's Physician's order dated 4/16/26. LN A confirmed, the Physician's order indicated that Resident 46 could keep the Albuterol inhaler at the bedside. During an interview on 4/23/26 at 11:59 am, Director of Nursing confirmed, there was no IDT note present in Resident 46's electronic medical record indicating that the IDT had assessed or approved Resident 46's ability to safely self-administer the Albuterol inhaler.

Based on interview, record review and policy review, the facility failed to ensure that one of twelve residents sampled (Resident 8) right to have an Interdisciplinary Team Meeting (IDT meeting, a meeting where the Interdisciplinary Team, a group of facility managers, discuss the care and services that the facility provides to their residents) with all the team members present to ensure decisions made regarding Resident 8 was in their best interest.This failure had the potential to result in decisions being made about Resident 8's health care that were not in their best interest.Refer to F841Findings:Review of a facility policy titled Consent: Residents Unable to Provide Informed Consent and Without a Health Care Decision-Maker- CA reviewed 1/16/26 indicated, It is the policy of this facility that an Interdisciplinary Team can make treatment decisions for residents when a physician determines that resident is unable to provide informed consent for a proposed treatment intervention because they cannot articulate a decision or cannot understand the risks or benefits of a proposed intervention and where the resident had no health care decision-maker to consent to the proposed intervention. And 2. Interdisciplinary team: A team comprised of at least the following individuals.Attending Physician.Review of Resident 8's admission Record, dated 9/29/25, indicated that they were admitted to the facility on [DATE] with diagnoses which included mild cognitive impairment (impairment involving noticeable memory or thinking problems including poor judgment).Review of Resident 8's quarterly Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) BIMS (Brief Interview for Mental Status-a cognitive assessment tool used to screen for memory, orientation, and judgement status ability) dated 2/19/26, completed by the Social Services Director (SSD) indicated that Resident 8 had a score of 6 out of 15 indicating poor decision-making ability.Review of Resident 8's health record titled Special Instructions, undated, indicated, Resident does not have capacity to make decisions; Surrogate (a substitute who acts on another person's behalf) decision-maker is the MD (Medical Director).During an interview on 4/23/26 at 4:42 pm the facility Medical Director (MD) indicated that she was not required to be at the IDT meetings and that the Director of Nursing (DON) gathers information at the IDT meetings and they review it later.During an interview on 4/24/26 at 8:15 am with the DON and the facility Administrator (Admin), the DON indicated that there had been no IDT meetings to make decisions for Resident 8 but rather that the MD had been making decisions for Resident 8.

Based on observation, interview, and record review, the facility failed to ensure two out of twelve sampled residents (Resident 6 and Resident 25) received the necessary services to maintain good personal grooming and hygiene when:1. Resident 6 did not receive a shower for twelve days.2. Resident 25 had a dark unknown substance crusted under their fingernails.These failures resulted in frustration and discomfort for Resident 6 and placed Resident 25 at risk for negative health outcomes related to poor hand hygiene.Findings: 1.Review of a facility policy titled ADLs (Activities of Daily Living e.g., feeding, bathing, dressing), Services to carry out reviewed 2/1/26 indicated, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities.2. Residents who are unable to carry out activities of daily living will receive necessary services to maintain.Personal hygiene. Review of Resident 6's admission record indicated admission to the facility on 2/25/26 with diagnoses which included rhabdomyolysis (a condition in which muscles breakdown and could cause organ damage, pain, or weakness) and generalized muscle weakness. Review of Resident 6's Minimum Data Set (MDS is a resident assessment tool) Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 3/2/26 and completed by the Social Services Director (SSD) indicated a score of 15 out of 15 which indicated good decision-making ability. During an interview on 4/21/26 at 11:20 am, Resident 6 indicated that they had not received a shower from 4/3/26 until 4/15/26. Resident 6 indicated that she usually got showers on Tuesdays and Fridays. Resident 6 indicated that not receiving a regular shower made her frustrated and uncomfortable. During a review of Resident 6's record titled MDS 3.0 Section GG – Functional Abilities (how much help a resident needs to do different ADL tasks) dated 3/3/26 and completed by the MDS nurse indicated that Resident 6 needed partial assistance from staff for bathing. During a concurrent interview and record review on 4/22/26 at 3:33 pm, with the Director of Staff Development (DSD), of a facility record titled Shower Schedule no date, the DSD confirmed that Resident 6 was scheduled to receive showers on Tuesdays and Fridays. DSD confirmed that Resident 6's record titled Shower Tracking Calendar for the month of April 2026, showed that Resident 6 did not receive the showers that she should have received on Tuesday 4/7/26 and Friday 4/10/26. 2. The facility policy titled Nail Care; Routine Procedure, dated 1/16/2026, indicated It is the policy of this facility to promote cleanliness, safety, and neat appearance. The facility policy titled Hand Hygiene dated 1/16/2026 indicated This facility considers hand hygiene the primary means to prevent the spread of infections. Residents. will be encouraged to practice hand hygiene. Resident 25 was admitted on [DATE] with diagnoses that included dementia, Parkinsonism (movement problems,) cognitive communication deficit (difficulty speaking) and need for assistance with personal care. The record for Resident 25 was reviewed. Their most recent Quarterly Minimum Data Set (MDS - a resident assessment tool,) dated 1/29/26, indicated Resident 25 was dependent upon staff for toileting hygiene, bathing, and personal hygiene. During an observation on 4/21/26 at 10:30 am, Resident 25's fingernails had a dark dry substance caked under their fingernails on both hands. The nails on both hands appeared to be dirty and untrimmed. During a concurrent observation and interview, on 4/22/26 at 10:25 am, Licensed Nurse (LN) D was asked about Resident 25's fingernails. LN D confirmed that the resident's nails were dirty and needed to be trimmed. LN D confirmed that Resident 25 was dependent upon staff for nail care and hand hygiene. LN D indicated that, for dependent residents, nail care was carried out as needed or twice weekly at the time a resident showers. LN D reviewed the shower schedule and confirmed that Resident 25 had received a shower earlier in the day and was not able to find documentation [NAME] indicated that nail care was offered. LN D confirmed that this placed Resident 25 at increased risk for infections or to spread germs to others.

Based on interview and record review, the facility failed to ensure that two of two Certified Nurse Aid (CNA) staff currently providing resident care received a performance evaluation annually. This resulted in the facility failing to asses staff's knowledge and skills to ensure staff had adequate skills and knowledge to provide quality care to all residents. During a concurrent interview and record review, on 4/24/26 at 9:00 am, with the Director of Nursing (DON) and the Director of Staff Development (DSD), both confirmed that a process to ensure all CNAs received annual evaluations had not been implemented by the facility. DSD indicated she was aware that staff performance evaluations had not been carried out annually, but was unclear how long this had been an ongoing problem. DSD confirmed that the annual evaluations were necessary to identify areas where training was needed. Both DON and DSD confirmed that these evaluations had not yet been initiated for CNA's B and C. During an interview and concurrent record review, on 4/24/26 at 11:00 am, CNA B and CNA C's employee files were reviewed with DSD and Licensed Nurse Consultant (LNCon) both confirmed the following; The employee file for CNA B was reviewed. The employee file indicated CNA B was hired 6/27/11. DSD confirmed that the most recent annual evaluation for CNA B was dated 7/2/2014 (11 years past due).The employee file for CNA C was reviewed. The employee filed indicated CNA C was hired 11/28/22. DSD confirmed that the most recent annual evaluation for CNA C was dated 8/29/24.

Based on observations, interviews, and record reviews, the facility failed to ensure their medication error rate was less than 5 percent (5%), when the Medication Administration Pass Observation reflected three medication errors out of 25 opportunities resulting in a medication error rate of 12 percent (12%) as evidenced by: Resident 8 was not provided with a Physician ordered medication,2a. Resident 46 was not provided with a Physician ordered medication; and2b. Resident 46 was administered a higher dose of a medication than what the Physician ordered. This had the potential for residents to not attain or maintain their highest practicable level of physical, mental, functional and psycho-social well-being and have adverse medication outcomes.Findings: 1. A review of the facility's policy and procedure titled, Medication Administration, dated 1/16/26, indicated, medication would be administered as prescribed by the Physician. A review of Resident 8's admission Record, dated 9/29/25, indicated, admission to the facility on 9/29/25 with the diagnosis of bipolar disorder (a mental health condition that included extreme and intense mood swings). A review of Resident 8's Physician's order, dated 1/31/26, indicated that the physician prescribed Depakote (an anticonvulsant medication that was being used to treat bipolar disorder) 125 milligrams (a unit of measure) to be taken by mouth once a day. During a concurrent observation and interview on 4/23/26 at 8:39 am, Licensed Nurse (LN) A was observed preparing Resident 8's morning medications and did not administer the Depakote. LN A indicated Resident 8 was out of Depakote and it was on order with the pharmacy. 2a. A review of Resident 46's admission Record, dated 4/14/26, indicated admission to the facility on 4/14/26 with the diagnoses of atrial fibrillation (top part of the heart shakes instead of beating effectively causing an irregular heartbeat) and hypertension (a high blood pressure). A review of Resident 46's Medication Administration Record (MAR), dated 4/23/26, indicated that on 4/17/26, the Physician ordered two Lidocaine patches 4 percent (%) (pain relief patch applied to the skin) to be applied to painful areas once a day. During a concurrent observation and interview on 4/23/26 at 9:09 am, LN A was observed preparing Resident 46's morning medication and did not provide the Lidocaine patches. LN A confirmed that the facility was out of Resident 46's Lidocaine patches and stated, I'll have to call the pharmacy to get them. 2b. A review of Resident 46's MAR, dated 4/23/26, indicated that the Physician prescribed Fluticasone nasal spray (liquid allergy medication administered in the nose) 50 micrograms per each spray. The directions indicated one spray in each nostril, once a day. During a concurrent observation and interview on 4/23/26 at 9:09 am, LN A handed Resident 46 the Fluticasone without providing any verbal instructions. Resident 46 administered two sprays to the left nostril and three sprays to the right nostril. LN A confirmed the observation and indicated the Physician's order indicated one spray per nostril. During an interview on 4/23/26 at 11:59 am, the Director of Nursing (DON) was asked who was responsible to ensure that residents did not run out of medication. DON stated, all nurses are responsible to ensure meds do not run out but, ultimately I am responsible.

Based on observations, interviews, and record reviews, the facility did not ensure that medications stored in one of two medication carts contained labels for use that matched the Physician's orders for Resident 8. This failure had the potential to cause a medication error or for medication to run out early. Findings: A review of the facility's policy and procedure (P&P) titled, Labeling and Storage of Drugs, dated 1/16/26, indicated, medication labels would include specific directions for use. The P&P indicated, when the medication label was incorrect, the medication would be returned to the pharmacy, or the Licensed Nurse (LN) would flag the medication label indicating there was a change in the directions for use. A review of Resident 8's admission Record, dated 9/29/25, indicated, admission to the facility on 9/29/25 with the diagnoses of mild cognitive impairment (a decline in memory or thinking that was not related to normal aging) and breakdown of internal fixation device (hardware such as metal plates, rods, or screws) of right humerus (upper arm bone). During a concurrent observation, interview, and record review, on 4/23/26 at 8:39 am, LN A was observed preparing Resident 8's morning medication. The label on the medication blister pack (a card that contained individually wrapped medication) indicated Celebrex (a medication used to treat pain) 100 milligrams (mg, unit of measure), take one capsule by mouth, daily (every 24-hours), as needed. LN A reviewed the Physician's orders and confirmed there were two separate Physician's orders for Celebrex. LN A confirmed one Physician's order indicated Celebrex 100 mg would be administered once every morning (scheduled) and the other Physician's order indicated Celebrex would be administered once every 24 hours as needed for pain. LN A confirmed there was no blister pack located in the medication cart for the Celebrex that was ordered to be given daily and indicated that LN A had always utilized the blister pack that was labeled for PRN (as needed) use. During an interview on 4/23/26 at 11:59 am, the Director of Nursing (DON) was asked how the facility ensured the blister pack medication label matched the Physician's order. DON stated, ideally we get a new label.

Based on interview, record review, and policy review, the facility did not ensure that the Medical Director (MD) effectively implemented resident care policies for one of two sampled residents (Resident 8) when:1. The facility failed to obtain a resident representative (RP, medical decision maker) who was unaffiliated with the facility (a person who is not connected to the business) for Resident 8.2. The MD acted as Resident 8's RP.This had the potential to result in decisions that were in the interest of the facility rather than the interest of Resident 8.Findings:Review of a facility policy titled, Consent: Residents Unable to Provide Informed Consent and Without a Health Care Decision-Maker - CA, reviewed 1/16/2026, indicated that the facility was responsible to assist residents in obtaining an RP if they were no longer able to make their own decisions, or had no family who could fill that role.Review of a facility policy titled Compliance Manual undated, indicated Personnel and employees.should not place themselves in a position where their actions, or the activities or interests of others with whom they or a member of their family may have a financial, business, professional, family, or social relationship.Examples of conflicts of interest include.A direct or indirect interest in any transaction which might in any way affect a person's objectivity, independent judgment, or conduct in carrying out his or her job responsibilities.Review of a facility document titled, Medical Director Attestation of Compliance with Health and Safety Code dated October 17, 2025 As medical director I declare and attest to awareness of, and responsibility for ensuring profession and facility compliance with all applicable.governing state and federal laws.Review of Resident 8's admission Record dated 9/29/25, indicated admission to the facility on 9/29/25 with the diagnosis of included mild cognitive impairment (impairment involving noticeable memory or thinking problems including poor judgment).Review of Resident 8's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 2/19/26, completed by the Social Services Director (SSD) indicated that Resident 8 had a score of 6 out of 15 indicating poor decision-making ability.Review of Resident 8's health record titled Special Instructions, undated, indicated Resident does not have capacity to make decisions; Surrogate (a substitute who acts on another person's behalf) decision-maker is the MD.Review of Resident 8's medical record titled, Encounter - Nursing Home Visit Date of service: 01/05/26 written by MD indicated SSD informed me that patient refused to have sister as decision maker.I went in with patient with SSD and reminded him I had been his doctor for 15 years - since 2011. He states he remembered and when I asked him if I could be his decision maker if he is not able, he clearly and happily agreed. Asked him a second time and received the same answer.During an interview on 4/21/26 at 3:48 pm the DON indicated that Resident 8 did not want his sister to be the RP and Resident 8 did not currently have an RP. The DON indicated that the MD was acting as an intermediary between Resident 8 and his sister. The DON indicated that by the time Resident 8 arrived at the facility his condition was such that he was unable to make his own decisions, but that the MD knew Resident 8 and his sister before Resident 8's condition deteriorated and that the MD called Resident 8's sister when there were decisions to be made about Resident 8's care.During a phone interview on 4/23/26 at 4:42 pm the MD indicated that Resident 8's sister refused to be his decision maker. When asked if the MD knew the facility's policy on responsible parties, the MD stated Nope. and indicated that she did not feel like it was her responsibility to know non-medical policy. When asked how the IDT was involved in Resident 8's decision making, the MD indicated that the IDT meetings happen on Mondays and that she was not required to be at them, that the DON gathers the information from the meetings and reviews the information with her. When asked if the facility had reached out to the Department of Aging to obtain a patient representative for Resident 8, the MD stated No, because Resident 8 would not be able to express what he wants to someone he doesn't know, and I've known him forever and know what he wants.During a concurrent interview and record review, on 4/23/26 at 4:59 pm, the SSD stated that Resident 8's sister, would gladly be his RP, but he says no. When asked if the facility contacted the Department of Aging (and agency assists in signing consent forms for people who have no RP), the SSD indicated that she believed that the DON did.During an interview on 4/23/26 at 5:10 pm, the DON indicated that she believed that she had contacted the Department of Aging related to Resident 8 and obtaining a patient representative for him, but that she was not sure if she could access the email. No further documentation was produced related to obtaining a patient representative via the Department of Aging for Resident 8.

Based on interview and record review, the facility failed to develop, implement, and maintain an in-service training program for two of two Certified Nursing Assistants (CNAs) to ensure areas of deficiencies in job performance that were identified during annual performance reviews were addressed and ensure that the facility provided 12 hours of continuing education for CNAs. This had the potential to negatively impact the quality of care to residents, particularly those with specialized care needs such as those with dementia or other cognitive impairments.Findings:During a concurrent interview and record review on 4/24/26 at 9:00 am, with the Director of Nursing (DON) and the Director of Staff Development (DSD,) both were asked to described the facility's current training program for Certified Nurse Assistant (CNA) staff. DSD stated she did not have documentation of in-service trainings to meet the annual requirement of 12 hours of training that included dementia management, abuse training, and training to address any areas of weakness identified during annual evaluations. DON and DSD confirmed that a process to ensure that all CNAs received annual evaluations had not been implemented by the facility. During a concurrent interview and record review on 4/24/26 at 11:00 am, employee files were reviewed with DSD and Licensed Nurse Consultant (LN Con.) Both confirmed the following: The employee file for CNA B was reviewed. The employee file indicated CNA B was hired 6/27/11. DSD confirmed that the most recent annual evaluation for CNA B was dated 7/2/14. DSD confirmed the most recent training was for hand washing and the use of personal protective equipment (gloves, gowns, mask), dated 4/16/25. DSD confirmed CNA B's employee file did not contain documentation that CNA B had received the 12 hours of required training.The employee file for CNA C was reviewed. The employee filed indicated CNA C was hired 11/28/22. DSD confirmed that the most recent annual evaluation for CNA C was dated 8/29/24. DSD confirmed that CNA C's employee file did not contain documentation that CNA C had received the 12 hours of required training.

Based on interviews and record reviews, the facility did not ensure there was ongoing communication regarding resident rights during group activities. This had the potential for residents not to know how to effectively exercise their rights.Findings: A review of the Resident [NAME] of Rights, dated 8/1/25, indicated that residents had the right to be fully informed of their rights at the time of admission and during their stay in the facility. A review of the Resident Council Minutes, dated 10/23/25 through 4/16/26, did not include any information about resident rights being discussed. During an interview on 4/23/26 at 10:01 am, five out five confidentially interviewed residents were asked if the facility talked about or reviewed resident rights with them. Five out of five confidential residents indicated resident rights were not discussed during Resident Council meetings (a group of residents that meet monthly to discuss care concerns and their rights). Activities Director (AD) was present during the Resident Council at the request of the residents and confirmed, resident rights had not previously been discussed. AD stated, I haven't ever done that.

Based on interview, record review, and policy review, the facility failed to ensure that a resident who entered the facility without a pressure injury (PI, a bedsore) did not develop a PI, for one of two residents sampled for PI (Resident 1). Resident 1 developed a PI to her sacrum (bottom of the spine), which progressively worsened and the facility failed to follow their policies regarding wound care and changes of condition and inform Resident 1's physician when her PI changed and worsened.This delayed treatment for Resident 1's PI by six days, and resulted in a worsened and infected PI. Within two days of Resident 1 discharging from the facility, she was admitted to the acute care hospital for an infected PI and sepsis (an infection in the bloodstream) and osteomyelitis of the sacrum (an infection in the bone). This failure had the potential to delay wound healing for any resident who had wounds and/or PI's and subject them to substandard quality of care.Refer to F726 Findings:Review of the National Pressure Injury Advisory Panel's (a nationally recognized resource for professionals), website document titled, NPIAP Pressure Injury and Stages, at https://npiap.com, dated September 2016 indicated;Stage 1 pressure injury: non-blanchable (skin redness or discoloration that does not fade or turn white when pressure is applied) erythema (reddening of the skin), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes.Stage 2 pressure injury: partial-thickness skin loss with exposed dermis (the middle layer of the skin). The wound bed is visible, pink, or red, moist and may also present as an intact or ruptured serum-filled blister (a raised pocket of skin filled with fluid, caused by skin injury from friction (rubbing), heat, or certain diseases). Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue may be visible (a type of new, temporary tissue that forms during the wound healing process). These injuries commonly result from adverse microclimate (temperature and moisture on the skin), and shear in the skin (injury that occurs when skin layers are pulled in opposite directions, damaging tissues, and blood vessels beneath the skin).Unstageable Pressure Injury: Obscured (hidden or difficult to see) full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thick stringy yellow or gray dead tissue or eschar (black, brown or tan scab-like dead tissue attached firmly to the wound). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stage 3 pressure injury: full-thickness loss of skin, in which adipose is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Undermining (the destruction of tissue or injury extending under the skin edges so that the pressure injury is larger at its base than at the skin surface), and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) may occur. Fascia (a thin fibrous connective tissue that surrounds and supports all muscles, organs, and other structures in the body), muscle, tendon (a tough, fibrous cord-like tissue that connects muscles to bone), ligament (a tough, fibrous band of connective tissue that connects two bones together, providing stability and support to joints), cartilage (a smooth, elastic connective tissue that provides support and protection to joints, bones, and other tissues in the body), are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.Stage 4 pressure injury: full-thickness loss of skin and tissue with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough or eschar may be visible. Epibole, undermining (tissue separation that creates a pocket of dead space), and/or tunneling often occur.According to the NIH National Library of Medicine (a nationally recognized professional resource for healthcare providers), website at www.ncbi.nlm.nih.gov, dated 1/3/2024, the most common problem with Stage 3 and Stage 4 pressure injuries is infection. Bacteria in the pressure ulcer wound spreads to deeper tissues and bone causing sepsis (infection in the bloodstream) and osteomyelitis (infection in the bone). Older patients with pressure injuries have a 3.6-fold increased mortality (death) rate. Managing pressure injuries should always be done with an interprofessional approach such as consulting with a general surgeon, a wound care physician (a physician who specializes in wound care), or a dermatologist (a physician who is an expert on skin care).Review of a facility policy titled, Change in a Resident's Condition or Status revised February 2021, indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a: d. significant change in the resident's physical/emotional/mental condition.Review of the admission record for Resident 1, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included a fractured (broken) sacrum bone (the large triangular bone at the base of the spine). Resident 1 discharged from the facility, on 8/11/25. Review of Resident 1's admission Minimum Data Set (MDS, a federally mandated assessment that measures the health status in nursing home residents), dated 7/11/25, and completed by MDS/Registered Nurse (MDS/RN), indicated under Section C Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment of a resident's memory and decision-making skills and uses a scoring system of 0-very impaired to 15-no impairment). Resident 1 scored 12 of 15, which indicated Resident 1 had no memory or decision-making problems. Section M indicated Resident 1 was admitted without a PI.Review of Resident 1's progress note, dated 7/24/25, written by Wound Care Nurse/Registered Nurse (WCN/RN) indicated, Wound Rounds for week of 7/20/25 - 7/24/25: Late last week noted skin discoloration over sacrum that resembled wounding under wrinkled skin. This week, however, noted discolored areas beginning to break down. Upon closer inspection, characteristics of breakdown resembles stage 1 pressure injury. Exposed tissue coated with yellow fibrotic residue. There was no documentation that the WCN/RN notified Resident 1's Attending Physician (AP) of this change in the condition of Resident 1's PI.A review of Resident 1's progress note, dated 7/25/25, written by Registered Nurse (RN) A indicated, Wound rounds:.Wound looks worse than 3 days ago. There was no documentation that RN A had notified Resident 1's AP, that Resident 1's PI had worsened.A review of Resident 1's progress note, dated 7/28/25, written by RN A indicated, Wound is getting worse. There was no documentation that RN A had notified Resident 1's AP that the PI had worsened.During a phone interview on 9/9/25 at 2:07 p.m., RN A confirmed that she had not notified Resident 1's AP when there was a change of condition and Resident 1's PI began to worsen. RN A stated that she notified the WCN/RN, instead of Resident 1's AP, because the WCN/RN would decide what changes needed to be reported to the AP. A review of Resident 1's record titled, Wound Management Detail Report dated 7/24/25 to 8/11/25, documented by the WCN/RN indicated the following; On 7/24/25, Resident 1 had a PI on her sacrum that measured (length by width), 6.5 centimeters (cm, 2.5 cm equal approximately 1 inch) by 4 cm and was a Stage 2 with no tract/tunneling present, and a light amount of seropurulent exudate (watery pus that is cloudy, yellow or tan and is a sign of infection), that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified.On 7/30/25, Resident 1's sacrum PI worsened to 7 cm by 3.5 cm, and was Unstageable with slough and eschar, no tract/tunneling present and a light amount of seropurulent exudate that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified of this change from a Stage 2 PI to an Unstageable PI.On 8/3/25, Resident 1's sacrum PI continued to worsen and measured of 7.3 cm by 3.5 cm, and was Unstageable with slough and eschar, no tract/tunneling or undermining present, and a moderate amount of seropurulent exudate (increased seropurulent drainage-a sign that the wound was becoming infected), that was yellow, or tan, cloudy and thick. The report had not indicated that Resident 1's AP was notified.On 8/11/25, the WCN/RN documented that she performed Conservative Sharp Wound Debridement (CSWD, a procedure where dead tissue is removed from a PI by using sharp instruments such as a scalpel, scissors and forceps), on Resident 1's sacrum PI. WCN/RN documented, CSWD completed.with scissors/forceps, then using forceps with #15 [number 15, the size of a scalpel blade], scalpel blade, sm-mod [small to moderate], amount slough removed. Documentation reflected that Resident 1's PI then measured, 6 cm by 2.5 cm, and was a Stage 4 with undermining that measured 2.6 cm and a heavy amount of seropurulent exudate (increased sign of infection), that was yellow, or tan, cloudy and thick. There was no documented evidence that Resident 1's AP was notified of the change in the condition of Resident 1's PI, or that CSWD procedure had been done.During a review of Resident 1's record titled, Physician Order Report: 7/2/25 - 8/20/25, the record indicated that there were no orders for the WCN/RN to perform a CSWD on Resident 1's PI.A review of a facility document titled, Physician Notification & Orders dated 7/30/25, indicated that six days after Resident 1's PI was determined to be a Stage 2 (identified on 7/24/25), AP was notified but at that point, on 7/30/25, Resident 1's PI had already worsened to an Unstageable PI. There were no other Physician Notification & Orders notification documents for Resident 1.During a concurrent interview and record review of Resident 1's record titled, Physician Order Report: 7/2/25 -8/20/25 on 8/20/25 at 2:38 p.m., with the Director of Nursing (DON), the DON confirmed that there was a six-day delay, from 7/24 to 7/30/25, in notifying Resident 1's AP and getting orders for treatment and during that time, Resident 1's PI had worsened from a Stage 2 to an Unstageable PI. DON confirmed that RN A should have notified Resident 1's AP on 7/24/25, when she identified that Resident 1's PI was worsening. DON confirmed the WCN/RN had not notified Resident 1's AP when she identified that Resident 1's PI had progressed from a Stage 2 to an Unstageable PI and finally to a Stage 4. DON confirmed that WCN/RN had not obtained a physician's order prior to performing the CSWD on Resident 1's PI.During an interview on 8/22/25 at 10:33 a.m., with WCN/RN, the WCN/RN confirmed that Resident 1 was admitted without a PI. WCN/RN confirmed that Resident 1 acquired a Stage 2 PI while in the facility on 7/24/25, and the PI was not healing and worsened to a Stage 4 within 18 days. WCN/RN confirmed that she had not reached out to Resident 1's AP at any time during the deterioration of Resident 1's PI, to consider referring Resident 1 to their wound care physician for an evaluation and stated she did not think it was necessary. WCN/RN confirmed that RN A should have notified Resident 1's AP when she determined that Resident 1's PI was worsening on 7/24/25, instead of waiting for WCN/RN to make her weekly visit, because this delayed treatment. WCN/RN confirmed Resident 1's PI had already deteriorated from a Stage 2 to an Unstageable PI by the time her AP was notified and orders were obtained for treatment. During a second interview on 9/9/25 at 9:42 a.m., with WCN/RN, the WCN/RN confirmed that she had not obtained a physician's order to perform the CWSD on Resident 1's PI on 8/11/25. WCN/RN stated she did not need a physician's order to perform CSWD. The WCN/RN stated she could not recall whether or not she had notified Resident 1's AP each time Resident 1's PI worsened and was not showing signs of healing or that the PI was possibly infected. WCN/RN stated that she did not have direct communication with Resident 1's AP. During a phone interview on 8/22/25 at 10:47 a.m., with Resident 1's AP, AP confirmed the facility had a wound care physician available that they could consult with. AP stated, I believed that [Resident 1's] wound care was very routine and she did not need the to see wound care physician. The AP indicated she thought Resident 1 still had only a Stage 2 PI.During a second phone interview on 9/9/25 at 1:01 p.m., with AP, she indicated that she did not know about the progressive worsening and lack of healing to Resident 1's PI. AP stated that the WCN/RN and DON do not usually notify her unless they need her to do something. AP confirmed she had not given specific orders to WCN/RN to perform a CSWD procedure. AP stated she, had no clue that nursing staff had identified Resident 1's PI was worsening and not healing. AP stated if she had known there were problems with worsening or lack of healing to Resident 1's sacrum PI, she would have referred her to their wound care physician for an evaluation.A review of Resident 1's acute care hospital records, dated 8/13/25, indicated that Resident 1's family had taken her to a local hospital on 8/13/25, two days after Resident 1 had left the facility, because Resident 1's PI was not healing and had a bad smell. The hospital's admission Note, dated 8/13/25, reflected that Resident 1 had sepsis and osteomyelitis of the sacrum, from her PI being infected. Resident 1 passed away at that hospital 10 days later.

Based on interview, record review, and policy review, the facility failed to ensure the care plan (a document that outlines a patient's health care needs and the actions and interventions required to address them), was revised and updated when one of two sampled residents (Resident 1), had a pressure injury (PI, a bedsore) that worsened and the care plan had not reflected this.This failure resulted in no identified problem, goals or interventions to promote the healing of Resident 1's PI to her sacrum (the large triangular bone at the base of the spine), and inconsistencies and delayed treatments of Resident 1's PI, which had a negative impact on her clinical status.Findings:Review of a facility policy titled, Goals and Objectives, Care Plans revised April 2009, indicated, 5. Goals and objectives are reviewed and/or revised: a. when there has been a significant change in the resident's condition.Review of the National Pressure Injury Advisory Panel's (a nationally recognized professional resource for the staging and treatment of pressure injuries a global driver of quality improvement and patient safety in healthcare) website document titled, NPIAP Pressure Injury and Stages, at https://npiap.com, dated September 2016 indicated;-Stage 1 pressure injury: non-blanchable (skin redness or discoloration that does not fade or turn white when pressure is applied) erythema (reddening of the skin), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes.-Stage 2 pressure injury: partial-thickness skin loss with exposed dermis (the middle, living layer of the skin, located between the outermost epidermis and the innermost hypodermis).Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thick stringy yellow infected tissue or eschar (black dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. -Stage 3 pressure injury: full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough (dead tissue, usually moist and stringy) and/or eschar (dead tissue that is hard or soft) may be visible. If slough or eschar obscures the extent of tissue loss this is and Unstageable Pressure Injury.-Stage 4 pressure injury: full-thickness loss of skin and tissue with exposed Fascia (a thin fibrous connective tissue that surrounds and supports all muscles, organs, and other structures in the body), muscle, tendon (a tough, fibrous cord-like tissue that connects muscles to bone) ligament (a tough, fibrous band of connective tissue that connects two bones together, providing stability and support to joints), cartilage (a smooth, elastic connective tissue that provides support and protection to joints, bones, and other tissues in the body) in the injury. Slough or eschar may be visible. Epibole, undermining (the destruction of tissue or injury extending under the skin edges so that the pressure injury is larger at its base than at the skin surface) and/or tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) often occur.Review of the admission record for Resident 1 indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including sacrum fracture (a break in the large triangular bone at the base of the spine), and was not admitted with any PIs.Review of Resident 1's admission MDS (Minimum Data Set- a federally mandated assessment tool that measures the health status in nursing home residents), dated 7/11/25, completed by Minimum Data Set/Registered Nurse (MDS/RN), section C indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 out of 15 indicating she was cognitively intact. Section M indicated no pressure injuries.A comparison review of Resident 1's records titled, Wound Management Detail Report dated 7/24/25 to 8/11/25, and Care Plan History dated 7/30/25 reflected that: On 7/24/25 Resident 1 had a Stage 2 PI on her sacrum and the care plan was not updated until 7/30/25, a week later and the PI had already worsened to an Unstageable PI.On 8/3/25 Resident 1's Unstageable PI worsened to a Stage 4 and showed signs of infection with eschar (dead black tissue) and slough (stringy thick yellow dead tissue, which is a breeding ground for bacteria and prevents wounds from healing), and there were no revisions or updates to her care plan.On 8/11/25 Resident 1's PI worsened to a Stage 4, and and no revisions or updates were made to her care plan.During a concurrent interview and record review on 8/22/25 at 10:33 a.m., with Wound Care Nurse/Registered Nurse (WCN/RN), the WCN/RN confirmed Resident 1's skin integrity care plans had not been updated since 7/30/25, and had not reflected her current status, treatments, and interventions. During an interview by email with the Director of Nursing (DON) on 8/29/25 11:12 a.m., the DON confirmed there was no evidence that Resident 1's care plan for her PI to the sacrum, had been update or revised since 7/30/25. DON confirmed Resident 1 left the faciity on 8/11/25.

Based on interview, record review, and policy review, the facility failed to ensure safe discharge for one of two residents sampled (Resident 1), when Resident 1 chose to leave the facility Against Medical Advice, (AMA, when the physician does not agree with the resident leaving the facility because of their medical condition) and the facility failed to ensure;1. There was a physician's order to discharge Resident 1 AMA.2. Discussion and documentation was done with Resident 1 of alternatives to discharging AMA to the location to which Resident 1 discharged .3. An Against Medical Advice form (A form that a resident signs acknowledging understanding of the consequences for leaving the facility AMA), was not offered to Resident 1.4. A facility investigation was done and an Adult Protective Services (A government service to protect vulnerable individuals in the community from abuse, neglect and exploitation) report filed.These combined failures resulted in Resident 1 not being informed by the facility of the consequences of leaving the facility AMA and Resident 1 was admitted to the acute care hospital within two days after leaving the facility, with an infection. Findings:1.Review of a facility policy titled, Discharging a Resident without a Physician's Approval, revised October 2022 indicated, A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice, 3. If the resident or representative (sponsor) requests discharge without the approval of the attending physician, the resident and/or representative (sponsor) will be asked to sign a release of responsibility form. 4. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will: a. discuss with the resident, (and/or his or her representative, if applicable) and document the implication and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b. document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; c. document that despite being offered other options that could meet the resident's needs, the resident refused those more appropriate settings; d. determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge. Review of the admission record for Resident 1, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included a sacrum fracture (a break in the large triangular bone at the base of the spine).Review of Resident 1's admission MDS (Minimum Data Set- a federally mandated assessment tool that measures the health status in nursing home residents), dated 7/11/25, completed by Minimum Data Set/Registered Nurse (MDS/RN), section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS), score of 12 out of 15 which indicated that Resident 1 had good memory and decision making skills. Review of Resident 1's record titled, Physician Order Report: 7/2/25 to 8/20/25 indicated that there was no physician's order discharging (the official directive from a doctor to a healthcare facility that a patient no longer requires inpatient care and can safely transition to another level of care, such as home) Resident 1.2.Review of Resident 1's progress note dated 8/11/25 at 7:29 p.m., written by the Wound Care Nurse/Registered Nurse (WCN/RN, a registered nurse with specialized training and certification in wound care), the WCN/RN indicated that upon preparing for Resident 1's unplanned AMA she educated the family about Resident 1's extensive treatment for a Stage 4 (Bedsore, a severe form of skin damage, that involves full-thickness tissue loss that exposes muscle and bone), care needs that Resident 1 had developed while in the facility. There was no documentation of discussion of the implications and/or risks of being discharged to a location that was not equipped to meet her needs or an attempt to ascertain why the resident chose that location. There was no documentation of discussion on more suitable options of locations that were equipped to meet the needs of Resident 1. There was no documentation completed that despite being offered other options that could meet the resident's needs, the resident refused those more appropriate settings. Review of Resident 1's progress note dated 8/11/25 at 4:25 p.m. written by Registered Nurse (RN) B indicated that Resident 1's family arrived at the facility at 11:00 a.m., and requested to take Resident 1 home and that Resident 1 left the facility at 2:15 p.m. with her family.Review of Resident 1's, Transition of Care/Discharge Summary dated 8/11/25 indicated, Discharge Destination: Resident to return to independent living with spouse support after acute stay. This statement was incorrect, however, because Resident 1's home was in a nearby town, but she left the facility with her family to a city that was three hours away.During an interview on 8/22/25 at 11:52 a.m., with Family Member (FM) 2, FM 2 indicated that she was angry about how Resident 1 was taken care of by the facility, and there were nurses in the family who could do better.During an interview on 8/22/25 at 12:14 p.m., with FM 3, FM 3 indicated that her family did not think that the facility was making sure Resident 1 was being turned often enough, and they had concerns because the WCN/RN was only available once a week which delayed treatments and interventions for healing Resident 1's pressure injury. 3.During an interview on 9/9/25 at 10:24 a.m., with FM 2, FM 2 confirmed that the facility had not explained or offered to Resident 1 or FM 2, alternatives to taking Resident 1 to a town three hours away or the consequences of leaving the facility AMA. During a phone interview on 8/20/25 at 1:54 p.m., with the Medical Director (MD), the MD indicated that it is not her decision when a resident discharges, rather it is a determination that is made by the Social Services Director (SSD) and DON) The MD indicated that the SSD monitors how the residents are doing and if they are meeting criteria to be discharged . The MD indicated that she was not notified by the SSD or DON when Resident 1 left AMA and stated, It was very sudden.4.During an interview on 8/21/25 at 10:42 a.m., with the SSD in her office. The SSD indicated that FM 2 stated, I'm taking her [Resident 1] home right now. The SSD indicated that she did not know that Resident 1 was not going to her home in a nearby town, but rather to FM 2's home in a town three hours away until after Resident 1 left the facility. The SSD indicated that she did not think it was an appropriate discharge. The SSD confirmed the facility did not complete an AMA document or investigate if there should have been a referral to APS.During an interview on 9/9/25 at 9:42 a.m., with WCN/RN regarding Resident 1's leaving AMA, the WCN/RN confirmed, We should have done an AMA, I was really worried about the three-hour drive for her.During an interview on 8/20/25 at 2:38 p.m., with the DON the DON confirmed that Resident 1 left the facility AMA and that Resident 1's physician had not given orders for Resident 1 to discharge AMA and that the facility had not notified APS to check on Resident 1 once she returned to the community, and all of those things should have been done.

Based on interview, record review, and policy review, the facility failed to ensure nursing staff demonstrated competency in following the facility's policies in regard to wound care management and changes in resident conditions for one of two sampled residents (Resident 1) when;1.Registered Nurse (RN) A and Wound Care Nurse/ RN (WCN/RN), had not notified Resident 1's physician that Resident 1's sacrum (base of the spine) pressure injury (PI-a bedsore), had worsened. 2.WCN/RN performed conservative sharp wound debridement (CSWD, an invasive procedure to remove dead tissue from a PI using sharp instruments such as a scalpel (knife), scissors, and forceps (tweezers)), to Resident 1's PI, without a physician's order. These cumulative failures caused in a delay in the treatment and healing of Resident 1's PI and caused the PI to worsen. Subsequently, Resident 1 was hospitalized within two days after she left the facility, for sepsis (an infection in the blood stream) and osteomyelitis of the sacrum (an infection in the sacrum bone). This had the potential to negatively affect all residents who required care to heal wounds.Refer to F686 Findings:Review of a facility policy titled, Change in a Resident's Condition or Status revised February 2021 indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a d. significant change in the resident's physical/emotional/mental condition. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.Review of the National Pressure Injury Advisory Panel's (a nationally recognized professional resource for the staging and treatment of pressure injuries a global driver of quality improvement and patient safety in healthcare) website document titled, NPIAP Pressure Injury and Stages, at https://npiap.com, dated September 2016 indicated;-Stage 1 pressure injury: non-blanchable (skin redness or discoloration that does not fade or turn white when pressure is applied) erythema (reddening of the skin), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes.-Stage 2 pressure injury: partial-thickness skin loss with exposed dermis (the middle, living layer of the skin, located between the outermost epidermis and the innermost hypodermis).Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thick stringy yellow infected tissue or eschar (black dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. -Stage 3 pressure injury: full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough (dead tissue, usually moist and stringy) and/or eschar (dead tissue that is hard or soft) may be visible. If slough or eschar obscures the extent of tissue loss this is and Unstageable Pressure Injury.-Stage 4 pressure injury: full-thickness loss of skin and tissue with exposed Fascia (a thin fibrous connective tissue that surrounds and supports all muscles, organs, and other structures in the body), muscle, tendon (a tough, fibrous cord-like tissue that connects muscles to bone) ligament (a tough, fibrous band of connective tissue that connects two bones together, providing stability and support to joints), cartilage (a smooth, elastic connective tissue that provides support and protection to joints, bones, and other tissues in the body) in the injury. Slough or eschar may be visible. Epibole, undermining (the destruction of tissue or injury extending under the skin edges so that the pressure injury is larger at its base than at the skin surface) and/or tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) often occur.According to California State regulations Title 22, S72317. Nursing Service-Administration of Medications and Treatments; (a) Medications and treatments shall be administered as follows: (l) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such orderReview of the admission record for Resident 1 indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including sacrum fracture (broken bone at the base of the spine).Review of Resident 1's admission MDS (Minimum Data Set- a federally mandated assessment tool that measures the health status in nursing home residents), dated 7/11/25, completed by Minimum Data Set/Registered Nurse (MDS/RN), section C, indicated Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 12 out of 15 indicating she was cognitively intact. Section M indicated that Resident 1 had no PI's upon admission to the facility.Review of Resident 1's acute care hospital record dated 8/13/25, indicated that Resident 1 was admitted to the hospital on [DATE], two days after leaving the skilled nursing facility, with sepsis (an infection in the blood stream) secondary to osteomyelitis (a bone infection) from the infected PI to the sacrum. Review of Resident 1's progress note dated 7/25/25, written by Registered Nurse (RN) A indicated, Wound rounds:.Wound looks worse than 3 days ago. The progress note reflected no evidence that RN A notified Resident 1's AP of this change in condition of her PI.Review of Resident 1's progress note dated 7/28/25 written by RN A indicated, .Wound is getting worse. There was no evidence that RN A notified Resident 1's AP.During a phone interview on 9/9/25 at 2:07 p.m., RN A confirmed that she had not notified Resident 1's AP of the worsening of her PI on 7/25 and 7/28/25. RN A stated that when she identified the worsening to Resident 1's PI, she notified WCN/RN a week later instead of the AP. RN A stated the WCN/RN was the one who decided what changes should be reported to the AP. RN A added that the WCN/RN only worked one day a week.A comparison review of a facility documents titled, Physician Notification & Orders dated 7/30/25, and concurrent review of Resident 1's record titled, Wound Management Detail Report dated 7/24/25 to 8/11/25 reflected: On 7/24/25, Resident 1 had a Stage 2 PI that she acquired while in the facility, and the AP was not notified.On 7/30/25, one week later, Resident 1's sacrum PI had worsened from Stage 2 to an Unstageable PI, and the AP was notified by a memo.On 8/3/25, Resident 1's Unstageable PI showed presence of infection with eschar (dead black tissue) and slough (stringy thick yellow dead tissue that is a breeding ground for bacteria and prevents wounds from healing), and the AP was not notified.On 8/11/25, WCN/RN performed CSWD procedure on Resident 1's Unstageable PI, without a physician's order, and the AP was not notified. Resident 1's PI was then a Stage 4. During a phone interview on 9/9/25 at 9:42 a.m., with WCN/RN, the WCN/RN confirmed she had not obtained a physician's order for CSWD prior to performing the procedure on Resident 1. WCN/RN stated that she does not need a physician's order to perform CSWD. The WCN/RN indicated that she could not recall informing Resident 1's AP of the changes and worsening of each stage of Resident 1's PI and stated, I do not have direct communication with the physician. During a phone interview on 9/9/25 at 1:01 p.m., with AP, the AP confirmed she was not notified by either RN A or WCN/RN of the comprehensive changes of condition and worsening of the stages of Resident 1's PI to her sacrum. During a phone interview on 9/9/25 at 10:47 p.m., with the Director of Nursing (DON) indicated that WCN/RN could perform CSWD using her own discretion and the protocol and does not need a physician's order.

Based on interview and record review, the facility failed to prevent verbal abuse for one of three sampled residents, (Resident 2) when Certified Nursing Assistant (CNA) A cursed at Resident 2. This failure violated Resident 2's right to be free from abuse and had the potential to negatively impact Resident 2's emotional and psychosocial well-being. Findings: Review of the facility's policy titled, Abuse Prevention Program, dated December 2016, indicated, Our residents have the right to be free from abuse . and As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone . Review of the admission record for Resident 2, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including diverticulitis of large intestine (a condition where small pouches in the lining of the large intestine become inflamed or infected), type 2 diabetes (high blood sugar), depression, and complications of colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body). Review of Resident 2's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool that measures the health status in nursing home residents), dated 5/16/25 completed by Registered Nurse B, indicated a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 indicating Resident 2 was cognitively intact. Review of Resident 2's progress note dated 5/30/25 at 4:10 p.m., written by the Director of Nursing (DON) indicated that Resident 2 said to the DON that CNA A had cursed at her and that Resident 2 did not want to talk about it. During a review of a facility document titled, Resident Abuse Investigation Report Form completed regarding Resident 2's abuse, dated 6/3/25, completed by the DON, the document indicated that on 6/2/25 the DON interviewed CNA A by phone, and CNA A indicated that she was frustrated with Resident 2 and told Resident 2 that it was bulls**t. During an interview on 6/18/25 at 12:15 p.m., with the DON, the DON confirmed that when CNA A was interviewed, she admitted she was frustrated with Resident 2 and said bulls**t to Resident 2. The DON indicated that she expected staff to treat residents with respect.

Based on observation, interview, record review, and facility policy review, the facility failed to implement a water management program as directed by their policy. This deficient practice had the potential to affect all residents who currently resided in the facility. The facility further failed to ensure a nurse washed her hands prior to medication administration, did not handle medication with her bare hands, and did not administer medications to a resident that had fallen on top of the medication cart for 1 (Resident #15) of 3 residents observed for medication administration. Findings included: 1. The facility policy titled, Legionella Water Management Program, revised 09/2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation l. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services. 3. The purposed of the water the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The policy specified, 5. The water management program includes the following elements: a. An interdisciplinary water management team (see above); b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. During an interview on 01/15/2025 at 11:20 AM, the Maintenance Director stated he had been employed at the facility for one year. He confirmed he had not tested the water for Legionella and had not implemented the facility policy. During an interview on 01/15/2025 at 11:42 AM, the Director of Nursing (DON) stated she believed the maintenance staff was generally responsible for the water management program. The DON stated she could not find the result of the last time water testing was done. During an interview on 01/15/2025 at 11:50 AM, the Administrator stated the facility had been monitoring the water, but changed maintenance staff, and Legionella was not a part of their orientation. Per the Administrator, the water should be tested annually, and he was not sure when the last time the water was tested . 45645 2. A facility policy titled, Handwashing/Hand hygiene, revised 10/2023, indicated, 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to the other personnel, residents, and visitors. A facility policy titled, Med [Medication] Pass Infection Control Review, dated 06/01/2023, indicated, Do not touch meds [medications] with ungloved hands. The policy specified, Use hand hygiene prior to handling medication and after administering to resident. Place a barrier between the cart and the medication while preparing the medication. A Resident Face Sheet, indicated the facility admitted Resident #15 on 09/10/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hypertension, paroxysmal atrial fibrillation, angina pectoris, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2024, indicated Resident #15 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. During medication administration observation on 01/14/2025 at 9:07 AM, Licensed Vocational Nurse (LVN) #1 did not wash or sanitize her hands before she prepared medications for administration for Resident #15. LVN #1 also handled the resident's medications with her bare hands. It was also noted, two pulls fell on top of the medication cart and placed them in the medication cup to be administered to the resident. During an interview on 01/14/2025 at 9:48 AM, LVN #1 stated she should not have handled the resident's medications with her bare hands. LVN #1 stated she should have discarded the medications that fell on to to the top of the medication cart. During an interview on 01/14/2025 at 12:19 PM, LVN #2 stated nurses must sanitize or wash their hands prior to administration of medication, and nurses must pour the resident's medication directly into the medication cup. Per LVN #2, if a pill hit the floor or an uncleaned surface, the medication must be tossed out. During an interview on 01/15/2025 at 9:31 AM, the Infection Preventionist stated nurses must wash hands, put medication in a cup, and not touch the medication with their bare hands. During an interview on 01/15/2025 at 10:47 AM, the Director of Nursing (DON) stated the residents' medication should not be touched with a nurse's bare hands, and when dropped those pills should be discarded. The DON said the expectation was for nurses to follow the protocols adopted by the facility such as washing hands before and after administration of medications. During an interview on 01/15/2025 at 10:58 AM, the Administrator stated staff must comply with infection control protocols such as wash or sanitize their hands and not touch medications with their bare hands.

Based on observation, interview, and facility policy review, the facility failed to lock the computer screen on 1 of 2 medication carts to ensure residents' protected health information (PHI) was not visible for all to see. Findings included: An undated facility policy titled Security of Medication Cart indicated, The cart must be locked with the computer charting system secured prior to entering the resident's room.4. Medication carts must be securely locked at all times when out of the nurse's view. During an observation on 01/14/2025 at 7:50 AM, the surveyor noted the computer on the medication cart was left unlocked and Resident #28's list of medications and other PHI for other residents was visible. The nurse assigned to the medication cat was not present. At 8:05 AM, the surveyor was told the nurse assigned to the medication cart was in the dining room. The surveyor observed Licensed Vocational Nurse (LVN) #1 in the dining room. LVN #1 stated she could not leave the dining room for another 30 to 35 minutes. LVN #1 acknowledged she could not visualize the medication cart from the dining room. LVN #1 stated she would have another staff member go and lock the screen on the computer on the medication cart. LVN #1 commented that she was glad you told me otherwise it would have stayed unlocked for another 35 minutes. During an interview on 01/14/2025 at 12:19 PM, LVN #2 stated nurses must lock the medication screen to keep PHI private and ensure others do not have access to residents' PHI. During an interview on 01/15/2025 at 9:40 AM, Director of Staff Development (DSD #5 stated staff received education that the computer screen on the medication cart should be locked when the medication cart is out of the nurses' visual field. During an interview on 01/15/2025 at 10:47 AM, the Director of Nursing (DON) stated computer screens must be locked. The DON stated the expectation was for the nursing staff to protect the residents' PHI. During an interview on 01/15/2025 at 10:58 AM, the Administrator stated the expectation was for the staff to follow PHI safety policies and ensure computer monitors were locked to protect residents' PHI.

Based on interview and record review, the facility failed to ensure that there was an alternative system in place by which resident Medication Administration Records (MARs), Treatment Administration Records (TARs), and Physician's Orders, could be accessed by staff in the event that the facility's Electronic Medical Record system (EMR, a computerized system that contained resident MARs, TARs, and Physician's Orders), was not available for 41 of 41 residents. On 7/17/24, the facility's EMR system administrator notified the facility that there was going to be a scheduled outage for EMR maintenance and that the EMRs would not be available on 7/18/24. The facility took no action to prepare for this planned outage and subsequently had no way for the nurses to administer medications, treatments (wound and skin care), or see what the physician currently had ordered for each resident. This failure resulted in the nursing staff ' s inability to know what each resident ' s current physician ' s orders were, therefore, the nursing staff was unable to administer medications or do wound care treatments for all residents, which had the potential for the residents to experience unnecessary pain, untreated blood sugar levels, breathing difficulties, anxiety and depression, which could negatively impact their physical, emotional, and psychosocial well-being. An Immediate Jeopardy (IJ- when the facility's non-compliance has the potential to cause serious injury, harm, impairment or death) situation was identified on 7/19/24 at 5:55 pm, in the presence of the Administrator (Admin), because the facility's EMR system had been unavailable and the residents had not received their physician ordered medications and treatments, for 19 hours. An IJ removal plan to immediately correct this problem was requested from the Admin. An IJ removal plan was provided by the Admin and accepted on 7/22/24 at 1:37 pm. The facility obtained a designated computer that worked off line (no internet was needed), and this computer would not be affected by EMR system outages, because the EMR information could be stored in that computer's hard drive (a self contained storage device). This off line computer downloads resident EMR information every 15 minutes and paper MARs, TARs and Physician's Orders for all residents can be printed on paper by the nurses and avoid delayed medications and treatments. The IJ removal plan was verified by the surveyor while on site to be fully implemented. The IJ was removed on 7/22/24 at 2:47pm. Findings: A review of the facility's policy titled, Electronic Medical Records dated March 2014, indicated Electronic medical records may be used in lieu of paper records when approved by the Administrator. The Administrator, in conjunction with the Quality Assessment and Assurance Committee (a group of facility managers that identify problems and develop actions to correct them), shall review requests for and the implementation of our electronic medical records system. A review of the facility ' s policy titled, Charting and Documentation dated July 2017, indicated, The following information is to be documented in the resident medical record: medications administered; treatments or services performed, changes in the resident ' s condition . During an interview on 7/19/24 at 2:30 pm, the Admin indicated their EMR system had been inaccessible since 7/18/24 at 3:00 pm, for 23 and a half hours. Admin stated, we are working on it. Admin confirmed the facility did not have access to all residents ' Physician ' s Orders, MARs and TARs. Admin indicated he did not have a policy with instructions on what to do during an EMR system outage. During an interview on 7/19/24 at 2:50 pm, with Resident 1 in her room, she indicated she had not received any medications yet today. Resident 1 indicated she usually took about 6 medications after breakfast, and she had not received them yet. Resident 1 indicated that last night she was told by an evening shift nurse, the computers were down. Resident 1 indicated she was anxious because, although she did not know the names of her medications, she had not received her heart medications. During an interview on 7/19/24 at 2:52 pm, with Resident 2 in her room, she indicated she did not think she got her morning or lunch medications today. Resident 2 indicated she did not get her stool softener last night or today and she was feeling constipated (unable to have a bowel movement), and that worried her. During an interview on 7/19/24 at 3:00 pm, with Resident 3 in his room, he indicated he did not get his evening medication on 7/18/24 or his morning medications today. Resident 3 indicated he was concerned because he had a condition called gout which caused pain in his left great toe. Resident 3 indicated he had not received the medication for his gout and his toe was hurting. During an interview on 7/19/24 at 3:14 pm, Certified Nursing Assistant (CNA) A indicated the nurse informed her today, 7/19/24, that residents were not getting their medications due to the EMR system outage. CNA A indicated she was very concerned about residents who had aggressive and wandering (moving to an unsafe area in the facility or even outside without staff knowledge), behaviors. During an interview on 7/19/24 at 3:14 pm, Licensed Vocational Nurse (LVN) B indicated that the EMR system went down yesterday on 7/18/24 around 3:00 pm. LVN B indicated the nurses were unable to administer current medication, provide wound treatments or respiratory treatments (inhalers and medication in breathing machines), because they did not have access to any residents' current MARs, TARs, and Physician ' s Orders. LVN B indicated she had checked the resident ' s paper charts (a binder that contained printed medical records for a resident), to retrieve current physcian's orders but the most recent orders she could find were April 2024 (90 days ago). LVN B indicated there should have been current printed Physician ' s Orders, that were signed by the physician, and placed in all residents' paper chart, but this had not been done. LVN B confirmed there was no back up system for the EMR, so they had no way of knowing what the current orders were for all 41 residents. During an interview on 7/19/24 at 3:25 pm, LVN D indicated they were unable to chart resident ' s conditions, administer medications, do wound care and respiratory treatments because the EMR system had stopped working on 7/18/24 around 3:00 pm. During an interview on 7/19/24 at 3:42 pm, the Admin stated, we thought we had back up orders for medication through our pharmacy but apparently, they had not updated them. During an interview at 7/19/24 at 3:50 pm, LVN B indicated that at 10:00 am 7/19/24, Resident 4 became diaphoretic (sweaty) and shaky. His blood sugar was recorded at 250 mg/dL (milligram per deciliter, a measurement) (According to the American Diabetes Association ' s goals for blood sugar control in people with diabetes are 70-130 mg/dl before meals .). LVN B indicated Resident 4 ' s blood sugar level required the Physician to be notified. LVN B indicated that Resident 4 had not been able to receive his usual blood sugar medication as ordered because of the EMR system outage. During an interview on 7/19/24 at 3:56 pm, Business Office Manager (BOM) indicated she had received a warning message on 7/17/24, that the facility's EMR system was scheduled for a planned outage that would occur on 7/18/24 at 1:00 am. BOM stated the warning indicated the following, As best practice we recommend running your eMAR [electronic Medication Administration Record] offline report [transferring MARs and TARS to a computer that can be accessed when the internet system was not working, which would allow the MARs and TARs to be printed and accessible to the nurses] to ensure it is installed and functioning properly for use during the outage. BOM indicated the EMR system would post this alert every time there were planned outages for updates to the EMR system. BOM indicated that this EMR warning was able to be seen on all computers that the nurses used and remained on their computer until the user responded to the message. The BOM indicated that these warnings from their EMR system provider get ignored because the outages only usually last about 2 hours. BOM added that there was also a global internet outage (disruptions across the world), which occurred on the same day, 7/18/24, which contributed to their EMR system being unavailable for a longer period than expected. During an interview with the Admin and a review of the facility ' s Emergency Preparedness/Disaster plan on 7/19/24 at 4:51 pm, the Admin indicated that there was nothing in the facility ' s disaster plan concerning what to do if the EMR system stopped working, but there should have been. The Admin stated, we are just in the process of rewriting it [the facility ' s Emergency Preparedness/Disaster plan manual]. During a phone interview with the Medical Director (MD) on 7/19/24 at 5:15 pm, MD indicated she does not have access to the EMR system that the facility uses. MD stated, I use a different system for EMR information than the facility does. It is not my job to know if the facility has a backup system for their EMR. The MD indicated that she was informed of the EMR outage by LVN C on 7/19/24 at 10:00 am. The MD indicated she gave LVN C directions to administer medications to all of the residents by using the directions on their medication cards (the container labeled by the Pharmacist that the medications are packaged in, from the Pharmacy), instead of using a MAR. During a phone interview with the Pharmacist (PM) on 7/19/24 at 5:43 pm. The PM indicated he was notified of the facility's EMR system outage by his supervisor at 3:00 pm on 7/19/24. PM indicated that he had began working on updating the Physician ' s Orders for the residents at that time. The PM indicated that the resident's medication card labels did not always have the correct or current directions, and should not be used to administer medications to residents. During an interview with the Admin and record review on 7/19/24 at 5:55 pm, the facility ' s manual titled, What to do in case of [EMR system] down time was reviewed. The Admin confirmed that there was no information about an offline EMR backup system that could be accessed and used or directions on how to print all MARs, TARs, and Physician ' s Orders on paper. The Admin indicated that this was a very serious situation because residents were not receiving medication or treatments which were important to their well-being. During an interview on 7/22/24 at 2:20 pm, the Director of Nursing Services (DNS), indicated the EMR system was offline for a total of 30 hours. DNS stated, [LVN E] let me know [that the EMR system was down] on Thursday [7/18/24] at 4:14 pm. At that time, I did not realize it was going to be off for an extended amount of time. It had not even crossed my mind that this would ever happen so, no, we have no backup. The DNS indicated that she does receive EMR system outage warnings regularly, that she does not read. DNS stated, I got emails and alerts [from the EMR system], about this [EMR system outage] but I do not know what it said. The DNS indicated that she usually printed off current Physician's Orders at the beginning of each month but she had, gotten off track and May, June and July ' s Physician ' s Orders had not been printed. DNS stated, It has been very busy.

Based on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 1), sampled for unsafe wandering (a random, aimless or repetitive search for an exit that is non-goal-directed), and elopement (a resident leaves the premises or a safe area without the facility's knowledge and supervision) was assessed and monitored for unsafe wandering and elopement. Resident 1 eloped twice from the facility and had no wander/elopement risk assessments or care planning done, and the facility had no dedicated alarm system in place for residents who wandered or were at risk to elope. This resulted in Resident 1 eloping from the facility and was found by the police in a ditch near a highway with a scratched face, bruised chin and pain in her right leg. An Immediate Jeopardy (IJ) situation was identified on 7/2/24 at 4:18 pm, in the presence of the Administrator (Admin) and Director of Nursing (DON), due to not having an elopement system in place that ensured the health, safety and welfare of those residents who were at risk for wandering and elopement. An immediate corrective action plan (IJ removal plan) was requested from the Admin and DON. An IJ removal plan was provided by the DON and accepted on 7/3/24 at 1:04 pm. The IJ removal plan included wandering/elopement risk assessments for all residents who resided in the facility, the development of wander/elopement care plans, and the installation of a Wanderguard alarm system (an alarm system where the resident wears a bracelet that triggers an alarm system on the exit doors when they get too close). The IJ removal plan was verified by the surveyor while on site to be fully implemented. The IJ was removed on 7/5/24 at 1:01 pm. Findings: A review of the facility's policy titled, Wandering and Elopements revised March 2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy titled, Safety and Supervision of Residents revised July 2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Individualized, Resident-Centered Approach to Safety . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: d. Ensuring that interventions are implemented. Resident Risks and Environmental Hazards: 1. Due to their complexity and scope, certain resent risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include e. Unsafe Wandering. A review of Resident 1's Admission Record, undated, indicated Resident 1 was initially admitted on [DATE] and then readmitted on [DATE], after a short hospital stay. Resident 1's diagnoses included dementia (loss of memory and ability to make sound decisions), anxiety disorder, osteoporosis (a decrease in bone mass which causes an increase in risk for bone fractures), diabetes (high sugar in the blood), insomnia (difficulty sleeping), restlessness and agitation. A review Resident 1's Admission Minimum Data Set (MDS, a clinical assessment), dated 6/13/23, indicated Resident 1's cognition (thinking and decision making), was severely impaired and identified that she wandered. No care plan was developed for wandering on admission. A review of Resident 1's, Elopement Risk Documentation Tool (which was kept in an elopement book at the nurse's desk) dated 7/5/23, was reviewed and indicated a single intervention to redirect resident when she was wandering. Types of supervision included, checks by staff, door alarm is on, and usually sits in common area. A review of the facility's daily, Quality Assurance/Interdisciplinary meeting dated 7/6/23, indicated Resident 1 walked out the front door on 7/5/23 and became combative when redirected. Follow up was to do elopement monitoring. No care plan was developed following that elopement. A review of Resident 1's, Wander/Elopement care plan dated 11/7/23 (4 months after first attempted elopement), indicated she was at risk for elopement related to Alzheimer's disease and dementia as evidenced by multiple attempts to leave the facility. Interventions included to assess Resident 1 for elopement/wander risk upon admission and as needed as appropriate. Document elopement attempts. Staff to monitor front door when front door alarms. A review of Resident 1's annual MDS assessment dated [DATE], indicated that wandering behavior for Resident 1 occurred daily. She was independent for getting around in her wheelchair and she could walk 150 feet with supervision. A review of Resident 1's progress notes dated 5/8/24 at 11:14 pm, indicated that Licensed Vocational Nurse (LVN) A documented, Resident was sitting in her wheelchair in the hallway around 9:00 pm - 9:10 pm . CNA [Certified Nursing Assistant] staff approached me around 9:15 pm and stated that she [Resident 1] was unable to be found. I searched with staff around the entire facility, and she was not found by staff .police department called at 9:25 pm stating they found resident on Highway 97 and stated she had a fall with a scratch on her face and they were sending her to the ER [emergency room ] for further work up. A review of Resident 1's Hospital emergency room Visit on 5/8/24 at 11:10 pm, the Physician (MD) documented, [Resident 1] is an [AGE] year-old female with history of dementia reportedly wandered off from [facility name] brought in by ambulance after getting a ride to [Highway] 97 and getting out of the car and falling into a ditch. She has some bruising in her chin which is the only thing she says hurts on initial assessment but on secondary assessment she reports her right leg hurts a little bit as well. A review of Resident 1's Wander/Elopement care plan updated on 5/9/24, indicated new interventions to include; every 15 minute visual checks until no elopement attempts occurred after 5 days, Resident 1 to have one-to-one monitoring by staff (a staff with Resident 1 at all times), on PM (evening) shift when she is the most active to maintain safety and ensure someone is with her if she wishes to go outside and Admin/DON to obtain tracking/safety monitoring device to ensure/maintain resident's safety. A review of Resident 1's progress notes dated 6/11/24 at 11:09 pm, LVN B documented, 8:00 pm-This LVN was unable to locate resident to administer HS [evening] meds. I found resident [Resident 1] sitting on bench [outside] in front of facility. She asked if I could start her car for her so she could go home. A review of Resident 1's Wander/Elopement care plan last edited on 6/14/24, had no mention of her 6/11/24 elopement episode and no new interventions were developed. One-to-one staffing was still mentioned as an intervention and tracking /safety device was still an intervention to maintain Resident 1's safety. On 7/1/24 at 12:45 pm, the front door and Resident 1 were observed. When the front door was opened an alarm would chirp and the sound would stop when the door was closed. Resident 1 was sitting in the hallway near the nurse's desk. During an interview on 7/1/24 at 12:58 pm, the DON indicated they had a sensor on the front door and sliding glass back door that would alarm every time those doors were opened, but it would automatically turn off when the doors closed. The DON continued to say there was no additional system or alarm to indicate when a resident was leaving the facility as opposed to staff and visitors. DON stated that all other exit doors had a loud alarm when opened and had to be turned off with a key. During an interview on 7/1/24 at 2:11 pm, the DON stated there was no formal unsafe wandering or risk for elopement assessments done for the residents upon admission or at any time frame thereafter for reevaluating a residents risk for wandering or elopement. The DON stated that, it's just talked about it at a stand-up meeting, (IDT meeting, a daily meeting where the Interdisciplinary Team, a group of facility managers, discuss the care and services that the facility provides to their residents). The DON indicated there were 4 other residents that the facility's IDT had informally identified that had a risk to wander/elope. During an interview and record review on 7/1/24 at 2:20 pm, Resident 1's care plan was reviewed with the DON. The DON indicated that on the PM shift starting on 5/9/24, a CNA would sit with Resident 1 until she was in bed for the night. She stated they did this for a few weeks then stopped. The DON confirmed that one staff member was to provide dedicated supervision to Resident 1 at all times and this was still an intervention on Resident 1's care plan, but indicated they did not have the staffing to continue this, so they were not doing it anymore. They just kept an eye on her. The DON confirmed that Resident 1's care planned interventions were to have a tracking/monitoring device but that they had not done this. The DON stated, the door alarms will let us know if someone was going out and that they all kept an eye on [Resident 1]. During an observation and interview on 7/1/24 at 3:21 pm, the front doors were observed with a Housekeeping/Maintenance (HSK) staff. Resident 1 was sitting at her usual spot near the nurse's station. HSK indicated the front doors have a chirping/alarm sound when it was opened and the alarm would stop when the door closed. He stated the sound was very low because it needed new batteries. HSK confirmed that the chirp/alarm would alarm every time the door opened whether it was a resident, staff or visitor. He confirmed that if staff were down the hallways, and a resident went outside, they may not hear the alarm sound. He said that the alarm goes on and off all day long and there was nothing different to indicate that the door was opened by a resident. During an observation and interview on 7/1/24 from 3:30 pm to 3:38 pm, 5 other exit doors were observed with the HSK. HSK indicated 4 other exit doors had emergency alarms that would alarm whenever opened and the alarm would not turn off unless a staff used a key at the door. The dining room sliding glass door led to an outside patio and grassy area surrounded by a fence and unlocked gate. This door did not alarm when opened. HSK indicated the chirp alarm was turned off. During an observation on 7/1/24 at 3:51 pm, this surveyor opened the front door and initiated the chirp/alarm. No staff came to see what initiated the alarm. When the door closed the alarm turned off. No one was at the nurse's station which was in view of the front door. During an interview on 7/1/24 at 3:53 pm, LVN C indicated she was the Resident Care Manager (RCM) and she sat at the nurse's desk most of the day and watched the front door to make sure residents did not elope. She confirmed that she was not at the desk a few minutes ago and did not know the front door was opened. She confirmed that there was no other system to alert staff when a resident went outside unsupervised. She indicated that she was away from the desk for about 30 minutes every day for a stand-up meeting and at that time she would not be watching the front door and it was possible for a resident to elope. During an interview on 7/1/24 at 4:10 pm, Registered Nurse (RN) D indicated that Resident 1 was confused and impulsive. RN confirmed that Resident 1 was supposed to have one-to-one supervision (one staff member dedicated to only Resident 1's supervision), on the PM shift, but she did not because there was not enough staff to do this. RN D stated they checked on Resident 1 every 15 minutes but was unable to provide documentation that this was done. RN D continued to say that no one was in charge of monitoring who went in or out of the front door. RN D confirmed that it was possible that a resident could get out of the facility without their knowledge. During an interview on 7/1/24 at 4:46 pm, CNA E stated she was taking care of Resident 1 on 5/8/24, the night she eloped and ended up in the ER. CNA E indicated that the Maintenance Supervisor (MS) was going in and out of the front doors that evening so the front door chirp/alarm was constantly alarming. Resident 1 was sitting by the nurse's station like she always did. CNA E indicated Resident 1 was out of her sight for 15 min while she helped another resident, and when CNA E returned to help Resident 1 to bed Resident 1 was gone. CNA E indicated that the nurse at the desk did not notice Resident 1 go out the front door. During an interview on 7/1/24 at 4:55 pm, CNA F indicated she was working the night Resident 1 left the faciity on [DATE]. CNA confirmed that she did not hear the front door alarm because she was down the hall in resident rooms helping them to bed. She indicated that the front door alarm did not differentiate between a resident, staff member or the pharmacy delivering medications. CNA F indicated that when she does hear the alarm she does not go and investigate it. During an observation on 7/2/24 at 9:30 am, this surveyor entered the facility through the front door which alarmed when opened but stopped when closed. No staff came to identify who opened the door and there was no staff at the nurse's desk. During an interview on 7/2/24 at 9:46 am, MS stated that the front door alarmed so much that some staff may get, immune to it. During an interview with LVN G and a record review on 7/2/24 at 11:00 pm, Resident 1's progress notes and Wandering/Elopement care plans were reviewed. LVN G indicated that Resident 1 was to be a one-to-one on the PM shift because that was when she tried to leave the facility. LVN G confirmed that the one-to-one was not being done because of a staffing shortage but it should be. LVN G confirmed that the facility had not developed new interventions following each elopement for Resident 1 to protect her from eloping again and stated, we should because she could elope again. During an interview on 7/2/24 at 12:32 pm, the DON confirmed they were not doing assessments upon admission to identify a resident's risk for unsafe wandering and elopement. The DON was not aware of an assessment form that she could use for that. The DON confirmed that there was no care plan developed for Resident 1 on admission for being at risk for unsafe wandering and elopement, and there should have been. The DON confirmed that Resident 1 had eloped on 6/11/24. The DON indicated that she had not been informed of that elopement. The DON confirmed that there was no documentation that the facility was checking on Resident 1 every 15 minutes.

Based on observation, interview and record / policy review, the facility failed to operationalize their Abuse policy and procedures when: a. Resident 1 sustained a left ankle fracture of unknown origin and the injury was not investigated, per policy; and b. Resident 2 alleged that she had been verbally abused by Certified Nursing Assistant (CNA) B, the allegation was not reported or investigated, and Resident 2 was not offered protection from further mistreatment, as the policy directed. These failures resulted in emotional distress for Resident 2 and placed 30 of 30 residents at risk for on-going and unrecognized mistreatment and injury. An Immediate Jeopardy (IJ) situation was identified due to a lack of Administrative oversight which ensured that resident abuse allegations and injuries of unknown origin were reported and investigated, and that residents were provided protection while such investigations were being conducted. On 10/31/14 at 10:55 am, an IJ was declared in the presence of Registered Nurse (RN) A and the Director of Staff Development (DSD), a Licensed Vocational Nurse, as the Administrator (Admin) and the Director of Nurses (DON) were absent from the facility. An immediate action plan was requested to correct this failed facility system and ensure resident safety. On 11/5/14 at 10:05 am, a corrective action plan was accepted from the Governing Body (GB), owner of the facility, which ensured resident safety and prevention of future occurrences, and the IJ was abated. Refer to F 490 and F 493. Findings: a. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, a standardized resident assessment), dated 9/12/14, showed that Resident 1 could not make decisions, required extensive assistance and two staff members to transfer, and was not able to walk. Resident 1's daughter was her responsible party. Resident 1's record was reviewed. On 9/14/14 at 6:30 am, Nursing Note documentation revealed that Resident 1 had a swollen and painful left outer ankle which had a bruised area on the backside that measured 9.5 by 5 centimeters (cm- 2.5 cm equals one inch), and the DON was notified. There was no explanation regarding how Resident 1's ankle had been injured. On 9/15/14, Resident 1 was evacuated to a nearby hospital, due to a fire in the community, and returned to the facility on [DATE]. On 9/20/14, Nursing Note documentation revealed that Resident 1's left ankle continued to be swollen, painful, and bruised and she was sent to the Emergency Department for an x-ray. A review of the x-ray report, dated 9/20/14, showed that Resident 1 had a left fibula fracture (the small thin bone that connects the ankle to the knee), and the source of the injury with fracture had not been investigated by the facility. The facility's policy and procedure titled, "Abuse," revised 10/3/14, was reviewed. The "Identification" section directed, "Falls, bruises and skin tears of unknown origin will be investigated to rule out abuse/neglect." On 10/31/14 at 12:45 pm, the Admin and DON were not present in the facility, therefore, they were both interviewed via telephone. The Admin and DON both confirmed that they had knowledge of Resident 1's left ankle fracture and that an investigation to discover the origin of the injury, and to rule out abuse, had not been conducted, as their Abuse policy directed. b. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 2 was frequently incontinent (loss of control) of her bladder and required extensive assistance of one person to manage her hygiene needs. Resident 2 had moderately impaired decision making skills and her daughter was her responsible party. On 10/31/14 at 9:15 am, the Activity Director (AD) informed the surveyor that, "two days ago," on 10/29/14, another resident had informed her, during the Resident Council Meeting, that Resident 2 told her that she had been spoken to "inappropriately" by a staff member when she had wet the bed. The AD stated that she had not reported the allegation to the Admin, DON, or to the California Department of Public Health (CDPH), but instead suggested the DSD give an inservice to staff on using "appropriate tones" when speaking to residents. The AD stated that she had not interviewed Resident 2 to obtain more information or notified Social Services to evaluate Resident 2's psychosocial and emotional needs because she still was not sure if the allegation met the criteria for abuse. The AD stated, "now I realize that I should have reported" Resident 2's verbal abuse allegation to the Admin and CDPH, immediately. On 10/31/14 at 9:45 am, the DSD was interviewed. The DSD stated that she was "in charge" of the facility in the absence of the Admin. The DSD confirmed she was informed by the AD that Resident 2 had made a verbal abuse allegation toward a staff member, two days ago. The DSD confirmed that she had not notified the Admin or DON or initiated an investigation; Therefore, Resident 2 and others were still at risk for further mistreatment due to the facility's lack of attempting to identify the alleged perpetrator. The DSD stated that she did not know how to conduct an alleged abuse investigation and would have to call the Admin (the facility's Abuse Coordinator). The facility's policy and procedure titled, "Abuse," revised 10/3/14, was reviewed and described verbal abuse as, "the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend or disability." The policy directed the following guidance: "PROTECTION: If the suspected perpetrator is an employee: Immediately remove the employee from the care of the resident. Suspend the employee during the investigation. Social Services will evaluate the psychosocial impact of the incident on the resident and develop a plan to meet the psychosocial needs of the resident." "INVESTIGATION: Any complaint, observation or suspicion of resident abuse/neglect or misappropriation of resident property will be thoroughly investigated. Initiate the investigation during the shift on which it is reported. Interview the resident and other resident witnesses. Interview the suspected perpetrator if the individual is available. Interview any other available witnesses. Continue the investigation until all witnesses have been interviewed and there is enough objective information to make an informed decision." "REPORTING: Any employee, visitor or Healthcare Practitioner who witnesses, is informed of, or suspects that abuse, neglect or misappropriation of resident property is occurring or has occurred will report this information to the Administrator and the Director of Nursing. If the Administrator and/or Director of Nursing are unavailable the person designated to act on his/her behalf will contact him/her immediately, by telephone if necessary. The Administrator and the Director of Nursing or their designees notify the California Department of Public Health, Licensing and Certification via telephone immediately or as soon as is practically possible within 24 hours." On 10/31/14 at 10:05 am, Resident 2 was interviewed. Resident 2 stated that a CNA had "reprimanded" her about a week ago for wetting in the bed. Resident 2 began to sob and stated that she felt like she was in "trouble" because her "water pill" occasionally makes her wet the bed and kept repeating, "but I can't help it." On 10/31/14 at 10:55 am, the DSD and RN A were informed that the residents were determined to be at immediate risk for continued abuse and/or mistreatment due to the facility's lack of sufficiently operationalize their Abuse policy and procedures regarding reporting, investigation and resident protection, and an IJ was declared. On 10/31/14 at 12:20 pm, RN A stated she had substantiated that it was CNA B who had been verbally inappropriate toward Resident 2 regarding her incontinence. RN A stated that she had just suspended CNA B. On 10/31/14 at 1:35 pm, CNA B was interviewed. CNA B stated "about two weeks ago" Resident 2's daughter informed her that "mom doesn't want to call you to change her because she thinks you are too busy to take care of her." CNA B stated she told Resident 2 not to "ever feel like I don't have time for you, that's what I'm here for" and her intent was to make it clear to Resident 2 that she was happy to change her when she was incontinent and that it was not "healthy" to lay in a wet bed. CNA B stated that she was trying to be reassuring to Resident 2, not disrespectful or abusive. On 10/31/14 at 12:45 pm, a phone interview was conducted with the Admin and DON. The Admin confirmed that the AD and DSD had both received Abuse/Mandated Reporter training and should have been able to sufficiently follow the Abuse protocol, in his absence. The Admin was asked to develop and fax an immediate action plan to correct the IJ situation to the CDPH. An action plan was submitted by the Admin on 11/3/14, but was not sufficient. On 11/5/14, the GB submitted an immediate action plan which was accepted and the IJ was abated at 10:05 am.

Based on interview and record and policy review, the facility Administrator (the Abuse Coordinator) failed to operationalize and ensure that key personnel (Department heads) were competent to operationalize the facility's Abuse policy and procedures on his behalf when he was absent from the facility when: a. The Administrator failed to investigate an injury of unknown origin to Resident 1, when she sustained a fractured left ankle; and b. The Activity Director (AD) and the Director of Staff Development (DSD), both failed to report, investigate, and protect Resident 2, when she made a verbal abuse allegation. These failures resulted in emotional distress for Resident 2 and placed 30 of 30 residents at risk for on-going and unrecognized mistreatment and injury. An Immediate Jeopardy (IJ) situation was identified due to a lack of Administrative oversight which ensured that resident abuse allegations and injuries of unknown origin were reported and investigated, and that residents were provided protection while such investigations were being conducted. On 10/31/14 at 10:55 am, an IJ was declared in the presence of Registered Nurse (RN) A and the Director of Staff Development (DSD), a Licensed Vocational Nurse, as the Administrator (Admin) and the Director of Nurses (DON) were absent from the facility. An immediate action plan was requested to correct this failed facility system and ensure resident safety. On 11/5/14 at 10:05 am, a corrective action plan was accepted from the Governing Body (GB), owner of the facility, which ensured resident safety and prevention of future occurrences, and the IJ was abated. Findings: a. Resident 1's record was reviewed. On 9/14/14, nursing note documentation revealed that Resident 1 had a swollen, painful and bruised left ankle, the cause of the injury was not determined, and the Director of Nursing (DON) was notified. On 9/20/14, it was confirmed by x-ray that Resident 1's left ankle was fractured. According to the facility's Abuse policy, revised 10/3/14, the Administrator is the Abuse Coordinator and all injuries, bruises and skin tears of unknown origin will be investigated to rule out abuse. On 10/31/14 at 12:45 pm, the Administrator confirmed during a telephone interview that Resident 1's left ankle fracture was never investigated; Therefore, abuse could not be ruled out. b. According to the facility's Abuse policy, revised 10/3/14, all resident abuse allegations will be reported to the Administrator and DON and investigated immediately, will be reported to the California Department of Public Health within 24 hours, and the resident involved will be protected from the perpetrator until the investigation is completed. During an interview on 10/31/14 at 9:15 am, the AD stated that on 10/29/14, a resident informed the AD that Resident 2 told her that she had been verbally abused by a Certified Nursing Assistant (CNA). The AD discussed the allegation with the DSD, and neither reported, investigated or ensured that Resident 2 was protected from further verbal mistreatment. At this time, two days after receiving the abuse allegation from Resident 2, the AD reported the allegation to a surveyor who was in the facility. The AD stated that she was not sure if what she had been told about Resident 2 was considered abuse and did not know what she should do about it. The AD confirmed that she did not seek further information, protect Resident 2, or report the allegation to the Administrator and DON, who she stated were both absent from the facility on that day. On 10/31/14 at 9:45 am, during an interview with the DSD, it was noted that both the Administrator and DON were absent from the facility. The DSD stated, "I guess I'm in charge." The DSD confirmed that she knew Resident 2 had alleged that a CNA had been verbally inappropriate to her two days ago, but was not sure if that was "abuse," therefore, took no action to identify the CNA, investigate, or report the allegation to the Administrator and DON. The DSD indicated she was aware that a suspected abuse investigation needed to be initiated, further stating, "I have no clue how to conduct an abuse investigation." On 10/31/14 at 9:50 am, Registered Nurse (RN) A was interviewed and stated that she did not know how to conduct an abuse investigation. On 10/31/14 at 10:55 am, the DSD and RN A were informed that the residents were determined to be at immediate risk for continued abuse and/or mistreatment due to the facility's lack of sufficiently operationalize their Abuse policy and procedures regarding reporting, investigation and resident protection, and an IJ was declared. On 10/31/14 at 12:20 pm, RN A stated that she had phoned the Administrator and he refused her request to come in and help with the abuse investigation, but gave her instructions on how to conduct the investigation over the phone. On 10/31/14 at 3:40 pm, a telephone interview was conducted with the GB. The GB revealed that there had been problems with the current Administrator's ability to administer the facility for "some time now." The GB stated that the Administrator and Director of Nursing were not physically spending an adequate number of hours at the facility to properly manage it. On 11/5/14 at 10:05 am, a corrective action plan was accepted from the Governing Body (GB), owner of the facility, which ensured resident safety and prevention of future occurrences, and the IJ was abated. The GB stated that he had terminated the Administrator.

Based on observation, interview, and record review, the facility failed to systematically implement its abuse policies when: 1. Resident 10's allegation of staff abuse and neglect was not reported to CDPH, was not thoroughly investigated and documented by the facility's Abuse Coordinator, and protective actions were not immediately initiated (staff reassignment or suspension and care plan development) for Resident 10 as she continued to have care provided by staff who she alleged had placed a hand upon her mouth to quiet her down when she asked for help and had left her in the bed soaked in urine through the night. 2. An allegation of verbal abuse between Residents 5 and 8 was not thoroughly investigated and documented by the facility's Abuse Coordinator. 3. The facility Mandated Reporting policy contained exclusions for mandated reporting that were not consistent with other sections of the policy. As a result of the above systemic failures, all the facility's residents were in Immediate Jeopardy (IJ) of potential harm from abuse. An IJ was declared on 6/30/14 at 7:18 pm, in the presence of the Administrator and the Director of Nurses (DON), due to the administrative systemic failure to report, investigate, protect, and intervene to ensure resident safety. The Immediate Jeopardy was abated in the presence of the DON, on 7/2/14 at 1:40 pm, after the facility implemented a corrective plan of action which ensured resident safety. 4. The facility failed to screen new employees to ensure residents were protected from potential abuse when the facility did not verify previous employers and/or current employers and check with the appropriate licensing boards for all new employees hired to work at the facility since 9/2013. Twenty new employees hired since 9/2013, did not have verification of their previous employers prior to starting work at the facility. Twelve of the 20 employees hired since 9/2013, to work in the nursing department, did not have verification from the appropriate licensing boards and registries. The verification would have included any disciplinary actions taken by the board and/or registry. This failure had the potential for the facility not to detect if an employee was unfit to provide resident care or services which could result in abuse, neglect, or mistreatment toward all residents who resided in the facility. Due to the system failure and the potential for resident abuse when employees were not adequately screened for employment past or current, and licensure/certifications were not verified prior to being hired at the facility and in contact with residents, an IJ was declared on 6/25/14 at 5:20 pm, in the presence of the Administrator and the DON. The IJ was abated on 6/26/14 at 12:48 pm, in the presence of the Administrator and DON, after the facility implemented a corrective plan of action which ensured a system was in place to screen all new potential employees for abuse, and the current employees hired since 9/2013 were also screened. Findings: 1. The facility's Abuse Prevention and Administrator Protocol Policy, dated 1/12, contained the following: "Definitions... 1. Abuse...mental abuse - includes but is not limited to, humiliation, harassment, threats of punishment or deprivation... 2. Neglect - failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." "Protection... 2. If the suspected perpetrator is an employee: Immediately remove the employee from the care of the resident. Suspend the employee during the investigation... 4. Social Services will evaluate the psychosocial impact of the incident on the resident and develop a plan to meet the psychosocial needs of the resident." "Investigation... Policy: Any complaint, observation or suspicion of resident abuse/neglect or misappropriation of resident property will be thoroughly investigated. Procedure: 1. Initiate the investigation on the shift that it was reported... 5. Continue the investigation until all witnesses have been interviewed and there has been enough objective information to make an informed decision... 6. The investigation will include attempts to identify: ... d. names of witnesses and their account when applicable... f. employee's account of incident when applicable... h. recommendations for corrective action if applicable i. outcome of investigation j. follow up resolution or further action if necessary" A review of Resident 10's record disclosed she was admitted to the facility on [DATE], for physical rehabilitation with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, an assessment tool), dated 4/22/14, identified that Resident 10 needed two person extensive assistance with her toileting needs. A social service progress note, dated 6/2/14, read "SOC 341 completed...," a form used to report allegations of elder neglect and abuse." The note also read that Social Service met with resident and two family members, made a call to Ombudsman (a resident advocate) and resident's responsible party. The note also documented a call to the facility Administrator to notify. The note did not identify the nature of the allegation. On 6/19/14 at 6 pm, Resident 10 was observed seated in her wheelchair next to the front lobby door with oxygen in use. She stated, "I don't have a complaint now. They are doing everything right now." She stated that she had "Made a remark and became very upset." On 6/20/14 at 11:30 am, Social Service Director (SSD), who had documented the social service note, dated 6/2/14, provided a longer typed narrative note that she had signed which documented Resident 10's allegations. The SSD note read that Resident 10 had reported to her an incident of being left "laying in urine all night" and that another facility staff was aware she had made the complaint a few nights before, "...and staff were concerned that she is still repeating it." It continued to read, Resident 10 stated to SSD on 6/2/14, "For the last four or five nights I have had to lay in urine all night..." Resident 10 reported to SSD that the last night this occurred was on 6/1/14. Resident 10 stated that a PM shift nurse had assisted her with a bed change, then later that evening she had to urinate again and used her call light, "I kept calling and calling and finally someone came." Resident 10 stated the female staff who responded "...shoved a porta potty under me and said there! Now pee! Pee! Pee! And left me there." Resident 10 stated that the bed pan had overflowed onto her bed and she was wet all night. Resident 10 stated to SSD that she had used her call light but that the staff that had responded said, "If I would shut my mouth, she would help me but can not help me if I won't shut up! She put her hand on my mouth." Resident 10 was able to give a description of the staff that interacted with her that night. On 6/20/14 at 11:30 am, SSD stated that she had followed the facility policy when she used a guide presented by the Ombudsman's office that excluded mandated reporting to CDPH from all types of reporting, except physical abuse. She stated that she thought that the state and ombudsman were the same department. SSD stated that she believed Resident 10 may have experienced neglect or abuse and that Resident 10 had ongoing anxiety. SSD stated that she did not initiate a care plan for Resident 10 regarding the neglect and abuse she may have experienced. No further social service follow up was done to determine if Resident 10 had fabricated her allegations or had continued fear of facility staff. On 6/23/14 at 3:45 pm, Resident 10 was interviewed and stated, "Anything that happened was taken care of and done with." On 6/30/14 at 5:07 pm, the facility Abuse Coordinator (the facility Administrator- Admin) was interviewed. Admin stated, "(Resident 10's) allegations should have been reported to the State (CDPH). He said he had not investigated her allegations beyond having a Interdisciplinary Team (IDT) meeting with (Resident 10) on 6/3/14, and her family, where her descriptions of staff involved had changed." Admin confirmed none of the staff who had been described by Resident 10 were suspended, pending an investigation, and continued to care for her and other residents. 2. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admin then provided an SOC 341, dated 5/16/14, completed by the facility Occupational Therapist (OT) that read, on 5/16/14 at approximately 4:15 pm, Resident 5 made an abusive statement to her roommate, Resident 8, that resulted in Resident 8 being fearful of returning to her room and being in tears. The reporting section of the SOC 341 report was blank. During an interview on 6/30/14 at 5:07 pm, Admin stated, "he was unable to provide any reports of facility investigation for abuse allegations over the past survey year." Admin confirmed he had not kept records of investigations and follow up to allegations. Admin stated, "The facility usually followed the Ombudsman guide for reporting and usually the person that witnesses the incident faxes the reports and slips it under my door." On 7/3/14 at 9:45 am, OT stated, "she was the staff that Resident 8 had reported the verbal abuse allegation to, that she coordinated a room change with nursing, SSD, and notified the Administrator." OT stated, "She did not notify the ombudsman or State (CDPH) of the incident because the Administrator said he would take care of the reporting." On 7/3/14 at 10:30 am, during a concurrent interview and record review with the Director of Nursing (DON), both Resident 5 and Resident 8's records were reviewed. DON stated both records did not contain nursing notes or care plans or social service notes for follow up of the 5/16/14 allegations or room change. During an interview on 6/30/14 at 5:07 pm, Admin stated, "he thought that his OT had reported to the Ombudsman the allegation of verbal abuse between Residents 5 and 8." Admin confirmed he did not follow up and investigate. 3. Two pages were inserted in the Abuse Prevention Policy in place of pages 14 and 15, revised 1/15/13, and read: "Mandated Reporting...A mandated reporter shall not be required to report, a suspected abuse/neglect, for an incident where all the following conditions are met: a. The mandated reporter is aware that there is a proper plan of care b. The mandated reporter is aware that the plan of care was properly provided or executed c. a physical, mental, or medical injury occurred as a result of care provided pursuant to the Above previous points d. The mandated reporter reasonably believes that the injury was not the result of Abuse/neglect..." The "Mandated Reporter" policy continued on the second page to read: "Reporting Actual and Suspected Physical Abuse" includes notifying law enforcement, ombudsman and licensing within two hours of a physical abuse resulting in serious bodily injury, and within 24 hours of physical abuse not resulting in serious bodily injury. No further reporting guidance was provided in the "Mandated Reporter" section of the Abuse Prevention Policy, for required reporting of neglect, verbal abuse, sexual abuse, financial abuse, mental abuse, involuntary seclusion or misappropriation of resident property. The above policy's reporting requirement was inconsistent with the reporting requirements of the Administrative Protocol as below. Page 17/23 of the Abuse/Admin Protocols under Administrative Protocol," revised 1/12, read: " Reporting: ... 1. An initial written report is completed and the Department of Health, Licensing and Certification, is notified within twenty-four (24) hours 2. To complete the Investigation, the Administrator notifies all appropriate state agencies of the results of the investigation within five (5) days of the incident ... " On 6/30/14 at 5:30 pm, Admin stated that he did not keep files and notes of the allegations made by Resident 10 or a report of an investigation, as required, for Resident 10, that he did not report Resident 10's allegations of staff abuse and neglect to the State, and he did not keep a file of investigation or make a report to the ombudsman for allegations of verbal abuse toward Resident 8 by Resident 5, as required by the facility policy. 4. On 6/26/14 at 2 pm, the facility's screening process for new employees was reviewed with the Business Office Manager (BOM). Two of the five employees whose records were reviewed revealed the following: License Nurse (LN) E was hired on 2/14/14, and Certified Nurses Assistant (CNA) F was hired on 4/8/14. Neither of the employees' files indicated the previous employment had been verified or the current license or certifications had been verified. The BOM stated it was not her responsibility to verify past or current employment or verify if the employee had a current license or certification and stated it was the responsibility of the department heads or the Director of Staff Development (DSD) to verify employment and licenses. During an interview on 6/25/14 at 4 pm, the DSD stated she became the DSD on 1/27/14. She stated she was not aware it was her responsibility to verify a new potential employee's previous employment, or verify if the licensure or certification the nursing staff was current and without incidents against their license. On 6/25/14 at 4:20 pm, LN G stated he had been the previous DSD for two months, from September 2013 - November 2013. LN G stated when he was DSD, he had not verified prior employment for all new potential employees, or verified if licensure or certification were current for potential new nursing staff. On 6/25/14 at 4:40 pm, the Admin stated he was responsible for the abuse policy which included screening of new employees and it was the job duty of the DSD to ensure screening was done prior to hire. On 6/25/14 at 5:10 pm, a concurrent review of a list of employees hired by the facility from 5/1/13 to 4/8/14, and interview was conducted with the DSD. The employee list indicated since September 2013, there were 20 new employees (EE 1 -20), hired by the facility. The DSD stated she had a file for each of the EEs for inservice training and did not verify past employment. The list indicated 13 of the 20 (EEs 3, 5, 6, 7, 11, 12, 13, 14, 15, 16, 18, 19, and 20) new employees were in the nursing department, and were either licensed or certified. The DSD stated the 13 EE's had not had their license or certification verified and stated the verifications needed to be done to ensure potential abusive staff were not hired. A policy, dated 1/12, titled, "Screening" included "All potential employees will be screened prior to employment. The facility will not employ individuals who have been found guilty of abuse ... ." All CNA's will be screened through the California Department of Health (DHS), Licensing and Certifications' CNA's Abuse/Neglect Registry and Certification Verification Program. Individuals who have findings related to abuse, neglect or misappropriation of property will not be eligible for hire. Under Procedure, 2. The applicant will be required to provide professional references when applying for a position. 6. The Department Manager will verify the certificate/license with the appropriate state agency and document findings, per facility policy.

Based on observation, interview, and record review the facility failed to ensure two of eleven sampled residents (3 and 6) and 12 residents (14, 16, 17, 19, 21, 23, 25, 26, 27, 28, 29, and 30) outside the sample received necessary care to maintain their health in accordance with their assessment, and physician's plan of care. 1. On 6/19/14, five of five residents (Residents 14, 16, 23, 27, and 30) did not have their blood glucose (bg, blood sugar normal range is 70-110) levels checked in the morning before breakfast, as ordered by their physician; and one resident (Resident 23) who was tested , could not be re-tested , when the bg level reading was low (60). The facility ran out of supplies (bg monitor test strips) and could not perform tests (a drop of blood is placed on the bg monitor test strip and the bg monitor displays a bg reading level) necessary to check the residents' bg levels. Because the facility did not have enough bg monitor test strips to perform Resident 30's bg test, it was unknown if Resident 30 needed insulin or treatment prior to when he received his morning meal. The facility failed to notify the above residents' physicians and/or the physician's assistant (PA) that the bg testing not performed. 2. Four residents, Residents 16, 17, 21, and 26 did not receive stomach medication, [MEDICATION NAME], to reduce acid levels, for eight days. 3. Six residents, Residents 6, 19, 21, 25, 28, and 29 did not receive physician ordered medicated cream (BAZA) for 6 weeks. (BAZA Anti-fungal Cream is a moisture barrier cream made from a Zinc oxide-based with antifungal medication, [MEDICATION NAME] to inhibit fungal growth. BAZA is used to treat yeast, and provides a moisture barrier against urine and feces to prevent skin breakdown). The facility failed to notify the above residents' physicians and/or the physician's assistant (PA) that the Baza cream was not given. or bg testing not performed. 4. The facility failed to ensure that outdated/expired drugs and treatment supplies were not used for the treatment of [REDACTED]. These failed practices put residents at risk for: 1. [DIAGNOSES REDACTED] (not enough blood sugar) or [MEDICAL CONDITION] (too much blood sugar) which could result in coma and death when bg was not properly assessed as ordered and treated for [REDACTED]. 2. Rebound gastro-[MEDICAL CONDITION] reflux (stomach acid in the esophagus), esophagitis (irritation of the esophagus - throat), and risk for gastro-intestinal (GI) bleeding when acid reducing medication, [MEDICATION NAME] was not provided as ordered. 3. Skin deterioration and breakdown when ordered medicated cream, BAZA cream, was not available for weeks. 4. Further complications to residents when the medical providers were not informed of the residents' accurate and current medical care information and needs. 5. Outdated/expired drugs and treatment supplies were stored in the treatment cart and were available for use for all residents in the facility. This failure had the potential to cause and or contribute to a wound infection for Resident 3 and other residents who required treatments, and other adverse clinical outcomes. Due to the facility's system failures, the inability of the facility to provide the necessary care and services, and ensure basic medications and diabetic supplies were available, diabetic monitoring could not be done and physician's orders [REDACTED]. On 6/20/14 at 4:48 pm, the facility provided an acceptable corrective action plan which included: identification of a process to order diabetic supplies, ensure necessary medications and supplies, as ordered by the physician, were available for use, staff responsible for the inventory of supplies, in-service staff regarding the process to order supplies, notification of the physician in the event of missed medication or bg testing. On 6/24/14 at 3:05 pm, the IJ was abated in the presence of the Administrator and DON, when the facility provided evidence of implementation of the corrective action plan. Findings: 1. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14 was previously on "sliding scale" (ss, amount of insulin varies according to the results of the bg) insulin and fasting (before eating) bg testing three times daily. On 6/10/14, the physician discontinued the ss insulin and ordered fasting (before eating) am and bedtime bg testing. Resident 16 was admitted to the facility on [DATE] with Type 2 Diabetes (non-insulin), pain, and feeding problem. The physician ordered [MEDICATION NAME] 20 milligrams (mg) daily for Gastro-Intestinal (GI) distress, and on 1/22/14 daily FSBS (fasting blood sugar) check daily before breakfast. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Insulin ([MEDICATION NAME], a certain type of insulin) 37 units subcutaneous (sq, under the skin into the tissue) was ordered daily at bedtime, and ss insulin in addition, for bg test over 140, starting with 3 units of [MEDICATION NAME] (short acting) insulin, and increasing amounts, up to 10 units with bg of 300. If the bg test was low and below 60, then additional orders included to give [MEDICATION NAME] (glucose) if still conscious. Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered bg testing every morning. Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30 also received two oral medications to treat his diabetes, [MEDICATION NAME] and [MEDICATION NAME] daily. On 6/16/14, the physician added [MEDICATION NAME] 5 units sq at bedtime. On 6/19/14 a document titled, "Assure 4 Blood Glucose Monitoring System: Daily Quality Control Record," dated June 2014, was reviewed. The night shift nurse indicated on 6/19/14, she could not perform the daily control test done on night shift which ensured the bg monitor machines were calibrated (a check done to ensure accuracy) and worked correctly, and on line 19 noted, "No Done - No Test Strips." On 6/19/14 at 8:38 am, Licensed Nurse (LN I) confirmed the above document findings and stated the night nurse had saved two test strips to use for the two diabetic residents who received insulin. LN I stated one of the test strips had failed due to a lack of enough blood on the bg test strip and she was unable to check Resident 30's need for insulin prior to his meal. LN I stated Resident 30 had received 4 units of insulin last night at bedtime based on the bg test results. On 6/19/14 at 8:50 am, LN H stated Resident 23's bg was checked and was 60, which was low. LN stated she was unable to re-test Resident 23's bg level because the facility was out of bg test strips and no more were available for use. Two of the non-insulin dependent residents, Residents 14 and 16, did not have their bgs tested before breakfast, as ordered on [DATE]. Resident 14 received two oral diabetic medications (anti-hyperglycemic) and was not checked to ensure her bg level was within a safe range, and the oral diabetic medications were effective. Resident 27, an insulin dependent resident, was not tested to determine her bg before she received insulin. On 6/19/14 at 8:54 am, the DON entered the facility and stated she had to purchase a new bg monitor (BGM) because the bg monitor strips for the two BGMs the facility had were not available. The DON stated she had received a message from a nurse at 6:30 am, "the facility had only two bg test strips, could not do all resident's bg testing, and could not calibrate the two BGM's during the night. She stated that Residents 23 and 30, who required insulin on a "sliding scale" had been tested . The DON then calibrated the new BGM at 9:30 am, and stated, "what is the use of testing the diabetic residents who have already had their breakfast." The DON then spoke to LN H and LN I, and was informed at 9:40 am, only one bg test had been completed for Resident 23 and Resident 30 had not been tested . The DON stated the nurses had let the BGM testing supplies run out and this was unacceptable and stated the nurses know to put a "sticky note" and hang it on her office door or at the nurses station. She stated the BGMs were recently purchased and had come with plenty of bg testing strips and "should not be out." During a confidential staff interview (CS A), stated a note to the attention of the DON had been posted at the nurses station over a week ago informing the DON more bg test strips were needed. CS A stated for the last three months it was not uncommon to run out of dressing supplies and over the counter medications. On 6/19/14 at 9:15 am, LN H and I confirmed Residents 14, 16, 23, 27, and 30's physician(s) had not been informed bg testing was not done as ordered. On 6/19/14 at 6:30 pm, the Medical Provider (MP, Physician or Physician Assistant) for Residents 14, 23, 27 and 30 was interviewed. The MP stated it was unacceptable and dangerous for diabetics residents not to be tested and the residents are at risk for [MEDICAL CONDITION] (high to blood sugar) or [DIAGNOSES REDACTED] which could cause a severe reaction and can even cause death if untreated. 2. During the observation of the medication pass, it was identified on 6/18/14 and 6/19/14, Residents 16, 17, 21, and 26 did not receive stomach medication, [MEDICATION NAME] 20 mg as ordered for up to eight days. A review of the June 2014 Medication Administration Record(s) (MAR) indicated the following: a. Resident 16 did not receive [MEDICATION NAME] 20 mg twice daily as ordered on June 7, 8, 9, 10,12, 13,14, and on June 11, the am dose. b. Resident 17 did not receive [MEDICATION NAME] 20 mg once daily as ordered on June 7, 8, 9, 10, 12, 13, and 14. c. Resident 21 did not receive [MEDICATION NAME] 20 mg twice daily as ordered on June 7, 8, 9, 10, 11, 12, 13, and 14. d. Resident 26 did not receive [MEDICATION NAME] once daily as ordered on June 6, 7, 8, 9, 10, 12, 13, and 14. All of the above June 2014 MARs indicated the reason [MEDICATION NAME] was not given was because [MEDICATION NAME] was not available. Residents 16 and 26's June 2014 MARs indicated on 6/9/14, [MEDICATION NAME] 20 mg not available, "Administration aware." A review of the record indicated, Resident 16 was admitted to the facility on [DATE] with Type 2 Diabetes (non-insulin), pain, and feeding problem. The physician ordered [MEDICATION NAME] 20 milligrams (mg) daily for Gastro-Intestinal (GI) distress. A review of the record indicated, Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician also ordered [MEDICATION NAME] 20 mg daily for [MEDICAL CONDITION] acid reflux (stomach acid in the esophagus). A review of the record indicated, Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered both TUMS calcium chews as needed and [MEDICATION NAME] 20 mg twice daily for [MEDICAL CONDITION] reflux. A review of the record indicated, Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered [MEDICATION NAME] 20 mg daily for [MEDICAL CONDITION] reflux. On 6/19/14 at 1:48 pm, during a concurrent record review and interview, LN I verified the above findings of orders and medication, [MEDICATION NAME] not given as ordered. During a confidential staff interview CS B stated the facility has had issues with over the counter medications for the past three to four months, including [MEDICATION NAME], being available to administer as ordered. CS B stated the Administration was aware of the missing medication and told the nursing staff the medications were on back order and did not attempt to obtain the medication from an outside pharmacy. CS B stated the physician(s) had not been informed of [MEDICATION NAME], BAZA cream. On 6/19/14 at 6:30 pm, the MP stated residents who did not receive [MEDICATION NAME] as prescribed and the medication was stopped abruptly without reducing the medication slowly were at risk for GI bleeding, gastro-[MEDICAL CONDITION] reflux and esophagitis. MP stated the residents were too fragile to stop [MEDICATION NAME] abruptly due to their age and condition, and needed their medication as ordered. 3. During the observation of the medication pass and treatments, it was identified on 6/18/14 and 6/19/14, and during record review that Residents 6, 19, 21, 25, 28, and 29 did not receive physician ordered medicated cream (BAZA) for weeks. The June 2014 Treatment Administration Records (TAR) indicated the following: a. Resident 6 did not receive BAZA cream as ordered June 1-19. b. Resident 19 did not receive BAZA cream as ordered June 3-19. c. Resident 21 did not receive BAZA cream as ordered June 2-19. d. Resident 25 did not receive BAZA cream as ordered June 1-19. e. Resident 28 did not receive BAZA cream as ordered June 3-19. f. Resident 29 did not receive BAZA cream as ordered June 3-19. During a confidential staff interview, CS C stated the facility has had difficulty with medications including BAZA cream being available to administer as ordered, and the problem had been getting worse over the last three months. A review of the record indicated, Resident 6 was admitted to the facility on [DATE]. On 4/25/14 the physician ordered BAZA cream, apply each shift (there are three shifts daily) for treatment for [REDACTED]. A review of the record indicated, Resident 19 was admitted to the facility on [DATE]. On 2/22/14 the physician ordered BAZA cream each shift to buttocks, coccyx (tail bone area) and peri area, and after each brief (adult diaper) change. A review of the record indicated, Resident 21 was admitted to the facility on [DATE]. On 11/10/13 the physician ordered BAZA cream each shift to the peri area and buttocks and as needed with each brief change. A review of the record indicated, Resident 25 was admitted to the facility on [DATE]. On 4/25/14 the physician ordered BAZA cream each shift to buttocks, peri area, groin, abdominal folds for redness and excoriation (loss of skin layer). A review of the record indicated, Resident 28 was admitted to the facility on [DATE]. On 4/19/14 the physician ordered BAZA cream each shift to under breasts, abdominal folds, peri area and coccyx. A review of the record indicated, Resident 29 was admitted to the facility on [DATE]. On 4/19/14 the physician ordered BAZA cream to under breasts, perineal area and coccyx. On 6/19/14 at 4:20 pm, the DON verified the above findings, the orders for BAZA cream and the TAR's which indicated BAZA was not applied as ordered. The DON stated the facility could not get BAZA cream from the current company they ordered supplies from and ordered a substitute, Zinc Oxide 20 % (percent) cream, in place. The DON stated she "thought the physician(s) who had ordered BAZA for their residents were informed of the change to zinc oxide 20% cream" and the orders needed to be changed to show the new treatment. On 6/19/14 at 6:30 pm, the MP stated medicated cream (BAZA) was ordered for a specific treatment of [REDACTED]. MP stated the facility had not informed MP Residents 6, 19, 21, 25, 28, and 29 had not received BAZA cream as ordered for weeks, or Residents 16, 17, 21, and 26 had not received [MEDICATION NAME] as ordered. On 6/20/14 at 5 pm, the Medical Director stated it was not acceptable and was dangerous for Residents not to have diabetic testing as ordered, medications given as ordered ([MEDICATION NAME]) or prescription skin care cream, BAZA as ordered. The Medical Director stated they had not been notified medications had not been given as ordered until yesterday, after the surveyors had identified the problem. 4. A review of the record indicated Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. An open area to the coccyx was noted on 4/27/14. Resident 3 had a history of [REDACTED]. Resident 3's physician's orders [REDACTED]. Mix [MEDICATION NAME] (antibiotic) powder with wound hydrogel (wound treatment that contains a high percentage of water in a gel), saturate gauze packing with mixtures. Pack wound loosely. Apply foam dressing, secure with [MEDICATION NAME] (transparent dressing) and change daily." On 6/18/14 at 9:30 am, Licensed Nurse (LN) B was observed performing dressing changed to Resident 3's coccyx. The supplies were placed at Resident 3's bedside table before the treatment and the following were found to be outdated: plain packing strip (expiration date 5/2013), [MEDICATION NAME] ointment (expiration date 10/2013), collagen hydrogel wound dressing (expiration date 2/2014). LN B mixed the expired [MEDICATION NAME] ointment and collagen hydrogel wound dressing without looking at the expiration date and applied to Resident 3's coccyx. During a concurrent interview and document review on 6/18/14 at 9:35 am, LN B confirmed that the [MEDICATION NAME] ointment and collagen hydrogel wound dressing were both expired. LN B confirmed that the bottle of curity packing strip, although not used during the dressing change, had expired 5/2013. She also confirmed that the physician's orders [REDACTED]. On 6/18/14 at 9:45 am, the treatment cart (where extra supplies were stored) was checked together with LN B and two more tubes of collagen hydrogel wound dressing with an expiration date of 11/2013, and one tube with an expiration date of 2/2014 were found.

Based on observation, interview and record review, the facility failed to ensure three of 11 sampled residents (Residents 3, 7, and 13) did not develop a pressure ulcer (bedsore), when they did not receive necessary treatment and services to promote healing, prevent infection, prevent the pressure ulcers from worsening and prevent new sores from developing. 1. The care plan for Resident 3's Stage II (partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough/dead tissue) pressure ulcer to coccyx (tailbone) was not followed by staff, and staff did not revise or develop a new care plan when the pressure ulcer progressed to a Stage III (full thickness tissue loss, subcutaneous tissue may be visible but bone, tendon or muscle are not exposed. The area may display tunneling and undermining). The interventions in the pressure ulcer care plan and the facility's policy and procedure that included providing an alternating air mattress overlay, multivitamins, and notification of the physician of the worsening of the wound, were not implemented. The Interdisciplinary team did not meet, as required by the facility's policy, to discuss the interventions or any changes that were necessary. The physician's order for an appetite stimulant to help with Resident 3's nutritional status was not implemented. The Registered Dietitian's (RD) recommendations for nutritional support were not implemented in a timely manner (more than three months). Resident 3's pressure ulcer was treated with expired medication and treatment supplies. As a result, Resident 3 who was admitted on [DATE], without a pressure ulcer, acquired a pressure ulcer that progressed to a Stage III by 6/14/14, and became infected by 6/26/14. The outdated/expired drugs and treatment supplies that were used on Resident 3 were available for use on all residents in the facility. This had the potential to contribute to wound infections for all other residents who required treatments. 2. Resident 7 was admitted with a Stage II pressure ulcer and acquired another Stage II pressure ulcer after admission. The RD's recommendations for nutritional support to aid in wound healing were not followed in a timely manner. 3. Resident 13 was assessed to have an "excoriated" (raw, irritated area where the skin has been abraded) coccyx on 6/12/14. There was no nursing assessment, documentation, care planning, or placement of an Alternating Pressure Pad (APP) mattress as the facility's policy directed. The IDT was not involved in the development of interventions, treatment and care planning specific to Resident 13's pressure ulcer needs. Nursing staff had not recognized that excoriation on a bony prominence, such as the coccyx, was Stage I (an area of persistent redness) pressure ulcer formation. These failures resulted in the development of a Stage II pressure ulcer on Resident 13's coccyx and increased her potential for infection and pain. Due to the system failure, lack of implementation of the Wound and Pressure Ulcer Prevention and Management Policy and Procedure as well as multiple care plan interventions including an alternating air mattress overlay, administration of expired medication and treatment supplies, failure to conduct a significant change of condition assessment, failure to investigate and address the situation, and develop and implement a plan of action to prevent similar occurrences, on 6/25/14 at 5:35 pm, an Immediate Jeopardy was declared in the presence of the Administrator and Director of Nurses (DON). The Immediate Jeopardy was abated in the presence of the Administrator and DON, on 6/25/14 at 6:30 pm, after the facility implemented a corrective plan of action which ensured resident safety and needs and services were met. Findings: 1. A review of the medical record indicated Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 3 had a history of [REDACTED]. Resident 3 did not have a pressure ulcer upon admission. An open area to the coccyx was noted on 4/27/14. This area was noted to be a Stage III pressure ulcer by 6/14/14. According to the "National Pressure Ulcer Advisory Panel," a pressure ulcer is "localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear." a. The facility's policy and procedure titled, "Wound and Pressure Sore Prevention and Management Program" revised 4/2008, indicated that "2. Assessments are completed during admission, weekly for the first four weeks after admission, quarterly, and when the resident experiences a significant change of condition. 4. Based on facts identified during assessments, an interdisciplinary plan of care is developed to meet the resident's individual needs." "Preventative interventions are based upon assessment results, implemented as soon as risk is identified and reviewed and updated by the interdisciplinary team routinely. The facility has a wound committee that is interdisciplinary and meets regularly." Under Stage II and Stage III Pressure Ulcer Guidelines to "notify responsible party and the physician of the development of the pressure ulcer, reducing device in bed and chair, begin high protein supplement, request for multivitamins with minerals and Vitamin C order from the physician, develop a plan of care or update current plan of care." Resident 3's Pressure Risk Assessment form from TriLine (tool for estimating resident's risk for developing a pressure ulcer), was reviewed. According to directions on the form, it was to be completed quarterly and upon change of condition. A total score of 7 was assessed upon admission, on 2/14/14. The pressure ulcer risk assessment was next conducted on the following dates with the corresponding total scores: 5/15=16, 5/19=18, 5/21=21, 6/4=24 and 6/11=24. A total score of 12 or more represented a high risk for pressure ulcer development. Initially, Resident 3 was assessed as a low risk to develop a pressure ulcer but, after 5/15/14, was continually assessed as a high risk. A plan of care titled, "Potential for Pressure Sore Development and Potential for Loss of Skin Integrity" care plan was initiated in 2/2014, with the lists of interventions that included skin check daily, moisturizer to skin during care daily, and high protein supplement. Although skin breakdown was noted on 4/27/14 in the nurses' note, there was no care plan that addressed, actual as opposed to potential, skin breakdown, until 6/4/14 when a care plan for Resident 3's Stage II pressure ulcer was initiated. A review of the Stage II care plan that was initiated on 6/4/14, included the following interventions: notify MD (medical doctor), treatment per MD, turn and reposition every 1-2 hour, keep clean and dry, pressure reducing device on bed and chair, high protein nourishment, multivitamins, notify MD if treatment ineffective, notify dietician, keep MD aware of changes in wound and discuss risk of non-compliance and benefits of compliance. There was no evidence that multivitamins were ordered, the MD was notified, and no pressure reducing device was applied to Resident 3's bed. The following weekly "Dermal Wound Progress Note" and Documentation for Resident 3's pressure ulcer to coccyx measurements were as follows: 6/04/14, length 2 cm, width 1.6 cm, and depth 1 cm; 6/07/14, length 2 cm, width 1.6 cm, and depth 1 cm; 6/14/14, length 3.1 cm, width 2.4 cm, and depth 1 cm; 6/22/14, length 3 cm, width 2.8 cm, and depth 1 cm. An interview was conducted with LN C on 6/25/14 at 4:30 pm. LN C stated that Resident 3 was non-complaint with repositioning, had poor appetite, was very bony and losing weight. When asked about the open area on coccyx on 4/27/14, she stated she did not call it a pressure ulcer but mentioned excoriation. LN C confirmed that open areas which occurred in a bony prominence like the coccyx was considered a pressure ulcer and that Resident 3's open area to coccyx should have been identified as a pressure ulcer. LN C stated she did not know the policy and procedure on "Wound and Pressure Sore Prevention and Management Program." During a concurrent interview and record review with the DON on 6/19/14 at 4:45 pm, DON stated that any open areas in bony prominences should be considered a pressure ulcer. DON also stated that pressure ulcer care plan should be updated to reflect the current status and treatment. She confirmed that Stage II pressure care plan interventions were not followed such as pressure reducing device, multivitamins, high-protein supplement and that there was no actual care plan developed for Stage III pressure ulcer. She further stated that she was not aware of the interventions for treatment of [REDACTED]." An interview was conducted with LN C on 6/25/14 at 4:30 pm. LN C stated she developed the care plan and the interventions. She stated that for the pressure reducing device for the bed, sometime in 4/2014, a call was made to a company to order a couple of mattresses. LN C was told that the facility was no longer in contract with them. LN C notified the DON and was told that the facility would find a new company where they could order the mattresses and get a new wound nurse consultant. LN C confirmed that multiple interventions for the Stage II pressure care plan were not followed and there was no actual care plan for the Stage III pressure ulcer. LN C also stated since the new DON took over, they had not been meeting as a team. She stated, "everything was pretty disorganized, there was no collaboration on what to do." LN C stated that a lot of supplies including treatment supplies were not available and supplies that had been requested were still not available a couple of weeks later. During an interview with the DON on 6/20/14 at 1 pm, she stated that a dynamic mattress (helps reduce pressure)was ordered for Resident 3. She confirmed that the facility's system was broken. She stated, "I can't argue what's in the paper and what we talked about." DON also stated that she got written up by the Administrator for not following the facility's policy by not ordering an appropriate pressure reducing device for Resident 3's pressure ulcer. There were telephone orders to treat the pressure ulcer from Resident 3's physician documented by the nurses in the record for 4/27/14, 6/4/14, and 6/14/14 and these orders were documented as done on the Treatment Administration Record (TAR). The TAR indicated that on 5/29/14, a new treatment was started but there was no physician's order for this treatment. The facility's treatment communication binder for nurses that was provided by the facility was reviewed. On 6/8/14, the document indicated that Resident 3 had a Stage III on his coccyx that was cleaned with wound cleanser, triple antibiotic ointment applied, covered with foam and two suresites (transparent dressing) used to secure. The staff documented, "did not use [MEDICATION NAME] (topical medication used to treat bedsores) for open area. Call me for pow wow. This deepened by 5 mm. (millimeter) in one day." There was no documentation in Resident 3's medical record that this treatment was ordered by the physician nor he was notified of the progression of the pressure ulcer. A review of the Physician's Progress Notes from 2/2014-6/2014, disclosed that the physician did not address the pressure ulcer from the date of onset, on 4/27/2014 through the present. On 6/27/14 at 10:30 am, an interview was conducted with Resident 3's physician. He stated he was not notified of the pressure ulcer and that it did not reflect on his physician's progress notes. He confirmed that he was not called for any telephone treatment orders for Resident 3's coccyx pressure ulcer. During an interview on 6/20/14 at 1 pm, the DON confirmed that the facility did not follow the policy for "Wound and Pressure Sore Prevention and Management Program." When asked if this pressure ulcer could have been prevented, she stated, "there was no guarantee but it sure would have been good if the facility followed the interventions and the facility's policy." b. On 6/14/14, a new physician's telephone order was received that read, "1. discontinue current treatment for [REDACTED]. Coccyx wound: clean with wound cleanser. Mix [MEDICATION NAME] (antibiotic) powder with wound hydrogel (wound treatment that contains a high percentage of water in a gel), saturate gauze packing with mixtures. Pack wound loosely. Apply foam dressing, secure with [MEDICATION NAME] (transparent dressing) and change daily." On 6/18/14 at 9:30 am, Licensed Nurse (LN) B was observed performing a dressing change to Resident 3's coccyx. The supplies were placed at Resident 3's bedside table before the treatment and following were found to be outdated: plain packing strip (expiration date 5/2013), [MEDICATION NAME] ointment (expiration date 10/2013), collagen hydrogel wound dressing (expiration date 2/2014). LN B mixed the expired [MEDICATION NAME] ointment and collagen hydrogel wound dressing without looking at the expiration date and applied to Resident 3's pressure ulcer. Use of expired medication and supplies can be ineffective toward prevention of infection. During a concurrent interview and document review on 6/18/14 at 9:35 am, LN B confirmed that the [MEDICATION NAME] ointment and collagen hydrogel wound dressing were both expired. LN B confirmed that the bottle of curity packing strip was expired. Although it was not used during the dressing change, it was available and on Resident 3's bedside table. LN B also confirmed that the physician's order was to use [MEDICATION NAME] powder. She confirmed she did not use [MEDICATION NAME] powder as ordered by the physician, but instead used [MEDICATION NAME] ointment. On 6/18/14 at 9:45 am, the treatment cart (where extra resident supplies were stored) was checked together with LN B who confirmed two more tubes of collagen hydrogel wound dressing with an expiration date of 11/2013, and one tube with an expiration date of 2/2014 were found. These supplies were available for use for all residents in the facility. A wound culture collected on 6/26/14 indicated the wound was infected with [MEDICAL CONDITION] Resistant Staph Aureus (MRSA, a drug resistant bacteria that is spread by contact and common among people with weak immune systems). c. An article published in 2009 by the National Pressure Ulcer Advisory Panel and titled, "The Role of Nutrition in Pressure Ulcer Prevention and Treatment," addressed the issue of nutrition. It read, "General consensus indicates that nutrition is an important aspect of a comprehensive care plan for prevention and treatment of [REDACTED]. Adequate calories, protein, fluids, vitamins and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown." Resident 3's physician had given a telephone order on 4/30/14, for [MEDICATION NAME] (medication to stimulate the appetite) without a dose and frequency. The order was documented in the diet order and was noted by the Director of Nurses (DON). On 6/19/14 at 5 pm, an interview and concurrent record review was conducted with the DON. DON confirmed that [MEDICATION NAME] was ordered by the physician and she processed the order but could not remember the exact dose and frequency. She also confirmed that it was not brought forward in the Medication Administration Records (MARs) for the months of 5/2014 and 6/2014 and had not been given. During a concurrent interview and record review with the Medical Record (MR) on 6/20/14 at 10:45 am, she stated that she printed the monthly physician's order on 4/28/14 for the month of 5/2014. MR further stated that the licensed nurse who was responsible for monthly recaps (physician orders from one month are carried over to the next month) did not include the [MEDICATION NAME] order on the MAR. MR confirmed that [MEDICATION NAME] was not given in 5/2014 and had not been started. On 6/27/14 at 10:30 am, an interview was conducted with Resident 3's physician. He stated he had not been notified that the [MEDICATION NAME], which he had ordered on [DATE], had not been started. The Nutrition Care Assessment completed by RD on 2/14/14 was reviewed. RD noted Resident 3's admission weight of 155 lbs and noted his usual weight was 163-165 lbs. RD recommended Resident 3 to start on health shakes (nutritional supplement) stat (immediately) for any weight loss. On 3/6/14, Resident 3's weight was 146.6 lbs. with total of 8.4 lbs. weight loss in less than one month (5.4%). The RD's recommendation to start health shakes for any weight loss was not acted upon until 5/30/14, which was two and one half months after Resident 3's initial (3/6/14) weight loss of 5.4%. During an interview on 6/27/14 at 2:25 pm, RD confirmed she had recommended health shakes for Resident 3 on 2/14/14. RD stated, "for a while her recommendations were not carried out, and that could be the reason Resident 3 did not get the health shakes right away." She confirmed the health shakes were not ordered by the physician until 5/30/14. 2. A review of the medical record indicated Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The "Admission Nursing Assessment" dated 1/4/14, was reviewed. It indicated Resident 7 had a pressure ulcer defined as a Stage II to her coccyx. The "Nutrition Care Assessment" completed by RD, dated 1/10/14, was reviewed. It indicated Resident 7's nutritional intake of calories and protein was "inadequate for healing" of the pressure ulcer and recommended a liquid supplement to increase calories and protein. The next RD assessment dated [DATE], indicated the initial recommendation of 1/10/14 had not been implemented and Resident 7's nutritional intake was "inappropriate" for pressure ulcer healing. The recommendation of 1/10/14 was repeated and a request for an increased protein diet was also made by the RD. Another RD assessment completed on 1/24/14, indicated none of the prior RD recommendations had been implemented by the facility and Resident 7's nutritional intake was still "inadequate for healing" of the pressure ulcer. Another recommendation was made for a liquid supplement to increase Resident 7's calorie and protein intake to promote wound healing. A document titled, "Pressure Ulcer Risk Assessment," was reviewed. The document was completed by the facility's licensed nurses to score the resident on their individual risk for developing and/or delaying of healing of pressure ulcers. The scores for Resident 7 dated 1/4, 1/11, 1/18, 1/25 and 2/1/14 were reviewed. Resident 7 scored 18 on each assessment. A score of 12 or above indicated the resident was at a high risk for pressure ulcer development, and/or delayed healing of a pressure ulcer. An RD assessment on 4/7/14 indicated Resident 7 had developed a new stage II pressure ulcer. The RD assessment on 5/22/14, indicated Resident 7's nutritional intake was "inadequate for healing" of the newest pressure ulcer and RD recommended protein powder be added to Resident 7's diet to promote healing. An RD assessment on 6/6/14, indicated no follow up by the facility related to the recommendation for protein powder on 5/22/14, to promote pressure ulcer healing and the recommendation was repeated. During an interview with the Director of Nursing on 6/19/14, at 5:30 pm she stated she alone reviews the RD interventions for "appropriateness" and RD interventions were not always communicated to the attending physician. DON stated no documentation was completed to know which recommendations have or have not been passed onto the attending physician for their review. DON stated the RD does sometimes recommend protein powder as it may assist in wound healing but the facility has not been able to obtain protein powder since March (3 months ago) from their usual supplier and no alternative supply source has been sought. DON further stated she should communicate all RD recommendations to the physician as it should ultimately be the physician's decision what recommendations will be initiated. DON could not show evidence any of the recommendations from the RD to the physician to enhance wound healing for Resident 7 had been communicated to the physician or acted upon by the facility. 3. Resident 13 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], showed that Resident 13 did not have a pressure ulcer but was at risk for developing one due to diabetes, weight loss and urinary incontinence (unable to control her bladder). Resident 13's medical record was reviewed. On 6/12/14 at 4 am, a registered nurse documented in the Nurse's Notes that Resident 13 had an "excoriated area" to her coccyx (tailbone) which measured 0.2 x 0.2 cm, and a physician ordered treatment was obtained. There were no further nursing assessments or documentation regarding Resident 13's excoriated coccyx, since it had been discovered on 6/12/14. There was no evidence that the IDT had met or discussed with Resident 13, a plan of care and treatment interventions to resolve her pressure ulcer. There was no care plan developed for the management of Resident 13's excoriated coccyx and an existing "Pressure Sore Prevention" care plan which had been initiated on 6/8/13, was not updated. Documentation on the "Skin Insults Tracking Log" dated 6/21/14, showed that Resident 13's coccyx wound progress had, "worsened." A "Dermal Wound Management Report" was not initiated until 6/24/14, twelve days after the discovery of Resident 13's excoriated coccyx, and showed that the excoriation had progressed to a Stage II pressure ulcer which measured 1.3 x 1.5 cm, an increase of six times the original size. The facility's policy titled, "Wound and Pressure Sore Prevention And Management Program" revised 4/2008, was reviewed and described a Stage I pressure ulcer as; "An observable pressure related alteration of intact skin whose indicators, as compared to an adjacent or opposite area of the body may include changes in one or more of the following parameters: 4. a defined area of persistent redness..." On 6/25/14 at 4 pm, an observation and interview was conducted with Resident 13. Resident 13 did not have an APP mattress on her bed. Resident 13 stated that she had not been offered an APP mattress. Resident 13 stated that she had not been invited to any discussions regarding a plan for the treatment of [REDACTED]. On 6/25/14 at 6 pm, the DON was interviewed. The DON confirmed that per facility policy any resident with a Stage II pressure ulcer was to have an Alternating Pressure Pad (APP, pressure reducing) mattress applied to their bed and Resident 13 did not have one. The DON stated, "it's my fault- I missed it." The DON confirmed that Resident 13's care plans were not developed and/or updated and that the IDT had not intervened.

Based on observation, interview, and record review, the facility failed to ensure residents and employees who cared for the residents were provided a safe, sanitary, and comfortable environment to prevent the development and transmission (spread) of disease and infection when: 1. a. Residents became ill (residents had symptoms of nausea, vomiting and diarrhea [MEDICATION NAME] up to 24 hours) and the facility's Administration failed to recognize and acknowledge an infectious "outbreak" (when three or more residents have the same symptoms within a short period of time on the same unit or area) had occurred in the facility. On [DATE], three residents developed symptoms of nausea and vomiting in the same area of the facility, and on [DATE], two more residents in the same area, had symptoms of vomiting and diarrhea. The Administrator and the Director of Nurses (the Infection Control Nurse-ICN), did not recognize the facility had an infectious outbreak and did not start the protocol to contain the spread of the outbreak until [DATE], when 15 residents had already developed symptoms of nausea, vomiting, and diarrhea. From [DATE] through [DATE], approximately 32 of 46 residents (Residents 1, 2, 4, 5, 7, 8, 9, 10, 11, 12, 14, 18, 19, 20, 21, 22, 25, 26, 27, 28, 29, 31, 32, 34, 35, 37, 38, 39, 40, 41, 42, and 43) who lived at the facility and became ill (residents had symptoms of nausea, vomiting and diarrhea [MEDICATION NAME] up to 24 hours) during an infectious outbreak at the facility and 16 employees (EE 1 -16) who cared for those residents became ill and were unable to work. 1. b. The facility failed to report an infectious outbreak to the local or State agency, in a timely manner (within 24 hours per state regulations). The facility outbreak was reported to the California Dept of Public Health (CDPH) on [DATE], five days after the facility should have known the facility had an infectious outbreak. 1. c. The facility failed to have an infection control program which provided oversight including planning, organizing, implementing, operating, monitoring, and maintaining all of the elements of the program when the nursing staff did not have the complete infection control information and the reference manual, directed in the policy to use, to implement the program when necessary. The manual was titled, Association for Professions in Infection Control (APIC). 2. The DON failed to follow the facility's policy and procedure and protect a resident (Resident 1) from the potential of the spread of an infectious organism (germ) when Resident 1's roommate, Resident 3, had a wound infection, Methicillin Resistant Staph Aureus (MRSA, a drug resistant organism to most antibiotics and can become life threatening due to the inability to manage and clear the MRSA organism ), and allowed Resident 1 to remain in the same room (co-habit) as Resident 3. Resident 1 had an indwelling catheter in his bladder which increased his potential for infection and the risk of developing the same MRSA infection. These failed practices resulted in resident exposure to the infectious outbreak for an additional period of time (48 hours), during which time it spread to a large number of the residents who lived at the facility, who were considered to be vulnerable to infection and have compromised health status. Residents experienced nausea, vomiting, diarrhea for ,[DATE] hours, and the risk of further permanent decline in their health status, up to and including the potential for death from complications from the infectious outbreak. All residents at the facility experienced restrictions in their daily activities, socialization, and limited staff to provide care, and a decline in their quality of daily life during the outbreak. Because the local and State agencies were not informed and aware of a serious outbreak which had the potential to impact the residents, their families and visitors, the agencies were not able to monitor and provide resident and public safety information and concerns. Nursing staff did not have available for immediate use, the infection control resources to identify, manage, and follow a protocol/policy for an infectious outbreak or other illness which resulted in the cohabitation of two residents, where one of the residents had a serious infection which put a resident at risk to have an increase exposure to a serious, life-threatening infection. Findings: 1. During the initiation of an investigation for a Complaint and Entity Reported Incident on [DATE] at 11 am, regarding an infection outbreak at the facility, the DON stated she was the ICN. Two documents titled, "Infection Log" (IL-Residents and IL-Staff) were reviewed with the DON. The IL-Residents indicated 32 residents and the IL-Staff indicated 15 facility staff had been identified by the facility, and had experienced symptoms (nausea, vomiting and/or diarrhea) of an infectious outbreak from ,[DATE] through [DATE]. The DON stated the facility identified the outbreak on Saturday, [DATE], three days after the first resident had become ill. The DON stated on [DATE], Residents 14, 42, and 43 had symptoms of nausea and vomiting, and she was not sure if the symptoms were related to each other. On [DATE], another two residents (Residents 33 and 34) had vomiting and diarrhea. The DON stated even though five residents had symptoms by the second day, the symptoms were "quick symptoms" [MEDICATION NAME] "four hours with nausea and vomiting, and the next day progressed to diarrhea, then the symptoms were over." The IL-Resident record indicated all five residents (Residents 14, 42, 43, 32, and 33) lived in the same area (wing) of the facility. The DON confirmed this finding. She stated by the third day, [DATE], the two residents who had been on comfort care (Residents 32 and 33) died (expected), and another resident (Resident 2) developed diarrhea and lived in the same wing. DON stated she was not sure if the ill residents and the symptoms they had was an outbreak. On [DATE], A concurrent review of the facility's policy, dated ,[DATE], titled, Viral Gastroenteritis Outbreaks was conducted with the DON. Page 5 directed, "5. Limit new admissions until the incident of new cases has reached zero for at least 48 hours. If new admissions are necessary, admit resident to an unaffected unit... ." Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the IL-Resident record was reviewed with the DON. Resident 4 was included on the IL-Resident log and indicated Resident 4 became ill with symptoms of diarrhea on [DATE] (3 days after admission to the facility during an outbreak), and her symptoms had resolved on [DATE]. The DON confirmed Resident 4 was admitted when resident symptoms were present in the facility, and stated the facility had not decided there was an outbreak at the time Resident 4 was admitted . On the same day Resident 4 was admitted to the facility, the facility had become aware of a potential outbreak, when five residents had developed symptoms of nausea, vomiting and diarrhea. On [DATE], LN H had attended the morning meeting with administrative staff and department heads present, and stated there were five residents in the facility with nausea, vomiting, and diarrhea. The DON stated, on [DATE] in the pm, there were no new cases, and on [DATE], when she called the facility, she was told there were 12 more residents with symptoms of nausea, vomiting and diarrhea. She stated she instructed the nurse on duty, Licensed Nurse (LN) M, to "shut it down." She stated all activities were canceled, both dining rooms were closed, a sign was placed on the facility entrance door about the outbreak and family members were called and told not to visit unless necessary. She stated residents, visitors, and staff, if able, were asked to wear a mask, and housekeeping staff cleaned with bleach solution on Saturday, [DATE]. The Medical Director was notified on [DATE], and he instructed to get a lab (stool) specimen when able, and gave orders for medication for the residents' symptoms. The DON stated today, [DATE], was the first day residents were allowed out of their rooms and able to resume activities outside their rooms, "they all have cabin fever from being kept in their room." The DON stated the facility administrator reported to both the local public health department and CDPH on [DATE], after 5 pm via fax. The DON stated she was not aware the facility had to report a potential infectious outbreak to the local public health or the CDPH within 48 hours. She stated she did not have a policy which directed the facility of when to report. The DON stated the facility did not have a specific Infection Control Manual. She stated she had become the DON on [DATE], and was still setting up manuals and procedures. A copy of faxed documents sent to the CDPH which contained a letter, dated [DATE], was reviewed by the DON. The documents indicated the facility was reporting the outbreak to CDPH. The DON confirmed the fax and the date of the letter was [DATE], six days after the first symptoms of the outbreak had started, and fours days after the facility identified there was an outbreak. On [DATE] at 1:30 pm, the DON stated her background was in emergency room and she did not have knowledge about "outbreaks" and did not think a quick illness could be an "outbreak." She stated a nurse (LN H) had come to the morning meeting, on [DATE], when all department managers were present, and stated she thought the facility had a "possible outbreak." The DON stated she did not have a manual or resources, and she had to find information about "what was an outbreak." DON stated she did not know there were reporting requirements to CDPH. On [DATE] at 1:30 pm, a concurrent review of an undated policy titled, Unusual Occurrences was conducted with the DON. The policy instructed, "Title 22, , Occurrences such as epidemia outbreaks ... and unusual occurrences ... shall be reported by the facility within 24 hours either by phone, fax to the local health department and Department of Health Services (CDPH)." The DON stated she did not know about this policy "until today." A concurrent review of the facility's policy, dated ,[DATE], titled, Viral Gastroenteritis Outbreaks was conducted with the DON. Page four directed, "An outbreak of viral gastroenteritis should be suspected when two or more resident and/or staff develop a new onset of vomiting and diarrhea within one to two days." The DON stated she later found a reference book titled, APIC (pertaining to Infection Control) and used the information from APIC precautions and advised staff what to do. She stated there is a policy that refers to the APIC manual kept in her office, which contained references and steps to take for a gastro-intestinal outbreak. The DON stated she did not come to the facility on [DATE], because she was ill herself with the outbreak symptoms and told the nurses what to do by phone. On [DATE] at 12:40 pm, LN H stated she had worked on [DATE], and after she had received the morning report from the night nurse and was told about the residents who had vomiting and diarrhea on her side of the facility, she went to the morning meeting at 9 am, and told the people at the meeting, which included the DON and the Administrator, she thought the facility had an outbreak. She wanted to let the Administrative staff know there were one to two sick residents the day before and now five residents were ill. She was told by the Administrator, in front of the group present at the meeting, "it was not an outbreak." LN H stated she informed the group that hand hygiene was important. LN H stated she was embarrassed how the Administrator spoke to her. LN H stated she told the Certified Nurses Aides (CNA) to "use extra precautions." During a confidential interview, a LN stated some of the staff became ill, and some of the staff was told to go home because activities had been canceled and the residents were in their rooms. LN stated it was a struggle to provide care, the CNA's ran from room to room, changing residents and trying to give them fluids. LN stated there was not enough staff to provide for all of the residents' care needs, and because of the outbreak, the residents who needed to be fed, were fed in their rooms, and meals were often not completed before the trays were picked up. LN stated there was not enough staff, and due to the additional needs of the residents because they were ill, more staff should have been utilized. On [DATE], in a confidential interview, a non-nursing staff stated the facility ran out of soap and staff had to get more. They did not know until [DATE] that the facility had an outbreak and additional supplies were needed, and there was not enough for an emergency or the outbreak. On [DATE], during a confidential interview, a Certified Nurses Aide (CNA) stated the facility ran out of soap and paper towels on [DATE], when many of the residents were ill and staff had to go and buy more. The CNA stated the facility ran out of tissue and briefs (adult incontinence pants) in the larger sizes and the residents who needed to wear a brief had to use a smaller size than what they needed. CNA stated the tape on the sides of the briefs left marks on the larger residents' skin. On [DATE] at 3:05 pm, the Minimum Data Set (MDS) nurse stated, on [DATE], a nurse at the morning meeting reported there were three or four residents with symptoms of vomiting and diarrhea, possible outbreak. MDS stated the Administrator stated, "three or four ill residents do not make an outbreak, and then criticized the nurse in front of the entire staff present at the meeting." On [DATE], resident rooms were observed and there were no tissue boxes at any of the bedsides, and rolls of toilet paper were found on some of the bedside tables or stands. During the resident rooms observations, a confidential family (CF) interview was conducted. CF stated there was no tissue to use during the outbreak and to date, there was not enough tissue. CF stated, during the outbreak, family members tried to help the staff, including CF because the CNA's told them they were short and it was "OK" to help them. During a confidential interview on [DATE], an LN stated the residents were all sick on one side of the building on ,[DATE] and ,[DATE], and by [DATE], the outbreak had spread throughout the building. LN stated the nurses stations ran out of soap, but someone got more so by the end of the shift more was available. The staff had to look for soap and some of the resident's rooms were also out. LN stated the DON and the Administrator were not present over the weekend of the outbreak, ,[DATE] and [DATE], leaving the staff to take care of things. LN stated the DON and Administrator did not provide the leadership they needed during the outbreak. During a confidential interview on [DATE], a CNA stated the facility ran out of briefs during the outbreak in larger sizes and instead had to use pull-ups (protective adult underwear with absorption) in the right size resulting in some of the residents being wet more than normal because of the lack of supplies. CNA stated there was no tissue and residents were given rolls of toilet paper at the bedside to wipe their noses. CNA stated the Administrator informed staff that many items were on "back order" and to "make do," the CNA borrowed items from other residents including shower soap, skin care products and searched for briefs in any size in other rooms. CNA stated the soap dispensers were frequently empty, and during the outbreak, it was hard at times to find hand sanitizer or soap. During an observation on [DATE] at 2 pm, the hand sanitizer dispenser in the hall between rooms [ROOM NUMBERS] was observed to be empty. This observation was verified by a confidential LN. On [DATE] at 6 pm, the Medical Director stated he was notified of the outbreak on [DATE], when over 15 residents were involved. He stated he was available and should have been notified when the first symptoms appeared. He stated the outbreak was worse than it should have been and a larger numbers of residents were ill because of the delays in communication from the Administrator and the DON. 2. On [DATE] at 8 am, the survey team identified that a resident (Resident 3) had developed a severe infection (MRSA) in a pressure ulcer (bedsore). Resident 3 shared a room with another resident (Resident 1) who had an indwelling catheter in his bladder to drain his urine. Resident 1 had a history of [REDACTED]. In a concurrent interview, LN G stated, at 9:15 am, the DON told the nursing staff it was "OK" to keep the two residents together because only Resident 1 used the bathroom and sink, and Resident 3 never got out of bed. On [DATE] at 11 am, Resident 1 and 3 were observed, continuing to share the same room. The DON was interviewed about the co-habitation of Resident 1 with Resident 3, and she stated she had checked the facility's policy which referred to the APIC manual. She stated the APIC manual did not have specific instructions and if the facility used precautions and protective gowns, gloves, and hand washing, the two residents could remain together. The policy and APIC information was requested for review. The DON stated the nurses do not have a copy of the APIC manual and she informed the nurses what they needed to do. A review of the facility's APIC manual, guideline ,[DATE] recommended isolation of patients with MRSA. On [DATE] at 4:30 pm, Medical Provider stated Resident 1 was already at risk due to his indwelling catheter and should not share a room with another resident who has MRSA. On [DATE] at 5 pm, the DON acknowledged the above findings, confirming Residents 1 and 3 should not share the same room.

Based on observation, interview, and record review, the facility failed to provide treatment and services for one of eleven sampled residents, Resident 1, when: Resident 1 (an alert and oriented resident) was given a different brand (Company B) of catheter to use, due to the cost, for his intermittent catheterization program (ICP, insertion and removal of a straight catheter into the bladder several times a day to drain urine) and the facility did not provide catheter-related education and training in the use of the new catheter, did not develop a care plan for Resident 1's ICP, and the ICP was not included in monthly Physician's orders. These failed practices resulted in staff not having orders or instructions how Resident 1 would be provided the necessary services, supplies and care to perform an ICP and Resident 1 inserting the wrong end of the catheter into his bladder, causing injury, bleeding, and pain to his urethra (a tube that connects the bladder to the urinary meatus for removal of urine from the body. In males the urethra travels through the penis). After this injury, Resident 1 was unable to continue with his ICP and had to use an indwelling catheter to drain his urine, putting him at further risk for complications for infection from having a constant catheter in place. Resident 1 suffered harm, pain, and his right to choose was violated, compromising his identity as a male, and dignity. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/31/13, the physician indicated in the history and physical that Resident 1, "... does have the mental capacity to understand ... [DIAGNOSES REDACTED]. On 10/1/13, the physician ordered to discontinue Resident 1's indwelling catheter and "start self straight cath as needed." (From the time of initial order, an order for [REDACTED]. A Daily Medicare nurses note, dated 10/1/14, included "... resident has been straight cath self for six months. May need patient education for ICP clean procedures." The Medicare nurses notes, dated 10/4 and 10/5/14, and Nurses notes, dated 10/1, 10/4, 10/5, and 10/6/14, reviewed Resident 1's education in using sterile technique for his ICP. On 10/6/13, the nurse documented Resident 1 was using sterile technique (catheter insertion under sanitary, sterile conditions in order to prevent the spread of bacteria into the bladder and urinary tract/bladder infection). On 12/9/13, nurses notes indicated Resident 1 was "tolerating self cathing well." Nurses notes, dated 3/29/14 at 1400 (2 pm), revealed, "Resident reported 2-3 days ago he inserted catheter with the wrong end, the cap was missing, painful with blood. About 0500 (5 am) resident weak with cathing (ICP). Urethra feels sore. Will continue to monitor." Physician's Orders, dated 4/8/14 at 11:15 am, revealed, "Foley Cath (indwelling catheter) ... for [MEDICAL CONDITION]." The next nurses note in the record, dated 4/8/14 at 11:20 am, read, "Foley Cath (indwelling catheter) inserted." Nurses notes dated, 5/23/14 at 2000 (8 pm) indicated, Resident complained of, "I don't like this leg bag thing (urinary drainage bag)." Advised resident as to necessity of Foley indwelling verse. self cath. Resident remains unhappy about situation. Patient education will continue." The physician progress notes [REDACTED]. " The next note, dated 6/10/14, "Plan - Appointment with urologist as soon as possible for evaluation of need for indwelling Foley verses daily self cath." Continue to treat (urinary) infections as they arrive. The next note, dated 6/24/14, included, "... complicated urological history ... . Patient has current indwelling Foley after urethral trauma from self cathing (ICP) with "wrong end" of a new brand of Foley." On 6/11/14 at 4:30 pm, during an interview and concurrent observation, Resident 1 stated when he arrived at the facility he had an indwelling Foley catheter, and had previously performed ICP for over six months when he lived at home. He stated when the indwelling catheter was removed, the nurse would bring him supplies to use each night. At first the catheter kits were contained in a (sterile) kit, including the catheter. He stated the Administrator informed him the kits were expensive and he was then provided sterile catheters and supplies separately. He stated the catheters he was given were soft and were green on the end where his urine would drain out. He stated he did have urinary infections even though he had learned the technique the nurses had instructed to keep the catheter clean during his ICP. Resident 1 stated, "in the beginning of March 2014, the Administrator informed him the catheters he was using were "too spendy" and he (Administrator) wanted him to have an indwelling catheter." Resident 1 stated he informed the Administrator at that time he did not want an indwelling catheter. Resident 1 stated he was given a new catheter, despite his objection, a clear hard one, with no specific markings on the package, except for an arrow where he would open the package that contained the catheters. He stated he used the catheters the same way he had used the others catheters with the "green end." Resident 1 stated the new clear catheters hurt each time he used them, and he used "more and more lubricant" to insert the catheters to drain his urine. He stated he did not want to complain because he knew the Administrator did not want him to do the ICP and he continued to use the catheters until he could not tolerate the pain and bleeding. He informed a nurse about the issue and was then told he had to have an indwelling catheter. Resident 1 stated he does not want the indwelling catheter but he "put the wrong end in and he was now hurt." During a concurrent observation, Resident 1 had two different catheters still in their packages. One catheter package was labeled, "Self Cath" by Company A, straight tip male" and was a tan flexible catheter with a rounded tip at the insertion end and a larger "green end" for the urine to drain from. There was clear markings and writing on the package which indicated with an arrow which end to open the catheter package, at the "green end." Resident 1 demonstrated by doing the motion of how he used this catheter and stated he would open the end with the arrow and "green end" and peel the package open, pull the catheter back and place lubricant on the tip of the catheter as it advanced out of the package, and would then insert the catheter. Resident 1 then reviewed the other catheter. The label was marked (Company B) clean cath 14 Fr (french, a size of catheter), 16" (inch). The package was clear with white paper. The catheter was clear, stiff, less flexible and was equal size on both ends. In the normal light of Resident 1's room, the ends of the catheters looked the same and to tell more detail, the catheter package was moved to the hallway light. One end of the catheter was slightly rounded at the end and the other end was straight. There was an arrow at the end of the catheter package, the end where the rounded end was, the insertion tip, and the drainage end was not marked. The two different catheters had the arrow to indicate where to open opposite of each other. Resident 1 then stated again, he would follow the arrow and open the arrow end of the package. He stated he could not see any difference in the ends of the (Company B) brand of catheter, so he continued to do his ICP as he had always done and open the package at the arrow, pull it out, apply lubricant when advanced out, and insert the catheter (the wrong end). When Resident 1 was asked if he could tell if there was a difference in the two ends of the Company B brand, he replied, "No, they looked the same, so I did what I had always done with the "green end catheter and opened it the same and inserted it from the same direction." He stated he could clearly see what end was the insertion end with the "green end" catheter. Resident 1 stated he did not receive any instruction or demonstration with the new catheter from the nursing staff, Administrator or DON. During a concurrent interview and record review with the Director of Nurses on 6/30/14 at 4 pm, she confirmed the physician's orders did not contain monthly orders for Resident 1's ICP. She confirmed the care plan for "ADL (Activities for Daily Living)" included 11/22/13: "Self cath per MD order," and did not include specific instructions what supplies the nurse should provide for Resident 1's ICP, and did not reflect there was a change in brand of catheters, and to re-instruct Resident 1 in the use of the new catheter. She also confirmed the nurses notes did not reflect Resident 1 had been given education or demonstration in use of the new catheter for his ICP and had been instructed in the use of the catheter. The DON stated, it was "sad" that Resident 1 was not instructed in the use of the new catheters he was given in March 2014. The DON stated she had to drive to a pharmacy to get the catheters Resident 1 liked to use, and "they were expensive." She stated she "remembered" there had been a change in the brand of the catheters supplied to Resident 1 for his ICP in March 2014. She stated she did not know Resident 1 had not been instructed in how to use the new brand of catheters. The DON stated the Administrator was responsible for ordering supplies, and that she was responsible for how the nurses or resident used the supplies. On 6/19/14 at 2 pm, the Administrator stated the facility had changed the company used to provide medical supplies in March 2014. On 6/27/14 at 2 pm, a concurrent review of the "Order Confirmation" from the suppliers was reviewed with the Administrator. There were receipts from a pharmacy for catheter supplies and signed by the DON for receipt for: 3/14/14 - 10 catheters, 3/19/14 - 12 catheters, and 3/24/14 - 30 catheters. (The Pharmacy verified the catheters were (Company A) 14 Fr, 16 inches straight catheters with a "green end" drainage on 7/8/14 at 2:30 pm). Also reviewed was the "Order Confirmation" and "Packing Slip," dated 3/19/14 and 4/1/14, from a provider, both included one case of (Company B) 14 Fr vinyl catheters (the last catheter supplied to Resident 1 for ICP). physician progress notes [REDACTED]. Patient has current indwelling Foley after urethral trauma from self cathing (ICP) with "wrong end" of a new brand of Foley (catheter)."

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status when staff did not recognize, evaluate, and address decreased intake for two of 11 sampled residents (Residents 3 and 5). The facility failed to act upon the Registered Dietitian's (RD) recommendations in a timely manner, failed to follow its weight management policies, and failed to follow physician's orders [REDACTED]. These failures contributed to Resident 3's continued avoidable weight loss, due to a delay in the implementation of measures to correct the weight loss, and contributed to delayed healing of a pressure ulcer (bedsore), and further decline in his health condition; and had the potential to contribute to severe weight loss and further decline in the condition of Resident 5. Findings: 1. A review of the record indicated Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. An open area to the coccyx (pressure ulcer over the tail bone) was noted on 4/27/14. The most recent Minimum Data Set (MDS, a resident assessment), dated 5/22/14, indicated that Resident 3 needed supervision with feeding, a history of poor appetite and dietary intake, and had severe weight loss. a. Resident 3's weight record was reviewed. Resident 3's Weight Monitoring Report Sheet indicated that on 2/14/14, his weight was 155 pounds (lbs.). The Nutrition Care Assessment completed by RD on 2/14/14 was reviewed. RD noted Resident 3's admission weight of 155 lbs and noted his usual weight was 163-165 lbs. RD recommended Resident 3 to be on "weekly weights for four weeks and to start on health shakes (nutritional supplement) stat (immediately) for any weight loss." There was nothing in the record to indicate that her recommendation for health shakes and weekly weights for four weeks after admission was acted upon. During an interview on 6/27/14 at 2:25 pm, RD confirmed she had recommended health shakes and weekly weights for four weeks for Resident 3. RD stated, "for a while her recommendations were not carried out," and that could be the reason Resident 3 did not get the health shakes right away. She confirmed the health shakes were not ordered by the physician until 5/30/14. During a concurrent interview and record review with the Director of Nursing (DON) and Dietary Manager (DM), on 6/19/14 at 12:45 pm, both confirmed that the recommendation from RD for weekly weights for four weeks and health shakes was not acted upon. An additional weekly weight information provided by DM, that was not in Resident 3's medical record, indicated that he refused the post admission weekly weights. DON stated she was not made aware of the refusal. b. An undated policy titled, "Nutritional Care Management Weight Variance Committee," was reviewed. It read as follows, "2. The Weight Variance Committee meets monthly, but may meet weekly if there are any significant weight issues. 8. Each resident on the agenda is discussed for possible nutritional interventions or other modifications in care plan to help resident achieve optimal weight or meet goals." During an interview on 6/19/14 at 12:45 pm, the DON was asked about the Weight Variance Committee and stated that the committee was composed of DON, DM, Social Services, Activities Director and Therapy. DON stated that per the facility's practice, they should meet thirty days after a resident's admission and weekly if significant weight loss was identified. DON confirmed that there was no weight variance meeting held in 3/2014 and that the facility did not follow their policy. c. On 6/18/14 at 8 am, Resident 3 was lying in bed asleep with his breakfast tray at his bedside covered and untouched. During an interview with Certified Nursing Assistant (CNA) 1 on 6/18/14 at 8:20 am, she stated that Resident 3 was very non-compliant with all care and had been refusing meals. CNA 1 stated that Resident 3 refused his breakfast this morning. On 6/19/14 at 8 am, Resident 3 was again lying in bed asleep with his breakfast tray at his bedside, covered and untouched. During an interview on 6/19/14 at 9:30 am, CNA 2 stated Resident 3 had eaten only three bites for breakfast. She stated that his health had been declining lately and he was non-compliant. On 3/6/14, Resident 3's weight was 146.6 lbs. with total of 8.4 lbs. weight loss in less than one month (5.4%). On 4/1/14, Resident 3's weight was recorded in his record as 134.4 lbs. This was a 12.2 lbs. weight loss from the previous month which was 8.3% loss in a month, 20.6 lbs (13.3%) weight loss in less than two months. The Dietary Progress Notes, dated 4/7/14, indicated, "PO intake after last week was 24%, including multiple meal refusals." Resident 3's physician had given a telephone order on 4/30/14, for [MEDICATION NAME](a medication that stimulates the appetite) without a dose frequency. The order was documented in the diet order and was processed by the DON. On 6/19/14 at 5 pm, an interview and concurrent record review was conducted with the DON. DON confirmed that the [MEDICATION NAME] was ordered by the physician and she processed the order but couldn't remember the exact dose and frequency. She also confirmed that the [MEDICATION NAME] was not included in the Medication Administration Records (MARs, part of the record where nurses document when medications were given) for the months of 5/2014 and 6/2014, and had not been given. During a concurrent interview and record review on 6/20/14 at 10:45 am, Medical Record (MR) staff stated she printed the monthly physician's orders [REDACTED]. MR further stated that the licensed nurse who was responsible for review of monthly orders did not include the [MEDICATION NAME] order on the MAR. MR confirmed that [MEDICATION NAME] was not given in 5/14, and as of 6/20/13, had not yet been started. During an interview on 6/27/14 at 10:30 am, Resident 3's physician (MD 1) confirmed he had ordered [MEDICATION NAME] in 4/14. MD 1 stated he had not been notified that [MEDICATION NAME] had not yet been started. A review of the record indicated that Med Pass (a nutritional supplement) was recommended by the RD on 4/7/14. It was not ordered by the physician and started until two weeks later on 4/22/14. This was more than one month after Resident 3's initial 5.4% weight loss and three weeks after he had lost 13.3% body weight. An order to fortify (add extra calories) Resident 3's diet and to start [MEDICATION NAME] was given by the physician on 4/30/14. As of 6/20/14, the [MEDICATION NAME] had not been started. The RD's recommendation to start health shakes for any weight loss was not acted upon until 5/30/14 which was almost three months after Resident 3's initial (3/6/14) weight loss of 5.4%. On 5/1/14, Resident 3's weight was recorded in the record as 127.2 lbs. with a total of 7.2 lbs. weight loss from the previous month which was 5.4% weight loss in a month, and 27.8 lbs. (17.9%) in less than three months which represented a severe weight loss. 2. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's admission weight was 92.2 pounds. The physician ordered a regular fortified diet on 8/29/12. Resident 5 gained weight, and on 9/1/13 weighed 98.2 pounds. On 2/1/14, Resident 5 weighed 88.4 pounds. The RD assessed Resident 5 on 2/7/14, and documented, "weight down 2 pounds in one month, 7.6 pounds in three months and 10.2 pounds in six months - underweight. Oral intake is 25-30 percent (%) of daily fortified diet plus Med Pass three times daily (100 %). Plan: Continue fortified diet, Med Pass three time daily. Start [MEDICATION NAME] to increase appetite. ... monitor weight change, monitor oral intake." On 3/1/14, Resident 5 weighed 86.4 pounds. The RD assessed Resident 5 on 3/14/14, and documented intake at 40%, gets high calorie snack at bedtime, fortified diet and Med Pass. "... very active, walks the halls all day. Endured two bouts of upper respiratory infection after six weeks, all resolved. Recommend [MEDICATION NAME] to increase appetite, small dose... . Triggered for weight loss, 7.7 % in three months and 12 % in six months." The RD assessed Resident on 5/28/14, and reviewed Resident 5's weight which was 82.4 pounds on 5/28/14. Resident 5 was re-weighed again and was 81.8 pounds. Intake and current interventions were reviewed, and again the RD recommended, "[MEDICATION NAME] to increase appetite." On 5/28/14, the DON wrote on a form titled, "Diet Order and Communication," a phone order from Resident 5's physician, "Start [MEDICATION NAME]." The order did not include the amount (dosage) of [MEDICATION NAME] and was an incomplete order. On 6/1/14, Resident 5 weighed 83.6 pounds. On 6/10/14, the RD reviews intake, diet, Med Pass and 10.2 pound weight loss in six months. The RD again recommended, "Consider [MEDICATION NAME] to increase appetite." A physician's orders [REDACTED]." A document titled, "Quarterly Nutrition Progress Record" indicated there was a review of Resident 5's intake and diet orders completed by the Dietary Services Supervisor (DSS) on 3/26/14 and 5/28/14. The record did not contain evidence of a weight variance committee meeting with more that one facility staff which included a review of Resident 5's care needs, weight, nutritional needs and recommendations by consultants. A document titled, Weight Variance Evaluation and Progress Note, dated 4/23/14, was reported and noted by both, the DON and the DSS. The form did not include recommendations or review of the RD consults. On 6/30/14 at 3:22 pm, the DON stated the "Diet Order and Communication" dated 5/28/14, was an order, but was incomplete and did not include the amount of [MEDICATION NAME] to administer to Resident 5. The DON acknowledged it took another four weeks to obtain a correct order. The DON confirmed the RD had made recommendations for [MEDICATION NAME] to stimulate the appetite of Resident 5 the first time on 2/7/14, almost five months ago, and the RD had continued to recommend [MEDICATION NAME] as an intervention for Resident 5's weight loss. The DON stated there had not been meetings for weight variances which would have included a review of the RD's recommendations.

Based on observation, interview, and record review, the facility failed to provide a psychiatric assessment, by a mental health professional, when indicated for one of 13 sampled residents (Resident 3). As a result of the facility's failure to provide necessary care and services, Resident 3 suffered symptoms that included withdrawn behavior, hallucinations, paranoia and delusional thoughts which caused her sadness, fear, and anxiety. Resident 3 had a decline in her cognitive abilities, activities of daily living, and weight loss. Resident 3 harmed herself on 1/3/13 using scissors and stated that she wanted to die. Resident 3 continued to make statements that she wanted to die. On 3/27/13, Resident 3 wrapped a cord around her neck in an attempt to harm herself. The facility's consultant pharmacist recommended that Resident 3's physician (MD - also the facility's Medical Director) consider obtaining a psychiatric evaluation and safer medication alternatives, however, the MD did not follow these recommendations. Resident 3 was determined to be at risk for self harm, receiving unnecessary medications with adverse medication effects, and sustained, prolonged mental distress. An Immediate Jeopardy (IJ) was declared on 5/7/13 at 8:08 am in the presence of the Administrator and Director of Nurses (DON). A corrective plan of action was accepted on 5/8/13 at 8:15 pm, and the IJ was abated in the presence of the Administrator. Refer to F 329 and F 428 for additional information. Findings: Resident 3's record was reviewed on 4/29/13. Resident 3 was admitted to the facility 3/21/10 with [DIAGNOSES REDACTED]. Resident 3's primary language is Spanish. Her initial social service assessment, dated 4/6/10, indicated that she can understand and read some English. From 3/14/12 to 5/4/13, Resident 3's record showed that she suffered with symptoms that included withdrawn behavior, hallucinations, paranoia and delusional thoughts. These symptoms caused her sadness, fear, and anxiety. Resident 3 reported seeing people that were not present and hearing voices that were not present. Resident 3's delusional thoughts involved fear that her meals were poisoned, that her son was dead or had been killed, and that people were outside her window, upstairs, or on the roof and were out to get her and her son (the building did not have a second level). Her delusional thoughts included several episodes of believing that a physician had told her not to eat that resulted in weight loss and that her son was coming to pick her up that resulted in elopement attempts and tearful episodes of sitting at the facility front door. On 4/24/12, a Physician's progress not read that Resident 3 was started on an anti-psychotic medication, [MEDICATION NAME] 1 milligram (mg) at bed time, due to the resident and staff reporting that she was up all night and that "She admits to hallucinations." A "black box warning" (the strongest warning that the United States Federal Food and Drug Administration (FDA) requires on labeling for side effects) for [MEDICATION NAME] was listed on Resident 3's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"An increased risk of mortality in the elderly with dementia related [MEDICAL CONDITION]." Resident 3 had a physician's orders [REDACTED]." This order was renewed monthly by the physician. However, no Mental Health professional evaluated Resident 3. Resident 3 showed a decline in her cognitive abilities and activities of daily living (ADL's) between 5/11/12 and 2/13/13. On 5/11/12, Resident 3's Minimum Data Set (MDS-an assessment), read that she had a moderate cognitive impairment with a Brief Inventory of Mental Status (BIMS) score of 10 out of 15. The higher the BIMS score the more cognitively aware a resident is. Resident 3's BIMS had declined to 6 out of 15 when evaluated on 2/13/13, indicating that she had severe cognitive impairment when assessed. Resident 3's MDS, dated [DATE], read that she was independent with dressing, eating, hygiene and using the toilet, Resident 3's MDS, dated [DATE], showed a decline in all these areas of daily activity and that she needed prompting and staff assistance to complete these activities. On 12/13/12, Resident 3 continued to have hallucinations and her [MEDICATION NAME] was increased to 1 mg twice a day. On 12/19/12, a physician's telephone order was received to increase Resident 3's bedtime dose of [MEDICATION NAME] to 2 mg, for a daily total of 3 mg. [MEDICATION NAME] 1 mg for anxiety, if needed every six hours, was also ordered. A urine analysis that was ordered was negative. Resident 3 continued to report anxiety and hallucinations on 12/31/12 when she was seen by the physician. On 1/3/13 at 11:30 am, a nurses note read that Resident 3 had an open area on her left wrist. The note read that Resident 3 stated that she "had taken needles to her wrist and poked her wrist with it." On 1/3/13, time not legible, an Interdisciplinary Team (IDT) met to discuss Resident 3's situation. The IDT progress note read that Resident 3 admitted to cutting herself with scissors and "stated that she wanted to die." All sharp objects were removed from her room which "upset" Resident 3. A small pair of scissors was discovered later in Resident 3's coat pocket. The note included an "Addendum: Acute care imperative after finding Resident 3 going through drawers of social service desk attempting to take fingernail clippers." On 1/3/13, Resident 3 was sent to the emergency room (ER) for a psychiatric evaluation, her son was present for this evaluation, and she was seen by the emergency room physician. The ER physician determined that she had "Acute [MEDICAL CONDITION], a suspected medication side effect from [MEDICATION NAME]" and "Acute incidental urinary tract infection." The ER physician determined that she did not need a psychiatric evaluation and made recommendations for the facility physician (MD) to taper down the [MEDICATION NAME] and consider another antipsychotic medication, [MEDICATION NAME]. Resident 3 was given a dose of [MEDICATION NAME] 1/2 mg in the ER. [MEDICATION NAME] has the same "black box" warning as [MEDICATION NAME] regarding risk of mortality in the elderly with dementia related [MEDICAL CONDITION]. Resident 3 was incontinent of bowel in the facility upon return from the emergency room that evening, which was not usual for her. On 1/4/12, the physician lowered the [MEDICATION NAME] dose to 1 mg in the morning and [MEDICATION NAME] was continued at 1/2 mg every night. On 1/21/13, Resident 3's physician (MD) discontinued [MEDICATION NAME] that Resident 3 was taking for nerve pain since 1/20/2011. This drug had a "black box" warning that read "risk for increase suicidal behaviors." Nurses's Notes from 1/8/13 through 1/27/13 read that Resident 3 made several attempts to exit the facility, had packed belongings multiple times, and waited at the front door believing her son was coming to pick her up. Her food and fluid intake was poor during this time period. A nutritional progress record, dated 2/5/13, read that Resident 3 lost eight pounds in a one month period, and had lost 10 pounds in the three month period from 11/2012 to 2/2013. A nurses note, dated 1/24/13, read that Resident 3's son was called, while she was at the door waiting for him. The note read that Resident 3 stated that her son was a liar, and that he was the reason that she was in the facility. The note also read "States she hears voices." On 1/28/13, Resident 3's physician's progress note read that she was tearful and that she was not eating her food but only drinking her milk because the "doctor told her to." The MD determined that Resident 3 was continuing to have hallucinations and discontinued the [MEDICATION NAME] and increased the [MEDICATION NAME] from 1/2 mg daily to 2 mg twice a day. The above [MEDICATION NAME] dose exceeded recommended daily dosing for the elderly and can present other unwanted effects such as Tardive dyskinesia (an irreversible involuntary muscle movement disorder), including death. Resident 3's physician (MD) ordered [MEDICATION NAME] 1 mg daily as a precaution for these side effects. No psychiatric evaluation by a mental health professional was obtained. On 2/2/13 at 1:44 pm, a nurses note read that Resident 3 had shakiness in both hands (possible side effect of medication or due to hydration or nutrition deficits). On 2/3/13 at 10:55 am, a nurses note read that Resident 3 was found on her bedroom floor on her hands and knees and that she reported that her knees had buckled. No injury was found. The note indicated that the Certified Nurses Aide (CNA) had reported that Resident 3 was more confused than usual, changed her clothes two times before the incident, and was using the bedside commode instead walking to her bathroom as she had done in the past. On 2/6/13 at 1 pm, a nurse's note read Resident 3 "continued to be unsteady on her feet." Resident 3 continued to have a poor appetite. On 2/18/13, no time, Resident 3's [MEDICATION NAME] dose was doubled, increased to 4 mg twice daily by the physician. The physician's progress note read that she was refusing to eat because "she is afraid she is being poisoned and has had weight loss." The physician (MD) determined that Resident 3 had "[MEDICAL CONDITION]." On 2/20/13 at 6:05 am, a nurses note read that Resident 3 stated, "I want to die" about three times, and that she calmed down with reassurance. No psychiatric assessment by a mental health professional was obtained. On 3/2/13 at 3:45 pm, a nurses note read Resident 3 had difficulty swallowing water with her pills. (Swallowing difficulties can also be a side effect of [MEDICATION NAME] or dehydration) On 3/3/13 at 1 pm, a nurses note read Resident 3 reported frequency and burning with urination, and stated that she did not like to drink liquids and she reported feeling depressed and lonely. On 3/4/13, Resident 3's physician (MD) ordered an antidepressant, [MEDICATION NAME] 25 mg daily. On 3/8/13 at 9 am, a nurses note read that Resident 3 continued to have difficulty swallowing pills. On 3/8/13 at 11 am, a nurse's progress note read that Resident 3's [MEDICATION NAME] was decreased to 3 mg twice a day, after discussed with her physician (MD). On 3/12/13 at 2 pm, a nurses note read that Resident 3 refused breakfast, and continued to report that a doctor had told her not to eat. The note read that Resident 3 had one episode of bowel incontinence, which was not usual for her. On 3/18/13 at 2:30 pm, Resident 3 had another unwitnessed fall without injury. The nurses note read that she was attempting to use the bedside commode without assistance. On 3/19/13, no time, a consultant pharmacist wrote a "Note to attending Physician/Prescriber" that read, "Resident is given [MEDICATION NAME] 3 mg twice a day. Nursing notes and IDT are concerned about her increasing ADL dependency, onset of bowel incontinence and recent fall." The consultant pharmacist continued writing that there were problems with the treatment that included use of [MEDICATION NAME] in the elderly being contraindicated (not recommended), that the dose exceeded the recommendation of 1/2 mg twice daily to start, and for the physician/prescriber to consider "a psych. consult or using a safer alternative." The pharmacists recommendation was not followed by the MD. On 4/16/13, the physician (MD) responded, "No change" and no psychiatric evaluation by a mental health professional was obtained. On 3/27/13 at 6:10 am, a progress note read that Resident 3 was found with a call light cord wrapped around her neck. The CNA stated that she removed the call light cord from Resident 3's neck. On 3/27/13 at 8:30 am, a IDT progress note read that another nurse reported that Resident 3 had been trying to tie the call light cord around her neck when she was found. The note read that there were concerns about the effects that Resident 3's current medication regimen may have on her mood and behavior. A consultant pharmacist was called for a full review. The note read, "call in to behavioral health to help with evaluation." Resident 3's corded call light was replaced with a cordless call bell and she was placed on close monitoring. On 3/27/13 at 6 pm, a IDT meeting was held with the family and Resident 3. The IDT progress note read that Resident 3 reported hearing a voice that morning telling her that her son was killed and that it made her feel like she did not want to live anymore if her son was gone. On 3/27/13, no time, a lengthy physician's progress note was written by the facility's Physician Assistant (PA). The PA note read that a meeting was held in the facility and "Since January 2013 she has had rapid worsening of depression with increased anxiety and two soft suicide events including this AM." The PA wrote that "During this time period her meds have been adjusted dramatically, with [MEDICATION NAME] and [MEDICATION NAME] in elderly, increased risk of side effects, and increased blood levels of [MEDICATION NAME] ([MEDICATION NAME]) when used with an SSRI (The type of anti-depressant Resident 3 was receiving)." The note read that the plan for Resident 3 was to decrease her [MEDICATION NAME] to 2 mg twice a day with a goal of discontinuing the medication over a period of two to four weeks. No psychiatric evaluation by a mental health professional was discussed in the PA's note. In response to a nursing request for a pharmacist re-evaluation on 3/27/13, a consultant pharmacist note was brought to the attention of the PA on 4/3/13 by the Director of Nurses (DON). The "Note to Nursing" contained seven recommendations that included "2. referral to psychiatric evaluation 3. Psych consult... and 7. Quantitative monitoring of episodes of hallucinations and depression before and during each change in psychoactive drugs?" No psychiatric evaluation by a mental health professional was obtained. On 4/29/13 at 4:35 pm, Resident 3 was observed in her bedroom sitting in her wheelchair between her bed and the bedroom window. She appeared to be looking out the window and at the pictures on her wall. Resident 3 agreed to an interview with an interpreter. Resident 3 stated that she is often sad, but that her son makes her happy when he visits. She stated, when asked about hallucinations, that "I am one with the air." She also stated that "nobody believes that I see people or hear voices." Resident 3 denied any current thought of self harm. On 5/2/13 at 3:20 pm, Social Service Director (SSD) stated that she had not made a psychiatric referral for Resident 3 after her second attempt at self harm because of the first emergency room physician's statement that Resident 3 did not need one because of her symptoms being related to dementia and urinary tract infections. She stated that Resident 3 had not been tolerating the [MEDICATION NAME] well. On 5/6/13 at 4:38 pm, DSS stated that the county behavioral health system had refused to see Resident 3 when told that Resident 3 had dementia. The DSS stated that she had made other attempts to obtain a psychiatric evaluation by a mental health professional in the area, but was not successful. That after Resident 3's second attempt at self harm, on 3/27/13, the IDT and PA felt their actions were enough to keep Resident 3 safe. Due to current risk to Resident 3 for self harm, receiving unnecessary medications with adverse medication effects, and sustained, prolonged mental distress, an Immediate Jeopardy (IJ) was declared on 5/7/13 at 8:08 am in the presence of the Administrator and Director of Nurses (DON). On 5/7/13 at 8:57 am, a "Behavioral Health Division" referral form was faxed to the south county office by the DON for Resident 3. The facility's policy, dated 2/09, titled, "Use of Standard Orders" read, "State and Federal regulations require the organization to provide ancillary services to residents. Ancillary services include...Psychiatric evaluation and treatment." The policy read, "If an emergent situation exists where immediate treatment is required and the physician is not available, the Director of Nursing or his/her designee may activate the standard order." The facility's undated policy, titled, "Behavior Management Medication Protocol," read, "b. The following steps occur regardless on when and if a medication is ordered: ... c. Social Services completes referrals to the Psychologist and/or Psychiatrist if appropriate and ordered by the primary care physician." On 5/8/13 at 1:30 pm, during an interview with the facility's Social Service Consultant (SSC-who holds a Masters in Social work and PhD), the SSC reported that she had instructed the SSD to obtain a psychiatric evaluation after Resident 3's first attempt at self harm. She stated that it was her role as a consultant to support the DSS and that she was not able to do clinical evaluations for the facility in her capacity. She stated that she was not consulted about Resident 3's second attempt of self harm. She stated that based upon her record review, Resident 3 "absolutely needed" a psychiatric evaluation by a mental health professional. She stated that she was aware that the SSD was not able to get anywhere with behavioral health. She stated that she had instructed the previous DON to "keep trying." A corrective plan of action to address the Immediate Jeopardy was submitted by the facility and accepted by the survey team on 5/8/13 at 8:15 pm, and the Administrator was informed that the IJ was abated.

Based on observation, interview, and record review, the facility failed to ensure that residents who receive [MEDICAL CONDITION] medications (anti-psychotic, anti-anxiety, anti-depressant, mood stabilizers, and hypnotics) had adequate indications for use, monitoring, and/or gradual dose reductions (GDRs) for 32 of 32 residents receiving [MEDICAL CONDITION] medications (Ten sampled residents, Residents 1, 2, 3, 4, 6, 7, 9, 10, 11, 12, and 22 residents outside the sample, Residents 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35). The Medical Director (MD) was the primary physician for 30 of the 32 affected residents at the facility who received [MEDICAL CONDITION] medications. (Residents 1, 2, 3, 7, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35). Physician B was the primary physician for Residents 4 and 6. a. Resident 3 received an excessive dose of an anti-psychotic medication that resulted in hospitalization , harm, and Immediate Jeopardy (Refer to F309). b. Residents 1, 2, 3, 4, 6, 7, 9, 10, 11, 15, 17, 18, 20, 23, 24, 27, 28, 30, 31, 32, 33, and 34 did not have evidence of gradual dose reductions or adequate justification to continue [MEDICAL CONDITION] medications, resulting in excessive dose/duration. c. Residents 7, 10, 11, 25, 30, 31, 32, and 35 received [MEDICAL CONDITION] medications without adequate indications. d. Residents 1, 2, 3, 4, 6, 7, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 received [MEDICAL CONDITION] medications without adequate monitoring for effectiveness. These failures had the potential for residents to receive unnecessary drugs and suffer from the harmful side effects of those drugs. Findings: The facility's undated policy regarding psychoactive medication use, titled, "Behavior Management Medication Protocol," required the following: "Every effort is made to ensure that residents that do not require these medications do not receive them; ..."Residents who are experiencing behavior related problems are assessed by the interdisciplinary team to attempt to determine cause(s) of the problem(s) before contacting the physician regarding the use of psychoactive medication..."The interdisciplinary team members monitor non-drug interventions for a minimum of 72 hours and document their observations." "Assessing Psychoactive Medication ... 3. The assessments for drug effectiveness and the occurrence of adverse reactions are ongoing and are documented on the Medication Administration Record. In addition the specific behavior(s) are tallied and quantified on a monthly assessment form (a narrative nursing note may be written if it meets all the state and federal indicators for monitoring of drugs to alter behavior.)" "Monitoring Antipsychotic Medications ... 6. Gradual dose reduction is attempted with all residents who receive antipsychotic medication, unless a reduction is clinically contraindicated. At least two attempts at dose reductions in a one year period are made before it can be determined that such dose reductions are contraindicated. The primary care physician must provide an explanation of the contraindication for dose reduction along with a risk to benefit analysis, in the resident's medical record. 7. The consultant reviews residents receiving antipsychotic medications and notifies the primary care physician and the director of Nursing if any antipsychotic medication does not comply with these guidelines." "Monitoring Antianxiety Medications ... 1. ...Short acting antianxiety medications are used unless the physician documents the medical necessity and a risk to benefit analysis for use of a long acting anti-anxiety in the medical record. 2. When anti-anxiety therapy is initiated, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions, as specified in the procedure Assessment of Psychoactive medications... 6. Gradual dose reduction is attempted with all residents who receive anti-anxiety medications, unless a reduction is clinically contraindicated. At least two attempts at dose reductions in a one year period are made before it can be determined that such dose reductions are contraindicated. The primary care physician must provide an explanation of the contraindication for dose reduction, along with a risk to benefit analysis, in the resident's medical record." "Monitoring Antidepressant Medications. When antidepressant therapy is initiated, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions, as specified in the procedure Assessment of Psychoactive medications..." and "4. The dose of the antidepressant medication is not increased more that every 14 days in order to allow sufficient time to elapse to establish the effectiveness of the new dose and the presence of untoward effects." "Monitoring Hypnotic Medications ... 4. The resident is monitored per the procedure for Assessing Psychoactive Medications." An undated facility policy titled, "Behavior Interventions" read, "Procedure ... 1. The Social Service Designee will identify resident behaviors which are: a) Potentially harmful to self or others ... 5. Based upon the precipitating factors to the isolated behavior, the Social Service Designee. With the interdisciplinary team, will formulate a plan of care to reduce or eliminate the behavior ... 6. A system to monitor and document the reduction of behavior and evaluate the plan's effectiveness will be established by the interdisciplinary team. At minimum the monitoring system will document: ... b) The frequency of the behavior .... 7. In all cases of serious behavior problems, ongoing through assessment must occur to ensure proper facility placement. If the facility is unable to provide adequate care, alternative placement must be sought." On 5/7/13 at 1 pm, the MD stated that he generally does not agree with the pharmacist recommendations, they treat to regulations only, not to the residents needs, "because all they recommend is GDR and lab work. If they wanted to practice medicine, then they should just write the orders for the GDR and lab work." He stated that he "knew what his residents needed and did not agree with the regulations and surveys." The MD stated that there is no way to know the medication dose for a resident until tried. The pharmacists want residents taken off medication when they are stable, and he does not agree. Record reviews were conducted from 4/30-5/9/13. The facility could not provide any evidence that the following residents received gradual dose reductions (GDRs), adequate justifications or indications to continue [MEDICAL CONDITION] medications resulting in excessive dose/duration, and/or adequate monitoring to determine the effectiveness of [MEDICAL CONDITION] medication use: 1. Resident 3's record was reviewed on 4/29/13. Resident 3 was admitted to the facility 3/21/10 with [DIAGNOSES REDACTED]. On 4/24/12, a physician's progress note read that Resident 3 was started on an anti-psychotic medication, [MEDICATION NAME] 1 mg at bed time, due to the resident and staff reporting that she was up all night and that "She admits to hallucinations." On 12/13/12 Resident 3 continued to have hallucinations and her [MEDICATION NAME] was increased to 1 mg twice a day. On 12/19/12, a physician's telephone order was received to increase Resident 3's bedtime dose of [MEDICATION NAME] to 2 mg, for a daily total of 3 mg, and added [MEDICATION NAME] 1 mg for anxiety, if needed, every six hours. On 1/3/13, after Resident 3 made an attempt at self harm, Resident 3 was sent to the emergency room for a psychiatric evaluation, she was seen by the emergency room physician, but was not seen by a mental health professional. The physician determined that she had "Acute [MEDICAL CONDITION], suspect medication side effect from [MEDICATION NAME]." He made recommendations for the facility physician to lower the [MEDICATION NAME] dose and consider another antipsychotic medication, [MEDICATION NAME]. Resident 3 was given a dose of [MEDICATION NAME] 1/2 mg in the emergency room . [MEDICATION NAME] and [MEDICATION NAME] have a "black box" warning regarding risk of mortality in the elderly with dementia related [MEDICAL CONDITION]. Resident 3 was incontinent of bowel in the facility upon return from the emergency room that evening, but had no documented prior history of bowel incontinence. On 1/4/12, Resident 3's [MEDICATION NAME] dose was reduced to 1 mg in the morning and [MEDICATION NAME] was continued at 1/2 mg every night. On 1/28/13, Resident 3's physician's (MD) progress note read that she was tearful and that she was not eating her food but only drinking her milk because the "doctor told her to." The MD determined that she was continuing to have hallucinations and discontinued the [MEDICATION NAME] but increased the [MEDICATION NAME] from 1/2 mg daily to 2 mg twice a day. On 2/2/13 at 1:44 pm, a nurses note read that Resident 3 had shakiness in both hands (possible side effect of medication or due to hydration or nutrition deficits). On 2/3/13 at 10:55 am, a nurses note read that Resident 3 was found on her bedroom floor on her hands and knees and that she reported that her knees had buckled. The note continued to read that the Certified Nurses Aide (CNA) had reported that Resident 3 was more confused than usual and was using the bedside commode instead walking to her bathroom, as she did in the past. A nutritional progress record, dated 2/5/13, read that Resident 3 lost eight pounds in a one month period (since she had been administered [MEDICATION NAME]) and that she had lost 10 pounds in the three month period from 11/2012 to 2/2013. On 2/6/13 at 1 pm, a nurse's note read Resident 3 "continued to be unsteady on her feet." Resident 3 continued to have a poor appetite. On 2/18/13, no time, Resident 3's [MEDICATION NAME] dose was doubled, increased to 4 mg twice daily. The MDS progress note read that she was refusing to eat because "she is afraid she is being poisoned and has had weight loss." He diagnosed her with "[MEDICAL CONDITION]." The above [MEDICATION NAME] dose exceeds the recommended daily dosing for the elderly and can present other unwanted side effects such as Tardive dyskinesia (an irreversible involuntary muscle movement disorder). Resident 3's physician (MD) ordered [MEDICATION NAME] 1 mg daily as a precaution for these side effects. No risk versus benefit analysis from the MD was found in the record. On 2/20/13 at 6:05 am, a nurses note read that Resident 3 stated "I want to die" about three times. On 3/2/13 at 3:45 pm, a nurses note read Resident 3 had difficulty swallowing water with her pills. (Swallowing difficulties can also be a side effect of [MEDICATION NAME] or dehydration). On 3/3/13 at 1 pm, a nurses note read Resident 3 reported frequency and burning with urination and that she was feeling depressed and lonely. On 3/4/13 Resident 3 was ordered to start on [MEDICATION NAME] 25 mg daily for depression and a plan for lowering her [MEDICATION NAME] dosage was initiated by the Physician's Assistant (PA). On 3/27/13 at 6:10 am, a progress note read that Resident 3 was found with a call light cord wrapped around her neck. The CNA stated that she removed the call light cord from Resident 3's neck. On 5/2/13 at 3:20 pm, the Social Service Director (SSD) stated that Resident 3 did not tolerate [MEDICATION NAME] well, that she did not pursue a mental health evaluation for her second attempt at self harm on 3/27/13 because Resident 3 had dementia and urinary tract infection [MEDICAL CONDITION] related behaviors. The facility had tested Resident 3 for UTI twice in the month of 12/2012. Last one on 12/22/12, prior to her emergency room hospitalization . Resident 3 had negative results for a UTI. On 3/19/13, no time, a consultant pharmacists "Note to attending Physician/Prescriber" read, "Resident is given [MEDICATION NAME] 3 mg twice a day. Nursing notes and IDT are concerned about her increasing ADL dependency, onset of bowel incontinence and recent fall." The consultant pharmacist continued writing that there were "problems with the treatment that included use of [MEDICATION NAME] in the elderly being contraindicated (not recommended), that the dose exceeded the recommended dose of 1/2 mg twice daily to start, and for the physician/prescriber (MD) to consider a psych. consult or using a safer alternative." On 4/16/13, the MD responded to the pharmacists note, "No change." GDR's were not considered and/or were delayed by the MD, resulting in doses at higher than recommended levels, and in the presence of adverse side effects. On 5/2/13 at 3:20 pm, the SSD stated that over the past 12 months, the facility did not have time for monthly meetings of the behavior IDT committee, as was required by facility policy. The SSD stated because the facility was so far behind, the team went to meeting quarterly, and that often a DON had not attended these behavior meetings, until the past few months. Resident 3 did not have monthly tallied behavior data available to the MD, pharmacist, or IDT for evaluation of her medication effectiveness or side effects, per facility policy. 2. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MD ordered the following [MEDICAL CONDITION] medications: On 1/4/10, [MEDICATION NAME] 0.5 milligrams (mg) daily for anxiety and to monitor each shift for panic attacks; and On 1/20/10, [MEDICATION NAME] 25 mg for depression and to monitor for episodes of crying. The record did not indicate that a GDR had been attempted for both [MEDICATION NAME] and [MEDICATION NAME], for over two years. On 7/31 and 8/21/12, the pharmacist requested that the MD consider a [MEDICATION NAME] dose reduction, without a response from the MD. On 1/16/13, the pharmacist communicated in a NAP requesting consideration for GDR for [MEDICATION NAME] and [MEDICATION NAME], noting that Resident 1 had absence of behaviors for both medications, and to "provide rationale for your decision." On 1/22/13, the MD responded, "No change." Resident 1's record did not contain evidence that Resident 1's monitored behaviors of crying and panic attacks had been tallied and quantified on a monthly assessment form, as per policy, for over 1 year. For Resident 1, the following was found in the "stack" of NAPs that were not found in the record and were not acted upon by the facility and not responded to: 7/31/12, review of [MEDICATION NAME] and to consider GDR. 8/21/12, review of [MEDICATION NAME] and no behaviors noted for three months, and consideration for GDR. On 1/16/13, another NAP was sent to the physician to consider [MEDICATION NAME] GDR, and the physician (MD) responded on 1/22/13. The MD's response was five months later, from when the first NAP was sent to the MD to consider [MEDICATION NAME] reduction. 3. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/27/12, the MD ordered [MEDICATION NAME] 1 mg for behaviors of striking out. The record did not indicate that a GDR had been attempted for [MEDICATION NAME], since admission to the facility, 11 months ago, and did not contain evidence that Resident 2's behavior of striking out had been tallied and quantified on a monthly assessment form, per policy, since starting [MEDICATION NAME]. 4. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/10/10, Physician B ordered [MEDICATION NAME] 30 mg daily for depression, and to monitor for crying. The record did not indicate that a GDR had been attempted from 4/2012 - 4/2013. On 12/10/12, the pharmacist requested that Physician B consider a [MEDICATION NAME] dose reduction in a NAP, and the physician responded, "declined," without justification. Resident 4's record did not contain evidence that Resident 4's behaviors of crying had been tallied and quantified on a monthly assessment form, as per policy, for over one year. 5. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/20/12, the MD ordered [MEDICATION NAME] 0.5 mg every 12 hours for anxiety, and [MEDICATION NAME] 0.5 mg every six hours, as needed for agitation, if routine dose ineffective and to monitor episodes of anxiety; on 8/8/11 Trazadone 50 mg for sleeplessness for [MEDICAL CONDITION] without monitors; on 3/27/13 [MEDICATION NAME] 50 mg daily for depression and to monitor episodes of sadness/social withdrawal; on 2/23/13 [MEDICATION NAME] 2 mg every 12 hours for [MEDICAL CONDITION] and to monitor episodes of yelling out and repetitive comments. Resident 7's record did not indicate that a GDR had been attempted from 4/2012-4/2013, for [MEDICATION NAME]. The pharmacist wrote a NAP on 3/19/13, recommending a [MEDICATION NAME] dose reduction, to a lower dose of 1 mg twice daily, because the current dose exceeded the recommended dose for the elderly. The MD responded, "disagree" and wrote, "Patient is stable." The MD did not document justification for the excessive dose of [MEDICATION NAME], which increased Resident 7's risk for medication side effects. Resident 7's record did not contain evidence that Resident 7's behaviors of anxiety, sadness/social withdrawal, yelling out, and repetitive comments had been tallied and quantified on a monthly assessment form, per policy. 6. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/22/10, the MD ordered psych med, [MEDICATION NAME] 15 mg twice daily for constant motion restlessness. A notation with the order read, "Taper is clinically contraindicated due to resident's symptoms are stable and manageable on present dose, tapering can result in an exacerbation, risk to self/others." The record did not indicate that a GDR had been attempted from 4/2012 - 4/2013, and that the last attempted GDR was on 2/22/10, without further attempts for GDR. The record did not contain evidence that Resident 9's behavior of constant motion (movement response from [MEDICAL CONDITION]) had been tallied and quantified on a monthly assessment form, as per policy, for over one year. 7. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/27/12, the MD ordered [MEDICATION NAME] 0.5 mg at night for behaviors of striking out at others. The record did not contain evidence that Resident 14's behavior of striking out had been tallied and quantified on a monthly assessment form, per policy. 8. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/21/13, the MD ordered [MEDICATION NAME] 15 mg at night for [MEDICAL CONDITION] and to monitor episodes of sadness and tearfulness. The record did not contain evidence that Resident 16's behaviors of sadness and tearfulness had been tallied and quantified on a monthly assessment form, per policy. 9. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MD ordered: On 4/8/10, [MEDICATION NAME] 0.5 mg every night, for dementia with agitated features and to monitor episodes of striking out at staff and episodes of [MEDICAL CONDITION]; and On 2/1/11, [MEDICATION NAME] 0.5 mg every six hours as needed for anxiety state and to monitor for agitation. The record did not indicate that a GDR had been attempted from 4/2012 - 4/2013. On 5/29/12, the pharmacist communicated a NAP and requested that the MD consider a GDR for [MEDICATION NAME]. The MD replied, "previous dose reduction attempted in the facility had failed," and did not provide previous outcomes/reduction contraindication. On 4/23/13, the pharmacist communicated a NAP, requesting that the MD consider a GDR for both [MEDICATION NAME] and [MEDICATION NAME], and that few behaviors for both med's had been noted. The MD responded, "disagree, Patient is stable on current regime." The record did not contain evidence that Resident 17's behaviors of agitation and striking out had been tallied and quantified on a monthly assessment form, per policy. 10. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MD ordered psych meds: [MEDICATION NAME] 20 mg daily for depression, and to monitor episodes of sad affect and social withdrawal. The record did not indicate that a GDR had been attempted since Resident 18 had been admitted to the facility, over three years. On 12/9/12, the pharmacist communicated to the MD on a NAP requesting an annual reassessment. The MD checked a box on the form that read, "The resident has had a good response to treatment and requires this dose for stability. Dose reduction is contraindicated because benefits outweigh the risks." The MD checked a box on the same form, "Disagree" and wrote, "no change." The record did not contain evidence that Resident 18's behaviors of sadness and social withdrawal had been tallied and quantified on a monthly assessment form, per policy. 11. Resident 19 was admitted to the facility on [DATE]. On 2/26/13, the MD ordered [MEDICATION NAME] 50 mg for [MEDICAL CONDITION], and to monitor for episodes of sadness every shift. The record did not contain evidence that Resident 19's behavior of sadness had been tallied and quantified on a monthly assessment form, as per policy. 12. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MD ordered psych meds: On 9/12/11, [MEDICATION NAME] 50 mg daily, and [MEDICATION NAME] 2 mg daily, for "depression, and to monitor for episodes sadness/tearfulness; and On 10/21/11, [MEDICATION NAME] 0.5 mg every six hours for panic disorder and to monitor episodes of panic/striking out at staff. The record did not indicate that a GDR had been attempted since admission to the facility for [MEDICATION NAME] and [MEDICATION NAME], for over 20 months, and no attempted reduction on [MEDICATION NAME] since 10/21/11, for over 19 months. The record did not indicate a GDR had been attempted from 4/20/12 - 4/19/13. On 1/16/13, the pharmacist communicated to the physician on a NAP and documented that "Resident is given [MEDICATION NAME] 0.5 mg every six hours, was due for evaluation and potential dose reductions. The record shows consistently no episodes of panic attack for the last few months. Please document your assessment and rationale of your treatment decision for this medication." On 1/31/13, the MD replied, "No change." On 1/16/13, the pharmacist communicated to the MD on another NAP and documented that "Resident is given [MEDICATION NAME] 2 mg for "depression manifested by sadness and tearfulness." This is not a FDA (Federal Drug Administration) approved [DIAGNOSES REDACTED]. Please consider to change the indication and target symptom for this treatment." On 1/31/13, the MD replied, "No change." The record did not contain evidence that Resident 20's behaviors of sadness/tearfulness and episodes of striking out had been tallied and quantified on a monthly assessment form, per policy. 13. Resident 21 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 9/15/12, care plan for [MEDICATION NAME] did not include the medication side effects. The record did not contain evidence that Resident 21's behaviors of sadness and withdrawal had been tallied and quantified on a monthly assessment form, as per policy, for over one year. 14. Resident 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/4/13, the MD ordered [MEDICATION NAME] 2 mg twice daily for [MEDICAL CONDITION], and [MEDICATION NAME] 500 mg daily for [MEDICAL CONDITION] and mania. The MD ordered to monitor episodes of striking out and hallucinations every shift. The record did not include a care plan with indications, behaviors, or side effects for the above [MEDICAL CONDITION] medications, [MEDICATION NAME] and [MEDICATION NAME] and did not contain evidence that Resident 22's behaviors of striking out and hallucinations had been tallied and quantified on a monthly assessment form, per policy. 15. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/8/12, the MD ordered psych med [MEDICATION NAME] 15 mg daily for [MEDICAL CONDITION] and to monitor for tearfulness and expressions of sadness. The record did not indicate that a GDR had been attempted during the past year, through 4/29/13. On 3/19/13, the pharmacist communicated to the MD on a NAP documenting, "...takes [MEDICATION NAME] 15 mg for depression as manifested by tearfulness and expressions of sadness. Resident appears relatively stable with little or no behaviors charted over the last several months." On 3/30/13, MD checked a box on the form, "resident has had good response to treatment and requires this dose for stability. Dose reduction is contraindicated because benefits outweigh risks for this resident." The MD also responded, "No change." The record did not include a care plan for [MEDICATION NAME] to include the indications or side effects and did not contain evidence that Resident 23's behaviors of tearfulness and expressions of sadness had been tallied and quantified on a monthly assessment form, per policy. 16. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23 12, the MD ordered psych med [MEDICATION NAME] 20 mg daily for [MEDICAL CONDITION] and to monitor for episodes of sadness, tearfulness, and agitation. The record did not indicate that a GDR for [MEDICATION NAME] had been attempted since Resident 24 had been admitted to the facility on [DATE]. The record did not contain evidence that Resident 24's behaviors of sadness, tearfulness, and agitation had been tallied and quantified on a monthly assessment form, per policy. 17. Resident 25 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 1/3/13, the MD increased [MEDICATION NAME] to 10 mg three times daily for increased anxiety, due to a room change. On 11/26/12, the orders included Non-drug intervention, prior to psych med administration, and listed: assess pain, comfort, food/snack, diversional activity and re-direct as needed, and were also listed on the MAR. The record for Resident 25 did not show adequate indications for the increase in [MEDICATION NAME] when the record did not show that alternative interventions were attempted before [MEDICATION NAME] had been increased. The care plan for Resident 25 did not include the above alternative interventions, to help Resident 25 with adjustment to a room change. (Refer to F 250). The record did not contain evidence that Resident 25's behaviors had been tallied and quantified on a monthly assessment form, per policy. 18. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/1/12, the MD ordered [MEDICATION NAME] 60 mg for depression, and to monitor every episodes of crying every shift. The record did not contain evidence that Resident 26's behavior of crying had been tallied and quantified on a monthly assessment form as per policy. 19. Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/07, the MD ordered psych med [MEDICATION NAME] 20 mg daily for depression and to monitor episodes of social withdrawal. The record did not indicate that a GDR had been attempted since Resident 27 had been admitted to the facility. The record did not indicate GDR from 4/2012 - 4/2013. On 4/26/12, the pharmacist communicated to the MD on a NAP documenting, "...on [MEDICATION NAME] since 2007. Please perform annual eval for possible dose reduction or discontinuation." On 5/22/12, the MD checked a box, "Patient has had good response to treatment and requires this dose for condition stability. Dose reduction is function and/or cause psychiatric instability. "Please elaborate with patient specific information." The MD responded, "continue therapy as written." The record did not contain evidence that Resident 27's behavior of social withdrawal had been tallied and quantified on a monthly assessment form, per policy. 20. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/1/12, the MD ordered [MEDICATION NAME] (antidepressant) medication and to monitor for episodes of yelling, angry outbursts, and sad facial expression. On 2/12/13, the pharmacist communicated to the MD on a NAP, that [MEDICATION NAME] had not been reduced since 3/1/12. The physician replied, "no change." The record did not contain evidence that Resident 28's behaviors of yelling, angry outbursts, and sad facial expressions had been tallied and quantified on a monthly assessment form, per policy, for over one year. 21. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/1/13, the MD ordered [MEDICATION NAME] 15 mg for appetite and monitor episodes of restlessness, and on 4/4/13, the MD [MEDICATION NAME] mg daily for [MEDICAL CONDITION] and restlessness. The record did not include monitoring of Resident 29's hours of sleep and to evaluate the effectiveness [MEDICATION NAME] a care plan for both of the above medications and side effects [MEDICATION NAME]. The care plan had not been updated to include Ambien, and the hours of sleep for Resident 29. The record did not contain evidence that Resident 29's behavior of restlessness had been tallied and quantified on a monthly assessment form, per policy. On 5/9/13 at 12:30 pm, the Director of Nurses (DON) verified the above findings and stated that the care plan did not include [MEDICATION NAME], which was ordered to help Resident 29 with an increase appetite, and the medication side effects of this antidepressant. The DON stated that the total hours of sleep for Resident 29 needed to monitored to help evaluate the effectiveness of Ambien. On 5/1/13 at 1:15 pm, the DON stated that she started at the facility two months ago. The immediate focus need was resident care issues. [MEDICAL CONDITION] reviews by the IDT (Interdisciplinary team) have not been done yet, except for a few certain residents. The DON stated that communication between the physicians and pharmacists, the [MEDICAL CONDITION] review, and a system to review resident [MEDICAL CONDITION] medication information was still in the process of being developed, and was not in place. 22. Resident 6's record was reviewed on 4/29/13. Resident 6 was admitted to the facility 3/20/12 with [DIAGNOSES REDACTED]. On 3/20/12, Resident 6's primary physician (Physician B) ordered Klonopin (an antianxiety medication) 1 mg every night for anxiety, manifested by agitation and restlessness. On 4/12/12, Physician B ordered [MEDICATION NAME] 0.5 mg two tablets every 12 hours, if needed for breakthrough anxiety. On 9/12/12, Physician B prescribed [MEDICATION NAME] 2 mg every night for dementia with hallucinations and behavior (Dementia related [MEDICAL CONDITION]). Since Resident 6's admission to the facility, no monthly tallied behaviors were accumulated, per facility policy, for [MEDICAL CONDITION] medication, to determine if psychoactive medications were effective. No gradual dosage reductions were attempted, or risk versus benefit analysis written by the physician, to identify the need for ongoing [MEDICAL CONDITION] medication, per facility policy. 23. Resident 10's record was reviewed on 4/29/13. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/30/13, a physician's (MD) progress note read that she was started on [MEDICATION NAME] 0.5 mg at bedtime for depression and anger. [MEDICATION NAME] is not indicated for depression. On 4/23/13, a consultant pharmacist documented a NAP that read, "[MEDICATION NAME] had been written for two indications 1) Dementi