Every finding on record at Shasta View Care Center

Based on interviews and record reviews, the facility failed to ensure that three of three sampled Resident Council members (resident run group that meet to discuss concerns and offer suggestions about their care) concerns about long call light wait times were addressed when the facility had not completed a Department Response Form to show any follow up or actions taken. This failure resulted in care concerns to go unrecognized and violated the residents' rights.Findings: A review of the facility's policy and procedure (P&P) titled, Resident Council Meetings, dated 2026, indicated, the facility's Activity Director (AD) would assist the Resident Council members with concerns by acting as a liaison (go-between person) and sharing their concerns with the facility. The P&P indicated that the facility would act upon concerns and make recommendations and attempt to accommodate the residents. A review of Resident 1's admission Record, dated 1/9/24, indicated admission to the facility on 1/9/24 with the diagnoses of flaccid hemiplegia affecting left dominant side (the left side of the body was weak and unable to move) and chronic pain. Resident 1 was their own responsible party (RP, decision maker). A review of Resident 1's Quarterly Minimum Data Set (MDS, and assessment tool), dated 4/6/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, assessment for memory, attention, and awareness). Resident 1 scored a 15 out of 15 which indicated good memory. A review of Resident 2's admission Record, dated 3/16/26, indicated admission to the facility on 3/16/26 with the diagnoses of a broken right hip that did not require surgical intervention and difficulty in walking. Resident 2 was their own RP. A review of Resident 2's Quarterly MDS, dated [DATE], indicated that Resident 2 had a BIMS score of 14 out of 15 which indicated good memory. A review of Resident 3's admission Record, dated 9/11/25, indicated admission to the facility on 9/11/15 with the diagnoses of difficulty in walking and hypertension (high blood pressure). Resident 3, with the help of a family member, acted as the RP. A review of Resident 3's Quarterly MDS, dated [DATE], indicated that Resident 3 had a BIMS of 13 out of 15 which indicated good memory. During an interview on 5/19/26 at 10:20 a.m., Resident 1 indicated that on the last two Saturday evenings (5/9/26 and 5/16/26), when Resident 1 utilized the call light for assistance to use the bathroom, Resident 1 experienced long call light wait times. Resident 1 indicated waiting up to two hours for facility staff to respond to the call light, and after being assisted to the bathroom, it took 40 minutes for staff to respond to the bathroom call light. Resident 1 confirmed this concern was voiced at the Resident Council meetings. Resident 1 stated, It makes me angry. During an interview on 5/19/26 at 10:24 a.m., Resident 2 indicated that when staff were delivering meal trays, it was not uncommon for Resident 2 to experience call light wait times up to an hour. Resident 2 confirmed this concern was discussed at the Resident Council meetings. Resident 2 stated, I worry and feel ignored when they don't answer my call light. During an interview on 5/19/26 at 3:04 p.m., Resident 3 indicated utilizing her call light for her roommates. Resident 3 said sometimes her roommates needed assistance with repositioning and could not find their call light and Resident 3 utilized her call light for them. Resident 3 confirmed experiencing 30 minute call light wait times and stated this was discussed many times at the Resident Council meetings. During a concurrent interview and record review on 5/19/26 at 3:10 p.m., with the AD, Resident Council Minutes [meeting notes] dated 2/23/26 through 4/21/26 were reviewed. The AD confirmed the Resident Council meeting notes dated 2/23/26, 3/26/26, and 4/21/26 indicated that the Resident Council members had stated that call lights were not being answered in a timely manner. The AD confirmed there was no, Department Response Form completed regarding the concerns the Resident Council brought up and stated, I was not here for the Resident Council meeting held on 2/23/26. When asked if there was a reason the Department Response Form was not being completed, the AD indicated it was due to the AD's lack of knowledge regarding the use of the Department Response Form. During a concurrent interview and record review on 6/18/26 at 8:41 a.m., with the Administrator (Admin), a blank copy of the Department Response Form was reviewed. The Admin confirmed the Department Response Form included the resident's concerns, the facility's response to the concerns, and any follow up regarding a solution. The Admin confirmed the AD was responsible for completing the Department Response Form and stated, follow up should be done.

Based on observations, interviews, and record reviews, the facility failed to provide one out of two sampled residents (Resident 1) with the necessary care and services to prevent the development of three facility acquired Pressure Injuries (PI-skin and tissue loss with exposed fat, muscle, or bone) a Stage 4 PI on the coccyx (tailbone), a Deep Tissue Pressure Injury (DTI, serious type of PI that caused damage to the tissue or muscle) to the posterior (back of) right heel, and a DTI to the tip of the right big toe when: 1. Licensed Nurses (LN) and Certified Nurse Assistants (CNA) did not identify the progression of skin changes, over a 24 day period, which led to the discovery of the PI's at advanced stages. 2. The facility had not ensured Resident 1 was repositioned and turned per the facility's policy and procedure (P&P). 3a. There was a 14 day delay in providing Resident 1 with a Low Air Loss (LAL, a pressure-redistributing medical air bed that alternates pressure relief by airflow to maintain the temperature of the skin, keep skin dry and reduce areas of pressure to the skin) mattress after the coccyx PI was identified.3.b There was a 10-day delay in providing Resident 1 with an evaluation from the Wound Doctor (WD, a physician who specializes in the management and treatment of PI's).3c. The facility's Infection Preventionist (IP) did not follow up on a Physician ordered laboratory test result resulting in an infection to the coccyx PI left untreated. The cumulative effects of these failures caused Resident 1 actual harm by the development of three PI's, debridement (surgical procedure to remove dead tissue), and required a general acute care hospital admission. Findings: 1. A review of Nursing 2017, the National Pressure Injury Advisory Panel (NPIAP [formerly known as NPUAP] an internationally used, and professionally recognized pressure injury) resource), dated 2017, Pressure Injures are staged to indicate the extent of tissue damage. Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable (physically touched) fascia (fat layer), muscle, tendon, ligament. Cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (wound edge curled inward), undermining (cave-like pocket of space in the tissue), and/or tunneling (a passageway) often occur. Depth varies by anatomical location. If slough (white or yellow dead tissue) or eschar (thick, hard, often black in color, dead tissue) obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury (PI): 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 or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Deep Tissue Pressure Injury (DTI): Intact or non-intact skin with localized area of persistent non-blanchable (stayed red when pressure was applied) deep red, maroon, purple discoloration or epidermal (outer layer of skin) separation revealing a dark wound bed or blood-filled blister. A review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention and Management, dated 2026, provided by Director of Nursing (DON) A, indicated, the facility was committed to the prevention of avoidable PI's. The P&P indicated, Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors. The P&P indicated, 3 c. Licensed Nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. The P&P indicated, 3 e. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. The P&P indicated, The RN [Registered Nurse] Unit Manager, or designee will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document summary of findings in the medical record. A review of Resident 1's admission Record, dated 2/25/26, indicated admission to the facility with the diagnoses of myocardial infarction (a medical emergency also known as a heart attack), shortness of breath (inability to get enough air into the lungs), and presence of a left artificial hip joint (hip replacement). Resident 1 was their own decision maker and Family Member (FM) was the alternative decision maker (made decisions for Resident 1, when they could not make their own). A review of the admission Minimum Data Set (MDS, an assessment tool), Section C, dated 3/4/26, indicated that Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment for memory or confusion) and scored an eight out of 15, which indicated Resident 1 required assistance with complex decision making. A review of admission MDS, Section GG, dated 3/4/26, indicated, Resident 1 had impairment (functional issue that affected a resident's daily life) to one lower extremity (leg), required substantial to maximal assistance (helper does more than half the effort) to roll from side to side in bed, wash their face, comb their hair, sit up in bed, and transfer from the bed to a chair. A review of the admission MDS, Section M, dated 3/4/26, indicated that upon admission to the facility, Resident 1 did not have any PI's, was at risk for developing PI's, did not have any foot problems, and had moisture associated skin damage (MASD, weakened skin caused by prolonged exposure to moisture). The MDS indicated that Resident 1 was not on a turning or repositioning program. During a concurrent interview and record review on 5/20/26 at 10:00 am, with Assistant Director of Nursing (ADON), Resident 1's progress notes titled, Nurses Notes, written by LN K, dated 2/25/26 was reviewed. ADON confirmed the Progress Note, dated 2/25/26 indicated, Resident 1 was admitted to the facility on [DATE] and had no PI's. During a concurrent interview and record review on 5/20/26, at 10:10 am, with ADON, Resident 1's Nursing-Skilled Service Note-V2 (daily nursing notes), dated 2/25/26 through 3/16/26 were reviewed. ADON confirmed that the daily nursing notes had not reflected any changes to Resident 1's skin and the skin assessments indicated Resident 1's skin was normal without any indications of PI's, during that time frame. ADON confirmed, the daily nursing notes required a visual inspection of the skin. During a concurrent interview and record review on 5/20/26 at 10:00 am, with ADON, Resident 1's Nursing-Weekly Summary-V4, dated 3/9/26 and another weekly summary dated 3/17/26 and time stamped at 7:08 am, were reviewed. ADON confirmed both Weekly Summaries were completed by LN E, a head-to-toe skin assessment (assessing all the skin from the top of the head to the toes) was completed, and there were no identified concerns regarding Resident 1's skin. During a concurrent interview and record review on 5/20/26 at 10:40 am, with ADON, Resident 1's Nursing-Weekly Skin Alteration (Non-Pressure) Evaluation (an assessment that described changes that were not PI), completed by LN E, dated 3/17/26 and time stamped 11:34 pm, (16 hours and 26 minutes after LN E's Weekly Summary), indicated LN E assessed Resident 1's sacrum area (the small of the back just above the coccyx), and there was a wound (LN E did not identify the wound as a PI) and documented the wound was not located in a pressure area (an area of skin that is close to the bone where PI's form). LN E measured the wound to be 1.66 centimeters (cm, two and a half cm equals about one inch) in length, 1.56 cm in width, and 0 cm in depth. LN E described the tissue loss as partial thickness and purple in color. LN E called the facility's on-call Physician, obtained treatment orders, and the Physician had recommended the facility's Wound Doctor (WD) follow up and provide treatment. The note did not indicate that LN E notified the WD. ADON confirmed, LN E's 3/17/26 Nursing-Weekly Skin Alteration (Non-Pressure) Evaluation was incorrect and confirmed, the wound was located on the coccyx, not on the sacrum, and was located in a pressure area. A review of Resident 1's progress note titled, Alert Note, dated 3/21/26, written by LN I and time stamped 10:48 am, indicated, Coccyx wound continues with no improvement. New wound DTI to Rt [right] foot, new pressure sore to rt heel and top of right toe per wound care nurse. Boots [foam heel protector that elevated the feet off of the bed] and resident to be turned q [every] 2 hours for offloading [kept the heels elevated]. A review of Resident 1's progress notes titled, Skin/Wound Note, dated 3/21/26, written by Treatment Nurse (TN) D and time stamped 11:34 am, indicated TN D assessed a DTI to the right posterior (back of) heel that measured 5 cm in length and 5 cm in width. Skin intact but is deep red/purple in color. MD [Physician] notified with new order for soft boots to both feet. During an interview on 5/20/26 at 11:57 am, CNA J indicated when a shower or bath was provided to residents, the CNA looked at the resident's skin. CNA J stated, We look for any skin concerns seen on the resident, bruises, abrasions, looking for open wounds, rashes, skin tears, or if the skin is red. It's documented on the shower sheet and we notify the nurse. CNA J confirmed that anytime there was an observed change noted to the resident's skin, the CNA would alert the resident's nurse. During a concurrent interview and record review on 5/20/26 at 12:53 pm, with Medical Records (MR) and Director of Staff Development (DSD), both indicated there were two shower sheets for Resident 1, between the dates 2/25/26 and 4/7/26, even though Resident 1 was supposed to be showered twice a week, dated 3/4/26 and 3/11/26. Upon review both shower sheets indicated that Resident 1 had refused to be showered on those days. MR stated regarding the missing shower sheets, We usually don't keep them, they are internal documents. During a concurrent interview and record review on 5/20/26 at 2:21 pm, with TN C, Resident 1's progress notes titled, Nurses Note, dated 3/11/26 was reviewed. TN C confirmed, the Nurses Note indicated Resident [1] had refused a shower multiple times, no new skin issues. During an interview on 6/2/26 at 1:47 pm, LN E was asked how LN E obtained assessment information for skin assessments. LN E stated, I rely heavily on my CNAs to report skin changes for my residents, they change them, they shower them. LN E indicated that she documented skin assessments based on information from previous skin assessment information that was obtained from the electronic medical record (EMR) and stated, I look at the admission note, treatment orders, and skin and wound evaluations and LN E confirmed, she documented that Resident 1 had no skin problems but had never visually inspected Resident 1's skin, until she identified the coccyx PI on 3/17/26. A review of Nursing 2026, dated 7/1/2010, [NAME] and [NAME], Inc; 2008, (a nationally recognized premier healthcare and medical publisher) indicated, A SKIN ASSESSMENT captures the patient's general physical condition, based on careful inspection and palpitation (feeling/touching) of the skin and documentation of your findings. A review of Resident 1's initial Wound Assessment Details, completed by the WD, dated 3/27/26 indicated, WD had assessed Resident 1, 10 days after Resident 1 had developed three PI's that were acquired in the facility, and it was the WD's first time assessing them. The WD note indicated Resident 1 had an Unstageable, open area to the coccyx that measured 3 cm in length, 4.5 cm in width and 0 cm in depth. The WD note indicated that WD performed a surgical debridement (removal of dead tissue using sharp instruments like a scalpel knife and scissors), at Resident 1's bedside on 3/27/26. The Unstageable PI to the coccyx was then considered a Stage 4 PI and measured 3 cm in length, 4.5 cm in width, and 1.1 cm in depth. The WD note indicated that Resident 1 had a DTI located on the bottom, posterior of the right heel that measured 3.5 cm in length, 5 cm in width, and 0 cm in depth. The WD note indicated Resident 1 had a DTI on the outer tip of the right big right toe that measured 0.4 cm in length, 0.3 cm in width and 0 cm in depth. Additionally, the WD note indicated Resident 1 had moisture associated skin damage (MASD, skin damage caused by prolonged moisture to the skin) to the left gluteal fold (the crease between the bottom of the buttocks and upper thigh). 2. A review of the facility's P&P titled, Turning and Repositioning, dated 2025, provided by the Director of Staff Development (DSD) indicated, It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. The P&P indicated that all residents at risk of, or with existing pressure injuries, would be turned and repositioned. The P&P indicated, The frequency of turning and repositioning will be documented in the resident's plan of care. The P&P indicated that repositioning techniques included placing the resident in a side lying position, utilizing pillows or wedges for positioning and pressure reduction, and elevating the heels with pillows to keep the heels off the surface of the bed. The P&P indicated, when the resident was in a chair, repositioning techniques included encouraging pressure relief every if 15 minutes if the resident was able and if the resident was unable to make position changes, facility staff would reposition the resident every hour. During an interview on 4/14/26 at 12:30 pm, Resident 1's FM indicated visiting Resident 1 in the facility almost daily. FM indicated between 2/25/26 and through 4/7/26, FM witnessed Resident 1 sitting in the wheelchair for three hours or longer without any facility staff providing Resident 1 with repositioning. FM stated, I've sat in the room for three hours or longer without anyone coming in to check on [Resident 1]. During a concurrent observation of Resident 1 and interview with CNA G on 4/15/26 at 10:09 am, in Resident 1's room, Resident 1 was lying on their back and their eyes were closed. CNA G entered the room at 10:14 am, and indicated CNA G was going to reposition Resident 1. CNA G provided almost all the help that was required to turn and reposition Resident 1 because Resident 1 was unable to reposition or turn herself. During a concurrent interview and record review on 4/15/26 at 10:26 am, with CNA G, the CNA Task section (the section of the medical record where the CNA documented the care that was provided) of Resident 1's medical records were reviewed. CNA G indicated the CNAs should document turning and repositioning residents every two hours in the CNA Task section and stated, I document every two hours in the computer, I don't document as it happens, I document it all when I have a chance. CNA G confirmed there was no evidence located in the CNA Task section that indicated Resident 1 was being turned and repositioned every two hours. During an interview on 5/19/26 at 3:31 pm, LN H indicated that between 3/8/26 and 3/14/26, one week prior to the identification of Resident 1's Stage 4 PI, CNA F had verbalized not changing Resident 1's brief (adult diaper) for one eight-hour shift and LN H had provided CNA F with verbal education on the importance of repositioning and turning Resident 1 every two hours and the importance of changing the brief, even if the brief was not soiled. During a concurrent interview and record review on 5/19/26 at 3:52 pm, CNA F confirmed providing care to Resident 1 in the past and stated, I don't document that I turn them [the residents] every two hours. CNA F indicated there was an Attestation (a formal statement, located in the CNA Task section, that indicated the CNA repositioned and turned Resident 1 every two hours, during their shift) and CNA F had electronically signed it. CNA F was asked to review the Attestation in Resident 1's EMR and CNA F confirmed there was no Attestation located in the CNA Task section of the EMR. CNA F confirmed there was no documentation present that CNA F provided Resident 1 with turning or repositioning. CNA F confirmed that CNA F had not changed Resident 1's brief for the entire eight-hour shift because it was not soiled and had not visualized the skin on Resident 1's buttocks that day. CNA F could not recall the exact date and confirmed LN H had provided CNA F verbal education regarding repositioning and turning Resident 1 every two hours (between 3/8/26 and 3/14/26). During an interview on 5/20/26 at 2:21 pm, TN C was asked what the facility did to prevent PI's from developing for at risk residents. TN C stated, I educate the CNAs to float heels (elevating the feet so the heels are not in contact with the mattress) with two pillows, turn and reposition every two hours, and that most residents are at high risk. TN C indicated that verbal instruction to the CNAs was informal and not documented. TN C confirmed that not turning or repositioning a resident increased the risk for developing a PI. During a concurrent interview and record review on 5/21/26 at 8:44 am, with MDS Nurse and MDS Resource Nurse (RN), Resident 1's admission MDS, Section GG, completed by MDS Nurse, dated 3/4/26 was reviewed. MDS Nurse confirmed, Section GG indicated, Resident 1 had a loss of function to one leg and required substantial to maximal assistance from facility staff to comb hair, wash face, and to roll from side-to-side while in bed. MDS Nurse confirmed, the admission MDS, Section M, completed by MDS Nurse, dated 3/4/26, indicated Resident 1 was at risk for developing PI's and did not have any PI's upon admission to the facility. MDS RN indicated turning and repositioning residents was considered basic routine care and should be provided to all residents. During a concurrent interview and record review on 5/21/26 at 10:10 am, with MDS Nurse and MDS RN, Resident 1's care plan (a resident specific plan that outlined how staff should support and care for the resident) titled, Potential for Pressure Ulcer Development (Pressure Ulcer was another term for PI), dated 2/28/26, was reviewed. MDS Nurse and MDS RN both confirmed, Resident 1's care plan included the risk factor of being at risk for developing PI's and that the care planned interventions included that staff would encourage Resident 1 to reposition as often as tolerated which was inconsistent with Resident 1'a ability to reposition or turn herself. MDS RN confirmed Resident 1's care plan had not included resident specific instructions on the steps that were to be taken to prevent Resident 1 from developing PI's. MDS RN stated, [Resident 1's] care plan should have reflected staff will assist with turning and repositioning as tolerated, knowing that [Resident 1] can't reposition on [their] own. During a concurrent interview and record review on 5/22/26 at 9:56 am, with Infection Preventionist (IP), Resident 1's CNA documentation record titled, Documentation Survey Report, dated 2/25/26 through 4/30/26 was reviewed. IP confirmed that the Documentation Survey Report, was the information that the CNAs documented in the CNA Task section and it did not indicate that the CNAs had turned or repositioned Resident 1. IP indicated that the section titled GG-Roll left and Right, indicated how much assistance the CNAs gave to Resident 1 when rolling from side to side in bed. IP was asked to show documented evidence that CNAs had turned and repositioned Resident 1. IP indicated there should have been a CNA task list in the EMR, but this task was not available in Resident 1's EMR, and that was where the CNAs documented. IP, stated I don't see it under the task list. IP indicated the task for CNAs to reposition and turn Resident 1 should have been created by the DSD and included in the CNAs task list to do and was not, therefore there was no documented evidence to show Resident 1 had been repositioned or turned every two hours. During an interview on 5/22/26 at 11:48 am, DSD was asked who reviewed the CNA's documentation. DSD stated, I don't know how to look at the notes, I don't review the CNA documentation, and I thought [IP] was auditing it, but I'm not sure. 3a. A review of the facility's P&P titled, Pressure Injury Prevention and Management, dated 2026, provided by DON A, indicated, interventions for promoting wound healing included, 4 c Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic and routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal [bowel movements] contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Provide non-irritating surfaces; and v. Maintain or improve nutrition and hydration status where feasible. A review of the facility's undated P&P titled, Wound Treatment Management, provided by DON A, indicated that the facility promoted wound healing and treatment decisions would be based on the characteristics (appearance or condition) of the wound which included presence of an infection. A review of Resident 1's Physician's order, dated 3/25/26, indicated that a LAL mattress was ordered for wound care and management, (eight days after Resident 1's coccyx PI was identified). During a concurrent interview and record review on 5/1/26 at 12:42 pm, Maintenance Director (MD) was asked to describe the protocol for obtaining an LAL mattress. MD indicated when nurses requested an LAL mattress MD completed a work order and would then retrieve the LAL mattress from their shed and set it up for the resident. Work orders were reviewed with MD from 2/25/26 through 4/7/26 to determine what date Resident 1 had received the LAL mattress. MD indicated he had not created a work order and was unable to confirm what date Resident 1 had been provided with an LAL mattress. During an interview on 5/1/26 at 3:01 pm, DON A and TN D both confirmed that the LAL mattress was provided to Resident 1 on 3/27/26, 11 days after Resident 1 developed a Stage 4 PI and three days after the Physician's order was written. DON A stated, I would have liked it to have been sooner. DON A was asked if Resident 1 could have benefited from the use of an LAL mattress prior to the development and discovery of the three PI's and DON A did not provide a response. 3b. During a concurrent interview and record review on 5/20/26 at 10:40 am, with ADON, Resident 1's Nursing-Weekly Skin Alteration (Non-Pressure) Evaluation, completed by LN E and dated 3/17/26 was reviewed. ADON indicated, LN E had identified an open area to Resident 1's sacrum area. LN E called the Physician, obtained treatment orders, and the Physician had recommended the facility's Wound Doctor (WD) follow up and provide treatment. The note did not indicate that the WD had been notified. During an interview on 5/1/26 at 10:54 am, WD confirmed that on 3/27/26 (10 days after the Physician ordered a WD evaluation of the coccyx PI), was the first time WD had assessed Resident 1's coccyx PI and stated, I saw her when they notified me. WD was not able to recall what date the facility notified WD or who had notified him. During a concurrent interview and record review on 5/1/26 at 3:28 pm, with DON A, Resident 1's progress notes titled, IDT (Interdisciplinary Team, facility supervisors/managers meet to discuss resident care concerns and implement interventions), dated 3/19/26, and completed by DON A, indicated Resident 1 would be seen by the WD on 3/20/26. DON A confirmed, the first documented visit by the WD for Resident 1's coccyx PI was on 3/27/26. DON A was asked why there was a delay in the WD seeing Resident 1. No response was provided. 3c. A review of the Physician's Progress Note, with the service date of 3/30/26 and signed by Resident 1's Physician on 4/2/26, indicated that the information in the progress note had been obtained over a period of four days. The progress note indicated nursing staff had reported a significant change of condition and worsening of Resident 1's acquired coccyx PI. The progress note indicated there was significant drainage (liquid draining from wound), tissue sinking (the center of the wound drops below the level of surrounding healthy tissue and can be caused by poor healing, tissue death, or infection), and appeared to be infected. The progress note indicated the wound bed (the deepest part of the wound) contained slough (soft yellow or white dead tissue), pus (thick, cloudy or white drainage), redness, and a foul odor that was consistent with an infection. The progress note indicated the Physician ordered a wound culture (a laboratory test that identifies the specific bacteria and what antibiotics would work on that particular bacteria that is causing an infection) of the coccyx PI that was to be done on 3/30/26. On 3/31/26, a preliminary report was faxed to the facility (generally, cultures take about 3 to 5 days to grow before a final report is available however, around day 2 an early report of the bacteria most likely causing the infection is provided by the lab, in case the physician wants to get antibiotics started). The preliminary results were communicated to the WD. The Physician's progress note had not indicated what bacteria was causing the infection or that antibiotics were to be started for Resident 1. A review of Resident 1's care plan titled, Stage 4 PI, dated 3/30/26, indicated, the facility would obtain laboratory tests as ordered and report the results to the Physician. The care plan was updated on 3/31/26 and indicated that the preliminary report from the lab for the results for Resident 1's wound culture contained 100,000 colonies (a term for how many bacteria were visualized growing together and was at a level consistent with infection) of mixed pathogens (a term used when multiple infectious agents such as viruses, bacteria or fungus are seen growing together in one colony). During a concurrent interview and record review on 5/20/26 at 2:21 pm, with TN C and ADON, Resident 1's progress notes titled, Nursing Notes, completed by TN C, dated 4/2/26 and timestamped 12:14 pm, was reviewed. TN C confirmed the progress note indicated Resident 1's preliminary wound culture results were back but provided no date that the facility received the results, that the WD was notified, and that TN C was waiting for a reply from the WD. TN C was asked when or if Resident 1 had been given antibiotics for the coccyx PI infection and TN C was unable to answer. Resident 1's progress note titled, Nurses Notes, completed by TN C, dated 4/2/26 and time stamped 3:35 pm, was reviewed with ADON. ADON indicated TN C's Nurses Notes reflected that the WD recommended an antibiotic called Bactrim (a broad spectrum antibiotic that kill most types of bacteria) but WD had not actually given the order. The note indicated that the WD said the antibiotic needed to be ordered by Resident 1's primary care Physician. The note indicated that TN C had notified the IP and DON A. TN C could not confirm if TN C had followed up with Resident 1's primary care Physician with the WD's recommendation to start Bactrim. ADON reviewed all of Resident 1's discontinued orders from 4/2/26 through 4/7/26 and confirmed there had been no order for Bactrim. During a concurrent interview and record review on 5/20/26 at 3:43 pm, with IP, Resident 1's Physician orders, dated 4/2/26 through 4/7/26 were reviewed. IP confirmed there was no order for Bactrim and indicated that until the final wound culture report was available, Resident 1's primary care Physician would not likely order an antibiotic. IP was asked if there was a final wound culture report and IP confirmed there was no final wound culture report and indicated that the facility had not received it. IP confirmed the final culture report was not followed up on and went unrecognized, therefore, no antibiotics to treat Resident 1's Stage 4 PI infection were ever ordered. A review of Resident 1's, Skin/Wound Note, completed by TN D, dated 4/3/26, indicated the WD had assessed Resident 1's Stage 4 PI to the coccyx and it had increased in size and measured 3.5 cm in width, 5.5 cm in length, 5 cm in depth and contained 2 cm of undermining (tissue damage that extended beneath the intact skin at the wounds edge). The DTI to the posterior right heel had increased in size and measured 3 cm in width, 4.5 cm in length, and 0 cm in depth. There was no documentation present which indicated the status of the DTI located on the tip of Resident 1's right big toe. A review of the hospital's History and Physical (H&P), dated 4/7/26, indicated Resident 1 was admitted to the hospital on [DATE] due to an infected sacral wound (the coccyx, sacral, and sacrum are all close in proximity and the terms are often interchanged) that required treatment with two different IV (intravenously, to be administered into the vein) antibiotics (Vancomycin and Zosyn, considered strong broad spectrum antibiotics). The H&P indicated that Resident 1 required .aggressive wound care. to be performed two times a day, close monitoring, and due to the infected Stage 4 PI, Resident 1 had the potential to develop sepsis (a life-threatening infection) and sustain life-threatening deterioration (decline in health status). A review of Resident 1's, Wound Care Note, completed by the hospitals Doctor of Osteopathic Medicine (DO, a doctor that has specialized training in the musculoskeletal [muscle and bones] system), dated 4/8/26, indicated Resident 1's Stage 4 PI measured 4 cm in width, 5 cm in length, and 7 cm in depth with 3 cm of undermining. The wound bed was described as containing 75 percent slough, the coccyx bone could be felt, there was a foul odor coming from the PI, and that the skin surrounding the PI was moderately red. The right posterior heel was described as an Unstageable PI that was 3 cm in width, 2 cm in length, 0 cm in depth and 100% of the posterior heel PI was covered in black dead tissue.

Based on interviews and record reviews, the facility failed to ensure two Treatment Nurses (TNs are also Licensed Nurses) and three Certified Nursing Assistants (CNAs) possessed specific competencies and orientation (a measurable pattern of knowledge and behaviors required to provide care) and skill sets necessary to provide safe and effective care to the residents when the facility did not complete or maintain competency evaluations. This failure had the potential to place residents at risk for avoidable harm due to improper assessments, delayed recognition of changes in condition, and inadequate delivery of required care.Findings: A review of the facility's policies and procedures (P&P) titled, Competent Nurse Staffing, revised 10/1/25, indicated, facility staff would demonstrate appropriate skills and competencies that were necessary to provide care and services to the residents (some examples of care and services the LN provided to residents included administering medication, obtaining Physician orders, providing wound care, performing accurate assessments, documenting, and recognizing changes in condition). A review of the facility's undated P&P titled, Orientation, indicated the facility would implement (carry out or start) and maintain an effective orientation process for all new and contracted (worked in the facility and employed through a different company commonly called registry) employees. The P&P indicated the new staff member would receive a preceptor (experienced professional that provided training) who would verify that the new staff member was competent in a skill. The P&P indicated, the initials of the preceptor indicated competency. The P&P indicated the Director of Staff Development (DSD) was responsible to ensure orientation plans were maintained, and submitted to the Human Resource Department once completed. During a concurrent interview and record review on 5/21/26 at 2:43 pm, with Assistant Director of Nursing (ADON), TN C's employee file was reviewed. TN C's hire date was 3/17/26. ADON confirmed, there were two competencies dated 3/17/26 titled, Hand Hygiene (cleansing hands) and Donning and Doffing Personal Protective Equipment (putting on and taking offing gloves, isolation gowns, and wearing masks correctly), and a Wound Care Competency Assessment, dated 4/26/26 that was present in TN C's employee file. ADON confirmed, there were no other competencies present such as LN duties of administering medication, obtaining Physician orders, performing accurate assessments, documenting, and recognizing changes in condition. During a concurrent interview and record review on 5/21/26 at 3:04 pm, with Licensed Nurse (LN) H, CNA F's employee file was reviewed. CNA F's hire date was 1/27/26 and LN H confirmed, at that time, LN H was the Director of Staff Development (DSD). DSD reviewed the document New Employee Orientation Agenda, dated 1/27/26 and confirmed, the section titled, Day 2, which included training topics to be provided, included training on the CNA job duties, resident rights, dementia (memory loss), residents that were choking, and the facility's P&P on turning and repositioning residents, was blank and not signed by the instructor. LN H indicated that orientation to the facility was done at a different facility and it was not her responsibility to provide orientation to newly hired staff. LN H was asked who was responsible to ensure orientation forms were completed and training had been provided and LN H did not provide an answer. During a concurrent interview and record review on 5/21/26 at 3:00 pm, with the Assistant Director of Nursing (ADON), TN D's employee file was reviewed. TN D's hire date was 2/16/26 and ADON confirmed, there were two competencies dated 2/16/26 and 3/17/26 titled, Hand Hygiene and Donning and Doffing Personal Protective Equipment. ADON confirmed, there were no other competencies present such as LN duties of administering medication, obtaining Physician orders, performing accurate assessments, documenting, and recognizing changes in condition. During a concurrent interview and record review on 5/21/26 at 3:36 pm, with ADON and Scheduler (SCH), CNA K's employee record was reviewed. SCH confirmed that CNA K was not an employee of the facility and worked at the facility through a registry and was not able to provide CNA K's first date working in the facility. ADON reviewed CNA K's Skills Checklist, dated 9/27/23 and confirmed, the Skills Checklist, was a self-evaluation (a tool used to self-identify and evaluate strengths, abilities, and area for improvement) and there was no competency check list that had been performed by the facility. During an interview and record review on 5/22/26 at 10:15 am, DSD and SCH were asked to review CNA L's employee file. SCH indicated that CNA L was registry, her first day working in the facility and providing care to the residents was on 5/20/26. DSD confirmed there was no employee file, or skills check list for CNA L and that SCH would reach out to the registry to obtain an employee file. DSD confirmed there were no competencies or skill checklists available to review for TN C, TN D, and CNA K. DSD was asked who was responsible to ensure CNAs and LNs had complete competency check lists. DSD indicated, she was responsible for the CNAs, and the Director of Nursing or Assistant Director of Nursing was responsible for the LNs.

Based on observation, interview, and record review, the facility did not ensure infection control practices were maintained when: 1. Certified Nurse Assistants (CNAs) did not wear required personal protective equipment (PPE, gowns, gloves, and masks) during resident care for two out of two sampled Residents (Residents 1 and 2).2. Treatment Nurse (TN) C pulled her face mask down past her mouth and pulled it back up to cover mouth with dirty gloves while providing care to one out of two sampled residents (Resident 2).3. TN C did not maintain infection control prevention before or after providing wound care for one out of two sampled residents (Resident 1). These failures had the potential to increase the risk of infections and cause a delay in wound healing. Findings: 1. A review of the facilities policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 5/20/26, indicated, enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms [an infection that was resistant to many different antibiotics] that employs targeted gown and gloves used during high contact resident care activities. The P&P indicated, residents who had wounds or indwelling (inserted into the body) medical devices (example: Foley/urinary bladder catheter, tube inserted into the bladder and drained urine into a bag) would be placed on EBP precautions. The P&P indicated high contact resident care activities included bathing, dressing, transferring, or providing hygiene (washing face or applying deodorant). A review of Resident 1's admission Record, dated 2/25/26, indicated admission to the facility with the diagnoses of myocardial infarction (a medical emergency also known as a heart attack) and shortness of breath (inability to get enough air into the lungs). Resident 1 was their own responsible party (RP, decision maker) and Family Member (FM) was the alternative RP (made decisions for Resident 1, when they could not make their own). A review Resident 2's admission Record, dated 9/6/24, indicated admission to the facility on 9/6/24 with the diagnoses of hypertension (high blood pressure) and chronic pain. Resident 2 was their own RP. During an observation on 4/15/26 at 10:09 am, EBP precaution signage was observed outside of Resident 1's room. CNA G was observed repositioning Resident 1 from a back lying position to a right-side lying position. CNA G was not wearing a gown. A urinary catheter bag was observed hanging on the side of Resident 1's bed. During an interview on 4/15/26 at 10:26 am, CNA G indicated that residents who had wounds and urinary catheters were placed on EBP and confirmed, Resident 1 had a wound and a urinary catheter. CNA G confirmed the observation and stated, I should have had on a gown. During an observation on 4/15/26 at 10:51 am, EBP signage was observed outside of Resident 2's room. CNA M was observed assisting Resident 2 put on deodorant. CNA M was not wearing a gown or gloves. During an interview on 4/15/26 at 11:02 am, CNA M confirmed the observation and confirmed not wearing a gown or gloves while assisting Resident 2 with applying deodorant to her armpits. CNA M indicated she had just assisted Resident 2 with a shower and was asked what type of PPE was required during a shower and no answer was provided. CNA M stated, I did not wear a gown in the shower, I only handed her the items [described as soap and shampoo] and she washed herself. During an interview on 4/15/26 at 1:30 pm, Director of Staff Development (DSD) confirmed, Residents 1 and 2 were on EBP and stated, gown and gloves should be worn for direct resident care. DSD was described the observations with CNAs G and M and confirmed, CNAs G and M should have been wearing gowns and gloves when providing care to Residents 1 and 2. 2. A review of the facility's P&P titled, Standard Precautions Infection Control, dated 5/20/26, indicated, facility staff would assume all residents were potentially infected. The P&P indicated, during resident care, facility staff should perform hand hygiene (washing hands with soap and water or utilize an alcohol gel-based hand sanitizer) after their hands have been in contact with a resident and before touching other surfaces to avoid spreading potential infection. During an observation on 4/15/26 at 11:15 am, TN C was observed performing a skin assessment and applying zinc oxide cream (thick cream that protected skin from moisture) to Resident 2's buttocks and antifungal cream (a medication cream used to treat skin infections, for example athlete's feet or yeast infections) under both breasts. TN C pulled her face mask down to her chin and pulled the mask back up to cover her mouth five times and opened Resident 2's door while wearing dirty gloves. TN C did clean the door handle. During an interview on 4/15/26 at 3:15 pm, TN C confirmed the observation and indicated touching her face mask and opening Resident 2's door while wearing dirty gloves was an infection control concern. 3. A review of the facilities P&P titled, Clean Dressing Change, dated 11/1/25, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and or cross contamination. The P&P indicated that a clean field would be utilized on the overbed table (table on wheels where residents ate their meals and personal items were stored) with the needed supplies for wound care, the overbed table would be cleansed, and a disposable pad would be placed on top of the overbed table. During an observation on 4/15/26 at 2:11 pm, TN C was observed preparing to perform Resident 1's wound care. TN C removed a partially eaten lunch tray, papers, and a vase with flowers from Resident 1's overbed table. The overbed table was not cleansed and there was no barrier pad placed on top of the overbed table. Onto the dirty overbed table, TN C placed two clear plastic bags full of gauze (fabric material used to clean wounds), a package of rolled gauze (gauze that was rolled up), a piece of Hyperfix (flexible tape), approximately six syringes (a tube with a plunger) filled with normal saline (salt water), three small bottles of normal saline, four small pink containers of normal saline, a pair of scissors, a small basin (similar to a bowl), a box of gloves, a tube of Santyl (a medication used to remove dead tissue from wounds), and a foam dressing (a padded dressing that was used to cover the wound) that was taken out of its package. TN C moved the overbed table next to Resident 1's bed and placed the box of gloves, directly onto the bed, on top of the bedlinen. When TN C had completed the wound care, TN C placed the box of gloves back into a wire rack that hung on the wall. TN C placed the unused supplies from Resident 1's wound dressing on top of the wound cart that was located outside of Resident 1's room. The unused supplies consisted of four small pink containers of normal saline, two small bottles of normal saline, two partially used plastic bags of gauze, one syringe of normal saline, and a pair of scissors. TN C used chemical cleansing wipes from a white and purple container with the name of micro-kill two to wipe down the unused wound care supplies, brushed her hair off her face, and placed them back into the wound care cart. During an interview on 4/15/26 at 3:15 pm, TN C confirmed the entire observation. TN C was asked to describe infection control measures while performing wound care and no answer was provided. During an interview on 4/15/26 at 4:10 pm, all observations were described to the facility's Infection Preventionist (IP). IP confirmed CNA G should have worn a gown while providing Resident 1 with care. IP confirmed CNA M should have worn a gown and gloves while providing care to Resident 2. IP confirmed TN C should not have touched her mask or Resident 2's door with dirty gloves. IP confirmed that TN C should have cleaned Resident 1's overbed table and placed a disposable barrier pad on it prior to placing clean wound care supplies on it. IP confirmed TN C should not have placed the box of gloves onto Resident 1's bed. IP confirmed TN C should not have cleansed the unused wound care supplies with the micro-kill two wipes and stated, it was not safe and those items are not compatible with use of those wipes.

Based on observations, interviews, and record reviews, the facility failed to ensure staff developed and implemented a resident specific care plan (a plan that detailed resident goals and care instructions for facility staff), for one of two sampled residents (Resident 1) when the care plan did not include instructions that directed Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) to assist Resident 1 with turning and repositioning. This failure had the potential to prevent Resident 1 from maintaining or attaining their highest practicable physical, mental, and psychosocial well-being. And resulted in the development of three pressure injuries (bed sores from pressure on the skin). Refer to F686Findings: A review of the facility's undated policy and procedure titled, Provisions of Quality of Care, indicated residents would receive treatment and care in accordance with the comprehensive person-centered care plan. A review of Resident 1's admission Record, dated 2/25/26, indicated admission to the facility with the diagnoses of myocardial infarction (a medical emergency also known as a heart attack), shortness of breath (inability to get enough air into the lungs), and presence of a left artificial hip joint (hip replacement). Resident 1 was their own decision maker and Family Member (FM) was the alternative decision maker (made decisions for Resident 1, when they could not make their own). A review of Resident 1's admission Minimum Data Set (MDS, an assessment tool), Section C, dated 3/4/26 and completed by MDS Nurse, indicated that Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment for memory or confusion) and scored an eight out of 15, which indicated Resident 1 required assistance with complex decision making. A review of Resident 1's admission MDS, Section GG, dated 3/4/26 and completed by MDS Nurse, indicated, Resident 1 had impairment (functional issue that affected a resident's daily life) to one lower extremity (leg), required substantial to maximal assistance (helper does more than half the effort) to roll from side to side in bed, wash their face, and comb their hair. A review of Resident 1's admission MDS, Section M, dated 3/4/26 and completed by MDS Nurse, indicated Resident 1 was at risk for developing Pressure Injuries (PI, damage to the skin and underlying tissue caused by staying in one position for too long). During an interview on 4/14/26 at 12:30 pm, Resident 1's family member (FM) indicated visiting Resident 1 in the facility almost daily. FM indicated, between 2/25/26 through 4/7/26, FM witnessed Resident 1 sit in the wheelchair for three hours or longer without any repositioning. FM stated, I've sat in the room for three hours or longer without anyone coming in to check on [Resident 1]. FM confirmed that Resident 1 could not turn or reposition herself without the assistance of facility staff. During an observation on 4/15/26 at 10:09 am, located in Resident 1's room, Resident 1 was lying on their back and their eyes were closed. CNA G entered the room at 10:14 am, and alerted Resident 1 and FM that CNA G was going to reposition Resident 1. CNA G provided almost all the help that was required to turn and reposition Resident 1. During a concurrent interview and record review on 5/21/26 at 10:10 am, with MDS Nurse and MDS Resource Nurse (RN), Resident 1's care plan titled, Potential for Pressure Ulcer Development (Pressure Ulcer also called PI), dated 2/28/26 was reviewed. MDS Nurse and MDS RN both confirmed that Resident 1 was at risk for developing PI's and that Resident 1's care plan indicated that staff would encourage Resident 1 to reposition as often as tolerated. MDS RN confirmed Resident 1's care plan had not included specific resident instructions on the steps that were to be taken to prevent Resident 1 from developing PI's. MDS RN stated, [Resident 1's] care plan should have reflected staff will assist with turning and repositioning as tolerated, knowing that [Resident 1] can't reposition on [their] own.

Based on observations, interviews, and record reviews, the facility did not ensure one of two sampled residents (Resident 2) was free from accident hazards when Treatment Nurse (TN) C used an oil-based product on a resident that received oxygen (extra air that was administered through a tube into the nose and was highly flammable). This had the potential to cause an injury and a decline in physical, mental, and psychosocial well-being. Findings: A review of the undated owner's manual, titled 5-Liter Oxygen Concentrator (the name of the equipment that delivered Resident 2's oxygen), indicated, substances that contained oil could cause a fire and should be kept away from all oxygen equipment. A review of the facility's undated policy and procedure (P&P) titled, Oxygen Administration, indicated, facility staff would take precautions to prevent fires when oxygen was in use. A review of Resident 2's admission Record, dated 9/6/24, indicated admission to the facility on 9/6/24 with the diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that made it difficult to breathe) and acute (sudden) and chronic (on going) respiratory failure (inability to get enough oxygen into the lungs) with hypoxia (the body does not get enough oxygen to function properly) and hypercapnia (elevated levels of carbon dioxide in the blood stream). Resident 2 was their own responsible party (decision maker). A review of Resident 2's Annual Minimum Data Set (MDS, and assessment tool), dated 5/1/26, indicated that Resident 2 received oxygen therapy. During an observation on 4/15/26 at 11:15 am, with TN C, Resident 2's room was observed and next to Resident 2's bed was an oxygen concentrator (a machine that delivered oxygen), it was on, and was set at 3 liters per minute (a moderate flow oxygen). Resident 2 was lying in bed and wearing a nasal cannula (a tube that connected to the concentrator and delivered oxygen to Resident 2 through the nose). TN C was observing Resident 2's buttocks, and asked Resident 2 if they had any allergies to zinc oxide (a thick cream that protected the skin from moisture) or petroleum jelly (a thick gel made from oil and wax). Resident 2 stated, no. TN C was observed mixing the zinc oxide and petroleum jelly together and applied the mixture to Resident 2's buttocks. During an interview on 4/15/26 at 12:45 pm, TN C was asked if it was contraindicated (not safe) to use petroleum jelly on residents who received oxygen. TN C stated, yes it can be applied to the skin, I put it on her bottom, not at her nose. During an interview on 4/15/26 at 3:49 pm, Director of Nursing A confirmed, petroleum jelly could not be utilized on residents who received oxygen because it was a fire hazard and stated, It's not safe.

Based on observations, interviews, and record reviews, the facility failed to ensure that medication administered to one out of two sampled residents (Resident 2) was safe when Treatment Nurse (TN) C provided medication without a Physician's order. This had the potential to cause a decline in resident health status.Findings: A review the facility's policies and procedures (P&P) titled, Wound Treatment Management, dated 2025, indicated, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. A review of the job description, titled, Treatment Nurse, dated 2003, indicated, the TN would provide skin care to the residents under the direction of the Physician. A review Resident 2's admission Record, dated 9/6/24, indicated admission to the facility on 9/6/24 with the diagnoses of hypertension (high blood pressure) and chronic pain. Resident 2 was their own responsible party (made own decisions). A review of Resident 2's care plan (a documented that described resident goals and care instructions for facility staff) titled, Resident has a rash, dated 4/20/26, indicated Resident 2 had a rash underneath both breasts and facility staff would administer treatment per the Physician's order. During a concurrent observation, interview, and record review, on 4/15/26 at 11:15 am, with TN C, Resident 2's Physician's orders were reviewed prior to entering Resident 2's room. TN C confirmed there were no skin treatment orders present. TN C was observed assessing Resident 2's skin. TN C indicated, underneath both of Resident 2's breasts and the apron area (the fold or overhanging fat that hung down over the lower abdomen) were assessed to be red, blanchable (the skin turned white when pressure was applied to the red area), and the skin was intact (not open). TN C applied an antifungal cream that contained miconazole (a medication used to treat skin infections that were caused by yeast) underneath both of Resident 2's breasts and nystatin powder to apron area. During an interview on 4/15/26 at 12:45 pm, TN C confirmed, that she applied an antifungal cream and powder under Resident 2's breasts, without a Physician's order. TN C indicated, after TN C assessed a resident's skin, TN C had decided what treatment was needed without consulting Resident 2's physician. TN C indicated that she performed the treatment that she felt was appropriate, then called the Wound Doctor (WD) afterwards with TN C's recommendations for treatment and would then obtain a Physician's order. TN C indicated that TN C would provide a different treatment to the residents if the residents primary care Physician or WD did not agree with the treatment she had provided. During an interview on 4/15/26 at 3:39 pm, Director of Nursing (DON) confirmed, a Physician's order was required prior to the administration of any treatment or medication. During a concurrent interview and record review on 4/15/26 at 4:23 pm, with DON and Infection Preventionist (IP), Resident 2's Physician's orders were reviewed. Both DON and IP confirmed, there was no Physician's order present in Resident 2's medical records for the use antifungal cream or powder and indicated that TN C should of obtained a Physician's order prior to putting the antifungal cream and powder on Resident 2. During an interview on 5/1/26 at 10:54 am, the facility's WD indicated, when the TN performed a skin assessment and identified an issue, the TN should call WD for treatment recommendations. WD indicated that the TN should provide his recommendations to the resident's primary care Physician and obtain an order for treatment prior to providing any treatment. WD confirmed, TN C did not call WD with Resident 2's skin assessment or for treatment recommendations.

Based on observations, interviews, and record reviews, the facility failed to ensure the environment was safe and sanitary when there was a large piece of plastic bag hanging from the ceiling in the rehabilitation room (where residents exercised and received therapy services) and was draining roof leakage water into a five-gallon bucket that was foul smelling, stagnant (motionless or trapped) water that also contained trash. This had the potential for mold or bacteria to grow which could negatively affect the safety and health status of residents, the public, and facility staff who utilized the physical therapy room.Findings: During an observation on 4/15/26 at 8:59 am, two large tarps (a flexible sheet of waterproof or water-resistant material that was used to protect objects from the weather) were observed covering the roof of the facility. During a concurrent observation and interview on 4/15/26 at 12:32 pm, with Maintenance Director (MD) and Occupational Therapist (OT, healthcare professional that helped residents regain their independence with dressing, eating, or showering), located in the rehabilitation room, a section of the wall that connected to the ceiling was observed to be missing and the inside of the wall was exposed. A large piece of plastic was observed hanging out of the open area. Two zip ties (plastic device that was used to secure something in place) were observed to be tightened around two separate areas of the hanging plastic which gave it a tube-like appearance. Underneath the hanging plastic was a five-gallon white bucket that contained stagnant, foul smelling, dirty water, and trash. To the right of the bucket of water, weighted exercise bags (placed around the resident's ankles or wrists during exercises) hung on the wall. To the left of the bucket of water was a large physical therapy table (used for residents to sit or lay on). A few inches away from the bucket of water was a wooden set of stairs and a scale. A leg rest for a wheelchair and a piece of exercise equipment were up against the bucket of water. MD and OT confirmed the observation, and MD was asked how long the wall/ceiling area had been in disrepair and how long the bucket of water had been there. MD did not provide an answer. OT was asked the same questions and stated, It's been like that for the three weeks I've been here. The inside of the plastic was wet, and MD indicated it was due to the zip ties trapping the water inside of the plastic. MD indicated there was a tarp on the roof, directly over the physical therapy room and the water inside of the plastic was caused by the rainstorms experienced the week prior to the observation. MD was asked what caused the water to drain into the plastic. No answer was provided. On 4/15/26 at 12:46 pm, MD was asked for a policy and procedure (P&P) regarding the facility's physical environment. On 4/15/26 at 1:23 pm, MD provided a copy of the undated Federal Regulation titled Physical Environment. MD indicated this was the P&P. A review of the untitled Federal Regulation titled, Physical Environment, indicated that the facility must be maintained (kept in good repair) to protect the health of the residents, facility staff, and the public. During a concurrent interview and record review on 5/1/26 at 12:10 pm, with MD, a work order titled, ceiling damaged in Rehab, dated 1/6/26 and created by MD, was reviewed. MD confirmed the work order indicated that on 1/6/26, the ceiling in the rehabilitation room had sustained water damage during a rainstorm and a section of the wall had been removed due to the water damage and was leaking. MD confirmed, the plastic hanging from the ceiling and the water bucket were placed there, by MD on 1/6/26.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was treated for pain in a timely manner and reassess the pain level after pain medication had been administered. This failure had the potential to result in the residents' need of pain management to not be identified, feeling depressed with poor self-esteem, and had the potential to negatively impact the resident's ability to attain or maintain their highest practicable level of well-being. During a review of the facility's policy and Procedure (P&P) titled, Administering Pain Medication, revised 3/2024, the P&P indicated, The purpose of this procedure is to provide guidelines for assessing resident's level of pain and administering analgesic (pain reliever) pain medication. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Document the following in the resident's medical record: Results of the pain assessment, medication, dose, and route of administration. Reporting: Notify the supervisor if the resident refuses the procedure and report other pertinent information in accordance with the facility policy and professional standards of practice. A review of the facility's policy and procedure (P&P) titled, Dignity, revised 10/2025, the P&P indicated, Residents shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, preferences, and individuality. Residents shall be treated with dignity and respect at all times. During a review of the facility's policy and Procedure (P&P) titled, Administering Medications, revised 10/2024, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. During a review of Resident 1's admission Record, not dated, the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included primary progressive multiple sclerosis (PPMS, an autoimmune disease that causes a block of the nerves of the body communicating with the brain, over time the symptoms gradually get worse and physical abilities slowly decline, rather than coming and going, nerve damage accumulates, making walking and activities of daily living difficult), chronic pain syndrome (complex and poorly understood pain, a condition where persistent pain lasts more than 3 months including aching, burning, shooting pain, along with fatigue, interrupted sleep, and can cause an avoidance of activity out of fear of pain), epilepsy (recurring bursts of electricity that temporarily alter behavior, movement and awareness), anxiety (a feeling of dread, worry, and uneasiness), depression (recurrent sadness, hopelessness and loss of interests), post-traumatic stress disorder, insomnia (difficulty sleeping), migraine (intense throbbing head pain), cramp and spasm (painful uncontrolled muscle movements), bed confinement (unable to tolerate getting out of bed), and high blood pressure. During a review of Resident 1's most recent, Minimum Data Set, (MDS, a resident assessment tool), dated 2/4/26, the MDS indicated, Resident 1 had no cognitive problems (ability to think, reason and make decisions), with a brief interview for mental status (BIMS) score of 14 out of 15. During a review of Resident 1's, Active Orders, dated 5/6/26, the Active Orders indicated, Pain: Record Non-Pharmacological Pain Interventions Every Shift: Using 0-10 Scale: 0: No. Non-Drug Intervention Needed. 1: Repositioning/Limb Elevation. 2: Reassurance/Emotional Support. 3: Provide Distraction/Diversionary Activities. 4: Exercise/ROM/Ambulation/ Stretching. 5: Rest Period/Quiet Environment. 6: Deep Breathing/Relaxation Exercise. 7: Guided Imagery/Meditation. 8: Laughter/Socialization. 9: Music. 10: Others every shift. During a review of Resident 1's, Active Orders, dated 4/2026, the Active Orders indicated, Pain: Monitor For Presence of Pain Every Shift Using Scale 0-10. 0: No Pain. 1-3: Mild Pain. 4-6: Moderate Pain. 7-9: Severe Pain. 10: Very Severe/Horrible/Worst Pain every shift. During a review of Resident 1's, Active Orders, dated 4/2026, the Active Orders indicated, Acetaminophen Tablet 325 milligrams (mg, a unit of measure). Give two tablets by mouth (PO) every four hours as needed (prn) for Mild Pain (1-3). During a review of Resident 1's, Active Orders, dated 4/2026, the Active Orders indicated, Ibuprofen Oral Tablet 200 mg. Give three tablets PO every eight hours prn for Moderate Pain (4-6) Administer with food. During a review of Resident 1's, Active Orders, dated 3/30/26 to 4/27/26, the Active Orders indicated, Percocet Oral Tablet 10-325 mg (Oxycodone with Acetaminophen, pain medication). Give 1 tablet by mouth PO every six hours prn for pain management. During a review of Resident 1's, Active Orders, dated 4/12/26 to 4/20/26, the Active orders indicated, Percocet Oral Tablet 5-325 mg, (Oxycodone with Acetaminophen) Give 10 mg PO every six hours prn for pain. Give two tablets of 5/325 mg (10mg/650mg) for pain. Discontinue (D/C) once 10/325 mg arrives from pharmacy. During a review of Resident 1's, Active Orders, dated 4/20/26 to 4/27/26, the Active Orders indicated, Percocet Oral Tablet 5-325 mg, (Oxycodone with Acetaminophen). Give two tablets by mouth every six hours prn for pain. Give two tablets of 5/325 mg (10/650mg) for pain. Give 1 tablet PO four times a day (QID) prn for moderate to severe pain (4-10/10 for Moderate Pain; Severe Pain. During a review of Resident 1's, Electronic Medication Administration Record (EMAR), indicated for April 2026, the days of 4/3/26 at 2:15 am, 4/24/26 at 7:04 pm, 4/25/26 at 01:05 am, and 4/27/26 at 4:38 am, all doses administered were documented with the follow up with Ineffective, and no other interventions were documented, and the Medical Doctor (MD) was not updated. During a review of Resident 1's, EMAR, indicated for April 2026, the days of 4/1/26 at 9:35 am, 4/3/26 at 9:51 am, 4/6/26 at 9:42 am, 4/7/26 at 7:49 am, 4/18/26 at 5:47 pm, 4/22/26 at 7:58 pm, 4/23/26 at 11:47 am, all doses were documented Unknown for effectiveness, and no other interventions were documented, and the MD was not updated. During a review of Resident 1's, EMAR, indicated for 4/1/26 to 4/27/26, Resident 1 received the pain medication Percocet oral tablet 5-325 mg, (Oxycodone with Acetaminophen) Give 10 mg PO every six hours prn for pain was administered every 6 hours for two days only, 4/5/26 and 4/9/26. All other days of 4/2026 Resident 1 received this medication two to three times a day only. During an interview on 4/27/26 10:55 with Licensed Nurse (LN) B, LN B confirmed Resident 1 had a lot of problems with getting pain medication on time as ordered. RN B stated, Pain management seems to be a problem around here. I stay on top it. I do know [Resident 1] tells me he has to wait for hours on some of the nurses to get his medication ordered for pain prn. I know he has pain; I make sure I get him his medicine on time. During an interview on 4/27/26 at 11:05 am, Resident 1 stated, I am so mad and aggravated. I get tired of begging for my pain medication, and almost all the nurses make me wait for hours. I hurt so bad, and it is ridiculous the way they treat me. I have had MS for over 10 years now; it is just not right to have to be in pain all the time. During an interview on 4/27/26 at 11:40 am with the MD, MD confirmed Resident 1 has a progressive stage of MS and chronic pain. MD stated, I do confirm some of the nurses have been late on Resident 1's pain medication. Unfortunately, some things fall through the cracks with changes in staffing. My expectation is the nurses call me if [Resident 1]'s pain medicine is not effective. I always answer my phone 24 hours, seven days a week, there are no excuses they cannot reach me. I confirm no one has updated me about Resident 1 not having his pain controlled. I will go evaluate Resident 1 for pain management today.

Based on interviews and record reviews the facility did not ensure the process for discharging residents was followed for two out of two residents (Residents 1 and 2) when they were provided with an incomplete notice of discharge and there was no discharge plan in place. This failure could prevent the resident from attaining or maintaining his/her highest practicable level or result in a decline in the resident's physical, mental or psychosocial well-being.Findings: A review of the facility's undated P&P titled, Transfer and Discharge (including AMA) (AMA meant leaving the facility against medical advice), indicated, the discharge notice would be provided in a way that they could understand. The P&P indicated the discharge notice would include the specific reason for discharge, the date of the discharge, the specific location the resident will be discharged to, the name and address of the local Ombudsman (state agency program that protected resident rights), and information for the state agency responsible for protecting the rights for people with mental health illness. The P&P indicated the notice for discharge was provided 30-days prior to discharge and facility would notify the local Ombudsman's office when a resident was provided a 30-day notice for discharge. A review of Resident 1's admission Record, dated 8/23/24, indicated, admission to the facility on 8/23/24 with the diagnoses of borderline personality disorder (a mental health illness that included intense emotions, fear of abandonment, and impulsive behaviors), bipolar disorder (a mood disorder that caused intense mood swings), suicidal ideation (thoughts about taking one's own life), and chronic obstructive pulmonary disease (COPD, a group of lung diseases that made it difficult to breathe). Resident 1 was her own responsible party (RP, decision maker). A review of Resident 1's Quarterly Minimum Data Set (MDS, an assessment tool), dated 1/2/26, indicated that Resident 1 utilized a wheelchair, had a good memory, required substantial assistance to bathe or shower, use the bathroom, and required moderate assistance to walk 10 feet. The MDS indicated that Resident 1 was incontinent of bowel and bladder (inability to control the need to go to the bathroom). A review of Resident 2's admission Record, dated 8/28/25, indicated, admission to the facility on 8/28/25 with the diagnoses of bipolar disorder, schizoaffective disorder (a mood disorder that included hallucinations and delusions), and COPD. Resident 2 was her own RP. A review of Resident 2's Quarterly MDS, dated [DATE], indicated that Resident 2 had a good memory. During an interview on 2/25/26 at 2:39 pm, Resident 1 stated, the day after care conference [a meeting that included the facility staff, the resident, and resident family members or their RP met to discuss health, goals, and the plan for discharge] I was served a 30-day notice. Resident 1 indicated there was no discharge plan and stated, They were going to send me to an apartment that I use to live in. There are other people living there now, they were going to send me without care, equipment, and what? Just meds [medication]. Resident 1 indicated that they had no place to live and the facility staff had been assisting with finding a new home so that Resident 1 could be discharged from the facility. During a concurrent record review and interview on 9/25/26 at 1:21 pm, with Resident 1, the Notice of Involuntary [against someone's will] Transfer or Discharge, (a paper document provided to Resident 1) dated 2/20/26, was reviewed. Resident 1 confirmed, the Notice of Involuntary Transfer or Discharge indicated, that on 2/20/26, Resident 1 would be discharged to a home or apartment of their choice that was in a different city and did not include a specific address that Resident 1 would be discharged to. The Notice of Involuntary Transfer or Discharge, indicated, the reason for discharge was because Resident 1's health had improved, skilled care was no longer required, and that the facility could not meet Resident 1's needs. There was no information provided to Resident 1 for contacting the state agency responsible for protecting the rights for people with mental health illnesses. A review of Resident 1's discharge care plan (written resident goals and the care instructions for facility staff), dated 7/3/25 indicated that Resident 1 did not have a safe discharge location and required assistance from the facility staff for medical needs. A review of Resident 1's quarterly Care Conference Summary, dated 2/19/26, indicated, Resident 1 did not have a reasonable discharge plan in place at this time. During a concurrent interview and record review on 2/25/26 at 1:34 pm, with Director of Nursing (DON), Resident 1's IDT-Notice of Transfer/Discharge, dated 2/20/26 was reviewed. DON confirmed the notice was incomplete. The notice was missing the date it was provided to Resident 1, the date the discharge was going to occur, specific information that indicated where Resident 1 would be discharged to, the reason for the discharge, and information regarding how to contact the local Ombudsman's office, or the state agency responsible for protecting the rights for people with mental health illnesses. The notice indicated that the facility had not notified the Ombudsman's office with the intent of discharging Resident 1. The notice was not signed by Resident 1 or the Assistant Director of Nursing (ADON). DON confirmed that Resident 1 did not have an appropriate discharge plan in place. During a concurrent interview and record review on 2/26/26 at 8:39 am, with the DON, Resident 2's IDT-Notice of Transfer/Discharge, dated 2/20/26 was reviewed. DON confirmed the notice was incomplete. The notice was missing the date it was provided to Resident 2, the date the discharge was going to occur, specific information that indicated where the Resident 2 would be discharged to, the reason for the discharge, and information regarding how to contact the local Ombudsman's office, or the state agency responsible for protecting the rights for people with mental health illnesses. DON confirmed that Resident 2 did not have an appropriate discharge plan in place. During an interview on 2/26/26 at 9:20 am, Resident 2 stated, The [ADON] told me I was being discharged in 30 days because I was high functioning and confirmed, there was no discharge plan in place when the ADON provided Resident 2 with a discharge notice. During an interview on 2/26/26 at 10:23 am, the facility's Administrator (Admin) stated, Before the 30-day notice, there should be a solid discharge plan in place. Admin indicated that there was no firm discharge plan in place for Residents 1 and 2, and stated, I wasn't even aware they were being provided with 30-day notices, and I should have.

Based on interviews and record reviews, the facility did not ensure that one of two sampled residents (Resident 1) was free from unnecessary medications when there was no behavioral monitoring in place.This had the potential for Resident 1 to not maintain their highest practicable mental, physical, and psychosocial well-being.Findings:A review of the facility's undated policy and procedure titled, Unnecessary Drugs, indicated, medication would be monitored to ensure the medication was effective.A review of Resident 1's admission Record, dated 8/23/24, indicated, admission to the facility on 8/23/24 with the diagnoses of borderline personality disorder (a mental health illness that included intense emotions, fear of abandonment, and impulsive behaviors) and anxiety (feelings of fear). Resident 1 was her own responsible party (decision maker).A review of Resident 1's anxiety care plan (document that contained resident goals and staff care instructions), dated 11/23/25, indicated that facility staff would monitor and track Resident 1's behaviors.A review of the Physician's order dated 11/22/25, indicated, Resident 1 was prescribed hydroxyzine (an antihistamine medication that treated allergies and could be used to treat symptoms of anxiety) 50 milligrams, give one tablet every six hours as needed for anxiety. The targeted symptoms the medication was being used for included being worried that their needs were not being met due to anxiety.During a concurrent interview and record review on 2/26/26 at 8:39 am, with the Director of Nursing (DON), Resident 1's Physician orders dated 8/23/24 through 2/26/26 were reviewed. DON confirmed, there was no behavioral monitor in place that tracked signs or symptoms of anxiety and stated, the purpose is to count the number of episodes, to monitor the effectiveness of the medication.

Based on interview and record review, the facility failed to implement their Infection Control Program policies and procedures for controlling the spread of a communicable disease and infection when four of seven sampled residents (Resident 4, 5, 6 and Resident 7), tested positive for Influenza A (influenza, a contagious respiratory illness caused by the influenza), and all residents in close contact were not tested in a timely manner, in accordance with the facility's infection control policy. This failure put the residents, staff and families at risk for contracting Influenza A infections and had the potential to result in serious negative clinical outcomes for this vulnerable population.Findings: The facility's policy revised 1/2026, titled, Influenza Exposure Control, was reviewed and indicated the purpose of this policy to establish procedures for prevention of and controlling exposure to influenza (a contagious respiratory illness caused by the influenza virus). The facility shall take a multifaceted approach to preventing transmission of the influenza viruses, including vaccination, testing, infection control, antiviral treatment, and antiviral chemoprophylaxis (taking medication to prevent illness). This policy indicated on page two, 14. b: Test for influenza for ill persons who are in the affected units as well as previously unaffected units in the facility. A review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included fracture of sacrum (broken bone that connects the spine to the pelvis), multiple fracture of ribs of the right side (broken bones protecting the lungs), acute respiratory failure (sudden condition when the lungs cannot properly get oxygen into the blood), chronic obstruction pulmonary disease (COPD, a progressive lung disease), dysphagia (difficulty swallowing), diabetes (too much sugar in the blood), paranoid schizophrenia (a brain condition when a person loses touch with reality and has mistrust of others), and heart disease. A review of Resident 5's clinical record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure, sepsis (the body's severe reaction to an infection), pneumonia (infection that inflames the air sacs in the lungs), dysphagia (difficulty swallowing), atrial fibrillation (fast and irregular heart beat), peripheral vascular disease (PVD, poor circulation in the legs and feet or hardening of the arteries), heart disease, major depressive disorder (persistent sadness, hopelessness, and loss of interest), and Bi-polar disorder (intense, extreme mood swings affecting behaviors). A review of Resident 6's clinical record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses that included dementia with agitation (a term for for impaired ability to remember, think, reason, or make decisions that interfere with daily life with irritability), heart disease, high blood pressure, repeated falls, anxiety (feelings of dread, fear, and uneasiness), shortness of breath uncomfortable feeling you cannot get enough air into your lungs), and major depressive disorder. A review of Resident 7's clinical record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses that included COPD, diabetes, dysphagia, heart disease, major depressive disorder, chronic kidney disease (permanent damage and loss of the ability to filter waste out of the blood), and cirrhosis of the liver (permanent, severe scarring and damaged liver). During an interview on 2/5/26 at 1:40 pm, the Infection Prevention Nurse (IP) stated, The local hospital called the facility and updated us that [Resident 6] was positive for Influenza A on 1/29/26, that is when we knew we had influenza in the facility. We had plenty of masks, gowns, and gloves, but no test kits for influenza in the facility. The Director of Nursing [DON] purchased 12 kits on 1/30/26, and I purchased 9 kits on 2/3/26. During an interview on 2/5/26 at 1:45 pm, the IP confirmed there have been four positive cases of Influenza A since 1/29/26. IP stated, [Resident 6] passed at the hospital, [Resident 5] is back in the facility, and [Resident 4] and [Resident 7] are still at the hospital. During an interview on 2/5/26 at 2:00 pm, IP confirmed she had only tested residents living in the same rooms with the other residents who tested positive for Influenza A and residents with flu-like symptoms. IP stated, The consultant told me I did not have to test all the residents. No, I did not look at our policy for an Influenza exposure. During a phone interview on 2/5/26 at 2:22 pm, Registered Nurse (RN) C confirmed she was the new consultant for the facility and did not review the facility's policy before advising IP on which residents needed to be tested for influenza. RN C stated, I have only been here a week, I am still learning. I will look at our policies moving forward. I confirm we should have tested more residents. During an interview on 2/5/26 at 2:25 pm, the DON confirmed the facility was not prepared for an influenza outbreak and the facility's policy for influenza was not followed for testing residents. DON stated, I confirm we should have tested all residents because they dined together and do activities together, and we had sick employees. We should have tested all residents to be safe.

Based on interview and record review, the facility failed to revise a wound care plan for one of three sampled residents, (Resident 1) when a new physician wound care order was prescribed for a wound vacuum-assisted closure (wound vac, medical device that uses gentle, constant suction to heal complex wounds), to be placed and maintained to the left hip pressure ulcer (a deep wound caused from pressure to the area). This failure had the potential for Resident 1's wound care not to be managed appropriately which could result in discomfort, further deterioration of the wound, and possible infection and hospitalization. Findings: The facility's policy revised 2025, titled, Care Plan Revisions Upon Status Change, was reviewed and indicated the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included paralytic syndrome following cerebral infarction affecting right side (stroke that caused permanent loss of voluntary movement), diabetes (too much sugar in the blood), chronic obstruction pulmonary disease (COPD, a progressive lung disease), dysphagia (difficulty swallowing), pressure ulcers (open areas to the skin and underlying tissues) chronic kidney disease (permanent damage and loss of the ability to filter wastes out of the blood), high blood pressure, [NAME] cell carcinoma (rare and fast growing type of skin cancer), pulmonary embolism (a blood clot that has traveled to the lungs) and chronic pain (persistent pain that lasts more than three to six months). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 1, dated 1/27/26, indicated that Resident 1 had a moderate cognitive (ability to think, reason and remember) deficit, with a brief interview for mental status (BIMS) score of 9 out of 15, and was totally dependent for staff with all activities of daily living (ADLs, basic needs as personal hygiene, dressing, toileting, transferring, walking, and eating). During a record review a document date range 9/3/25 to 1/31/26, titled, Order Summary Report, indicated Resident 1 was ordered a wound vac to the left hip on 1/20/26: Change every Monday, Wednesday and Friday am shift and as needed. Ensure wound vac dressing is sealed and intact with a setting of 125 millimeters of mercury pressure (mm/hg, a unit of measure) every shift every day. During a concurrent record review of Resident 1's care plans and interview on 2/5/26 at 1:10 pm, with the Director of Nursing (DON), the DON confirmed the wound care plan for Resident 1 needed to be revised with specific interventions for Resident 1's new wound care orders to include the new order for a wound vac. During a follow up interview on 2/5/26 at 1:15 pm, the DON stated, I confirm the care plan for [Resident 1] is not revised and needs to be more specific for non-compliance for wound care. [Resident 1] will allow one nurse to complete her wound care, we could add this to the care plan. We could also add to call the family member [FM, who was involved in Resident 1's care], if needed to assist us if [Resident 1] refuses wound care treatments, to make sure all wound care is completed per physician orders.

Based on interview and record review, the facility failed to protect two of five sampled residents, (Resident 1 and Resident 2) from financial abuse, manipulation and exploitation when:1.The Activity Assistant (AA) J played on Resident 1's sympathy and manipulated Resident 1 out of $800, and promised services she never delivered. 2.AA J loaded Resident 2's bank card onto her personal well-known online shopping website to buy her coffee creamer, when the facility could have bought the coffee creamer for Resident 2, without using her bank card. These failures caused Residents 1 and 2 anxiety, embarrassment, and humiliation and the potential for negative emotional and psychosocial outcomes. Findings: The facility's policy revised 2025, titled, Transactions Involving Resident Funds, was reviewed and indicated it is the practice of this facility that anytime there is a transaction involving resident funds, the resident must be provided with a receipt of such transaction. Copies of each transaction are filed in the business office. Policy Explanation and Compliance Guidelines: The facility will establish and maintain a system that assures a complete and separate accounting of each resident's personal funds and is according to generally accepted accounting principles. The facility will ensure resident funds are not comingled with facility funds or funds of someone other than a resident, such as a staff member managing the resident's personal funds. The Business Office Manager, or his/her designee, is responsible for providing residents with receipts for withdrawals and for requested or needed personal items when such funds are withdrawn from the resident's personal funds account managed by the facility. A copy of such transactions and receipts are maintained by the Business Office Manager, or designee, in order to verify account transactions and to reconcile resident fund balances with withdrawals and expenditures. Personal items purchased by Social Services, or other authorized staff members on behalf of residents, provide the Business Office Manager, or designee, with a copy of receipts upon return to the facility. The facility's policy revised 2025, titled, Abuse, Neglect and Exploitation, was reviewed and indicated the definition of Exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. The definition of Mistreatment means inappropriate treatment or exploitation of a resident. The facility's policy revised 2025 titled, Abuse, Neglect and Exploitation, was reviewed and indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 1.A review of Resident 1's record indicated she had been admitted to the facility on [DATE] with diagnoses that included osteomyelitis of cervical vertebra (an infection of the neck bones causing severe pain, stiffness, and can lead to numbness or weakness), acute respiratory failure with hypoxia (sudden loss of oxygen needed in the blood making it hard to breathe), pressure ulcer of sacral region stage 4 (a severe, open sore on the tailbone area that involves full-thickness tissue loss, extending through skin and fat to expose muscle, tendon, ligaments, or even bone), diabetes (too much sugar in the blood), chronic pain (long standing pain that persists), Bi-polar disorder (a mental health condition causing extreme mood swings), attention deficit hyperactivity disorder (condition that makes it hard to manage your attention, control impulses, leading to challenges with focus, organization, and self-control in daily life), history of deep vein thrombosis embolism (DVT, is a blood clot forming in a deep vein, usually the leg) and embolism (when the blood clot or part of it breaks off, travels, and blocks a blood vessel elsewhere, most dangerously in the lungs), major depressive disorder (persistent sadness, and loss of interest), and high blood pressure. The physician noted in his admission orders that Resident 1 was capable of making healthcare decisions and was listed as her own responsible party (RP). Resident 1 was discharged to home on [DATE]. During a review of Resident 1's most recent Minimum Data Set, (MDS, a resident assessment), dated 8/31/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, memory and decision making skills), score of 15 of 15 and was cognitively intact (able to think and reason). During an phone interview on 12/18/25 at 2:10 pm, Family Member (FM) stated, No one has called or contacted me from the facility about [Resident 1's] money being taken and services not being provided. [Resident 1] told me l about the plan with [AA J] before she was discharged home. [AA J] was supposed to buy groceries and make meals for [Resident 1] after being discharged . [Resident 1] is very detailed when it comes to money, she knows exactly what she has down to the penny. [Resident 1] was really upset over this incident. During a phone interview on 12/18/25 at 3:11 pm, Resident 1 indicated between August 2025 and October 2025, AA J played on her sympathy and borrowed money from Resident 1. Resident 1 stated, [AA J] was out at the smoking area and she kept complaining she didn't have any money, and she was broke and she couldn't afford cigarettes, and she didn't have gas money. I felt sorry for her and gave her my debit card and pin number. [AA J] took $500 from my bank account using the ATM and gave me $300 and kept $200 for herself. Then [AA J] asked me to borrow money and again took $500 from my account and kept $200, for herself. I was not paid back nor did I receive any receipts for these transactions. Just before I was going to be discharged home in October, [AA J] approached me and convinced me she was my friend and that I should have her come to my house and cook my meals once I was at home. I agreed, but then [AA J] said she would need gas money to get to my house and I gave [AA J] a $100.00 bill for gas and $200 for groceries. Once I was home, I tried calling [AA J] for three days about coming over and fixing my meals. [AA J] never did respond and never came to my house with groceries and this was very upsetting to me because I had called and called and left her many messages. I was so anxious. I eventually ended up calling the facility and told them that I had given [AA J] $100 for gas and $200 for groceries and she never showed up. In that same week before I discharged home, [AA J] approached me and asked if I wanted a going away party. Of course, I said yes. At the end of the going away party, [AA J] told me I had to pay her $100 because she had to pay for my going away party out of her own pocket, and she could not afford that and that the Administrator refused to reimburse her. I felt so guilty, I gave [AA J] a $100 right then an there. [AA J] had convinced me that was the rule. I did not say anything because she made me feel sorry for her that she was always broke and I did not want to make things worse for her, I thought we were friends. Now I feel so embarrassed and foolish for letting [AA J] manipulate me out of $800, I was taken advantage of by someone who pretended to be my friend. I thought [AA J] cared about me. I still have never heard from [AA J] or anyone else from the facility. An interview was conducted by phone on 12/23/25 at 10:17 am, with AA J. AA J stated, Yes, I did go to the bank for [Resident 1] one time. Yes, she gave me her pin number, and I took out $500.00 and gave all the money to [Resident 1]. I did make her cupcakes for her party, but I paid for all the supplies.A review of the facility's 5 day abuse investigation follow up report submitted by the Administrator (Admin) B to the California Department of Public Health (CDPH), on 11/5/25 indicated, Some time in November a conversation was had between Resident 1 and Staff 1 [AA J] regarding Staff 1 providing cooking services for Resident 1 upon discharge from [the facility name] Resident 1 indicated that she gave $200-300 to [AA J] to buy groceries before she discharged and once she discharged they never spoke again and she indicated that Staff 1 kept the money. Staff 1 indicated that she never received any money and that the idea was for Resident 1 to buy the groceries and she would prepare the meals. Once Resident 1 discharged Staff 1 was hit with automobile problems and indicated this to Resident 1. Staff 1 indicated that for now she would not be able to drive to Resident 1's home and cook the food and that possibly at a later date once the auto issues were dealt with she could. The report indicated that the facility would, reimburse Resident 1 $300. The report additionally indicated that they had not substantiated Resident 1's allegation and allowed AA J to return working at the facility. 2. A review of Resident 2's record indicated she had been admitted to the facility on [DATE] with diagnoses that included lupus (a chronic disease where your immune system mistakenly attacks your own healthy tissues, causing inflammation, pain, fatigue, and potential damage to skin, joints, kidneys, heart, and lungs. A lifelong condition with unpredictable flare-ups), chronic kidney disease (when the kidneys cannot filter the blood properly), schizoaffective disorder (a mood disorder with delusions and hearing voices), bi-polar, depression, chronic obstructive pulmonary disease (COPD, a progressive lung disease), hyponatremia (low sodium levels in the blood) and high blood pressure. During a review of Resident 2's most recent MDS, dated [DATE], indicated Resident 2 had a BIMS score of 15 of 15 and was cognitively intact. During an interview on 12/11/25 at 5:10 pm, the Business Office Manager (BOM) stated, It's under the abuse policy that Activity staff are not allowed to take any cash from any resident whatsoever. I never received receipts from [AA J] for withdrawing money from [Resident 1's] bank account or for the online purchase she made for [Resident 2], and I should have. During an interview on 12/18/25 at 12:50 pm, Resident 2 stated, Yes, I remember [AA J], she quit. Yes, she did order me coffee creamer. She ordered two bottles of French vanilla. That's the creamer I like to use in my coffee. I gave her [AA J] my bank debit card. She uploaded my bank card number onto her personal [on line shopping website] to order it. I didn't know I wasn't supposed to do that. I just talked to [Admin B] about this. Resident 2 added that she was not sure if she had received a receipt for the coffee creamer, but then her debit card came up missing and she had called the bank and cancelled the card immediately.During a phone interview on 12/19/25 at 8:41 am, Admin A stated, Yes, I remember the investigation of [Resident 1]. I tried to finish it before I left the facility, and I was told that the next administrator would do it. I confirm the investigation had not been completed for Resident 1 and it was late. I immediately suspended [AA J] until I could gather more information. I was never asked to reimburse money for [Resident 1's] going home party by [AA J]. I would never expect any residents to pay for their own party. I remember she did have a party. We have funds for all activities. I was there the day of the party. We have a money policy. No staff member can take any money from any resident for any reason. A review of an undated witness statement written by AA O indicated, Witness Statement. I am providing this statement regarding incidents I personally observed involving [AA J] and [Resident 1]. On multiple occasions, I witnessed [Resident 1] give money directly to [AA J] and her daughter [who is a volunteer]. I also overheard [AA J] and her daughter discussing the money that had been given to them by [Resident 1]. These are my personal observations, and this statement reflects what I directly witnessed and heard. During an interview on 12/23/25 at 8:50 am, AA O confirmed she had written the above statement regarding witnessed interactions between AA J and Resident 1. During an interview on 12/23/25 at 12:20 pm, Certified Nursing Assistant (CNA) M stated, I did hear [AA J] complain about the Activity budget a lot. I did hear residents gave her money to fund the activity budget. I do know [Resident 1] used her own money for some of the supplies. Some of the residents that used their money are no longer here, they're discharged . [AAJ] used to complain to all the residents. It did upset the residents to hear her complaints. Some residents only wanted to do activities with [AA J], so she could get more hours. A review of an email sent to Activity Supervisor (AS), by AA P, dated 11/12/25, titled, To Whom It May Concern, indicated the following, [AA J] is telling residents that she is getting less hours for work and that she is being overworked when she does come into work are unnecessary conversations to have with the residents. These are not concerns for the residents to have for her. If she has concerns about scheduled hours or that she's given too much to handle at once, she should be talking to her manager and not the residents. The residents have nothing to do with that aspect of her work. [AA J] sharing has caused residents to be uncomfortable, stressed out and unwilling to participate in activities when it's not [AA J] who leads those activities for the day. [AA J] is informing residents that she spends money out of her own pocket to provide for materials because the facility is not providing or doesn't have funds to provide. She says the facility lacks funding for materials to run activities for the residents. Again, this is unnecessary information to disclose to the residents. The budget on materials for activities shouldn't be something to share with the residents. Residents should not have to worry about the facilities funds. When [AA J] is telling residents about these things, it makes it difficult for employees to work with them. There shouldn't be conflict between employees and residents, and this is what is being caused because of how [AA J] is involving residents and things they should not have to worry about. Can someone please follow up. It would be greatly appreciated. During an interview on 12/23/25 at 9:35 am, AS confirmed she received the above email from AA P. AS stated, I did send the email up the chain of command, but nothing was done. AS indicated that she had already ordered the coffee creamer for Resident 2, and had informed AA J of this, but AA J took Resident 2's bank card and uploaded it to her personal online shopping site anyway. AS indicated that the creamer for Resident 2 was delivered to AA J's home. AS stated that was a violation of the facility's money policy. During an interview on 12/23/25 at 12:45 pm, AA P confirmed he had sent an email to AS on 11/25/25. AA P indicated that AA J was always talking about her personal problems in front of the residents. She would say things like we don't have specific supplies we need, and I have to pay out of my own pocket. It's not fair. They need to give us a bigger budget. These comments would upset the residents and then the residents would mention it to us. The residents felt sorry for her. A facility disciplinary action document for AA J titled, Violation of Facility Resident Finance Policy, dated 11/28/25, was reviewed. The document indicated; Date of Violation 11/23/25. Nature of violation: Conduct, uncooperative, carelessness, and disobedience. Final written warning. 3-day suspension effective 11/28/25. Admin B documented on 11/28/25, Employee walked out of discussion meeting, said that she is done and not going to work. We will get a written statement of resignation/Admin to term. During an interview on 12/24/25 at 8:54 am, with Regional Registered Nurse Consultant, she confirmed the facility's Transactions Involving Resident Funds policy was violated by AA J for Residents 1 and 2.

Based on interview and record review, the facility failed to thoroughly investigate a financial abuse allegation and report the results of their investigation within five (5) days to the California Department of Public Health (CDPH) for one of five sampled Residents. (Resident 1)Refer to F600 This failure had the potential to result in further financial abuse to other residents.Findings: The facility's policy revised 2025 titled, Abuse, Neglect and Exploitation, was reviewed and indicated, Investigation of Alleged Abuse, Neglect and Exploitation, will include the following: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations that are included: Identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); Investigation of different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and provide a completed and thorough documentation of the investigation.The facility's policy revised 2025 titled, Abuse, Neglect and Exploitation, was reviewed and indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. A review of Resident 1's record indicated she had been admitted to the facility on [DATE] with diagnoses that included osteomyelitis of cervical vertebra (an infection of the neck bones causing severe pain, stiffness, and can lead to numbness or weakness), acute respiratory failure with hypoxia (sudden loss of oxygen needed in the blood making it hard to breathe), pressure ulcer of sacral region stage 4 (a severe, open sore on the tailbone area that involves full-thickness tissue loss, extending through skin and fat to expose muscle, tendon, ligaments, or even bone), diabetes (too much sugar in the blood), chronic pain (long standing pain that persists), Bi-polar disorder (a mental health condition causing extreme mood swings), attention deficit hyperactivity disorder (condition that makes it hard to manage your attention, control impulses, leading to challenges with focus, organization, and self-control in daily life), history of deep vein thrombosis embolism (DVT, is a blood clot forming in a deep vein, usually the leg) and embolism (when the blood clot or part of it breaks off, travels, and blocks a blood vessel elsewhere, most dangerously in the lungs), major depressive disorder (persistent sadness, and loss of interest), and high blood pressure. The physician noted in his admission orders that Resident 1 was capable of making healthcare decisions and was listed as her own responsible party (RP). During a review of Resident 1's most recent Minimum Data Set, (MDS, a resident assessment), dated 8/31/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a test of memory and decision making abilities) score of 15 of 15 and was cognitively intact (able to think and reason). During a review of a facility document titled, Facility, dated 10/29/25, indicated CDPH received a verbal report of an allegation of financial abuse on 10/30/25 at 8:37 am to Resident 1 by the facility's Activity Assistant (AA) J. A 5 day report of the results of the facility's abuse investigation should have been submitted to CDPH by 11/3/25. During a review of the facility's document titled, Update for Facility Reported Event dated 11/5/25, indicated CDPH received the facility's 5 day abuse investigation results report on 11/5/25 at 2:42 pm, two days late, from the facility. The report indicated, [AA J] will be in-serviced regarding receiving money from residents and that will go in her employee file. The facility will reimburse [Resident 1] $300.00. During an interview on 12/18/25 at 12:03 pm, Administrator (Admin) B confirmed the investigation of alleged abuse by AA J towards Resident 1 was submitted late to CDPH. Admin B stated, I entered the facility on 11/3/25, and the report was dated 11/5/25. It was only a few days late. During a follow up interview on 12/18/25 at 12:25 pm, Admin B confirmed the facility had not reimbursed Resident 1 the $300 as they indicated in their 5 day abuse allegation investigation results on 11/5/25. Admin B stated, I did not substantiate the abuse. I didn't have any proof that it happened. There was no written contract statement, it was a verbal agreement if she wanted [AA J] to cook meals. [Resident 1] confirmed there was a car problem or a delay, but I have no proof. [AA J] explained she needed to replace her tires and there was a conversation between them both, so I cannot substantiate it. During an interview on 12/18/25 at 1:55 pm, the Director of Nursing (DON) confirmed the abuse allegation for Resident 1 was not complete or thorough. DON stated, I confirm the investigation was no complete, we need more witnesses and more interviews. During a concurrent interview and record review of the facility's Abuse Policy part V: A and B, page 4 (Investigation of Alleged Abuse, Neglect and Exploitation), on 12/18/25 at 2:03 pm, Admin B confirmed the investigation of the abuse allegation of Resident 1 was not complete and did not follow their facility's abuse policy instructions to provide complete and thorough documentation of the investigation.During an phone interview on 12/18/23 at 2:10 pm, Family Member (FM) of Resident 1 stated, No one has called or contacted me from the facility to ask what I knew about [AA J] taking money from [Resident 1] and not providing promised services. During a phone interview on 12/18/25 at 3:11 pm, Resident 1 indicated that she was never reimbursed any money by the facility or contacted by the facility regarding the abuse allegation or the results of their investigation. During a phone interview on 12/19/25 at 8:41 am, Admin A stated, Yes, I remember the investigation of [Resident 1]. I tried to finish it before I left the facility, and I was told that the next administrator would do it. I confirm the investigation had not been completed for Resident 1 and it was late. I immediately suspended [AA J] until I could gather more information. I was never asked to reimburse money for [Resident 1's] going home party by [AA J]. I would never expect any residents to pay for their own party. I remember she did have a party. We have funds for all activities. I was there the day of the party. We have a money policy. No staff member can take any money from any resident for any reason. During an interview on 12/23/25 at 10:25 am, the Regional Registered Nurse Consultant stated, I confirm this was not a proper or complete investigation. [AA J] should have never been allowed to come back to the facility until this allegation was thoroughly investigated. I also confirm [AA J] never had the one on one abuse training as the report indicated that was sent to [CDPH]. The last abuse training for [AA J] was completed in August 2024. During an interview on 12/23/25 at 11:10 am, DON confirmed the abuse investigation was not thorough. DON stated, I have a list of all the names of the alert and oriented residents I interviewed on 12/20/25, which should have been part of the documentation for this investigation of alleged financial abuse.

Based on observation, interviews, and record reviews, the facility failed to appropriately implement their infection control program to mitigate the spread of COVID-19 (symptoms include fever, fatigue, cough, breathing difficulties, loss of smell, and taste). Both Certified Nursing Assistant (CNA) A and Activity Assistant (AA) did not adhere to the necessary precautions for isolation rooms when they did not follow the proper procedures for putting on or taking off Personal Protective Equipment (PPE, masks, gowns, gloves and eye protection) as per the facility policy.These lapses in following standard protocols posed a significant risk by potentially facilitating the development and transmission of COVID-19 within the facility. This could lead to severe adverse consequences for residents, staff, and visitors. During a record review of facility policy titled COVID-19 Prevention, Response and Reporting dated 2024, indicated Healthcare Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 (have the ability to filter particulates, while surgical masks do not) filters or higher, gown, gloves and eye protection.During an observation of signage posted outside of room four on 8/27/25 at 10:02 am, indicated Contact Precautions and Droplet Precautions included everyone must clean their hands, including before entering and when leaving the room; put on gloves before room entry, discard gloves before room exit; put on gown before room entry, discard gown before room exit, do not wear the same gown and gloves for the care of more than one person; make sure their eyes, nose and mouth are fully covered before room entry, remove face protection before room exit; use dedicated or disposable equipment.During a concurrent observation and interview on 8/27/25 at 10:12 am, with AA, AA entered room [ROOM NUMBER] with a snack cart and handed snacks to the three residents inside the room. Room four had signage on the outside of the door that indicated, Contact Precautions and Droplet Precautions (a resident inside the room was positive with COVID-19). AA entered the room with no gown or gloves. AA did not perform hand hygiene when he exited the room. AA did not wear eye protection while in the room. AA did not remove his N95 mask when he left the room. AA stated he forgot there was a resident in room four that had COVID-19. AA confirmed the signage on the outside of the room indicated staff needed to complete hand hygiene when they exited the room, wear eye protection while inside the room, wear gloves while inside the room, and remove N95 mask when he exited the room. AA confirmed he did not adhere to any of those instructions and should have. AA also stated he probably shouldn't have taken the snack cart into the room and created a risk of spreading COVID-19 to other residents and staff by doing so.During a concurrent observation and interview on 8/27/25 at 10:40 am, with CNA A, room [ROOM NUMBER] had signage on the outside of the door that indicated Contact Precautions and Droplet Precautions (a resident inside the room was positive with COVID-19). CNA A put on a gown and gloves inside of room [ROOM NUMBER]. CNA A did not tie her gown at the neck or waist. CNA A did not throw her N95 mask away when she exited the room. CNA A did not perform hand hygiene. CNA A performed care to more than one resident in the room and did not change her gown or gloves in between resident care. CNA A stated she did not know she was supposed to put on gown, gloves, eye protection and mask prior to entering the room. CNA A confirmed she did not perform hand hygiene. CNA A confirmed she did not change her gown or gloves in between residents because I didn't know I needed to. CNA A confirmed she attended the PPE, N95 masking and hand hygiene in service on 8/21/25 with Infection Preventionist (IP).During an interview with IP on 8/27/25 at 11:00 am, IP stated she held a staff in service on 8/21/25 and 8/25/25 for N95 masking etiquette, hand hygiene, and PPE requirements with all staff members. IP stated staff are required to put on a gown, mask, eye protection, and gloves prior to entering the resident's room from the PPE supply drawers outside of the room. IP stated when staff exited the resident's room, staff were required to take gloves, eye protection, gown and mask off, dispose of them, exit the residents room, and perform hand hygiene. IP stated staff must use a new N95 mask every time they exited a room. IP confirmed AA and CNA A did not follow facility policy for putting on and taking off PPE for contact and droplet precautions and should have.During an interview with Administrator (Admin) on 8/27/25 at 11:45 am, Admin stated she was not happy with the staff that did not follow facility policy because IP had recent in-services with staff regarding PPE, N95 masks, and hand hygiene. Admin confirmed staff did not adhere to facility policy and should have.

Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) was provided with appropriate Preadmission Screening and Resident Review (PASARR, a screening, that was done prior to admission to the facility or as needed, and screened residents for possible serious mental health illness) when: The PASARR completed prior to facility admission did not accurately reflect Resident 1's serious mental health illnesses (SMHI); and The facility did not follow up on a subsequent PASSAR that indicated a Level 2 screening (a State agency performed a comprehensive evaluation and made recommendations for care and services) was required. These failures had the potential to cause a decline in psychosocial well-being or cause a delay in required mental health services. Findings: 1. A review of the facility's undated policy and procedure (P&P) titled, Resident Assessment-Coordination with PASARR Program, indicated, the facility would coordinate assessments prior to admission to ensure residents with mental disorders received the necessary care and services. The P&P indicated, The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. The P&P indicated, The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. A review of the admission Record, dated 8/23/24, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of post-traumatic stress disorder (PTSD, a SMHI that developed after experiencing or witnessing a terrifying event), nightmare disorder (a SMHI, repeated, frightening dreams that cause distress), bipolar disorder (a SMHI, extreme shifts in mood, energy, thinking, and behavior), prolonged grief disorder (a SMHI, missing a loved one who passed away so much it interfered with day-to-day activity), unspecified mood [affective] disorder (a SMHI, severe and prolonged shifts in mood), anxiety (a SMHI, feelings of dread, fear, or unease), borderline personality disorder (a SMHI, long term pattern of emotional instability and impulsive behaviors), and suicidal ideations (when a person had thoughts of ending their own life). Resident 1 was her own responsible party (made own decisions). A review of the hospitals History and Physical, dated 7/21/24, indicated, Resident 1 had the diagnoses of bipolar disorder, depression with suicidal ideation, nightmares, and PTSD. A review of the admission Note, dated 8/23/24, indicated Resident 1 had bipolar episodes with catatonia (a state of being awake but appearing to be frozen and unresponsive, or uncontrolled purposeless movements which was caused by mental health conditions) and severe anxiety. During a concurrent interview and record review on 8/20/25 at 1:40 pm, with Business Office Manager/Social Services (BOM/SS), Resident 1's PASARR Level 1 Screening (the initial screening that determined if a Level 2 Screening was required), dated 7/19/24 was reviewed. BOM/SS confirmed, the PASARR indicated, Resident 1 did not have any serious mental health diagnoses. BOM/SS stated, the PASARR was wrong, we do not do the initial PASARR, and it was done by the hospital. BOM/SS was not able to identify who was responsible for ensuring the initial PASARR screening was completed accurately prior to admission to the facility and stated, I am just filling in and assisting with social services until the newly hired social services starts. During a concurrent interview and record review on 8/20/25 at 2:33 pm, with the Infection Preventionist (IP), Resident 1's PASARR Level 1 Screening, dated 7/19/24 was reviewed. IP confirmed, the PASARR indicated, Resident 1 did not have any serious mental health diagnoses and was inaccurate. IP stated, at the time of her [Resident 1] admission, the Director of Nursing was responsible for reviewing the PASARR for accuracy and should have fixed it. A review of the Level 2 Mental Health Evaluation letter, dated 7/19/24, indicated that Resident 1 did not have a serious mental health illness and a level 2 screening was not required. 2. A review of the facility's undated P&P titled, Resident Assessment-Coordination with PASARR Program, indicated, The P&P indicated, The Level II resident review must be completed within 40 calendar days of admission. During a concurrent interview and record review on 8/20/25 at 1:40 pm, with BOM/SS, Resident 1's PASARR Level 1 Screening, dated 6/23/25 was reviewed. BOM/SS stated, the PASARR was not redone until 6/23/25 and confirmed, the PASARR indicated, Resident 1 was positive for serious mental health illness and a Level 2 Screening was required. BOM/SS reviewed Notice of PASARR Level 1 Screening Results (a letter from the State's PASARR agency) and confirmed, the letter indicated, Resident 1 had a serious mental illness and required a Level 2 Screening. BOM/SS reviewed, Notice of Attempted Evaluation, dated 6/26/25, and confirmed, the notice indicated, Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level 1 Screening. The notice indicated that the case was closed. During a concurrent interview and record review on 8/20/25 at 2:33 pm, with IP, Resident 1's PASARR dated 6/23/25 and Notice of Attempted Evaluation, dated 6/26/25 was reviewed. IP stated, someone should have reached out to social services to get the Level 2 Screening completed.

Based on interview and record review the facility failed to ensure one out of three sampled residents (Resident 1) was fully informed of treatment that was provided when the consent form for a psychotropic medication (a medication that alters mood and behavior), was missing important information and not complete. This violated Resident 1's rights to be fully informed of treatment and could negatively affect psychosocial well-being.Findings: A review of the facility's undated policy and procedure (P&P) titled, Use of Psychotropic [medication that affected how the brain worked] Medications, indicated, the resident would be fully informed prior to initiating or increasing a psychotropic medication. A review of the admission Record, dated 8/23/24, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses bipolar disorder (extreme shifts in mood, energy, thinking, and behavior) and borderline personality disorder (long term pattern of emotional instability and impulsive behaviors). Resident 1 was her own responsible party (made own decisions). A review of the Physician's order, dated 8/23/24, indicated that the Physician ordered Aripiprazole (also called Abilify, an atypical antipsychotic medication that was used to treat bipolar disorder and affected how the brain worked) 10 milligrams, give three tablets by mouth one time a day for bipolar. The Physician's order indicated, a verified informed consent had been obtained. During a concurrent interview and record review on 8/20/25 at 2:51 pm, with Licensed Nurse (LN), Resident 1's Consent and Disclosure of Risks and Benefits Regarding The Use of Anti-Psychotic Drugs, dated 8/24/25, indicated, an informed consent for the use of Abilify had been obtained. LN stated, the consent was not correct. The consent doesn't have the dose [amount of medication] or why the medication was ordered [the diagnosis]. During an interview on 8/22/25 at 10:45 am, the Administrator acknowledged the Abilify consent was incomplete and missing required information.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) rights were protected when the facility attempted to transfer Resident 1 to another facility out of the area without his permission, or the permission of his Responsible Party (RP). This failure caused Resident 1 to feel anxious and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes. Findings: During a review of the facility's policy revised 2025, titled, Resident Rights, indicated the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This facility's policy also indicated self-determination: The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. During a review of Resident 1's medical record, the admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur (upper thigh bone, sometimes referred to as hip fracture), metabolic encephalopathy (problem in the brain caused by a physical illness, or by organs not functioning properly), dysphagia (difficulty swallowing), cardiomegaly (enlarged heart), pleural effusion (fluid buildup between the lungs and chest cavity), hypotension (low blood pressure), anxiety (feeling of worry, nervousness, or unease), urinary tract infections (UTI, infection of any part of the urinary system, usually the bladder), and [NAME]-Barre Syndrome (a rare neurological disorder that causes the body's immune system to attack nerves outside the brain and spinal column causing inflammation, weakness and pain), and a history of of falling. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 7/15/25, indicated that Resident 1 had a Brief Interview for Mental Status, (BIMS) score of 6 out of 15 and had a severe cognitive (able to think and reason) deficit. During an interview on 8/1/25 at 11:15 am, the admission Coordinator stated, I did not know we had to give every resident a 30-day notice to discharge residents. During an interview on 8/1/25 at 11:45 am, the Social Worker (SW) stated, The Family Member (FM) is the RP for [Resident 1] and she agreed to the transfer at a meeting on 7/30/35 with the business office manager present. [Resident 1] also agreed to the transfer. He barely got out of the parking lot, and I called the driver to turn around, he only went a few blocks down the road. The FM called and stopped it. During a concurrent observation and interview on 8/1/25 at 12:45 pm, Resident 1 was sitting in his wheelchair beside the bed, well groomed. Resident stated, I am glad you are here; I was so upset yesterday. I did not know where they were taking me. I never agreed to moving out. My [FM] stopped it, thank you for checking in on me, I feel better now. During a review of Resident 1's medical record there is no documentation of an Interdisciplinary Team (IDT, gathering of healthcare professionals from various disciplines who collaborate to provide comprehensive care to a resident to ensure patient centered care) meeting that discussed a transfer or discharge, and no progress note entered on 7/30/25 for a planned and safe discharge. During a review of Resident 1's medical record, a document dated 7/31/25 pm, titled, Social Services Progress Note, indicated the following, Called Resident 1's [FM] to provide information related to a lateral transfer. [FM] became verbally aggressive, stating she called administration this morning and stopped the discharge. [FM] states she no longer wants [Resident 1] moved to another facility, and stated, he will stay there until I say so. SW explained that resident and FM previously agreed to this as a way to get resident into a assisted living waiver program so he can transition to memory care. FM states, Do not send him to any other facility or else. Resident returned to the facility. During a phone interview on 8/8/25 at 9:41 am, FM confirmed she had never approved the transfer to another facility. FM stated, I told the facility staff I would consider looking into finding another facility when we had a meeting, but I never agreed to a transfer on 7/30/25. I would never agree to a facility so far away, I would want to visit, and [Resident 1] does not have dementia, he has never been diagnosed with it, so I don't understand why they thought he needed memory care. I called and demanded that they bring [Resident 1] back to the facility because I had not approved this transfer so far away. During a interview on 8/8/25 at 11:15 am, the facility Administrator confirmed the transfer to another facility that started on 7/31/25 for Resident 1 was a violation of his rights.

Based on observation, interview, and record review, the facility failed to ensure five of 15 sampled residents (Resident 1, 2, 4, 7, and Resident 15) had a safe, comfortable and home like environment when the facility air conditioning was not working adequately.This failure caused restlessness, irritability, increased anxiety (a feeling of fear, dread, and uneasiness), insomnia (loss of sleep) and the potential for negative clinical outcomes.Based on observation, interview, and record review, the facility failed to ensure five of 15 sampled residents (Resident 1, 2, 4, 7, and Resident 15) had a safe, cool, and home-like environment when the facility's air conditioning was not working effectively. This failure caused restlessness, irritability, increased anxiety (a feeling of fear, dread, and uneasiness), insomnia (loss of sleep) and the potential for negative clinical outcomes.Findings: A review of the facility's policy revised 8/2024, titled, Loss of Heating or Cooling, indicated it is the policy of this facility to take immediate actions when the facility's heating or cooling systems are inoperable in order to maintain temperatures within the facility at 71-81 degrees Fahrenheit ( F). The administrator is responsible for maintaining service contracts for routine and emergency maintenance of these systems. A review of the facility's policy revised 4/2025, titled, Safe and Homelike Environment, indicated In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely. Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/ hyperthermia and is comfortable for the residents.A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes (too much sugar in the blood), Bi-Polar disorder (a mental condition causing extreme shifts in mood, energy, and activities impacting daily life), anxiety, major depressive disorder (clinical depression with constant feeling of sadness and loss of interest), urinary incontinence with urinary device (supra-pubic catheter, a surgical insertion of a tube directly into the bladder that drains urine), fibromyalgia (a long term condition that causes widespread pain and fatigue), epilepsy (seizure disorder, abnormal brain activity), dysphagia (difficulty swallowing), and insomnia. During an interview on 7/11/25 at 3:45 pm, Resident 1 stated, I am miserable even with this fan, I am hot. I keep complaining and no one listens. It is hard to sleep when it is this hot. During an observation at 7/11/25 at 3:47 pm, with the Director of Maintenance (DM) the temperatures in Resident 1's room area were 80.4 F, 79.7 F, and 82.7 F.A review of Resident 2's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included myocardial infarction (commonly known as heart attack), pulmonary embolism (PE, a blood clot or blockage in the lung artery), atrial fibrillation (fast and irregular heart beat), congestive heart failure (CHF, long term condition when the heart struggles to circulate blood effectively), Takotsubo Syndrome (broken heart syndrome, when the heart muscle becomes suddenly weakened following severe emotional or physical stress), hypothyroidism (underactive thyroid), adjustment disorder with anxiety and depressed mood (mental health condition that develops in response to a stressful life event or change with a group of symptoms including anxiety and sadness), and history of falling. During a concurrent observation and interview on 7/11/25 at 3:50 pm, Resident 2 was lying in bed, wearing a t-shirt, no pants, only a brief with no covers. Resident 2 stated, I am sorry to not be completely dressed, it is too hot to wear clothes. I am hot.During an observation at 7/11/25 at 3:51 pm, with DM the temperatures in Resident's 2's room area were 81.1 F and 79.7 F.A review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included diabetes, atrial fibrillation, CHF, cardiac pacemaker (a small electrical device surgically placed into the chest, used to control or increase the heart rate), Alzheimer's disease (most common cause of dementia, that slowly destroys memory and thinking skills, and eventually the ability to complete simple tasks), major depressive disorder and insomnia. During an interview on 7/11/25 at 3:52 pm, Resident 4 stated, We are all hot, it is hard to sleep, and my blood sugars have been running higher. I think it is the heat, because I am stressed about this. I have a fan beside me, but it is still too hot. During an observation at 7/11/25 at 3:53 pm, with DM the temperatures in Resident 4's room area were 81.5 F and 78.4 F.A review of Resident 7's clinical record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included diabetes, CHF, cirrhosis of the liver (scarring of the liver which limits the function of the liver to filter toxins), dysphagia, ascites (fluid buildup in the abdomen), hyponatremia (low sodium levels in the blood), major depressive disorder, schizoaffective disorder (a mood disorder with a mixture of hallucinations or delusions and mood changes), insomnia, chronic kidney disease (long term condition when the kidneys are not filtering blood as needed), and glaucoma (pressure in the eyes that cause damage to the optic nerve and can lead to vision loss and blindness). During a current observation and interview on 7/11/25 at 4:05 pm, Resident 7 was lying in bed with no shirt, and no clothes on. Resident 7 stated, It is too hot to wear clothes, I would rather be anywhere but here. During an observation at 7/11/25 at 4:06 pm, with DM the temperatures in Resident 7's room area were 79.8 F and 80.4 F.A review of Resident 15's clinical record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a progressive lung disease), morbid obesity (severe and dangerous level of being overweight), post-traumatic stress disorder (condition that can develop after experiencing or witnessing a deeply distressing and terrifying event), Bi-Polar disorder, nightmare disorder (frequent and recurring frightening dreams), prolonged grief disorder (persistent state of grief after losing someone close), hypothyroidism, anxiety, major depressive disorder, borderline personality disorder (intense emotions, impulsive behaviors, and rapid mood swings). During an interview on 7/11/25 at 5:02 pm, Resident 15 stated, Yes, I am hot. It is hard to sleep when it is this hot. I am burning up. During an observation at 7/11/25 at 5:06 pm, with DM the temperatures in Resident 15's room area were 77.0 F and 75.7 F.During an interview on 7/1125 at 5:15 pm, the DM confirmed the temperatures taken in all of the Residents rooms were accurate and he used 2 separate thermometers. DM confirmed that an air conditioning company would be on site in the facility first thing in the morning of 7/12/25 for repairs needed. During an interview on 7/11/25 at 5:20 pm, the Administrator (Admin) confirmed the company would be on site 7/12/25 and she knew the air conditioning was not cooling adequately. Admin stated, I have the repairs scheduled, tomorrow is as fast as they can come out, but they will be here both Saturday and Sunday and as long as it takes to complete the repairs needed. I will make sure we send you all temperature logs per your request. I bought more fans and air conditioners to get us through the weekend. During an interview on 7/13/25 at 1:40 pm, the Maintenance Technician (MT) confirmed all the residents' rooms had been checked, all repairs made including new motors, new switches, and he had one motor left to install to finish the repairs that were needed. MT stated, I will be done by end of day, and I ordered a tool the DM will need to check the switches periodically. I will give you a copy of the map I used for your records.

Based on observation, interview, and record review the facility failed to ensure a full time Registered Dietician (RD) or a clinically qualified nutritional professional (CDM) to provide direct oversight of dietary staff to deliver safe and sanitary food service for 49 of 49 residents when: 1. Dietary staff did not follow safe and sanitary food service practices. Refer to F 802 and F 812. 2. RD, Unqualified Dietary Manager (UDM), and CDM did not ensure all dietary staff had required state and federal competencies to work in the kitchen upon hire. Refer to F 802 3. RD did not ensure all identified issues in the kitchen/sanitation audits were acted upon and resolved. Refer to F 812 4. RD, UDM, and CDM members of the facility weight committee, did not ensure one of two residents (Resident 22) reviewed for weight loss, received interventions to prevent severe weight loss. Refer to F 692. These failures resulted from lack of qualified oversight to do daily kitchen inspections, provide feedback to staff, ensure staff is doing their job which had the potential to cause foodborne illness to 49 of 49 residents who were medically compromised. An Immediate Jeopardy situation (IJ, a situation in which facility noncompliance has placed the health and safety of a resident at risk for serious harm, injury, serious impairment or death) was declared on 8/6/2024 at 12:40 pm in the presence of Administrator 1 (ADMIN), Director of Nursing (DON), Certified Dietary Manager (CDM), Clinical Resources Nurse Consultant (CRNC) and Governing Body (GB) for not having full-time, competent oversight in the Food and Nutrition department which left staff, who were not competent or with the skill sets to carry out to the necessary tasks within the department safely. An acceptable plan of removal was provided by the ADMIN on 8/9/2024 at 5:30 pm which included hiring a full time qualified CDM to provide supervision to Food and Nutrition services staff starting in the afternoon on 8/7/24, plans to repair the freezer/dishwasher, remove all food that had potential to cause food borne illness, buy 2 freezers and train all dietary staff in dietary policies and procedures. During an onsite verification on 8/8-8/9/24, the IJ was removed on 8/9/2024 at 6 pm. Findings: During a review of the Food and Drug Administration (FDA) Federal Food Code 2022, indicates Except as specified in (B) of this section, the permit holder (entity that: (1) Is legally responsible for the operation of the food establishment such as the owner, the owner's agent, or other person; and (2) Possesses a valid permit to operate a food establishment) shall be the person in charge or shall designate a person in charge and shall ensure that a person in charge is present at the food establishment during all hours of operation. Designation of a person in charge during all hours of operations ensures the continuous presence of someone who is responsible for monitoring and managing all food establishment operations and who is authorized to take actions to ensure that the Code's objectives are fulfilled. During the day-to-day operation of a food establishment, a person who is immediately available and knowledgeable in both operational and Code requirements is needed to respond to questions and concerns and to resolve problems. In addition, The designated person in charge who is knowledgeable about foodborne disease prevention, Hazard Analysis and Critical Control Point (HACCP) principles, and Code requirements is prepared to recognize conditions that may contribute to foodborne illness or that otherwise fail to comply with Code requirements, and to take appropriate preventive and corrective actions. During a review of the FDA Food Safety.gov, last reviewed July 2020, the document indicated, Good food safety practices are vital in long term care facilities, as seniors are at an increased risk for hospitalization and death from foodborne illnesses. Seniors living in nursing homes face 10 times the risk of dying from bacterial gastroenteritis (an infection or inflammation in the stomach and intestine) than people in the community. The gastrointestinal tract (mouth, esophagus, stomach, and intestines) holds onto food for a longer period of time, allowing bacteria to grow. The liver and kidneys may not properly rid the body of foreign bacteria and toxins. The stomach may not produce enough acid. The acidity helps to reduce the number of bacteria in our intestinal tract. Underlying chronic conditions, such as diabetes and cancer, may also increase a person's risk of foodborne illness. 1. During a concurrent observation and interview on 8/6/24 at 9 am, during an initial tour of the kitchen, there were only two employees present, [NAME] (CK I) and Dietary Aide (DA H). There was no Certified Dietary Manager (CDM) present. CK I confirmed the garbage can top had dirt and it was not hands free. She confirmed you had to touch the top of the can to open and dispose of paper towels after washing hands at sink. -at 9:10 am observed dishwasher area had many dirty dishes with no active dishwashing happening. The dry storage area had multiple items without received dates or use by dates, for quick creamy wheat, sugar free individual sized grape jelly, dry breakfast cereals and ranch salad dressing. There was a dirty mixing bowl amongst the food in dry storage. -at 9:25 am CK I confirmed flies in the kitchen. A review of instructions titled Steps for 3-Compartment Washing dated 2023, posted to the far left of the sink area of the kitchen indicated there should be 3 sinks, one for washing, one for rinsing, and one for sanitizing. Sink Bay 1 for washing should have detergent (no amount listed) and hot water at a temperature of at least 110 degrees Fahrenheit ( F). Sink Bay 2 clean and clear water with a temperature of at least 110 F. Sink Bay 3 add two ounces of sanitizer per 8 ounces of water, check with test strip sanitizer solution for 60 seconds must read 200-400 PPM. Immerse all wash items for one minute. The 3-compartment sink had colored lines where the water should be filled to. - at 9:15 am, DA H was observed washing dishes in a 3-compartment sink. DA H removed food from dirty plates, then started putting plates in first compartment filled with water, then moved the dishes to the middle sink (no water) and used the overhead hand faucet to rinse quickly then dip in sanitizer, then immediately put into drying rack. DA H was unable to verbalize the key steps to the 3-compartment sink. DA H did not know where to look to verify the correct sink set up. The instructions were to the left of the sink on a poster board, not in clear sight. DA H redemonstrated the procedure. Observed the middle Sink Bay 2 had no water up to the required line and DA H did not ensure the dishes were placed in the sanitizer sink for a full minute. DA H stated she had been doing this a few days since the dishwasher was not working. DA H was asked if she tested the water temperature of the water used in the sink or the sanitizer levels. DA H stated, I never do that. DA H had not tested the water temperature or sanitizer level, and there was no 3-compartment sink washing log to document the results. CK I was unable to verbalize the steps of the 3-compartment sink. CK I stated she had been off for the past three days. CK I and DA H both thought the dishwasher had been out about a week. DA H continued to clean the dirty dishes and took multiple food plate covers stacked together to the 3-compartment sink. DA H did not wash them one at a time. DA H confirmed the liquids could not touch all the surface areas doing it this way. - at 9:30 am, multiple delivery boxes in the refrigerator were not unpacked. Multiple undated items observed throughout the area, shredded white cheese, sour cream, and jelly. A 24-pound pork loin roast was completely soft to touch on lower rack defrosting dated 8/5/24 for meal 8/8/24. CK I warned the surveyors of fall risk due to liquids on the refrigerator and freezer floor. CK I did not know when this started or what the cause of the liquids on the floor meant. CK I confirmed the freezer temperature was 35 F, not at required temperature of 0 F or below. Freezer had items that were not hard to touch, ice cream, cheese, deli meat, and two 10 pound rolls of hamburger soft to touch. Melted liquids throughout the freezer floor. At 9:35 am, CK I had logged 0 F for the freezer. Asked how long freezer was out of range, she was unaware and had not contacted anyone about the issue, due to being unaware of the issue. -at 9:40 am, went to ADMIN and requested to speak with CDM. ADMIN stated he requested her to come to facility. ADMIN stated CDM works at another long-term facility 45 minutes away. -at 9:50 am, went back into the kitchen to have DA H test the level of sanitizer in the bucket. Returned to the kitchen with ADMIN and Plant Operation Supervisor (POS). Requested DA H to test the level of sanitizer in the bucket they use for sanitizing kitchen surfaces. DA H could not find the test strips or the instructions for the correct level of sanitizer parts per million (PPM). DA H was unable to verbalize or reference instructions on how long test strip needed to be submerged into the sanitizer. DA H put the test strip into the sanitizer, which indicated a bluish-purple which according to the instructions indicated more than 400 ppm (over the allowed limit). ADMIN and POS were both unaware that the walk-in freezer was not at the required temperatures. A review of refrigeration service company invoices dated 8/2/24, indicated the service call was that the walk-in freezer was too warm. Service to correct the issue with the defrost (free the freezer of accumulated ice) timer due to an evaporator (heat exchanger where the refrigerant circulating inside the refrigeration circuit absorbs the thermal energy from the environment, which is then cooled) coil having ice buildup. A review of of refrigeration service company invoices dated 8/3/24, indicated the service call was that the walk-in freezer temperature was 30 degrees F upon arrival and the freezer temperature when they left was 40 degrees F. The service call identified the defrost clock not energizing, evaporator needs to be replaced. Need to order new timer. During a concurrent observation and interview on 8/6/24 at 10:41 am, CDM was interviewed about all the findings in the kitchen. CDM confirmed she works part time at the facility in the dietary department on the weekends mainly. CDM stated she worked at another facility during the week, and it was very difficult with the long drive back and forth. CDM confirmed the previous UDM was not qualified, had been working there since January 2024. CDM stated she was hired part time in April 2024 due to the RD coming one to two days a week as needed. CDM confirmed they staff the kitchen traditionally one dietary aid and one cook. When inquired if that was enough with having no dishwasher, since the 3-compartments are a lot of work? CDM stated UDM was in dietary manager school, and she did not finish, and had been in the laundry department. CDM stated the problem with the walk-in freezer started on 8/2/24 and the issue was the defrost cycle and timer. CDM was here on the weekend 8/3-8/4/24. CDM confirmed the dishwasher thermostat (measures water temperature) was not working for about a week and a half and a new electrical breaker was needed to fix it. CDM confirmed no one notified her this morning the freezer was not to at the required temperatures. CDM confirmed the multiple items in the dry storage and refrigerator were not dated as per policy. CDM confirmed the walk-in freezer was not at required temperature, the ice cream, deli meat, two 10-pound hamburger package rolls were soft to touch and not frozen. CDM stated she cannot confirm the pork roast was frozen (hard upon touch) when put in refrigerator for defrosting. CDM stated she was not sure how often RD was onsite at the facility, and she has not seen him. CDM explained the RD comes as needed and should perform monthly kitchen/sanitation audits and mock survey to get ready for the recertification survey. CDM did not state what actions would be taken to resolve these issues. CDM stated she would talk to ADMIN about getting two freezers. During an interview on 8/8/24 at 12:30 pm, CDM was unable to find all the kitchen logs for monitoring temperatures for the refrigerator, walk-in freezer, dishwasher temperatures, and sanitizer testing for the months of January, February, and March of 2024. CDM confirmed the bluish-purple color of the test strip of the sanitizer bucket on 8/6/24, indicated the level was above the recommended 400 PPM testing strip. CDM stated this meant too much sanitizer and would want dietary staff to inform someone of this finding. CDM stated not having the freezer maintain temperatures put all residents at risk for food borne illness. CDM stated she has no clinical corporate dietary consultant available; they are to access the clinical nursing consultant. Tray line observation on 8/9/24: - at 10:25 am, CDM confirmed multiple flies in the kitchen. CDM stated the back screen door where there were gaps on the top and bottom of the door was just fixed. CDM stated these gaps allowed flies to enter the kitchen. - at 12:30 pm, observed CK F preparing peanut butter and jelly using #40 scoop. The scoop was not clean, it had a dried substance in the scoop. CK F confirmed it was dirty and removed the scoop from the area. -at 12:40 pm, CK J was plating food during tray-line, one of the lids had a black bug crawling on the inside, she removed lid. Flies were observed landing on resident food trays. -12:45 pm, DA G came in to get coffee for a resident and did not wash hands upon entering or leaving kitchen preparation area. A freezer repairman with hair/beard came in through the kitchen while CK J was preparing food, he did not have his hair or beard covered with a hairnet when he came in and out of the kitchen multiple times. 2. A review of a Dietary Manager job description dated 2022, indicated the minimum requirements include one of the following certifications as a dietary manager, food service manager national certification for food service management from national certifying body, associate degree or higher in food service management and has two or more years in the position of director of food and nutrition services in a nursing facility. Must also meet the State requirements for food service managers. Major duties include maintains clean and sanitary environment, oversees safe timely meal preparation and food storage. Trains and coach's employees that work in the dietary department. Ensures adequate staff. Supports Registered Dietician duties as needed. A review of dietary staff employee files indicated: -CDM 1 had a Date of Hire (DOH) of 9/26/23, terminated on 12/22/23. -UDM, was hired at the facility on 3/1/22, as the Director of Environmental Services. On 2/1/24, started as Dietary Supervisor in the kitchen. UDM had no required Food Handler certificate training. UDM had no verification of job competency verbal and or demonstration for the kitchen duties and equipment in the dietary department. UDM did not complete her required Dietary Manager training and was terminated 6/3/24. -CDM Date of Hire (DOH) 4/9/24, part time, then full time 8/7/24. CDM did not have required Title 22 (California State Regulations) six-hour CDM training until 8/3/24, four months after hire. A review of a Dietary Aide job description dated 2023, indicated the DA works with the facility's RD and CDM as necessary. DA provided assistance in all food functions as directed/instructed in accordance with established food policies and procedures. DA assisted in daily cleaning duties, washes and cleans utensils, dishes, and cooking items following policy and procedures. A review of a facility policy titled Demonstrating Food Safety and Job Competency for Food and Nutrition Services Employees Dated 2023, indicated each Food and Nutrition employee must be able to demonstrate competency in the food and safety principles and job skills the facility requires. Verification of demonstrated job and equipment competencies. The Director of Food and Nutrition Services or Registered Dietician will sign off each skill after demonstrated properly on the competency forms. -DA G had a DOH of 10/31/23, as an Environmental Services Laundry worker. DA G had the California Food Handlers Certification dated 8/29/22. DA G did not have any verification of job competency verbal or demonstration for the kitchen duties and equipment for the dietary department. -DA C had a DOH of 6/19/24. DA C had Food Handlers Certificate dated 8/8/24, two months after hire. DA C had Dietary Aide Competency Demonstration and kitchen equipment on 8/6/24, two months after hire. -DA H had a DOH of 4/15/24, had no Food Handlers Certificate in her file. DA H did not have any verification of job competency verbal and or demonstration for the kitchen duties and equipment for the dietary department until 8/6/24. -DA E had a DOH of 11/21/23, had no Food Handlers Certificate in her file. DA E did not have any verification of job competency verbal and or demonstration for the kitchen duties and equipment for the dietary department until 8/6/24. -DA D had a DOH of 10/20/23, had a Food Handlers Certificate dated 1/10/24, three months after hire. DA D did not have any verification of job competency verbal and or demonstration for the kitchen duties and equipment in the dietary department until 8/6/24. A review of a Dietary [NAME] job description dated 2023, indicated ensures prepares food in accordance with applicable federal, state, and local standards guidelines, regulations, and policies/procedures. Works with RD, CDM as necessary and implements changes as required. -CK F had a DOH of 7/24/24, had Food Handlers Certificate dated 7/26/24. CK F did not have any verification of job competency verbal and or demonstration for the kitchen duties and equipment for the dietary department until 8/6/24. -CK I had a DOH of 1/26/24, had Food handlers Certificate on 7/26/22, six months after hire. CK I did not have any verification of job competency verbal and or demonstration for the kitchen duties and equipment for the dietary department until 8/6/24, six months after hire. During a concurrent interview and record review on 8/13/24 at 12 pm, CDM confirmed the dietary personnel files did not have the required trainings and competencies. CDM confirmed she did not have the required 6-hour Title 22 CDM training until 8/3/24 of this year. 3. A review of a job description for Dietician dated 2023, indicated the RD was responsible for planning, organizing, developing, and directing the nutritional care of the resident in accordance with current federal, state, and local standards, guidelines, and regulations. Performs regular inspections of food service areas for sanitation, order, safety, and proper performance of assigned duties. Monitors residents for weight changes, nutrition support, and makes recommendations as needed. Participates in inspections surveys, ensuring compliance with nutritional and dietary policies. A review of a sanitation audit dated 2/14/24 at 10:44 am, and emailed to ADMIN and GB, the RD identified issues in the kitchen: -debris in kitchen drawers -mold found in ice machine -crumbs found in toaster -garbage dumpster open upon arrival -ice buildup on sprinkler pipe in walk in fridge -no received date on turkey in walk in freezer A review of an RD inspection of the kitchen on 5/1/24 at 8:29 pm, emailed to ADMIN and GB, indicated findings for the audit: -.gap under screen door in kitchen, this door will be an issue with flies as weather heats up. -oven is not working to heat foods up -steam table not working to keep food hot -old debris found in toaster -food left in microwave -garbage dumpsters were overfilled -logs not being used for sanitation buckets or for dishwasher -dishwasher not reaching temperature for rinse -supplies not being stored correctly in dry storage -gasket to fridge is not adhered to door -freezer has buildup of frost and ice -recipe for thickening liquids not followed -boxes stored on top shelves in dry storage no under 18 inches from ceiling A review of a follow up email dated 5/1/24 at 8:43 pm, written by RD and sent to ADMIN and GB indicated: -RD observed non-dietary staff seem to be coming into the kitchen walk around, grab items. Please ensure staff they must not cross the red line in the kitchen. -During my visits, Unqualified Dietary Manager (UDM) was found out on the floor, in her office, and not involved in the kitchen. UDM informed RD that she is still helping with housekeeping. UDM was the Director of Environmental Services prior to starting in kitchen 2/1/24. -RD wrote I am glad a CDM is coming in on the weekends to help with the kitchen. A review of sanitation findings on 5/30/24 at 8:41 am, emailed to ADMIN and GB, RD indicated: -no current CDM full time in kitchen -spider webs and fly in kitchen -gaps on bottom of door by manager's office -oven was dirty -debris on shelf above stove and toaster -steam table not working -kitchen drawers with utensils had debris -vents on air conditioner dirty -gaps in logs for sanitation bucket -no thermometer in dry storage area to monitor room temperatures -temperature in kitchen/storage area not being regulated -boxes stored on top shelves in dry storage no under 18 inches from ceiling -gaps in freezer log -ice buildup in freezer -staff not wearing facial hair net -staff not using gloves when getting ice throughout the facility -gaps in log with resident refrigerator and above 40 degrees Fahrenheit During a concurrent interview and record review on 8/9/24 at 3:09 pm, RD stated he had been at the facility since it opened in October 2023. RD explained he comes to the facility in person based on needs of the kitchen and residents. RD stated he has a long drive and works for another facility as well. RD stated he comes to the facility usually one to two days a week, but it does vary based on the needs. RD stated the kitchen staff were struggling. RD stated he spent most of his time training new staff and correcting identified issues in the kitchen. RD stated it was always a challenge in the kitchen with UDM who was unqualified and in school. RD explained the facility did not have a consistent CDM and were struggling to find a qualified CDM. RD confirmed he suggested to the ADMIN about adding more staff for the kitchen since they could not keep up with the required tasks. RD stated the freezer and dishwasher had been an ongoing issue. RD stated he noticed a few months ago the freezer was staying at or below the required temperature and he had concerns then about food borne illness. RD stated he had concerns about sanitary and safe conditions in the kitchen due to dishwasher, freezer, multiple new staff and inconsistent CDM oversight. Reviewed RD's sanitation audits and he confirmed he only had three, for 2/14/24, 5/1/24 and 5/30/24. RD stated he could not provide any other kitchen audits due to mainly giving verbal reports not written. RD stated UDM was not in the kitchen in April 2024, no record of logging the required levels of sanitizer for the buckets (used to sanitize surfaces in kitchen), no logs for required temperature for dishwasher, supplies not being dated and stored correctly, gap in the back kitchen door which allows pests to enter kitchen, gaps in documenting freezer temperature on logs, and no qualified full time CDM to oversee the kitchen staff. RD was asked if any of these issues were being tracked and who was responsible for ensuring these were acted upon. RD stated the ADMIN was made aware. RD stated he struggled to keep the kitchen working. 4. Record review of facility policy Weight Monitoring 2023 indicated: -A weight monitoring schedule will be developed upon admission for all residents. Residents with weight loss - monitor weight weekly. A significant change in weight is defined as 5% change in weight in 1 month (30 days). -The physician should be informed of a significant change in weight and may order nutritional interventions .if the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietician, Dietary Manager, or the nursing department may initiate this process .the registered Dietician or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress note. Record review of document Weight Summary indicated Resident 22 weighed 153.4 pounds upon admission on 10/19/2023. Record review of document Weight Summary indicated on1/4/2024, Resident 22 weighed 141.0 pounds, which is a -6.62 % loss, a severe loss. Record review of document Weight Summary indicated Resident 22 weighed 140.0 pounds on 2/9/2024, down one pound. On 3/5/2024, Resident 22 weighed 139.0 pounds, down one pound. Record review of Physician Readmission Diet Orders 3/28/2024 indicated small portions, pureed texture, nectar-thick liquids, discontinued 4/19/2024. Record review of document Progress Note 4/11/2024 13:53 RD indicated Resident 22 had a gradual weight loss since October 2023. RD documented Resident 22's intake was 75% of meals with small portions. RD recommended discontinuing small portions to promote weight stabilization and ordered weekly weights for 4 weeks to monitor weight. Record review of document IDT - Care Conference Summary 5/2/2024 indicated Resident 22's weight was 132.0 pounds. A weight loss of 10% over 180 days was identified. Resident 22 was eating 76-100% of her meals. Resident was working on trials to upgrade diet with additional assistance. Diet orders were listed as regular, puree, honey-thick liquids, no fortified meals, or health shakes. Present at care conference were Resident 22, Responsible Party (residents decision maker), Social Services Director, and UDM. No change in dietary orders. This was the last documented IDT Care Conference. Record review of document Weight Summary indicated Resident 22 weighed 135.0 pounds on 4/2/2024, 134.7 pounds on 4/8/2024, 129.0 pounds on 4/22/2024, and 132.0 pounds on 5/1/2024. Record review of document Weight Summary indicated on 8/9/2024, Resident 22 weighed 119.0 pounds, which is a -8.46 % loss from 7/2/2024 to 8/9/2024, severe weight loss. During a concurrent interview with RD on 8/9/2024 at 3:40 pm, RD stated Resident 22 was on altered textures, thickened liquids, and small portions were discontinued. RD stated Resident 22 stabilized around April 2024, but had a history of going in and out of the hospital. RD stated he could not get to the weight committee meetings on time during time frame when Resident 22 was losing weight. RD stated weight meetings restarted when current Director of Nursing (DON) was hired at facility in April 2024. RD stated issue is when someone goes in and out of hospital, orders don't get restarted. RD stated he would not restart orders because I don't like to restart what they're currently on. I like to have a blank slate. RD stated accuracy of Activities of Daily Living (ADL) charting was hit or miss. RD stated Resident 22 was eating 75% or more. RD stated his process was to look at intakes in chart, and follow-up with staff to determine if residents were eating well. RD stated if resident was stable then he assumes they're eating. RD stated he was not a proponent of nutritional shakes. RD stated facility used nutritional supplements. RD stated if he wanted to, he could make recommendation for nutritional supplements. RD stated even if a resident was on comfort care, they are weighed weekly. RD stated he would expect a monthly weight for Resident 22. RD stated expectation was for staff to document if any resident refused weight checks. RD stated at beginning of [AGE] year, We had a DON that didn't want to be involved in my work so a lot of it were my own findings. RD discussed his role in the weight committee. RD confirmed that not having a consistent IDT and DON made it a challenge along with having to spend so much time in the kitchen when he was onsite at the facility correcting issues.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status when staff did not identify insidious weight loss (gradual, unintended, progressive weight loss over time), implement, or modify a plan of care that was individualized and consistent with the resident's needs or preferences for one of two sampled residents (Resident 22). These failures resulted in severe weight loss and put Resident 22 at risk for further health decline. Refer to F 801. Findings: Record review of facility policy Weight Monitoring 2023 indicated: -Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. -Interventions will be identified, implemented, monitored and modified, consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. -Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following . o Identified causes of impaired nutritional status. o Reflect the resident's personal goals and preferences. o Identify resident-specific interventions. o Timeframe and parameters for monitoring. o Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or new causes of nutrition-related problems are identified. o If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate. o The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences. - A weight monitoring schedule will be developed upon admission for all residents. Residents with weight loss - monitor weight weekly. A significant change in weight is defined as 5% change in weight in 1 month (30 days). - The physician should be informed of a significant change in weight and may order nutritional interventions .if the interdisciplinary care team (IDT, a group of healthcare professionals who work together to treat a patient's condition or diagnosis) desires to explore specific meal consumption information for a resident, the Registered Dietician, Dietary Manager, or the nursing department may initiate this process .the registered Dietician or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress note. Record review of document Admission Record indicated that Resident 22 was initially admitted on [DATE] from a local assisted-living facility (a housing and care facility for people who need some assistance with daily activities but don't require nursing home care). Resident 22 had medical diagnoses that included: Cerebral infarction (stroke) affecting right dominant side with resulting weakness on one side of her body, mild cognitive (mental) impairment of uncertain or unknown etiology (origin), other seizures, anxiety disorder, encephalopathy unspecified (term used to widely define brain illness), and difficulty swallowing. Record review of document Nursing - Clinical Admission Evaluation 10/19/2023 indicated Resident 22 was cognitively intact (able to make needs known, able to follow simple commands, able to understand others) and had a good oral intake. Resident 22 was able to self-report her pain level. Resident 22 stated that she occasionally has pain in her right arm at level 3 (a pain rating scale from 0 to 10, where 0 is no pain, and 10 is the worst pain) and tingling at times. Resident 22 was able to feed herself, and her weight status listed as stable during past 3 months. Resident 22 ate 50-75% of most meals, with a fluid intake of 1000-2000 mL (milliliters, a unit of measure) daily, and consumed all snacks/supplements offered. Record review of Physician Diet Orders 10/19/2023 Resident 22 was on a regular texture, regular diet with no added salt, discontinued on 3/19/2024. Record review of document Weight Summary indicated Resident 22 weighed 153.4 pounds upon admission on 10/19/2023. Record review of document Care Plan 10/20/2023 indicated weekly weights until stable, then weigh monthly. Weight management team would follow Resident 22 as needed. One documented IDT Weight meeting occurred on 8/12/2024. Record review of document Minimum Data Set (MDS, resident assessment) MDS - Section C 10/31/2023 indicated that Resident 22's brief interview for mental status (BIMS) score was 6 (severely cognitively impaired) on a scale of 0 to 15, where 0 is completely impaired and 15 is unimpaired. MDS - Section B 10/31/2023 indicated that Resident 22 had clear speech and was able to communicate her needs to others. Review of document Weight Summary indicated Resident 22 weighed 152.0 pounds on 10/23/2023 and 152.8 pounds on 10/30/2023. Record review of document Food Nutrition Services Evaluation - 10/27/2023 3:17 pm indicated that Resident 22's intake upon admission was near high end of 0-25% and low end of 26-50% ranges for meals with less than adequate intake. Registered Dietician (RD 1) recommended dietary manager visit Resident 22 to obtain her preferences and add 4 ounces of nutritional shake to add calories to Resident 22's intake twice daily. A review of Resident 12's physician orders and care plans indicated no orders placed to add 4 ounces of house supplement (nutritional shake that adds calories to person's intake) from 10/19/2023 to 8/9/2024. Record review of document IDT - Care Conference Summary 10/27/2023 indicated Resident 22's weight was 152.0 pounds, fair oral intake, weight stable. Resident 22 was not on special assistance with dining. Resident 22 was happy to be at facility and had no further concerns. Record review of document Progress Note 11/2/2023 11:30 am Entered by licensed nurse on 8/16/2024 at 3:02 pm, indicated a new order for 4 ounces of house supplement order twice a day was received. Record review of orders showed no order for house supplement shakes entered. RP (responsible party) was made aware. Record review of document Weights Summary indicated on 11/6/2023, Resident 22 weighed 151.0 pounds, a loss of 1 pound from 10/23/2023. Record review of document Weight Summary indicated Resident 22 was not weighed in December 2023. Record review of document Weight Summary indicated on 1/4/2024, Resident 22 weighed 141.0 pounds, which is a -6.62 % loss, a 10-pound loss (significant weight loss). Record review of document Weight Summary indicated Resident 22 weighed 140.0 pounds on 2/9/2024, down one pound. On 3/5/2024, Resident 22 weighed 139.0 pounds, down one pound. Record review of Food and Nutritional Services 2/23/2024 indicated by Unqualified Dietary Manager (UDM) a 7.5% weight loss, no physician notification, and no new interventions. Record review of document Progress Notes and type Social Service Evaluation 3/27/2024 indicated Resident's ability to communicate is impaired. Communication: Verbal, picture book. Resident is unable to communicate needs. Resident is not on hospice services (care for the terminally ill). Record review of Physician Readmission Diet Orders 3/28/2024 indicated small portions, pureed texture, nectar-thick liquids (fluids thickened to a nectar consistency), discontinued 4/19/2024. Record review of document Care Plan 3/28/2024 indicated Resident 22 had a communication problem related to dentition problems (missing or broken teeth) and neurological (cognitive) symptoms. Resident 22 would be able to make basic needs known by answering yes or no questions and using picture communication on a daily basis. Record review of document Progress Note 4/11/2024 13:53 RD indicated Resident 22 had a gradual weight loss since October 2023. RD documented Resident 22's intake was 75% of meals with small portions. RD recommended discontinuing small portions to promote weight stabilization and ordered weekly weights for 4 weeks to monitor weight. Record review of document Weight Summary indicated Resident 22 weighed 135.0 pounds on 4/2/2024, 134.7 pounds on 4/8/2024, 129.0 pounds on 4/22/2024, and 132.0 pounds on 5/1/2024. Review of document Physician Diet Orders 4/19/2024 indicated Resident 22's current diet order was a regular diet, puree texture, honey-thick (fluids thickened to a honey consistency) liquids consistency, and fortified (additional calories added) for trouble swallowing. No further physician diet orders found past this date. Record review of document Progress Note - Dietary Note 4/30/2024 by Assistant Director of Nursing (ADON) indicated RD was consulted and a new order for fortified meals due to poor oral intake. Record review of document Documentation Survey - Amount Eaten April 2024 indicated 18 meals out of 90 meals were not documented. A review of a policy titled Change in a Resident's Condition or Status, revised February 2021, indicated the nurse will notify the resident's attending physician if a significant change in the resident's physical/emotional/mental condition; a significant change of condition is a major decline that will not normally resolve itself without intervention and requires interdisciplinary review and/or revision of care plan. Record review of document IDT - Care Conference Summary 5/2/2024 indicated Resident 22's weight was 132.0 pounds. A weight loss of 10% over 180 days was identified. Resident 22 was eating 76-100% of her meals. Resident was working on trials to upgrade diet with additional assistance. Diet orders were listed as regular, puree, honey-thick liquids, no fortified meals, or health shakes. Present at care conference were Resident 22, the responsible party, Social Services Director, and UDM. No change in dietary orders. This was the last documented IDT Care Conference. There was no indication physician was notified, plan of care remained the same. Record review of document Speech Therapy Evaluation and Plan of Treatment 5/2/2024-6/26/2024 indicated that Resident 22 rarely could express ideas and wants. No interventions or treatments were indicated. Record review of document Weight Summary indicated Resident 22 weighed 133.0 pounds on 6/3/2024 and 6/12/2024. Record review of document Weight Summary indicated on 7/2/2024, Resident 22 weighed 130.0 lbs, a 3-pound loss. Record review of document Progress Notes and type Social Service Evaluation 7/9/2024 indicated Resident 22 was nonverbal and required a picture book to communicate. Resident 22 was unable to communicate her needs. Resident 22 was not on hospice services. Record review of document Progress Note 7/27/2024 11:33 pm indicated Resident is on comfort measures (medical treatments that allow a dying person to naturally pass away while still being as comfortable as possible) and is not eating and not drinking much fluids, resident was agitated this evening shift and was medicated per MD order with good results noted. Record review of document Progress Note 7/28/2024 1:17 am indicated Resident 22 recently returned from the hospital. Record stated Resident 22 on comfort care and is declining. Resident is taking some fluids but not eating any food. Record review of document Progress Notes and type Social Service Evaluation 8/1/2024 indicated Resident's ability to communicate is impaired. Communication: Verbal, picture book. Resident is unable to communicate needs. Resident is not on hospice services. Record review of document Weight Summary indicated on 8/9/2024, Resident 22 weighed 119.0 pounds, which is a -8.46 % loss from 7/2/2024 to 8/9/2024. During an interview with Durable Power of Attorney (DPOA - care only) on 8/7/2024 at 12:35 pm, she stated she was not sure how aware resident was of her preferences. DPOA stated Resident 22 does not eat too much, and has lots of UTIs, which cause seizures, which leads to her eating less. DPOA stated she thought Resident 22 received more liquid type food when she ate. DPOA stated Resident 22 preferred nutritional shakes, but she is unsure if Resident 22 could communicate when she wanted one. DPOA stated Resident 22 needed a picture board to point to pictures to adequately communicate what she wanted. DPOA stated she was concerned with Resident 22's current weight status. DPOA stated she rarely spoke with facility or received updates. During an observation on 8/7/2024 at 3:00pm, unable to locate communication picture book in Resident 22's side table, on top of side table, or in room. No fall mat observed. Observed resident rubbing her head with left hand, mouth gaping. Resident 22 made eye contact when requested. Resident 22 was unable to communicate yes or no verbally or physically when asked to raise hand for yes keep hand down for no. During an interview with DPOA on 8/7/2024 at 3:39 pm, DPOA stated she did not speak to facility regarding transitioning to comfort-focused treatment. DPOA stated she could not define what comfort-focused treatment meant. DPOA stated I just want what's best for her, but I think she'd prefer to be alive . DPOA stated I know she has these seizures when she has a UTI, but then she gets antibiotics and gets better, and I know that's what she would want. A review of a job description for Dietician dated 2023, indicated the RD was responsible for planning, organizing, developing, and directing the nutritional care of the resident in accordance with current federal, state, and local standards, guidelines and regulations. Performs regular inspections of food service areas for sanitation, order, safety, and proper performance of assigned duties. Monitors residents for weight changes, nutrition support, and makes recommendations as needed. Participates in inspections surveys, ensuring compliance with nutritional and dietary policies. During a concurrent interview and record review with Registered Dietician (RD) on 8/9/2024 at 3:40 pm, RD stated Resident 22 was on altered textures. Thickened liquids, and small portions were discontinued. RD stated she stabilized around April 2024, but had a history of going in and out of the hospital. RD stated he could not get weight committee meetings on time during time frame when Resident 22 was losing weight. RD stated weight meetings restarted when current Director of Nursing (DON) was hired at facility in April 2024. RD stated issue is when someone goes in and out of hospital, orders don't get restarted. RD stated he would not restart orders because I don't like to restart what they're currently on. I like to have a blank slate. RD stated accuracy of Activities of Daily Living (ADL) charting was hit or miss. RD stated Resident 22 was eating 75% or more. RD stated his process was to look at intakes in chart, and follow-up with staff to determine if residents were eating well. RD stated if resident was stable then he assumes they're eating. RD stated he was not a proponent of nutritional supplements. RD stated if he wanted to, he could make recommendation for nutritional supplements. RD stated even if a resident was on comfort care, they are not weighed weekly. RD stated he would expect a monthly weight for Resident 22. RD stated the expectation was for staff to document if any resident refused weight checks. RD stated at beginning of [AGE] year, we had a DON that didn't want to be involved in my work so a lot of it were my own findings. During an observation on 8/8/2024 at 12:30 pm, observed Resident 22 in dining room being fed by CNA A. Observed Resident 22 fidgeting with her hair with left hand, and brushing top of her head. CNA A stated Resident 22 was not eating like normal. CNA A stated Resident 22 usually grabbed the CNA's hand with spoon in it and guided the spoon to her own mouth. CNA A stated Resident 22 appeared extra fidgety. Observed Resident 22 unable to verbally communicate needs. Review of document IDT - Weight Meeting 8/12/2024 indicated Resident 22's weighed 119.0 pounds, 14 pounds in 2 months, 10.5% weight loss, supplement/nourishment house shake (nutritional supplement) TID (three times a day), and interventions house shakes, weekly weights. This was the only documented IDT Weight Meeting. During an interview with DON on 8/13/2024 at 9:25 am, DON stated she met with IDT weight committee every Thursday. DON stated she met with CNA B to identify who was at risk for weight loss when DON started employment at facility in April 2024. DON stated an IDT weight meeting was held on 8/12/2024 for Resident 22. DON stated that on comfort care, a resident is expected to lose weight and decline. DON stated she could not define facility standard for comfort care. DON stated she needed to read the facility comfort care policy before she could explain what it meant. DON stated Resident 22 was uncomfortable when she was fidgety. DON stated this was exhibited by Resident 22 pulling at her blanket and messing with her hair. DON stated the last care conference with DPOA was May 2024. DON stated care team would have another care conference with DPOA due to recently identified weight loss on 8/9/2024. DON stated Resident 22 on weekly weights for the next 4 weeks. DON stated meal intake slips were put in her box to ensure that the meal percentages were accurate in the documentation. DON stated Director of Staff Development (DSD) completed education with CNA new hires to make sure they are accurately charting meal percentages. During an interview on 8/13/2024 at 10:00 am, Social Services Director (SSD) stated Resident 22 does not communicate, is nonverbal and has been nonverbal since SSD began employment at facility in April 2024. SSD stated at last care conference on May 2, 2024, weight loss was identified. SSD stated there was a 10% weight change in 150 days with a plan to continue to monitor and no urology note. No new interventions or treatments documented. During a record request from facility on 8/14/2024 at 5:10 pm for Comfort Care policy, facility replied with Use hospice policy. Hospice Foundation of America (HFA) defined hospice as: Medical care for people with an anticipated life expectancy of 6 months or less, when cure isn't an option, and the focus shifts to symptom management and quality of life. An interdisciplinary team of professionals trained to address physical, psychosocial, and spiritual needs of the person; the team also supports family members and other intimate unpaid caregivers. HFA further stated that hospice is not A replacement for nursing home care or other residential care. https://hospicefoundation.org/Hospice-Care/Hospice-Services) National Cancer Institute defined comfort care as: The goal of comfort care is to control pain and other symptoms so the patient can be as comfortable as possible. (https://www.cancer.gov/search/results?swKeyword=comfort+care).

Based on observation, interview, and record review, the facility failed to ensure the safety and security for: 1. All residents that resided in the facility when five of eight facility entrance doors (Door 1 front door, Door 2 side door, Door 3 laundry hall door, Door 4 back door, Door 5 dining room door) were found to be unlocked during the night and staff were unaware how to lock them. 2. One of one sampled resident (Resident 1) when staff had disarmed, by unplugging, a wanderguard alarm system (a system that alarms and alerts staff when a resident, who was assessed to wander, (attempts to leave the building without staff knowledge or supervision), because the alarm was bothersome to the staff. This disregard for resident safety subjected residents to an unsafe environment which could have had a serious negative impact on their health, safety, and welfare. Leaving the facility unlocked at night and purposely disarming the wanderguard system had the likelihood to cause the residents who resided in the facility serious injury, harm, or death and an Immediate Jeopardy (IJ) situation was identified which required immediate action to be taken by the facility. On 4/12/24 at 7:40 am, in the presence of the Wound Nurse (WN) at the facility, and by phone to the Administrator (Admin), the facility was notified of the IJ situation concerning the doors being unlocked, and an immediate corrective action plan was requested. ON 4/12/24 at 3:39 pm, in the presence of the Admin, the IJ situation was amended to identify the disarming of the wanderguard system. On 4/12/24 at 5:06 pm, the surveyor was on site and the Admin presented an immediate corrective action plan which ensured the safety of all residents. Between the times of 7:40 am and 3:39 pm, the surveyor verified that the Admin had started implementing a plan of correction by educating staff on locking facility entrance doors. Education included all facility doors would be locked from 8:00 pm to 6:00 am. At 3:39 pm the Admin implemented securing the wandergaurd system and educating staff concerning unplugging or disarming the wanderguard system. On 4/12/24 from 5:07 pm to 5:15 pm, with the Maintenance Supervisor (MS), the surveyor was on site and the five facility entrance doors were observed. Doors 2 through 4 were locked and were unable to be opened from the outside. Door 1 was open as this was the main entrance to the facility and per their plan of correction. A screwdriver (which would lock Door 1 at 8:00 pm), was in the front lobby desk drawer and in each medication cart. The wanderguard strip at Door 5 was plugged in and connection to electrical source was secured. Training for day and evening staff, that were on site, had been trained on the locking procedures and the wanderguard system. Plan in place to educate all staff. Signatures were observed. On 4/12/24 at 5:16 pm, while the surveyor was on site and verified that the immediate plan of correction was implemented and no remaining non-compliance existed, the immediate corrective action plan was accepted from the Admin and the IJ was removed. Findings: A review of the facility policy titled, Accidents and Supervision revised February 2023, indicated the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. A review of the facility's census (official count of population), dated 4/12/24, indicated there were 49 residents in the building. 1.During observations conducted on 4/12/24 from 4:21 am to 4:29 am, eight facility entrance doors were inspected. Five of the eight doors were not locked as follows; On 4/12/24 at 4:21 am, the Front door (Door 1), was closed but unlocked. The door led into the lobby area and when opened had no alarm. The surveyor entered the facility through Door 1 without being noticed. One unidentified resident was observed sleeping on a couch and another unidentified resident was sitting in a wheelchair in this lobby area. On 4/12/24 at 4:23 am, the Side door (Door 2), was closed but unlocked. The door alarmed when opened but then within seconds, stopped alarming. Door 2 led directly to a hallway where resident rooms 1 through 9 were located. On 4/12/24 at 4:25 am, the Laundry hall door (Door 3) was closed but unlocked and opened easily. Door 3 led into a hallway by the laundry room and the surveyor entered the facility unnoticed and there was no alarm. Door 3 led to a hallway where resident rooms were located. On 4/12/24 at 4:27 am, the Back door (Door 4), was closed but unlocked. The surveyor entered the facility through Door 4, unnoticed and there was no alarm. Door 4 led to the Director of Staff Development (DSD) office and a Conference room which then opened into a hallway where resident rooms were located. On 4/12/24 at 4:29 am, the Dining Room door (Door 5), was closed but unlocked. The surveyor entered the facility through Door 5, unnoticed and there was no alarm. Door 5 led to the resident dining room and then opened into a hallway that led to resident rooms 10 through 23. On 4/12/24 at 4:31 am, the Surveyor re-entered Door 2 and walked past rooms 1 through 9 and was standing at the nurse's station and was not confronted by staff. During observations and interview on 4/12/24 from 4:35 am to 4:55 am, with Licensed Nurse (LN) A, the same eight facility entrance doors as above, were inspected. LN A confirmed five doors were unlocked and anyone off the street could walk in at any time. LN A stated, This is a bad neighborhood and there are homeless, transients, and a lot of drugs. They used to lock it [the doors], I do not know why it is not locked. LN A continued, Dear Lord, this is scary. LN A confirmed that she turned off the door alarm at the desk when she heard it go off earlier, at the time the surveyor had entered through Door 2, without checking to see if anyone had entered the facility. During an interview on 4/12/24 at 5:15 am, Certified Nursing Assistant (CNA) F indicated he started working at the facility about month ago. CNA F indicated during this month, he had to chase a person out of the parking lot at night because they were looking into cars with a flashlight. He stated, I do not know whose job it is to lock the doors. I assumed they were locked. During an interview on 4/12/24 at 5:25 am, LN A indicated she was not sure who was responsible to lock the doors at night and she did not know how to lock them. During an interview on 4/12/24 at 5:50 am, CNA G indicated the Front door had to be locked with a screwdriver but sometimes it was missing. CNA G indicated she did not know how to lock the other doors and that Door 3 had been unlocked for a long time. She stated, I just want to be safe but because other doors do not lock it is pointless [to lock the Front door]. I have concerns for my safety and the residents ' safety. Anyone can walk in. CNA G indicated she had informed the MS about the missing screwdriver. During an interview with Resident 2 in her room on 4/12/24 at 7:00 am, Resident 2 stated, I don't believe the Back door is locked. I believe anyone could get in. I know the other night someone came in and I heard them say, who let her in?, and she said the door was unlocked. During an observation and interview with the MS on 4/12/24 from 7:50 am to 8:00 am, the same eight facility entrance doors as above, were inspected. MS indicated that the screwdriver to lock Door 1 was kept in the receptionist's desk but upon looking, confirmed that it was not there. MS did not know where it went or how long it had been missing. MS confirmed that with the facility doors left unlocked at night, and no alarms on the doors, anyone could come in off the streets and no one would know they were in the facility. During an interview on 4/12/24 at 3:29 pm, the Admin indicated he was unaware that the facility doors were left unlocked at night. Admin stated Door 1 should be locked by the charge nurse at 8:00 pm and unlocked at 6:00 am, and that all other doors should always be locked. 2. A review of the facility's policy titled, Elopements [when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so] and Wandering [the person appears to be searching for something such as an exit] Residents dated 4/16/21, indicated, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .The facility is equipped with door locks/alarms to help avoid elopements. A review of the facility ' s Order Listing Report dated 4/16/24, indicated that Resident 1 was the only resident who currently wandered. An order for Resident 1 indicated, Apply wanderguard to resident for safety. A review of Resident 1's undated Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, depression, and anxiety. A review of Resident 1's Quarterly Minimum Data Set (MDS, a clinical assessment), dated 4/4/24, indicated she was severely cognitively impaired and exhibited wandering behavior one to three days during a seven-day assessment period (3/29/24 through 4/4/29). A review of Resident 1's Care Plan, revised 2/6/24, indicated a care plan focus area; The resident is an elopement risk/wanderer r/t [related to] disorientation to place and poor safety awareness. Interventions included wander alarm to her w/c (wheelchair). During observations and interview on 4/12/24 from 5:22 am to 5:29 am, with LN A, the wanderguard system was observed. Each exit door/area was equipped with a wanderguard strip that should alarm when a resident wearing a wanderguard device, either on their person or attached to their wheelchair, came near it. LN A indicated that a red blinking light should be on to indicate the alarm was working. Door 5 had a wanderguard alarm strip, but the light was not on. LN A confirmed there was no blinking red light on the wanderguard strip to indicate that it was functioning. There was an electrical cord attached to the strip that was hanging next to the electrical source but not plugged in. LN A confirmed that the strip was unplugged and would not alarm if a resident with a wanderguard device attempted to elope or leave the facility unannounced. LN A said it was, unplugged because the only resident wearing a wanderguard device [Resident 1] kept coming back here on purpose to set off the alarm and it was driving us crazy. During an observation and interview with the MS on 4/12/24 at 7:50 am, the wanderguard system was observed. MS confirmed the wanderguard strip in the dining room on Door 5, was disconnected from the power and would not alarm. He indicated the alarm was, driving the staff nuts. During an interview on 4/12/24 at 3:29 pm, the Admin indicated he was unaware that the wanderguard strip in the dining room was unplugged and it should not have been.

Based on interview, record review and policy review, the facility failed to ensure that registry Licensed Vocational Nurse (LVN) 1 (a nurse from a registry staffing agency is not a permanent employee of the facility), was oriented to the facility's medication administration system, was accompanied by a Charge Nurse for at least three days to ensure that the facility's established medication administration procedures had been learned, and that LVN 1 followed the five rights of identifying a resident before administering medication (right resident, right medication, right dose, right time and right route (as in by mouth, injection or intravenously), for one of two residents (Resident 1) sampled for medication errors. LNV 1 gave Resident 1 cardiac (heart medications) and blood pressure medications that were prescribed for Resident 2. This medication error had a significant negative impact on Resident 1's physical condition and resulted in a drop Resident 1's blood pressure to 94/56 (normal range is considered 120/80), and heart rate to 40 (normal range is considered 80), which required an emergency transfer to the acute care hospital and subsequent admission to the hospital's Intensive Care Unit (ICU, for critically ill patients), where he required treatment for two days to get his blood pressure stabilized. Findings: The facility's policy titled, Administering Medications revised April 2019, was provided by the Director of Nursing (DON) and reviewed. The policy indicated; 9. Individual administering medication verifies resident identification before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band, b. Check photograph attached to the medical record, c. Verify with another personnel. 10. The individual administering medications checks the label THREE (3) times to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication. 29. New personnel authorized to administer medication are not permitted to prepare or administer medication until they have been oriented to the medication administration system used by the facility. The facility's policy titled, Adverse Consequences and Medication Errors revised February 2023, was provided by the DON and reviewed. The policy indicated; Adverse Consequence refers to unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. Medication Error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services. A significant medication related error is defined as, b. Requiring hospitalization or extending a hospitalization . d. Requiring treatment with a prescription medication. f. Life threatening. Resident 1's Admission Record was reviewed and indicated that Resident 1 was admitted to the facility on [DATE] with a diagnoses that included heart disease (damaged heart vessels), high blood pressure, atrial fibrillation (an irregular heart beat), diabetes (high blood sugar), benign prostatic hypertrophy (BPH- an enlarged prostate gland), obesity, chronic obstructive pulmonary disease (COPD-lung damage that makes breathing difficult), weakness, and dependent on oxygen use (air delivered through a tube in the nose). A review of Resident 1's Admission Minimum Data Set (MDS, a standardized assessment tool), dated 12/12/23, reflected that Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that he had no cognitive (memory and understanding) problems. A review of a document titled, Facility Reported Incident dated 3/14/24 at 8 am, reflected that the facility's Administrator (Admin) reported by email to the California Department of Public Health (CDPH), that Resident 1 was mistakenly given his roommate's medication on the morning of 3/13/24. Resident 1 had an adverse reaction to those medications and was currently admitted into the ICU at the local acute care hospital. On 3/14/24 at 10 am, an interview and concurrent record review of Resident 1 and Resident 2's Medication Administration Records (MARs) for the month of March 2024 and Physician's Orders for March 2024, was conducted with the DON. The DON confirmed that Resident 1 was currently in the ICU at the local acute care hospital (H)1. The DON indicated that on 3/13/24 at around 9 am, LVN 1 had given Resident 1 Resident 2's medications and LVN 1 reported this to the DON. DON indicated that LVN 1 had not followed the facility's policy on identifying Resident 1 when LVN 1 asked Resident 1 if his name was [Resident 2's name]. At that time, Resident 1 indicated that was his name. DON indicated that LVN 1 had not used the facility's method for identifying a resident prior to giving medications and should have at a minimum, checked Resident 1's armband, or asked another nurse for help in verifying who Resident 1 was. The DON indicated that the MAR showed Resident 1 as being in the B bed and Resident 2 in the A bed, which was incorrect, and that Resident 1 was in the A bed and Resident 2 was in the B bed. DON indicated this was a data entry error on the facility's part. DON added that instead of administering medications according to the bed a resident was in- LVN 1 should have further verified who the resident was to ensure she was administering medications to the right resident. The DON indicated that LVN 1 gave Resident 1 the following 7 heart and blood pressure medications that were prescribed for Resident 2; Diltiazem (a medication to lower blood pressure in a drug class called Calcium Channel blockers, which block the movement of calcium and is more effective with large vessel stiffness), 360 milligrams (mg is a unit of measuring weight of medication), XR (Extented release, medication continues to be released slowly into the system for 12-24 hours), Eliquis (a blood thinner to prevent blood clots) 5 mg, Coreg (a medication to lower blood pressure and heart rate in a drug class called Beta blockers, which block adrenaline so the heart beats slower) 25 mg, Isosorbide Mononitrate (used to prevent chest pain) 30 mg, Lisinopril (a medication to lower blood pressure) 40 mg, Clonidine (a sedative and blood pressure lowering medication) 0.1 mg, and Lasix (a water pill that lowers blood pressure) 40 mg. Resident 1's MAR indicated that he currently had 2 heart and blood pressure medications prescribed; Metoprolol ER 25 mg (an extended release Beta blocker), and Losartan 50 mg (a blood pressure lowering medication). The DON indicated that around 10:20 am, Resident 1 was lethargic (sluggish) and that he had stated, I'm tired and want to lay down. At that point the facility called 911 and Resident 1 left shortly thereafter by ambulance. The DON confirmed that according to the facility's Adverse Consequences and Medication Errors policy, LVN 1 made a significant medication error. On 3/14/24 at 4:16 pm, an interview was conducted with LVN 1. LVN 1 confirmed that during the morning medication pass on 3/13/24, she had given Resident 1 the above medications which were prescribed for Resident 2. LVN 1 stated, I went in and asked A bed if his name was [Resident 2's name], he said yes and took the medication. He was so with it, I thought he knew his name. LVN 1 indicated that when she went on to give bed B (Resident 2) his medication she asked if his name was (Resident 1's name) and he said, No, that's the other guy. LVN 1 confirmed that she had not checked armbands or asked another nurse who was familiar with the residents to help her verify who Resident 1 and 2 were. LVN 1 stated, I just felt like oh my God, I just gave the wrong meds [to Resident 1], I told both residents and the DON and called the family of [Resident 1] and the doctor. LVN 1 stated, I could not see the pictures on the MAR because they are too small and poor quality and the residents were in the wrong beds. I am new here. I should have asked someone else to help me verify. LVN 1 indicated that within one hour Resident 1's blood pressure had dropped to 95/26 and his heart rate was 40, so we called 911. LVN 1 stated that her training by the facility consisted of, We get a packet of things. They give it to us and we review it. That's all. The Medication Administration policies are in the packet, but I did not have time to review them. All I got was oriented to the unit. The rest was in the packet. They gave it to me on the first day I was there and I started working immediately, with no training. On 3/26/24, Resident 1's medical records were obtained from a Registered Nurse at H1 and reviewed. The ED [Emergency Department] Physicians Notes dated 3/13/23 at 1:29 pm, dictated by the ED physician (MD) 1, indicated that Resident 1 had been brought into H1 by ambulance from the facility after having a dangerously low blood pressure and heart rate after taking his roommates heart and blood pressure medications. Blood pressure in the ED was 94/52 and Resident 1's heart rate was 47. Resident 1 was given intravenvenous (IV, directly given to the blood stream by way of a small plastic tube in the vein); Atropine (to increase heart rate), Glucagon (for low blood sugar), Calcium Gluconate (to block calcium and prevent a heart attack), and Levophed (used to treat life-threatening low blood pressure and requires constant monitoring and titration (adjustments)). MD 1 documented, Failure to initiate these interventions could result in multi-organ failure, serious morbidity (medical problems), and death, requiring my highest level of preparedness to intervene emergently. MD 1 requested Resident 1 be evaluated by a Critical Care physician (CCP) 2, (a doctor who generally works in the ICU and takes care of critically ill patients). The H1 Admission History and Physical [H&P] dated 3/13/24 at 1:54 pm, dictated by the CCP 2 was reviewed. The final report indicated that Resident 1's diagnoses were Shock (a life-threatening condition due to lack of blood flow and low blood pressure), Bradycardia (low heart rate), and Calcium Channel Blocker overdose (profound lack of blood flow to vital organs). CCP 2 admitted Resident 1 to the ICU for close monitoring by critical care nurses for the administration of IV Levophed and IV Dopamine (treats symptoms of shock by improving blood flow). The H1 Discharge Summary dated 3/15/24 at 9:11 am, dictated by CCP 2 was reviewed. The Hospital Course indicated that Poison Control had been contacted regarding Resident 1's Calcium Channel Blocker toxicity and overdose. CCP 2 indicated that the continuous IV Levophed was discontinued after 24 hours on 3/14/24, and Resident 1's blood pressure and heart rate began to stabilize. CCP 2 documented that his expectation was that the continuous IV Dopamine could also be titrated (lowered), the anticipation was that the dose medication [wrong medication that Resident 1 was given at the facility], would be cleared from his system in 24 hours. Once the continuous IV Dopamine dose was lowered, Resident 1's blood pressure once again dropped dangerously low and the continuous IV Dopamine medication had to be extended for another day. On 3/15/24, Resident 1 was discharged back to the facility with a normal blood pressure and heart rate. On 4/3/24 at 10 am, an interview was conducted with Resident 1 in his room. Resident 1 stated, Yes. She [LVN 1], gave me the wrong medicine. It was the medications for my roommate. It happened and she said she made a mistake. After that my blood pressure went down and I was not feeling well at all. So because of that they took me to the hospital and I had to spend a few days in the Intensive Care. Resident 1 stated, Usually, I would look at my pills and ask them if I thought something wasn't right. But this time I took her word for it and didn't even think of it. It was too late by the time we figured it out. She was new and didn't know me. I guess I didn't know her either.

Based on observation, interview, and record review, the facility failed to ensure that medications were ordered, reordered, available, and administered in accordance with their physician ' s orders for 13 out of 31 sampled residents (Resident 2, 4, 10, 12, 13, 19, 22, 24, 25, 28, 31, 37 and Resident 38) when: 1. Resident 2 was not given two doses of Lovenox (a blood thinner) on 12/21/23 and 12/22/23. 2. Resident 4 was not given Lasix (a diuretic medication) and Coreg (a heart medication) on 12/21/23 at 8:00 pm. Resident 4 was not given the following morning medications on 12/22/23 at 08:00 am: Digoxin (a heart medication), Coreg, Lasix, Potassium Bicarbonate (a supplement for high blood pressure), Jardiance (a diabetic medication), Nicotine patch (a tobacco cessation product), Spironolactone (a diuretic medication), and Lisinopril (a medication to treat high blood pressure). 3. Resident 10 was not given two doses of Hydrochlorothiazide (a diuretic medication) on 12/20/23 and 12/22/23. 4. Resident 12 was not given five doses of Amantadine Hydrochloride (a medication for shaking) on 12/20/23, 12/21/23, and 12/22/23. 5. Resident 13 was not given three doses of Potassium Chloride (a supplement) on 12/20/23, 12/21/23, and 12/22/23. 6. Resident 19 was not given one dose of Levemir (an insulin medication)on 12/22/23. 7. Resident 22 was not given one dose of Keppra (a medication for seizures), one dose of Xarelto (a blood thinner), and one dose of Lisinopril (medication for high blood pressure) on 12/22/23. 8. Resident 28 was not given one dose of Protonix (a medication for ulcer prevention) on 12/22/23. 9. Resident 31 was not given one dose of Thiamine HCL (a supplement), and one Nicotine patch (a smoking cessation product) on 12/22/23. 10. Resident 37 was not given one dose of Paxlovid (a medication to treat Covid) on 12/22/23. 11. Resident 38 was not given one dose of Soliqua (an insulin medication) on 12/22/23. 12. Resident 24 was not given two doses of Pyridium (a medication for urinary discomfort) on 12/21/23 and 12/22/23. Resident 24 was not given three doses of Sotalol (a heart medication) on 12/20/23, 12/21/23, and 12/22/23. 13. Resident 25 was not given one dose of Tresiba (an insulin medication) on 12/25/23. These failures resulted in an Immediate Jeopardy (IJ, situation is when the facility needs to immediately correct the problem to avoid serious injury, harm, impairment, or death to a resident), and had the potential for serious adverse clinical outcomes such as irregular heart rates, blood clots, high blood sugars, infections, seizures, stomach problems, hospitalization s, and death. An IJ was declared on 12/22/23 at 12:20 pm, in the presence of the facility ' s Administrator (Admin) and Director of Nursing (DON). The facility DON provided an acceptable immediate corrective action plan on 12/22/23 at 2:30 pm, and the IJ was removed on 12/26/23 at 4:00 pm. Findings: During a review of the facility ' s policy and procedure titled, Medication Ordering And Receiving From Pharmacy, Section IC3, revised 1/1/23, indicated, Medications and related products are received from local pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. This facility ' s policy indicated new orders can be written and called, faxed, or received electronically by the provider, (doctor or nurse practitioner) and include date ordered, resident name and date of birth, other identifying information, medication name and strength, dose and dosage form, time or frequency of administration, diagnosis and indications, directions for use, and indicate send or do not send. Refill of medication can be requested from pharmacy by faxing written requests on medication order form, or adhering reorder sticker from on hand medication label to refill reorder request form and faxing to the pharmacy, or by electronic request by the Electronic Medication Administration Record, (EMAR, Quick Mar system), or Point Click Care. During a review of the facility ' s policy and procedure titled, Medication Ordering and Receiving From Pharmacy, Section IC6, revised 1/1/23, indicated, The facility will notify the pharmacy if medication is needed immediately or within a limited time frame prior to the next scheduled delivery. If an immediate dose of medication is needed to prevent a medical emergency the item may be ordered using the stat or satellite process. Pharmacy will strive to deliver medications within 4 hours unless state regulations specify otherwise, of receiving the order. 1. During a review of Resident 2 ' s Admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included PVD (poor circulation), high blood pressure, and muscle weakness. During a review of Resident 2 ' s Active Orders 12/2023, dated 12/21/23, indicated Resident 2 was ordered Enoxaparin Sodium (Lovenox, a blood thinner), 30 milligrams (mg, a unit of measure)/0.3 milliliters (ml, a unit of measure) inject 30 units subcutaneous (SQ, fatty layer just under the skin), one time a day for Deep Vein Thrombosis (DVT, formation of one or more blood clots in large veins), prophylaxis, rotate with every administration, use until ambulatory. During a review of Resident 2 ' s Electronic Medication Administration Record, (EMAR) dated 12/21/23 through 12/22/23, indicated Resident 2 was not given Lovenox as ordered on 12/21/23 and 12/22/23 at 08:00 am, and the documentation on the EMAR indicated not available on 12/21/23 and on 12/22/23. During a concurrent observation and interview on 12/22/23, at 7:20 am, with Licensed Nurse (LN) I, at the medication (med) cart for hall two, LN I confirmed Resident 2 ' s Lovenox 30 mg was not in the med cart and stated, [Resident 2 ' s] Lovenox 30 mg is not in the med cart or in the refrigerator in the med room, and I think she refuses it now. During an interview on 12/22/23, at 11:06 am, the Director of Nursing (DON) confirmed that Resident 2 was at risks for blood clots, harm, complications, or sudden death by not getting her Lovenox. The DON confirmed she had not been informed that [Resident 2] had refused Lovenox. During an interview on 12/26/23, at 11:55 am, with the DON, the DON stated, I clarified the order for [Resident 2] and the Lovenox 30 mg is ordered daily, and she is not refusing the medication. This medication is now available, and [Resident 2] is receiving Lovenox every morning as ordered. 2. During a review of Resident 4 ' s medical record, the Admission Record, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included end stage heart failure, diabetes (a disease that occurs when your blood sugar is too high), and pulmonary hypertension, (high blood pressure in the heart-to-lung system). During a review of Resident 4 ' s Active Orders 12/2023, dated 12/21/23, indicated Resident 4 was ordered Digoxin (a medication that improves the strength of the heart) 125 micrograms, (mcgs, a unit of measure), 1 tablet daily for heart failure, Coreg (a heart medication that lowers the blood pressure by slowing the heart rate down), 3.125 mg 1 tablet two times a day (BID) for high blood pressure, Lasix, (a diuretic medication, or commonly called a fluid pill), to treat (edema, excessive fluid accumulation or swelling), 80 mg one tablet BID for edema, Potassium Bicarbonate (a supplement used to regulate high blood pressure, reduce the risk of stroke), 1 capsule daily for supplement, Jardiance (a diabetic medication used to lower the blood sugar), 10 mg one tablet daily for diabetes, Nicotine (a tobacco product), patch 21 mg daily topical (apply directly to the top layer of skin), for history of personal nicotine dependence, Spironolactone (a diuretic medication used to treat edema, heart failure, and high blood pressure), 25 mg 1 tablet daily for high blood pressure, and Lisinopril (a medication used to treat high blood pressure, and heart failure), 5 mg give 1/2 tablet daily for high blood pressure. During a review of Resident 4 ' s EMAR dated 12/21/23 through 12/22/23, indicated Resident 4 was not given Lasix and Coreg on 12/21/23 at 8:00 pm, as ordered, and Resident 4 was not given Digoxin, Lasix, Coreg, Potassium Bicarbonate, Jardiance, Lisinopril, Spironolactone, and the nicotine patch as ordered at 08:00 am on 12/22/23. The documentation on the EMAR indicated New admit, waiting on pharmacy delivery for 12/21/23, and 12/22/23. During a concurrent observation and interview on 12/22/23, at 7:31 am, with Licensed Nurse (LN) I, at the med cart for hall two, LN I stated, There are no medications available except for the pain meds, I am doing the best I can. LN I confirmed all of the morning medications ordered for 08:00 am were not available in the med cart, and she did not order these medications, or call the MD, or pharmacy for Resident 4. During an interview on 12/22/23, at 7:40 am, with Resident 4 at the doorway of her room, stated to LN I, Honey, can you help me get my heart meds? I really need them. 3. During a review of Resident 10 ' s medical record, the Admission Record, indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included MS (disabling, uncurable, long-lasting disease of the brain and spinal cord that causes communication problems between the brain and the rest of your body), high blood pressure, and history of Covid (respiratory infection). During a review of Resident 10 ' s Active Orders 12/2023, indicated on 11/12/23, Resident 10 was ordered Hydrochlorothiazide (a medication that reduces edema, and lowers the blood pressure), 25 mg 1 tablet daily for high blood pressure. During a review of Resident 10 ' s EMAR dated 12/20/23 through 12/22/23, the EMAR indicated Resident 12 was not given Hydrochlorothiazide as ordered at 08:00 am on 12/20/23 and 12/22/23. The documentation on the EMAR indicated on 12/20/23, Unable to administer, outside of parameters, and the documentation on the EMAR on 12/22/23 indicated, not on cart, will fax pharmacy to refill. During a concurrent observation and interview on 12/22/23, at 7:50 am, with Licensed Nurse (LN) I, at the med cart for hall two, the LN I stated, There is no Hydrochlorothiazide on this cart. I cannot find it, another med error. LN I confirmed the medication was not available and she did not re-order this medication, or call the MD, or pharmacy for Resident 10. 4. During a review of Resident 12 ' s medical record, the Admission Record, indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included MS, chronic pain, and reduced mobility (difficulty or unsteadiness while walking). During a review of Resident 12 ' s Active Orders 12/2023, indicated on 10/26/23, Resident 12 was ordered Amantadine Hydrochloride (a medication to reduce fatigue with the disease MS) 100 mg BID for MS. During a review of Resident 12 ' s EMAR dated 12/20/23 through 12/22/23, indicated Resident 12 was not given Amantadine Hydrochloride BID ordered at 08:00 am and 5:00 pm on 12/20/23, 12/21/23, and 12/22/23. The documentation on the EMAR dated 12/20/23 indicated awaiting pharmacy, and the documentation on 12/21/23 indicated med not available, and on 12/22/23 the documentation on the EMAR indicated, Not in cart, will fax pharmacy. During a concurrent observation and interview on 12/22/23, at 8:10 am, with Licensed Nurse (LN) I, at the med cart for hall two, the LN I stated, I cannot find the Amantadine 100 mg. Like I told you, no one orders the medicine. I am so irritated. LN I confirmed the medication was not available and she did not re-order this medication, or call the MD, or pharmacy for Resident 12. 5. During a review of Resident 13 ' s medical record, the Admission Record, indicated Resident 13 was admitted to the facility on [DATE] with diagnoses that included heart failure, kidney disease, and liver disease. During a review of Resident 13 ' s Active Orders 12/2023, indicated on 11/15/23, Resident 13 was ordered Potassium Chloride (a medication containing potassium, a mineral present in most human cells), Extended Release (ER, medicine released slowly over time), 20 milliequivalents (meq, a number of grams unit of measurement), 1 capsule once daily for hypokalemia (low potassium). During a review of Resident 13 ' s EMAR dated 12/20/23 through 12/22/23, indicated Resident 13 was not given Potassium Chloride ER as ordered at 08:00 am on 12/20/23, 12/21/23, and 12/22/23. The documentation on the EMAR indicated on 12/20/23, Unable to administer, outside parameters, documentation on the E[DATE]/21/23 indicated, Not available, and documentation on EMAR for 12/22/23, indicated, Med not on cart, will fax pharmacy. During a concurrent observation and interview on 12/22/23, at 8:40 am, with Licensed Nurse (LN) I, at the med cart for hall two, the LN I stated, I cannot find the potassium for [Resident 13], it is not in the cart; it is ordered once a day. LN I confirmed the medication was not available and she did not re-order this medication, or call the MD, or pharmacy for Resident 13. LN I confirmed the dose of medication was missed for 12/22/23. 6. During a review of Resident 19 ' s medical record, the Admission Record, indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included diabetes, high blood pressure, and dementia, (a term for impaired ability to remember, think, reason, or make decisions that interfere with daily life.) During a review of Resident 19 ' s, Active Orders 12/2023, indicated on 12/22/23, Resident 19 was ordered Levemir Insulin Flex pen (a type of long-acting insulin prepared in a pen vial), inject 35 units SQ daily for diabetes. During a review of Resident 19 ' s EMAR dated 12/22/23, indicated Resident 19 was not given Levemir insulin as ordered on 12/22/23 at 08:00 am. The documentation on the EMAR indicated, To be ordered. During a concurrent observation and interview on 12/22/23, at 9:50 am, with Licensed Nurse (LN) I, at the medication (med) cart for hall two, the LN I stated, [Resident 19 ' s] insulin is not here, I am not surprised. His blood sugar is 505, as of now. LN I confirmed the medication was not available and she did not re-order this medication, or call the MD, or pharmacy for Resident 19. 7. During a review of Resident 22 ' s medical record, the Admission Record, indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses that included Epilepsy, (a condition that affects the brain and causes seizures), Afib (a heart condition, with an irregular heartbeat, if untreated can cause stroke, heart attack, or sudden death), and high blood pressure. During a review of Resident 22 ' s Active Orders 12/2023, indicated on 10/18/23, Resident 22 was ordered Keppra (a seizure medication), 750 mg BID for seizure disorder, Xarelto (a blood thinner that treats or prevents blood clots), 20 mg daily for Afib, and Lisinopril 40 mg 1 tablet daily for high blood pressure. During a review of Resident 22 ' s EMAR dated 12/22/23 indicated Resident 22 was not given Keppra, Xarelto, and Lisinopril as ordered at 08:00 am. The documentation on the EMAR indicated on 12/22/23, Not in cart, will fax pharmacy. During a concurrent observation and interview on 12/22/23, at 10:20 am, with Licensed Nurse (LN) I, at the med cart for hall two, the LN I stated, I am missing three different meds for her, they did not order [Resident 22] ' s medicine. I hope something will change; this is not right. LN I confirmed the medications were not available and she did not re-order this medication, or call the MD, or pharmacy for Resident 22. 8. During a review of Resident 28 ' s medical record, the Admission Record, indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included acute gastritis with bleeding (inflammation and bleeding of the stomach), and Gastro Esophageal Reflux Disease, (GERD, commonly called heartburn), and diabetes. During a review of Resident 28 ' s Active Orders 12/2023, indicated on 12/14/23, Resident 28 was ordered Protonix (a medication for ulcer prevention), 40 mg to be taken daily for ulcer protection. During a review of Resident 28 ' s EMAR dated 12/22/23, indicated Resident 28 was not given Protonix as ordered on 12/22/23 at 08:00 am. The documentation on the EMAR indicated on 12/22/23, Not in stock, waiting on delivery. During a concurrent observation and interview on 12/22/23, at 7:40 am, with Licensed Nurse (LN) A, at the med cart for hall one, there was no Protonix 40 mg tablet available to be taken daily available for Resident 28. LN A confirmed the medication was not available and she did not re-order this medication, or call the MD, or pharmacy for Resident 28. 9. During a review of Resident 31 ' s medical record, the Admission Record indicated, Resident 31 was admitted to the facility on [DATE] with diagnoses that included personal history of nicotine use, pancreatitis, (serious condition when the pancreas becomes inflamed), and diabetes. During a review of Resident 31 Active Orders 12/2023, indicated on 12/13/23, Resident 31 was ordered Thiamine (a supplement of B1), 500 mg taken daily for supplement and Nicotine Patch 21 mg for personal history of nicotine dependence. During a review of Resident 31 ' s EMAR dated 12/22/23, indicated Resident 31 was not given Thiamine on 12/22/23 as ordered at 8:00 am. The documentation of the EMAR indicated on 12/22/23, Out of stock. Resident 31 was not given a nicotine patch as ordered on 12/22/23 at 08:00 am. The documentation of the EMAR indicated on 12/22/23, Out of stock. During a concurrent observation and interview on 12/22/23, at 7:50 am, with Licensed Nurse LN A, at the med cart for hall one, there was no Thiamine 500 mg tablet or Nicotine Patch 21 mg available for Resident 31. LN A confirmed the medications were not available and she did not re-order this medication, or call the MD, or pharmacy for Resident 31. 10. During a review of Resident 37 ' s medical record, the Admission Record, indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included active Covid (respiratory infection), heart disease, and high blood pressure. During a review of Resident 37 ' s Active Orders 12/2023,, indicated on 12/21/23, Resident 37 was ordered Paxlovid (a medication to treat Covid), 300/100 mg 2 tablets taken BID for Covid infection. During a review of Resident 37 ' s EMAR dated 12/22/23, indicated Resident 37 was not given Paxlovid as ordered 12/22/23 at 08:00 am. The documentation of the EMAR indicated, Out of stock, waiting on order. During a concurrent observation and interview on 12/22/23, at 8:15 am, with Licensed Nurse LN A, at the med cart for hall one, there was no Paxlovid medication available for Resident 37. LN A confirmed the medication was not available and she did not order this medication, or call the MD, or pharmacy for Resident 37. 11. During a review of Resident 38 ' s medical record, the Admission Record, indicated Resident 38 was readmitted to the facility on [DATE] with diagnoses that included diabetes, cardiac disease, and history of Covid respiratory infection. During a review of Resident 38 ' s Active Orders 12/2023, indicated on 12/6/23, Resident 38 was ordered Soliqua insulin pen 25 units subcut once daily take with food. During a review of Resident 38 ' s EMAR dated 12/22/23 indicated Resident 38 was not given Soliqua insulin on 12/22/23 at 08:00 am. The documentation of the EMAR indicated, Waiting on delivery. During a concurrent observation and interview on 12/22/23, at 8:20 am, with Licensed Nurse LN A, at the med cart for hall one, there was no Soliqua insulin pen for Resident 38 available. LN A confirmed the medication was not available and she did not re-order this medication, or call the MD, or pharmacy for Resident 38. 12. During a review of Resident 24 ' s medical record, the Admission Record, indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included neoplasm of left kidney (a cancerous growth or tumor on the kidney), high blood pressure, and diabetes. During a review of Resident 24 Active Orders 12/2023, indicated on 11/29/23, Resident 24 was ordered Pyridium 100 mg taken twice a day for malignant neoplasm of left kidney, and on 10/30/23, Resident 24 was ordered Sotalol 80 mg 1 tablet taken every 12 hours for high blood pressure and Afib. During a review of Resident 24 ' s EMAR dated 12/21/23 and 12/22/23 indicated Resident 24 was not given Pyridium as ordered on 12/21/23 and 12/22/23 at 08:00 am. The documentation of the EMAR indicated on 12/21/23 and 12/22/23, Medication not Available. This record also indicated Resident 24 was not given Sotalol as ordered on 12/20/23, 12/21/23, and 12/22/23. The documentation of the EMAR indicated on 12/20/23, Medication unavailable. The documentation of the EMAR indicated on 12/21/23, Medication not available. The documentation of the EMAR indicated on 12/22/23 indicated, Has not arrived from pharmacy, will call. During a concurrent observation and interview on 12/22/23, at 8:45 am, with Licensed Nurse (LN) A, at the med cart for hall one, there was no Pyridium 100 mg tablet or Sotalol 80 mg tablet for Resident 24. LN A confirmed the medication was not available and she did not order this medication, or call the MD, or pharmacy for Resident 24. During a phone interview on 12/22/2023, at 10:25 am, with Pharmacist (Pharm), Pharm stated Resident 4 ' s admission medication orders were received by the pharmacy via fax on 12/21/2023 at 10:40 am. Pharm stated the pharmacy prepared the medications, delivered the medications and facility staff LN C signed and accepted the medications on 12/22/2023 at 00:29 am. Pharm also confirmed the pharmacy had not been updated with any medications not available in the facility, and the facility did not follow their policy and procedure to obtain stat (an urgent need that cannot wait), medications needed for all residents who were out of medications. 13. During a review of Resident 25 ' s medical record, the Admission Record, indicated Resident 25 was admitted to the facility on [DATE] with diagnosis that included diabetes, high blood pressure, and muscle weakness. During a review of Resident 25 ' s Active Orders 12/2023, indicated on 12/14/23, Resident 25 was ordered was ordered Tresiba FlexTouch Insulin Pen, inject 30 units subcutaneously at bedtime for diabetes. Hold if blood sugar is less than 70 and notify the medical doctor. During a review of Resident 25 ' s EMAR dated 12/14/23, indicated Resident 25 was not given Tresiba insulin as ordered on 12/25/23 at bedtime. The documentation of the EMAR indicated on 12/25/23, This medication was not available and the pen available was empty, there was no pen available in the e-kit, therefore, the medication could not be given. During a concurrent record review and interview on 12/26/23 at 3:10 pm, with LN J, confirmed the insulin was not available in the med cart for hall one, and the bedtime dose was not administered on 12/25/23 as ordered. The fasting blood sugar was documented as a 0 at 2:53 am. During this concurrent record review and interview, LN J also confirmed there was a progress note that indicated the insulin was not administered as ordered on 12/25/23, stated unavailable, but the MD was not updated until 12/26/23 at 11:48 am from a different nurse, LN F. During a concurrent record review and interview on 12/26/23, at 3:18 pm, LN B confirmed Resident 25 did not receive any insulin as ordered on 12/25/23 at bedtime, and there were no updates to the DON, or MD and the blood sugar was not obtained as ordered. During an interview on 12/29/23 with the Medical Director (MD) at 12:10 pm, MD stated, It is my expectation for all medications that are missed for each resident is to call me immediately to try to get the medications or give a new order. This was unsafe for the residents, moving forward they need to call me, and I can assist with medications if needed. This is not professional standards, and I cannot tell you why this happened, but I am upset and concerned about the residents. MD confirmed he had not been updated on any medications unavailable in the facility through 12/22/23 until the DON called his office. MD stated he had many samples of different types of insulin and other medications in his office if he had been notified and would have brought medication in if needed. During an interview on 12/26/23, at 3:30 pm, the DON confirmed Resident 25 did not receive any bedtime insulin ordered, no blood sugar was obtained or documented, and LN P did not update the DON, or the MD per policy and procedures for missing medications. The DON also confirmed this was unsafe for Resident 25, and the blood sugar should have been obtained as ordered by the MD.

Based on interview and record review, the facility failed to take the following actions to help lessen the risk of urinary tract infection (UTI, bladder infection) for one of three sampled residents (Resident 1), admitted with an indwelling urinary catheter (IC - a urinary drainage system with a tube placed through the urinary tract that remains in the bladder and is attached to a drainage bag), when the facility failed to: 1. Identify and determine the reason for an IC on admission; 2. Notify the physician before removing an IC; 3. Document fluid intake and urinary output (I&O) after IC removal to ensure proper bladder emptying; 4. Document and perform an ordered procedure for straight catheterization (insertion of a thin tube into the bladder to allow the urine to flow out) due to the resident not voiding (urinating); and 5. Develop a care plan and consistently monitor for UTI and/or [MEDICAL CONDITION] (the inability to completely empty the bladder) when symptoms of abnormal abdominal distention (swollen abdomen due to pressure inside) and episodes of dark and odorous urine voids were noted. These failures resulted in Resident 1 having suffered [MEDICAL CONDITION] with a distended abdomen throughout her stay at the facility resulting in an acute hospitalization with [DIAGNOSES REDACTED]. Findings: Resident 1's facility medical record was reviewed. Resident 1 was admitted to the facility for post surgical rehabilitation on 2/26/18 from an acute care facility after surgical repair of a right [MEDICAL CONDITION] and with [DIAGNOSES REDACTED]. Resident 26 required re-hospitalization on [DATE] due to a condition change. During an interview with Resident 1's responsible party (RP), on 10/3/18 at 3:42 pm, he stated Resident 1 passed away on 4/28/18 after being transferred home from the acute care facility on hospice on 3/13/18. RP stated that on admission to the rehabilitation (rehab) facility, on 2/26/18, he was present and was aware that the acute care facility kept Resident 1's catheter in place upon discharge due to problems urinating on her own. RP stated he verbally informed the charge nurse on the day that Resident 1 was admitted that she was having problems passing urine. RP stated that the discharge information should have identified the issue regarding Resident 1's catheter. RP stated Resident 1 had a leak in her catheter bag on the day of her admission and that the catheter was removed by nursing staff. RP stated he had reported the concern that Resident 1 had a distended lower abdomen and questioned why it did not resolve during her stay at the facility. RP stated the facility did not do I&O to keep track of her fluid intake and urine output. RP stated Resident 1 was readmitted to the acute care facility [MEDICAL CONDITION] and had a back up of urine that needed to be removed. RP stated Resident 1 was a full code (all life saving measures to be taken), was able to recognize all family, and was fully independent with her activities of daily living (activities related to personal care including eating, bathing, dressing, transferring, and using the toilet) prior to a home fall that resulted in a fracture (broken bone) and the rehabilitation facility stay. RP stated that when Resident 1 awakened in the acute care facility after her re-hospitalization , she could no longer recognize her son and had such a severe change in her condition that it resulted in her death. A review of Resident 1's acute care facility records, dated 2/25/18, indicated Resident 1 had her IC removed and then reinserted. An acute care nurses note, dated 2/25/18 at 3 am, read (Patient) unable to void, straight (catheterization) performed . An acute care catheter assessment note, dated 2/25/18 at 8 pm to 9 pm, read Urethral Indwelling/Continuous 16 Fr (French - a measure used for catheter size) Catheter Continued Justification: Patient has [MEDICAL CONDITION] . A review of an Interfacility Transfer Report and Medicare Certification (a form that accompanies a resident during a transfer between facilities, and contains resident data, a nursing evaluation, physician's certification that continuous skilled care is required, discharge diagnoses, and discharge orders), located in Resident 1's facility record and dated 2/26/18, under Nursing Evaluation . B. Physical Status . Patient Uses: .Catheter, the Yes box was checked indicating Resident 1 was currently using a urinary catheter on facility transfer (from acute to rehab). A review of Resident 1's admit physician's orders [REDACTED]. A review of Resident 26's facility Resident Assessment - Data Collection Form, dated 2/26/18 at 1 pm, under the assessment section titled, Bowel and Bladder Evaluation . Bladder Habits indicated Resident 1 was not continent (had loss of urine control). Further bladder assessment details for type of incontinence (i.e. dribbles), catheter presence and type, urine color and consistency (if urine was clear, dark, odorous, had sediment, mucous, blood or other abnormalities), and time of last voiding were all left blank. The section that determined if Resident 1 could participate in a training program for her bladder incontinence was also left blank. This document was completed by Licensed Nurse (LN) A. A review of a Bowel and Bladder Assessment Tool, dated 2/26/18, also completed by LN A, read Resident 1 voids (urinates) appropriate without incontinence: but less than daily, is forgetful and confused, needs assist of one person, and is sometimes aware of need for toilet. There was no notation of an IC in the assessment, or that Resident 1 had trouble voiding, possible [MEDICAL CONDITION], or was at risk for UTI. There was no entry in the area of the tool that called for a summary of Resident 1's toileting history and elimination patterns. A review of a Nurses Note (NN), dated 2/26/18 at 3 pm by LN A, read Complete assessment done . The note did not contain any documentation regarding bladder concerns or the presence of a catheter. A review of a NN, dated 2/26/18 at 9:45 pm by LN B, read Removed catheter and did peri care (care of the genital area and groin). A review of a physician's telephone order, dated 2/27/18 (no time), signed as received by LN B, read Straight (Catheterization) x (times) 1 for no void. A review of a Daily Medicare Note (DMN), dated 2/26/18 (no time), read Shift: N[NAME] (nocturnal -the over night shift that runs from 6 pm 2/26/18 to 6 am 2/27/18) . Narrative Notes . Removed a Foley catheter (brand of indwelling urinary catheter) at (9:45 pm) and waiting for resident to void. The note also indicated Urine has a strong odor . (Abdomen) is firm and distended in pelvis (bladder area) region. Resident denies the urge to urinate . Encouraging fluids. This note was written by LN B. A review of a DMN, dated 2/27/18 (on the N[NAME] shift) by LN B, read . Resident shows no signs of distress or discomfort . Resident has wheezing and congestion in all lobes (of lungs) . Resident has strong odor in urine. Encouraging fluids and watching for signs and symptoms of UTI. The DMN also identified that Resident 1 was totally dependent on staff in use of the toilet. A review of Resident 1's history and physical examination [REDACTED]. The physician's genito-urinary assessment indicated deferred (not done). A review of a DMN, dated 2/28/18 (on the N[NAME] shift) by LN C, read 3 am, Slept well - Had an uneventful shift without (complaint of) distress/incident. Will continue to monitor. The general assessment area noted that Resident 1 had yellow, dark urine. No bladder distention was noted and the documentation did not specify what the resident was being monitored for (i.e., signs and symptoms of UTI). The area of the DMN to document the level of assist for toileting or if toileting had occurred was left blank. DMNs, dated 3/1, 3/2, and 3/3/18 by LN C, were reviewed. All three notes contained similar statements that Resident 1 had no complaints of distress or incident and monitoring was being done. All three notes contained documentation in the assessment area that Resident 1's urine was WNL (within normal limits), but did not contain documentation (area left blank) as to whether Resident 1 had used the toilet that shift. A review of a N[NAME] shift Weekly Summary, dated 3/2/18 by LN C, read Had gas pain tonight, given [MEDICATION NAME] with good effect, otherwise has had no (complaints of) distress or incident . (Abdomen) tight to slightly distended with (illegible writing) sound . No reference to Resident 1's care plans was addressed. A review of a telephone order, dated 3/4/18 (no time) and signed as received by LN B, read Transfer to Acute for (Evaluation) and treatment (related to Temperature). A review of a Resident Transfer Record, dated 3/4/18 at 6 pm, read Symptoms first noted: Date: 3/4/18, Time: (6 pm) . 6:40 pm T (temperature) 104.2 (degrees Fahrenheit (F)) . Vomiting, Abdominal distention, post hip surgery 2/19/18 . A review of a NN, dated 3/4/18 at 7:15 pm by LN B, read Resident 1 was transported to acute by ambulance. During an interview on 10/4/18 at 12:45 pm, with the Minimum Data Set Nurse (MDSN), a Registered Nurse, she stated that she was an interim DON for the facility at the end of 3/2018 up to a few weeks ago. MDSN stated, If a resident comes in with an IC, we need to review the record to see why the resident still has the catheter in (i.e., due to urinary blockage and retention). We then discuss it with the physician and get an order to discontinue if appropriate. If the catheter is removed and no void for eight hours, it requires a need to get an order to straight catheterize for urine. MDSN stated, We have no bladder scanner to check for residual urine. MDSN stated, If I wrote an order to discontinue a Foley catheter, in the notes I would write to monitor for [MEDICAL CONDITION]. MDSN stated that the Medicare charting identifies if an IC is in place. MDSN stated a care plan should have I&O monitoring checked for new admits. During an interview on 10/4/18 at 1:45 pm, the Assistant Director of Nursing (ADON), who was on duty during Resident 1's stay, stated the facility protocol for a resident admitted with an IC is for the LN to review and identify the reason(s) a catheter is left in place (by reviewing the transfer record and/or calling the hospital) and to speak with the resident's physician prior to removal. ADON stated a straight catheterization procedure is done when a resident does not void for eight hours after removal of an IC. ADON stated I&O should be done for all new admits for the first three days and for at least the first 30 days from admit for a resident with an ongoing IC. During an interview and concurrent record review of Resident 1's care, on 10/4/18 at 3:50 pm, the Director of Nursing (DON) and Administrator (Admin) acknowledged Resident 1's record did not contain an order to remove her IC, did not contain documentation of I&O, did not contain documentation of the straight catheterization that was done or the results (amount of urine retained), and that there was no care plan for the catheter removal and need for straight catheterization for not voiding and/or [MEDICAL CONDITION]. DON stated that she was the facility's new DON since 9/2018 and that she identified shortly after starting that there was no system was in place for the recording of resident I&O. DON stated she was not aware that the facility was doing anything to monitor I&O when needed. DON stated that she recently in-serviced the staff and created a document for use with I&O collection. During an interview and concurrent record review with LN A, on 10/4/18 at 4:15 pm, LN A stated the facility protocol for a resident admitted with an IC, is to first assess if the IC is needed before removing it. LN A stated the nurse needs to call the sending facility if the records don't indicate why the resident's IC was not removed, and to obtain a physician's orders [REDACTED]. LN A stated that after removal of an IC, the facility must monitor the resident's urinary output for eight hours and obtain a physician's orders [REDACTED]. LN A stated the amount of urine retained must also be reported to the physician. LN A stated if a resident continues to have no void, they would need to perform straight catheterization again in eight hours. LN A acknowledged she admitted Resident 1 on 2/26/18, but did not identify/document Resident 1 had an IC in place, did not contact the sending facility or the physician regarding the IC, and did not initiate a temporary care plan for removal of the IC. LN A stated, It is possible that I may have missed a catheter. During an interview and concurrent record review on 10/4/18 at 5 pm, LN C acknowledged he was responsible for documenting Resident 1's 2/28, 3/1, 3/2, and 3/3/18 NNs, and the weekly summary note dated 3/2/18. He stated that if a resident had a distended abdomen that an abdominal girth measurement (to identify amount of distention) should be made. LN C stated all residents should have I&O measured for the first three days following admission. LN C stated he did not identify that Resident 1 had a distended abdomen. He stated he would have encouraged fluids for the identified dark yellow urine. LN C stated he did not remember Resident 1's case well. LN C stated that if a resident was admitted with an IC, he would call the sending facility to determine why the IC was in place if the notes did not indicate the reason, or if he did not get a verbal report from the sending facility. LN C stated that when an IC is removed, the nurse should document how the resident tolerated the removal and a temporary care plan should be initiated for monitoring voiding or [MEDICAL CONDITION] after the removal. LN C stated that if the resident does not void in four to six hours, the nurse should palpate (assess by touch) the bladder for fullness, and if full, should perform a straight catheterization on the resident. LN C stated that he had no recollection of Resident 1 or her family. During a phone interview with LN B, who no longer worked at the facility, on 12/5/18 at 8:15 am, LN B stated she recalled Resident 1's case well. LN B stated she was the second nurse to work with Resident 1 on the day of her admission on 2/26/18 and that she did not call the transferring facility before removing Resident 1's IC on 2/26/18, and did not notify the facility physician. LN B stated she thought it was facility protocol to remove catheters on admit. LN B confirmed when a catheter is removed, the nurse should let the physician know. LN B stated after an IC is removed, the nurse should wait so many hours and then call the doctor for a straight catheterization order to empty the bladder if the resident is unable to void. LN B stated the facility did not have a process or flow sheet for follow up on I&O for residents. LN B stated she should have documented better in the progress notes and should have initiated a temporary care plan for monitoring Resident 1 for possible bladder infection and [MEDICAL CONDITION]. LN B stated she did not remember if she performed a straight catheterization on Resident 1 on the morning of 2/27/18 when an order was obtained or if anyone else had (the order dated 2/27/18 did not contain a time, but was noted by LN B). The reason that LN B stated she remembered Resident 1 well was because when she came back on duty on 3/4/18 after being off, she found Resident 1 in acute distress with an elevated temperature, vomiting, and abdominal distention. LN B stated Resident 1's condition was worse than when she had last worked with her. LN B stated the report she received from the offgoing nurse was that Resident 1 was slightly more confused that day (on 3/4/18). LN B stated Resident 1's abdomen was distended and firm as if she was pregnant and that Resident 1's distended abdomen appeared the same on 3/4/18, as the first day she worked with her, on 2/26/18. LN B stated the facility did not have a system set up for post void residual volumes (amount of urine retained in bladder after voiding), such as straight catheterization practice or bladder scanning (an external tool that can scan the bladder for volume of fluid) to determine [MEDICAL CONDITION]. She stated the facility did not do I&O unless ordered by the physician and that she did not receive any education or direction on the facility's practice related to catheters and I&O policy. A review of the acute care facility records from admission on 3/4/18 through 3/13/18 revealed the following: 1. A Triage Record, dated 3/4/18 at 7:42 pm, read that Resident 1 arrived by ambulance with flu like symptoms of generalized weakness, nausea, vomiting, diarrhea, and had a firm abdomen. Her elevated temperature was documented at 103.1 degrees F, and her blood pressure slightly low at 112/55. 2. The ED Report (a physician report that summarized Resident 1's ED visit), dated 3/4/18, read She is a [AGE] year old female, and she recently underwent a [MEDICAL CONDITION] about a week ago. She was discharged to (facility name). Apparently, she had a Foley catheter in place. They did remove the Foley catheter. They noticed that she started developing fevers up to 104. Her abdomen seemed distended. She has been having decreased (oral) intake. They noticed that she is having both nausea, vomiting and diarrhea, that her stools are runny. They therefore called 911 and the patient is brought to the emergency department for further treatment and care. The patient has early dementia and is not really able to answer any of my questions. a. The ED report assessment area titled Abdomen read, Soft. She has a distended abdomen about 2 cm (centimeters) above the level of the umbilicus. It is all in the suprapubic (region of the abdomen located below the umbilical region) area extending up to the level of the umbilicus . b. The ED report section titled emergency room Course read, We immediately did a bladder scan on her. Bladder scan shows that she has over 1000 cc (cubic centimeters) in her bladder. I did have my nurses emergently put a Foley catheter in her and an IV (intravenous catheter for fluids and medication). I was concerned she could be septic The report also identified that blood cultures were taken and she received an antibiotic. A urinalysis test identified urine abnormalities. The ED report read that Resident 1 also had elevated liver function tests. The ED report read, I did re-evaluate the patient's abdomen after she had the Foley catheter placed. Her abdomen is otherwise now soft, really non-tender and not distended. An ED chest and abdominal X-ray were also done and did not identify any other significant abnormalities. c. The ED report section titled Assessment and Plan read that Resident 1's blood pressure dropped down to 88/53 and that She continued to be low despite IV fluids . d. The ED report section titled [DIAGNOSES REDACTED]. Her (Liver Function Tests) were elevated. The patient became hypotensive here in the (ED). She did require aggressive fluid administration with 30 cc/kilos normal saline bolus (given rapidly into a vein). Early goal-directed antibiotics with [MEDICATION NAME]. Acute decompression (rapid drainage) of the patient's bladder with a Foley Catheter. Administration of [MEDICATION NAME] (to increase BP). 2. Acute urinary tract infection and probable pyelo (kidney infection). 3. Acute kidney injury. 4. Acute dehydration. 5. Acute lactic acidosis (build up of lactic acid due to decreased oxygen throughout the body), secondary [MEDICAL CONDITION] . This patient is admitted to the intensive care unit in fair condition. 3. A History and Physical, dated 3/4/18 at 11:06 pm, read during her prior hospitalization , the week before for a fracture, She had developed [MEDICAL CONDITION] and a Foley catheter had been placed and she was discharged to a nursing home on Foley. Today her husband has found her to be very confused and agitated. She was brought to the emergency room . She was found to be hypotensive and confused. She has been given 4 liters of IV fluid and [MEDICATION NAME] as she was found to be having a UTI and [MEDICAL CONDITION]. Foley catheter has been placed and 2 (liters) of urine has been drained . The Assessment/Plan read, 1) septic shock secondary to UTI . I explained to her husband about her critical condition and guarded prognosis. 2) altered mental status secondary to metabolic [MEDICAL CONDITION] (brain alteration) secondary to UTI [MEDICAL CONDITION] . 4. A Discharge Summary report, dated 3/13/18 at 2:15 pm, read that Resident 1 had been diagnosed with [REDACTED]. The report read that both blood and urine cultures were positive for E. Coli (organism that caused infection). The report read that while in hospital Resident 1 developed swallowing problems. Due to this and the patient's apparent functional decline, hospice was discussed with the family, they were agreeable .

Based on interview and record review, the facility failed to provide an adequate level of supervision and assistance, and accurate assessment and care planning, to prevent falls for two of three sampled residents (Residents 1 and 2) when: 1. Resident 1 (admitted after hospitalization for multiple falls at home) had fall prevention measures that were not adequate based on her assessed needs and risk. There was lack of evaluation for root cause, and lack of appropriate interventions to prevent further falls. This failure resulted in Resident 1 sustaining nine falls (during her first month in the facility), two resulting in head injuries that required hospital emergency room care. 2. Resident 2 was wheeled in her wheelchair in the hallway by CNA C, without the appropriate leg rests (support for lower extremities) attached. This resulted in Resident 2 falling from her wheelchair and an emergency room visit for evaluation of a laceration to her forehead. Findings: A review of the facility's Falls-Clinical Protocol, dated 9/2012, indicated, While many falls are isolated individual incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the under-lying cause. The protocol indicated, The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling: a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized The protocol also indicated, If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful. 1. A review of Resident 1's record indicated she was admitted to the facility on [DATE] after a hospitalization (from 5/27/18 - 5/31/18), with [DIAGNOSES REDACTED]. The record indicated that during the month prior to her hospitalization , Resident 1 lived independently at home, had multiple falls, and made 52 calls to the emergency line, 10 (of 52) resulting in emergency room visits. The record indicated Resident 1 was seeking skilled nursing care due to being unable to care for herself at home. A review of the initial nursing assessment, dated 5/31/18 at 2 pm, indicated Resident 1 required one person assistance for transfers and ambulation (walking). While the assessment indicated Resident 1 was alert, oriented, and readily answered questions, it also indicated that due to confusion, Resident 1 was unable to participate in a toilet training program and was unable to be oriented to the facility. A review of a Mini-Mental State Examination (a standardized memory test to identify dementia), dated 6/1/18, identified Resident 1 as having mild cognitive impairment (a slight but noticeable and measurable decline in cognitive abilities). A review of an initial fall risk assessment, dated 5/31/18, indicated Resident 1 was at high risk for falls (with a score of 14; a score of 10 or greater indicating high risk) due to intermittent confusion, having multiple falls in the past three months, ambulatory (able to walk) and incontinent (loss of bladder control), visual impairment, ambulation dysfunction, taking 1-2 medications that increase fall risk, and with a [DIAGNOSES REDACTED]. A review of a fall risk care plan, dated 6/1/18, indicated Resident 1's fall risk indicators also included poor judgement and poor safety awareness. Care planned interventions included assisting with toileting as needed, assisting with mobility and transfers as needed, and encouraging the resident to request assistance whenever needed. On 7/18/18 at 2:25 pm, during an interview and concurrent record review, Resident 1's falls, during her approximate one month stay in the facility, were reviewed. The following findings were confirmed with Licensed Nurse (LN A): a. Fall #1 A review of an Interdisciplinary Team (a team of facility staff who meet to review and plan for resident care needs) Post-Fall Assessment form (IDT-PFA, used by the IDT to evaluate the circumstances surrounding the fall, determine a probable cause, and make recommendations for necessary interventions/follow up to prevent further falls), date and time not indicated (did not indicate the date/time the IDT conducted the fall assessment or the date/time recommendations/interventions to prevent further falls were made), indicated the first fall occurred on 6/1/18 at 5:10 am, when Resident 1 was found sitting on the floor beside her bed. The assessment's probable cause indicated Resident 1 may have been attempting to transfer herself, but that it was unknown since it was not witnessed and the resident was unable to tell us due to confusion. IDT team recommendations included reminding Resident 1 to use the call light for assistance and to educate Resident 1 that the staff was here to help so that once the call light was on, someone would come and assist her with all of her needs. While a review of the record did not indicate the time Resident 1 was last toileted (taken to the bathroom or incontinence brief changed) prior to the fall, LN A stated she reviewed the fall evaluation tool (FET, not part of the residents permanent record) which indicated Resident 1 was last toileted at 4:45 am (25 minutes prior to the fall) and was last offered fluids at 4:30 am (40 minutes prior to the fall). A review of CNA narrative documentation, dated 6/1/18 during the night shift, indicated went to go answer a call light and resident was on the floor, sitting position, and call light was pulled out of wall. A review of a licensed nurses progress note, dated 6/1/18, only partially legible, indicated will continue to monitor. The note did not identify fall preventions measures in place at the time of Resident 1's fall, or include any indication as to why Resident 1 was getting out of bed. The facility's fall risk assessment form (required to be updated/completed after each fall) was not completed after this fall. Resident 1's short term fall care plan, dated 6/1/18, was reviewed. Interventions included frequent visual checking, resident kept clean and dry at all times, call light within reach, and neuro checks (a check for level of consciousness). b. Fall #2 A review of an IDT-PFA form (date/time not specified), indicated a second fall occurred on 6/4/18 at 4 pm when Resident 1 attempted to stand up in the hallway, grabbed onto the handrail and stood up, and fell before staff were able to get to her. The form's probable cause indicated, resident has generalized weakness and unsteady gait. (Resident) attempted to stand up unassisted by staff and was too weak, resulting in a fall. Recommendations included Staff to remind resident frequently to request assistance. (Wheelchair) and bed alarms (devices used to alert staff with alarms when a resident gets out of a chair or bed) initiated. The IDT-PFA did not indicate what Resident 1 needed/wanted when she was standing up unassisted or whether this was a trend. During an interview on 7/18/18 at approximately 2:25 pm, LN A stated the FET for this fall did not indicate when Resident 1 was last toileted or when fluids were offered prior to the fall. Record review revealed there was no narrative CNA documentation regarding Resident 1's fall #2. A review of a licensed nurses progress note, dated 6/4/18 at 12:30 pm (three and a half hours prior to fall #2 at 4 pm), indicated resident still attempting to stand or transfer without help from staff. A review of a licensed nurses weekly assessment summary, dated 6/5/18, indicated Resident 1 had been in the facility for five days and had fallen twice. The note indicated Resident 1 asks to use the restroom within 5-10 minutes after taken to the bathroom. She will keep using call light, we explained that she needs to wait just a bit longer. Does not sleep very much, up and down all night. Resident tries to get up and walk, grabs the bars on the walls and pulls herself out of chair. We monitor to avoid further falls The fall risk assessment form was not completed/updated after this fall. A review of a fall care plan, dated 6/5/18, indicated implementation of bed and wheelchair alarms and a fall mat (a floor mat used to cushion the impact from a fall) at bedside while in bed. The plan did not include interventions to address Resident 1's frequent need to use the bathroom or the underlying cause, and there were no interventions to increase supervision/available assistance. c. Fall #3 A review of an IDT-PFA (date/time not specified) indicated a third fall occurred on 6/8/18 at 3:45 pm when Resident 1 was in the dining room, attempted to stand up by pulling herself up using the dining room door, and as she did so, the wheelchair rolled out from behind her as she did not lock her wheels and she landed on her bottom. The probable cause for the fall indicated, Resident has a [DIAGNOSES REDACTED]. (Resident) was attempting to stand up unassisted, did not lock wheels on W/C (wheelchair) and W/C rolled out resulting in the fall. IDT recommendations included PT (physical therapy) to (evaluate) W/C for positioning and potential wedge cushion on a trial basis. The IDT-PFA did not include an assessment of Resident 1's needs, and/or why she was attempting to stand up unassisted. A review of a PT evaluation, completed on 6/9/18, indicated resident educated regarding call light and getting assistance/gait training/safety training/wheelchair transfer training. There was no evidence Resident 1 was evaluated for use of a wedge cushion. A review of the FET for this fall indicated Resident 1 was toileted at 2 pm and was given fluids at 3 pm. Record review revealed there was no CNA narrative documentation related to this fall. A review of a licensed nurses progress note, dated 6/8/18, indicated Resident 1 had a witnessed fall with no injury. There was no documentation found in Resident 1's permanent record regarding the details of the fall or observations by staff caring for Resident 1. The fall risk assessment form was not completed/updated after this fall. A fall care plan, dated 6/8/18, was reviewed and included a therapy referral to look at wheelchair positioning, safety, and strengthening. There were no interventions included to increase supervision or assistance for Resident 1. d. Fall #4 A review of an IDT-PFA (date/time not specified), indicated a fourth fall occurred on 6/9/18 at 1:35 pm when a nurse heard a bed alarm, entered into the room and found Resident 1 sitting upright on the floor next to her bed. Resident 1 sustained a laceration to the back of the head. The assessment indicated the last three falls occurred mid to late afternoon. The probable cause for the fall indicated the resident is impulsive, chose to attempt to transfer herself from bed to W/C before staff could get into room to assist. IDT team recommendations included, when resident requires assistance, staff will make her a priority as resident is impulsive and will attempt to transfer self. The IDT-PFA did not include an assessment of Resident 1's needs, and/or why she was attempting to stand up unassisted (urine test done at the emergency roiagnom on [DATE], indicated Resident 1 had a urinary tract infection which causes urgency and frequency for urination). No interventions were found for increased supervision/staffing to meet Resident 1's frequent need for assistance. A review of the FET indicated Resident 1 was last toileted at 12 pm prior to lunch (and one hour and 35 min prior to fall #4). A review of CNA narrative documentation, dated 6/9/18 during the morning shift, indicated, Resident pushed call light to go to bathroom, I answered light, said I was going to be right back, before I finished what I was doing resident's (Resident 1's) alarm was going off and nurse answered alarm and found resident on floor beside bed on floor mat. Resident has a cut on the back of the head, nurse aware. A review of a licensed nurses progress note, dated 6/9/18 at 2:30 pm, indicated Resident 1 was sent to the hospital after the fall. The notes indicated she was found sitting upright on the right side of the bed on fall mat. Laceration 4 centimeters (cm) by 0.2 cm to back of head. No complaints of pain. Documentation at 6:30 pm indicated Resident 1 returned to the facility with three staples to the back upper part of the head and that she would be closely monitored for safety. Documentation on 6/10/18 at 10 am indicated the resident was complaining of 7 out of 10 pain (on 1-10 scale with 1=no pain and 10=unbearable pain) to back of head from recent fall. Treated with routine pain medications. The note indicated Resident 1 was still attempting to self-transfer and stand without staff assistance, and that she had also been observed by staff pulling call light out of wall, and that staff would continue to monitor. A review of fall risk care plan, dated 6/9/18, interventions included, staff to make resident a priority when needing assistance for transfers as resident is impulsive and will attempt to self-transfer. No interventions were found for increased supervision/staffing to meet Resident 1's frequent need for assistance from staff. A review of IDT narrative notes, dated 6/11/18, indicated resident has had four falls since admission, she had put on call light, CNA responded, told Resident 1 she would be right back because was helping another resident. Demeanor impulsive and hurried. Will continue to work with PT/OT (occupational therapy) for strengthening and keeping environment safe. During a concurrent interview, LN A stated, As we continue to watch her fall, we discover that she puts herself on the floor on purpose. A fall risk assessment, completed on 6/11/18, was reviewed and had a score of 18 (high risk for falls). Documented risk factors included intermittent confusion, demonstrates poor safety judgement, multiple falls in past three months, ambulatory and incontinent, visually impaired, ambulation dysfunction, takes [MEDICATION NAME] medication, and with dementia. A review of CNA narrative documentation, dated 6/11/18 (during the evening shift before fall #5 at 4 am), indicated, Resident is up and down. We take her to bathroom and within 5 mins (minutes) alarms going off and resident is standing. A review of CNA narrative documentation, dated 6/12/18 (time not specified, but documented on night shift prior to 4 am fall #5), indicated, Resident always on call light, will walk into the room, resident will be sitting in bed, getting ready to crawl out of bed. When asked what res (resident) needed, she says she doesn't need anything. Res will also be dry. C/N (charge nurse) aware. A review of CNA narrative documentation, dated 6/12/18 at 12 am (four hours prior to fall #5) during the night shift, indicated, I hear chair alarm going off, res (resident) was standing, naked in the hallway trying to transfer herself. Alarm was plugged in but did not go off when resident got out of bed. I went to resident, dressed her, and brought her to lobby (across from nursing station). C/N (charge nurse) aware. e. Fall #5 A review of an IDT-PFA (date/time not specified), indicated a fifth fall occurred on 6/12/18 at 4 am when Resident 1 was found sitting on the floor next to her bed. The assessment indicated no trend was found related to Resident 1's falls (pattern of when, where or why they occurred). The probable cause for the fall indicated, Staff have stated that resident has told them that she falls on purpose though resident is also positive for UTI (urinary tract infection) - started on ABT (antibiotic) today 6/12/18. The IDT recommendations included, frequent checks to see if resident needs to be toileted, offer resident snack of choice for each day she does not have a fall to see if she is truly falling purposefully. Started on ABT therapy for UTI which may have been a contributing factor to res (resident) urgency to get up. No interventions were found for increased supervision/staffing to meet Resident 1's frequent need for assistance from staff. A review of the FET for this fall indicated Resident 1 was last toileted at 1:30 am (two and a half hours prior to the fall) and seen at 3:45 am. The FET indicated the patient stated she was trying to get up when she slid to the floor. IDT: consider probable cause indicated staff stated resident told them that she puts herself on the floor on purpose. Resident 1 was diagnosed with [REDACTED].#5). A review of CNA narrative documentation, dated 6/12/18 at 4 am, indicated, Resident was found on floor, no bed alarm was going off. Call light was pulled out of wall, but not lit up outside of the door. C/N aware. A review of CNA narrative documentation, dated 6/12/18 during the evening shift, indicated, Took resident to the bathroom several times and still caught resident trying to take herself to the bathroom not even 5 min after I took her. A review of a licensed nurses weekly assessment summary, dated 6/12/18, indicated the Resident has fallen multiple times in the past week, one resulted with her receiving staples to back of head. Floor mat in place and bed in lowest position. She is on constant watch. No signs or symptoms of adverse side effects due to falls. While in ER (emergency room ) a UA (urinalysis, urine test to check for infection). Results received today showing she (Resident 1) has a urinary tract infection [MEDICAL CONDITION]. Antibiotics started today . care plan reviewed and still appropriate at this time. The fall risk assessment form was not completed/updated after this fall. During a care plan review, no new interventions were found. The care plan contained no interventions for increased supervision/staffing to meet Resident 1's frequent need for assistance from staff. A review of CNA narrative documentation, dated 6/16/18, during the day shift, indicated, Res will not ask staff most of the time when she has to go to the bathroom. She will transfer self, very seldom she will ring call light. Also staff is taking res to the bathroom every 10-20 min and then when you leave the room res alarm is going off and she is trying to get out of her bed and states she has to go to the bathroom again. C/N notified. A review of a licensed nurses progress note, dated 6/14/18 at 11 pm, indicated Resident 1 frequently self-transferring without asking for assistance, and that Resident 1 was receiving antibiotic for a UTI. The notes, dated 6/16/18 at 2 pm, indicated Resident 1 was caught by staff at least five times of moving to the bathroom and then transferring without assistance onto the toilet by self The notes, dated 6/17/18 at 5:10 am, indicated Resident 1 continued to get up out of bed, then request to go back to bed within 20 min, after several hours we advised her she needed to stay up A review of CNA narrative documentation, dated 6/17/18 during the evening shift, indicated, Resident keeps trying to transfer herself, myself and hall partner have taken her to the bathroom [ROOM NUMBER] times and every time she gets put in bed and hits the call light 5-10 min later to go again. I tell her we just took her and she yells 'bullshit.' Resident has also stated she doesn't care if she gets hurt because she doesn't care about herself. A review of CNA narrative documentation, dated 6/18/18 during the evening shift, indicated, Residents alarm went off, nurse went down and she (Resident 1) was standing next to bed with pants down, nurse sat her down, and resident urinated all over her bed. Nurse came and got me to change her, when I asked resident why she keeps standing and not staying in bed and she said, 'because I can get away with it.' A review of a licensed nurses weekly assessment summary, dated 6/19/18, indicated .finished antibiotics for a UTI. During the last week her (Resident 1's) behavior ramped up with her getting out of bed or requesting to go back to bed almost immediately, saying she was wet and pulling off her brief. When they were still dry. We had her sit at the nurse's station for safety. She also would tell the aides that she would tell her family they were hitting her if they didn't do what she wanted them to do. Was started on [MEDICATION NAME] to help with sleep. She still spends most of the night at the front desk. Continues to work with therapy. Care plan reviewed and still appropriate at this time. f. Fall #6 During a record review, no IDT-PFA was found for Resident 1's sixth fall that occurred on 6/21/18 at 3:35 pm. During an interview on 7/18/18 at 5 pm, the Administrator (Admin) confirmed the IDT review had not been done for this fall. The Admin explained the MDS (minimum data set, a resident assessment tool) Nurse was the facility's acting Director of Nurses (DON) since the position was unfilled at this time. The Assistant DON (ADON) was currently on vacation and returning 7/19/18. The Admin stated this had caused a lapse in IDT functions. A review of the FET indicated Resident 1 was last toileted and offered fluids at 3:35 pm. Resident 1's record contained no CNA narrative documentation related to this fall. A review of a licensed nurses progress note, dated 6/21/18, indicated Resident 1 used the arm of her wheelchair to stand up, it was unlocked, so it slid out from under her so she landed on her bottom. The notes, dated 6/21/18 at 9:30 pm, indicated a new physicians order for [MEDICATION NAME] (a medication to treat anxiety) 0.5 milligrams, every eight hours as needed for agitation. The fall risk assessment form was not completed/updated after this fall. During a care plan review, no new interventions were found. No interventions were found for increased supervision/staffing to meet Resident 1's frequent need for assistance from staff. g. Fall #7 During a record review, no IDT-PFA was found for Resident 1's seventh fall that occurred on 6/24/18 at 4 pm. There was no documented evidence the IDT assessed/determined the root cause, or made recommendations regarding interventions to prevent future falls. A review of the FET indicated Resident 1 fell on [DATE] at 4 pm when she attempted to stand unassisted, in the dining hallway, but could not support herself so fell to the ground. A review of a licensed nurses progress note, dated 6/24/18, indicated Resident 1 fell while attempting to stand from wheelchair without staff assistance. The fall risk assessment form was not completed/updated after this fall. During a care plan review, no new interventions were found. No interventions were found for increased supervision/staffing to meet Resident 1's frequent need for assistance from staff. h. Fall #8 During a record review, no IDT-PFA was found for Resident 1's eighth fall that occurred on 6/26/18 at 2 am. There was no documented evidence the IDT assessed/determined the root cause, or made recommendations regarding interventions to prevent future falls. A review of the FET indicated Resident 1 had a fall on 6/26/18 at 2 am when she was found on the floor after attempting to get out of bed. Resident 1 had been toileted at 1:45 am (15 min prior to the fall). Resident 1 had pulled the bed alarm off, was unhooked from the bell that the pressure pad (device that alerts staff with an alarm when a resident gets out of a chair or bed) was connected to, and the call light out of the wall. Recent med change for [MEDICATION NAME]. A review of a licensed nurses weekly assessment summary, dated 6/26/18, indicated .continued to pull herself out of her chair and sit on the floor. Had two falls this week. Behaviors continue, still taking off brief, urinating in her bed, requesting to go to bed then getting back up, requesting to use the bathroom, then not having to urinate. [MEDICATION NAME] not helping her sleep. [MEDICATION NAME] started PRN (as needed) aggravation. No adverse side effects. Care plan reviewed, still appropriate. The fall risk assessment form was not completed/updated after this fall. A review of fall care plan interventions, dated 6/26/18, included monitoring resident closely, keep bed in lowest position, keep mat in place and notify physician of any injuries of change of condition. No interventions were found for increased supervision/staffing to meet Resident 1's frequent need for assistance from staff. i. Fall #9 During a record review, no IDT-PFA was found for Resident 1's ninth fall that occurred on 7/2/18 at 8:50 pm. There was no documented evidence the IDT assessed/determined the root cause, or made recommendations regarding interventions to prevent future falls. A review of an FET, dated 7/2/18, indicated Resident 1 fell when she attempted to get out of bed by herself, resulting in a laceration on her forehead above the right eyebrow, skin tear on the arm and into elbow, went to the ER and got 5 stitches to forehead. Neuro checks done. The FET indicated Resident 1 frequently tries to get herself up, kicks fall mat away from the bed, has stated she wanted to injure herself today. The FET indicated Resident 1's CNA stated after assisting with room [ROOM NUMBER], heard loud bang, went to room [ROOM NUMBER] (Resident 1's room) and assisted resident. The FET did not indicate Resident 1's positioning when found. Resident 1 was found by CNA B. On 7/19/18 at 4 pm, during an interview, CNA B confirmed the fall as described above. CNA B stated Resident 1 frequently tried to self-transfer or stand unassisted. CNA B stated Resident 1 continued to request frequent trips to the bathroom, explaining that seven times per shift, was normal and happened daily. CNA B stated Resident 1 did go each time she was taken to the bathroom. There was no documentation of this fall found in the CNA narrative notes or the licensed nurses progress notes. The fall risk assessment that was completed on 7/2/18, had a score of 18 (high risk for falls), and documented risk factors included intermittent confusion, demonstrates poor safety judgement, multiple falls in past three months, ambulatory and incontinent, visually impaired, ambulation dysfunction, takes [MEDICATION NAME] medication and with dementia. There was no new fall prevention care plan found in Resident 1's record after this fall. No interventions were found for increased supervision/staffing to meet Resident 1's frequent need for assistance from staff. A review of a licensed nurses weekly assessment summary, dated 7/3/18, indicated, Resident has fallen twice in the last week, when she fell the second time, she obtained a laceration above her right eyebrow requiring sutures. Resident states she doesn't care that she wants to fall and hurt herself. Skin tears are self-inflicted. She will continue picking at them removing any and all dressings, and steri-strips. She continues with attention seeking behaviors. If she does not get the attention immediately she will stand up and set herself on the floor. Urinate in her bed after pulling her brief off. [MEDICATION NAME] is ineffective in helping her sleep. [MEDICATION NAME] does not help with her behaviors. Resident is being kept under close supervision due to statements made about wanting to fall and die. Trying to implement one on one supervision 24 hours a day. Care plan reviewed and still appropriate at this time. On 7/18/18 at 1:15 pm, during an interview, CNA C stated Resident 1 continued to attempt unassisted transfers/standing multiple times each shift. CNA C stated Resident 1 requested assistance to the bathroom frequently and did go each time she was taken. On 7/18/18 at 2 pm during an interview, when asked about her needs for assistance from staff, Resident 1 explained her most frequent need was to go to the bathroom. Resident 1 stated she would wet herself if staff took too long and indicated she was only able to wait one minute. Resident 1 also indicated that because of having to wait too long, she tried to take herself to the bathroom even though she knew it wasn't safe. On 7/19/18 at 5:30 pm, during an interview, the Admin acknowledged that during the nine falls Resident 1 had in the facility, no interventions were found for increasing supervision/staffing adequate to meet Resident 1's frequent need for assistance from staff. The Admin explained Resident 1 had unresolved mental health concerns that contributed to her noncompliance so that it was not possible to keep her safe. The Admin confirmed Resident 1 continued to attempt unassisted transfers, and attempted to stand multiple times each day. The Admin confirmed that increased staffing to meet Resident 1's needs had not been attempted. On 7/26/18 at 9 am, Resident 1 was interviewed. When asked why she tried to stand without assistance so much, she stated there were two reasons, one was needing to go to the bathroom, and the other was that she wanted to walk more. She explained that she had always been an active person that was used to walking a lot. She explained she did not like sitting so much and that she wanted to walk more, a lot more. When asked how often she was assisted with walking, she stated, only one time each day. On 7/26/18 at 10:15 am, during an interview, CNA E (regular caregiver for Resident 1) stated staff all know that when her alarm goes off they have to run to her room. When asked about the staffing this morning, CNA E stated she and another CNA were assigned to 24 residents. CNA E stated Resident 1 would set off her alarm many times each shift because she was attempting to stand and/or transfer. CNA E stated that a couple days ago, housekeeping staff found Resident 1 surfing (standing on top of her bed in a crouched position). CNA E acknowledged Resident 1 continued to attempt to stand and/or transfer unassisted multiple times each shift. On 7/26/18 at 12 pm, during an interview with the acting Director of Nurses (DON), she explained she was familiar with Resident 1, but had not participated in the IDT reviews. The acting DON stated there were only two RNs on staff in the building and she was one of them. The acting DON explained that the second RN was a new nurse (just out of school) who was working on the floor. When asked who participated in the IDT meetings, the acting DON stated the main participants were the Admin, the Admission LVN, the ADON (Assistant Director of Nurses, also an LVN), and the Social Services Director (who was off for three weeks in 6/2018). On 7/26/18 at 2 pm, during an interview with the ADON, she acknowledged the IDT had not identified the frequent need to use the bathroom, as a root cause for Resident 1's frequent attempts to stand/transfer unassisted and subsequently falling. The ADON acknowledged the facility had not made attempts to identify whether or not there was an underlying physiologic problem that contributed to Resident 1's frequent need to use the bathroom. On 7/26/18 at 2:20 pm, during an interview and document review, the acting DON stated that after reviewing Resident 1's situation, the facility decided to implement 1:1 supervision (one staff assigned only to Resident 1 at all times) to meet her needs for assistance and keep her safe from falling. 2. A review of Resident 2's record indicated she was admitted to the facility on [DATE] with

Based on observation, interview, and record review, the facility failed to ensure the availability of portable oxygen tanks, necessary to care for six of 55 residents (Residents 1, 2, 3, 4, 5, and 6) in the event of an emergency evacuation, when the medical equipment supplier's bill was not paid. This failure had the potential to result in residents not having an adequate supply of oxygen, increasing the risk for [MEDICAL CONDITION] (when the blood doesn't carry enough oxygen to tissues). Early symptoms of [MEDICAL CONDITION] include confusion, anxiety, restlessness, and shortness of breath. Without oxygen, organs can begin to sustain damage, resulting in serious and life-threatening conditions. Due to a failure to protect residents from potential harm related to lack of available portable oxygen tanks in the event of an emergency evacuation, an immediate jeopardy (IJ) situation was declared on 3/30/18 at 3:40 pm, in the presence of the Director of Nursing (DON). The IJ was removed with the DON on 4/3/18 at 12:50 pm, when an acceptable corrective action plan was validated by observation and interview. Findings: The facility's external evacuation procedures, undated, were reviewed and indicated that the facility may be required to evacuate for a number of reasons, that notice to evacuate may be received via telephone call or by visual confirmation, and that there may be no time to prepare. The procedures indicated that when an order to evacuate is confirmed the person in charge will assign staff to prepare necessary supplies and special equipment as described in the Evaluation Check List. A review of the Evaluation Check List identified oxygen tanks and nasal cannulas as supplies that may be needed. An initial tour of the facility was conducted on 3/30/18 at 1 pm. No residents were observed using portable oxygen tanks throughout the facility. During an observation and a concurrent interview, on 3/30/18 at 1:15 pm, Resident 1 was in his bed and was receiving oxygen via an oxygen concentrator (a stationary device that delivers oxygen and is plugged into the wall). Resident 1 stated he was in bed 99% of the time and was unable to get up and down to go to the nurses station due to not having portable oxygen tanks. Resident 1 stated it was his understanding that there were no portable oxygen tanks available because the bill hadn't been paid. An observation of oxygen storage was conducted on 3/30/18 between 1:50 pm and 2:10 pm with the Assistant Director of Nursing (ADON) and Licensed Nurse (LN) A. One room labeled as the N[NAME] (night shift) closet contained 27 E (size) cylinder oxygen tanks and 2 small oxygen tanks. A second room, across from the N[NAME] closet, contained 15 E cylinder oxygen tanks and 2 small oxygen tanks. During a concurrent interview, the ADON and LN A confirmed that all the oxygen tanks stored were empty and that there was no portable supply of oxygen for resident use in the facility or in an emergency evacuation. During an interview on 3/30/18 at 2:15 pm, Physical Therapy Assistant (PTA) B and Certified Occupational Therapy Assistant (COTA) C confirmed that there were no portable oxygen tanks available in the facility for four to five days. During an interview on 3/30/18 at 2:40 pm, the Medical Equipment Manager (supplier of portable oxygen tanks) confirmed that the facility's management company had not paid their bill. During an interview on 3/30/18 at approximately 3 pm, the Vice President of Medical Equipment (VP), stated that in (MONTH) of (YEAR), the facility had not paid their bill and was two to three months behind. The VP stated the facility was in the same position again and that there was no other recourse except to stop providing service. The VP stated they had not been contacted by the facility's management company. On 3/30/18 at 3:20 pm, the records for Residents 1, 2, 3, 4, 5, and 6 were reviewed and indicated the following: 1. Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a physician's orders [REDACTED]. 2. Resident 2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 had a physician's orders [REDACTED]. 3. Resident 3 was admitted to the facility on [DATE]. During a concurrent interview with the Director of Nursing (DON), she stated Resident 3 required continuous use of oxygen. 4. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident 4 had a physician's orders [REDACTED]. 5. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5 had a physician's orders [REDACTED]. 6. Resident 6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6 had a physician's orders [REDACTED]. An interview was conducted with the DON on 3/30/18 at 3:40 pm. The DON stated there were 15 residents in the facility that had physicians orders for oxygen, and that six of the 15 residents required oxygen on a continuous basis. The DON confirmed the facility had been without portable oxygen tanks for six to seven days. The DON stated Corporate was aware and that the facility had been in contact with them throughout the week. The DON acknowledged there was no plan to ensure residents had oxygen available in an emergency evacuation, and stated they would just call 911. The DON acknowledged there was no way to know how long it would take for emergency responders to arrive and that there was the potential for residents to be without oxygen for an undetermined amount of time. The DON acknowledged the lack of portable oxygen tanks placed the residents at risk for harm. Due to the potential for harm, an IJ situation was declared on 3/30/18 at 3:40 pm in the presence of the DON. On 3/30/18 at 4:10 pm, the DON provided a copy of the facility's plan to address the immediacy of the situation which indicated the medical equipment supplier would deliver eight portable oxygen tanks to the facility within the hour and an additional 12 tanks before the end of the day. During an interview with the VP, on 3/30/18 at approximately 4:50 pm, he stated the medical equipment supplier would help ensure the residents at the facility received the care they needed and confirmed the delivery of portable oxygen tanks as described above. During an observation with the DON, on 3/30/18 at 4:55 pm, 10 portable oxygen tanks had been delivered to the facility. During an interview on 4/3/18 at 9:45 am, the Medical Equipment Manager confirmed the bill for services had been paid. During a concurrent observation and interview with the DON, on 4/3/18 at 12:50 pm, there were 26 full portable oxygen tanks stored in the oxygen closet at the facility. The DON was able to verify weekly delivery of oxygen by the medical equipment supplier, and the IJ was removed.

Based on observation, interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 5) was provided with sufficient fluid intake to maintain proper hydration. The facility was unable to demonstrate it properly assessed Resident 5's fluid status, followed physician's orders [REDACTED]. As a result, the facility was unable to determine the degree of severity of dehydration suffered by Resident 5. These failures contributed to Resident 5's severe dehydration and acute renal (kidney) failure which required treatment at an acute care hospital. Findings: According to the Mayo Clinic diseases and conditions definition of Dehydration dated 2/12/14, included that older adults and people with chronic illnesses are most at risk. Medications such as diuretics (increases urine production) as well as vomiting and diarrhea can also put people at risk. The signs and symptoms of mild to moderate dehydration include sleepiness and tiredness, dizziness or lightheadedness, and symptoms of severe dehydration include confusion in adults. This can result in kidney failure, a potentially life-threatening problem which occurs when your kidneys are no longer able to remove excess fluids and wastes from your blood. a. A review of Resident 5's record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, indicated Resident 5 was alert and oriented, and verbally oriented. A nurse's note dated 10/9/16 at 8:47 pm, indicated Resident 5 was found on the floor. Resident 5 stated she did not know how she fell and was noted to be confused. During an interview on 10/10/16 at 12:30 pm, Resident 5 was verbal but oriented to person and place only. During an interview on 10/11/16 at 8 am, Certified Nursing Assistant (CNA) E stated Resident 5 was shaking this morning and acting different so she was going to ask the nurse to check on her. During an interview on 10/11/16 at 3 pm. Registered Nurse (RN) F was told by the surveyor that Resident 5 seemed more confused today than yesterday. RN F stated, yes she has periods of confusion and periods where she is alert. A progress noted dated 10/11/16 at 6:25 pm, was reviewed and indicated that when Resident 5 was transferred to an acute care hospital. The facility's transfer form, dated 10/11/16, indicated the reason for transfer was altered mental status and possible dehydration. b. A review of the admission assessment dated [DATE], indicated that there was no hydration assessment after Resident 5 was admitted to the facility on [DATE]. The facility's nutrition assessment completed on 9/20/16, assessed Resident 5's fluid needs at 1540 milliliters (ml) per day. During an interview and concurrent record review, on 10/12/16 at 11:30 am, the DON confirmed that Resident 5's fluid intake was not recorded. DON stated, CNAs do not record fluid intake, only meals eaten. During an interview on 10/12/16 at 4:15 pm, the Director of Nurses (DON) was asked how the facility determines if a resident's fluid needs, as estimated by the Registered Dietitian (RD) and nutrition assessment, were being met. DON stated she was not sure, but if any residents had symptoms of dehydration it would have been noticed during daily rounds. A review of Resident 5's intake record did not include any fluid amounts. The amount of meals eaten indicated frequent refusals and poor appetite on the following dates: 10/3: 0-25% of one meal eaten, two meals refused; 10/4: 0-25% of two meals eaten, one meal refused; 10/7: 0-25% for one meal, one meal refused, and one meal not documented; 10/8: two meals refused; 10/9: one meal 25-50%, and two meals refused; 10/10: one meal 0-25%, and two meals refused; 10/11/16: 0-25% for one meal, one meal refused, and resident not available (out of facility) for the dinner meal. A review of the record indicated that Resident 5 had two loose bowel movements one on 10/8/16 and another again on 10/10/16. During an interview on 10/11/16 at 12:45 pm DON confirmed the above and stated the physician was notified on 10/10/16, and ordered a stool sample be sent to the lab. A review of Resident 5's record indicated that there was no additional hydration assessment done after Resident 5 had diarrhea on 10/8 and 10/10/16 or after she started having frequent refusals of meals. c. Labs done on 9/16/16 included a Blood Urea Nitrogen (BUN, a test to see how well the kidneys are working. Dehydration can make the BUN high). The result was 18 (normal range is 7-21). The labs also included a Creatinine level (test to check kidney function). The result was 1.1 (normal range is 0.6 - 1.2). These were repeated on 9/27/16 and the BUN had increased and was high at 43. The Creatinine had also increased and was high at 1.4. The physician circled the BUN level on the lab report and ordered, push oral fluids, start protein shakes TID (three times per day), and signed and dated the lab report on 9/28/16. During an interview on 10/11/16 at 12:45 pm, DON stated protein shakes ordered by the physician, for any resident, were not documented in the record so she would be unable to say how much of the protein shakes were consumed by Resident 5. During an interview and concurrent record review, on 10/12/16 at 11:30 am, the DON confirmed that the physician's orders [REDACTED]. DON reviewed all nursing progress notes and Skilled Nursing Assessments from 10/8 to 10/11/16 and did not find anything documented relating to oral fluids. A care plan for Resident 5 for a urinary tract infection, initiated on 10/7/16, included encourage po (oral) fluids. A care plan for dehydration was initiated on 10/10/16 that included encourage po fluids. The Administrator later reviewed the record and on 10/19/16, provided a faxed copy of one nursing note, dated 10/4/16, where the nurse charted she encouraged fluids. This note does not include whether Resident 5 drank any fluids, and if so, how much. During an interview on 10/13/16 at 10:10 am, DON stated the facility had no policy and procedure specific to resident hydration other than when IV fluids are given. Fluid intake was not tracked other than for the first seven days after admission. There was no process to track intake and output for residents at risk for dehydration. During an interview and concurrent record review, on 10/12/16 at 11:30 am, the DON stated the nurses called the physician and told him Resident 5 was not eating or drinking much and received an order to start IV fluids on 10/10/16 at 2:18 pm. DON confirmed Resident 5 received 50 ml per hour of IV fluids starting on 10/10/16 at 11 pm until 10/11/16 at 3 am (total 200 ml), at which time Resident 5 pulled out the IV. The IV was restarted on 10/11/16 at 11:28 am and Resident 5 received 50 ml per hour until she again pulled out the IV at 3 pm (total 250 ml). The facility's Infusion Therapy manual included a policy titled, Hydration and Antibiotics/Anti-infective Therapy: General Guidelines, dated 12/30/10, that read: Monitor intake and output on patients receiving infusion therapy. Orders for weights, vital signs, and laboratory monitoring should be obtained from the physician at the time therapy is initiated. The facility nurse is responsible for monitoring and the ongoing systematic assessment of the patient receiving infusion therapy. Using nursing knowledge, experience and assessment skills, the type of therapy and patient's condition should be considered. Assessments are documented and communicated to other members of the healthcare team. Recommend assessment at a minimum every 2 hours with documentation in medical record every 8 hours. The frequency of site (the area where the IV tubing goes into the body) assessments may need to be increased based on type of therapy, patient's condition, or other factors that affect the infusion therapy patient. During an interview and concurrent record review, on 10/12/16 at 11:30 am, the DON confirmed the intake and output (I&O) was not done for Resident 5. DON stated, I & O is only by physician order [REDACTED]. d. A physician's progress note for Resident 5, dated 9/21/16, read, Resident at risk for elevated BUN and Creatinine - which leads to dehydration and [MEDICAL CONDITION] due to diuretic use. Diuretics required at this time due to [MEDICAL CONDITIONS]. Benefits outweigh the risk. A review of the Medication Administration Records for the months of September and October 2016 indicated Resident 5 received [MEDICATION NAME] (a diuretic that causes increased production of urine) 40 milligrams daily from 9/16/16 through 10/11/16, and [MEDICATION NAME] (a potassium supplement. Too much potassium can lead to kidney failure. When a person is dehydrated it is easier for potassium levels to increase when getting supplements) from 9/20/16 thorough 10/11/16. During the interview on 10/12/16 at 11:30 am, DON was asked if the nurses who spoke to the physician about Resident 5's status, reminded him that Resident 5 was receiving a diuretic and potassium and she stated she did not know. DON confirmed that Resident 5's physician did not have Resident 5's electronic health record (containing a list of her medications) available to him at his office. During an interview on 10/12/16 at 2:45 pm, Medical Doctor (MD) 2 stated he was called by the nurses on 10/10/16, and was told Resident 5 was not eating or drinking very much. MD 2 stated he was not told of the number of ml she drank or how many times she urinated. MD 2 stated he was not told by the nurses that Resident 5 continued to receive [MEDICATION NAME] and potassium and knowing that would have changed his treatment. MD 2 also stated he ordered labs to be done on 10/11/16, and he would have tailored his treatment accordingly. He said Resident 5 was given IV fluids but pulled out her IV and after the third attempt to restart it was unsuccessful, she was sent to the Emergency Department (ED). MD 2 stated he did not have access to the ED record but was aware from the labs drawn at the facility on 10/11/16, that Resident 5's BUN was elevated at over 100. When asked about the order to push oral fluids written on 9/28/16, he said he would expect the nurses to call him if unable to carry out that order. A review of the local hospital ED Report dated 10/11/16, indicated that Resident 5 presented to the ED of a local hospital and was seen by the physician at 6:40 pm on 10/11/16 for a chief complaint of altered level of consciousness. A review of the ED records indicated Resident 5 was given one liter of IV fluids over 48 minutes. Lab tests showed an elevated BUN of 127 and an elevated Creatinine of 4.47. The ED physician wrote: the patient presented to the ED with new onset of [MEDICAL CONDITION]. This could be secondary to severe dehydration. The [DIAGNOSES REDACTED]. Resident 5 was not admitted to the local hospital but instead was transferred to a larger acute care hospital because of the possibility of needing [MEDICAL TREATMENT] (mechanical method of removing wastes from the body when the kidneys do not function).

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent an elopement for one of three sampled residents, Resident 2. This failure allowed Resident 2 to exit the building through the front door, in her wheelchair, while wearing a wander guard transmitter (a sensor, worn by the resident that alerts/alarms when the resident attempts to exit the facility through an alarmed doorway). Resident 2 traveled approximately 0.4 miles from the facility, alongside a busy two lane road, before getting her wheel chair stuck in a metal drain gutter on the side of the road. A concerned citizen, saw Resident 2, and notified the Red Bluff Police Department (RBPD). The facility was unaware that Resident 2 left the facility and was gone for over an hour before they were notified by a phone call from the RBPD. This failure had the potential to result in injury, serious harm, or death to Resident 2. Findings: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. cataract (clouding of the normally clear lens of the eye causing a decrease in vision). Resident 2's Elopement Risk Assessment, dated 2/17/14, identified Resident 2 as confused , forgetful and having a desire to exit the facility. Resident 2's Care Plan for impaired cognitive function related to dementia, impaired safety awareness, and behavioral fluctuations, date initiated 2/16/14, addressed Resident 2's elopement risk and identified her with a history of attempting to leave the facility unattended. Planned interventions included, encouraging resident to discuss feelings and frustrations, give as many choices as possible about care and activities, identify patterns of wandering, wander guard and window alarm in place for safety. A review of the Quarterly Elopement Risk Assessment, dated 8/31/14, indicated increased exit seeking related to resident starting to smoke again. Stated Staff continues with frequent reminders, wander guard and window alarms in place. Further elopement risk assessments show no behaviors or attempts of elopement since 12/1/14. However, the assessment states to continue current plan of care. A review of Order Summary Report, showed, on 3/24/14, orders were written for a wander guard transmitter to be placed on Resident 2's wheelchair for poor safety awareness. And, on 4/22/14 a sensor alarm was placed on Resident 2's room window. The facility's General Policy Guidelines titled, Elopement dated 4/01, read, It is the policy of this facility to protect residents from wandering away from the facility and to begin an immediate search if a resident is missing. A review of the Red Bluff Police Department (RBPD) Computer Aided Dispatch (CAD) Incident Report shows that on 8/5/16, a telephone call was received at 10:10 am reporting an Elderly female in wheelchair was stuck in the gutter. Reporting party (RP) believes she has wandered from a care facility. At 10:24 am, the RBPD officer contacted the facility and confirmed that the elderly woman (Resident 2) lived there. At 10:52 am, Resident 2 was returned to the facility by the RBPD. On 8/19/16 at 8:47 am, an interview was conducted with Resident 2. Resident 2 was alert and oriented to name, date of birth, and was able to carry on a coherent conversation. A wander guard transmitter was present on Resident 2's left ankle. When Resident 2 was asked if she remembers leaving the facility on 8/5/16 she stated that she remembered and that she was going home. Resident 2 said that she does not remember how far she got or how long she was gone from the facility. She stated she just wheeled herself out the door. When asked if there was any noise when she went out the door Resident 2 stated It made a beeping noise. During a interview on 9/14/16 at 9:40 am, Resident 2 was asked if she were to leave the building alone, would there be anything she would need to watch for or be concerned about for safety? Resident 2 replied, No, I don't worry about anything I guess. When asked, what about the cars on the road, she responded, Nope. An Interdisciplinary Team (IDT) Progress Note, dated 8/5/16 at 19:42 pm, for Resident 2's elopement on 8/5/16 at 10:15 am read, Approximately 10:15 am facility received phone call from RBPD that they have (Resident 2) in custody and resident was brought back to facility at 10:50 am in stable condition and without any injuries .Wander guard checked for proper function and it did sounded when resident returned to facility. During an interview, on 8/19/16 at 11:32 am, the Director of Nurses (DON) stated the expectation of her staff, when the wander guard alarm is triggered, would be to acknowledge the alarm immediately by looking outside for any resident and then to do a head count (count the residents) to ensure a resident had not exited the facility. The DON stated that following the elopement event on 8/5/16, she reviewed the surveillance video that showed Resident 2 exiting the facility around 9:00 am. The DON stated the alarm was triggered, however, staff failed to immediately acknowledge the alarm. By the time staff did acknowledged the alarm and checked outside Resident 2 must have been far enough away or in a blind spot because staff did not see her. The DON stated that the police department contacted the facility by phone around 10:15 am notifying them that Resident 2 had been found about a half mile away from the facility. During an interview, on 9/14/16 10:10 am, Restorative Nurse's Aide 1 (RNA 1) stated that on 8/5/16 she was working on the middle hall when the door alarm was triggered. I can't remember how long it (the alarm) was going off before I went to the front lobby and turned it (the alarm) off. RNA 1 explained that she had shut the alarm off multiple times that day because a resident, with a wander guard transmitter on his ankle, was in the lobby, sitting on a couch, near the front door. RNA 1 explained that the alarm goes off any time the door opens and there is a resident near the front door wearing a transmitter. RNA 1 said she assumed it was that resident who set off the door alarm. When asked to explain how staff are to responds to the wander guard alarm sounding RNA 1 stated, If an alarm goes off that is not witnessed we should get a head count (of residents) to make sure everyone is in the building. RNA 1 stated Technically I should have done a head count. RNA 1 said that she left the facility shortly after shutting off the alarm and was not aware an elopement had occurred. On 9/14/16 at 12:17 pm, the facility provided In-service/Continuing Education Attendance Record for the Wander Guard's and Door Alarms training that was conducted after Resident 2's elopement. The in-service records were compared with staffing schedules for the months of August and September. The comparison showed that nine of 16 licensed nurses, and twelve of 25 CNA's had no evidence of Wander Guard and Door Alarm training. On 9/14/16 at 2:49 pm, the Administrator was verbally informed of Immediate Jeopardy related to Resident 2's ability to elopement from the facility, failure of facility staff to immediately respond to the warning alarm, failure of facility staff to follow the established facility practice of counting residents following an unwitnessed triggering of the alarm, failure of the facility to include an immediate search of the facility grounds as part of their response to an unwitnessed alarm/potential elopement, and failure to ensure all staff were educated in the facility's policy and practice to prevent future elopements. On 9/15/16 at 3:03 pm, the facility provided a plan of action that consisted of the following elements: 1. The facility revised their response to a wander guard alarm sounding to include a search of the facility grounds concurrently with the resident count done in the building. 2. Education of all staff to the facility's elopement/wander guard practice and policy. 3. All resident will be assessed for elopement risk on admission and quarterly, with care plans updated to reflect assessment findings. 4. The door alarms will be tested weekly and if found not to be working, staff will be assigned to monitor all exit doors. 5. Door alarm bracelet, worn by resident's identified at risk for elopement, will be checked weekly and replaced if not working. During an on site visit, on 09/22/16, the surveyors met with the Administrator and verified the facility implementation of their action plan. At 11:55 am, the Administrator was informed that the Immediate Jeopardy was abated.