Every finding on record at Sundance Creek Post Acute

Based on observation, interview, and record review, the facility failed to provide the necessary care and services regarding dialysis (the process of removing waste or fluid from the blood with the use of a machine) when the physician's order for fluid restriction was not followed for three of four sampled Residents (Resident 1, 4, and 6) reviewed for dialysis. This failure had the potential for Residents 1, 4, and 6 to experience fluid overload (excess fluid in the blood) and complications such as edema (swelling), shortness of breath, high blood pressure, and weight gain.Findings: On August 6, 2026, an unannounced investigation took place at the facility for allegations of poor quality of care rendered for Resident 1.A review of Resident 1's medical record indicated, Resident 1 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included end stage renal disease (ESRD) with dependance on hemodialysis.The Minimum Data Set (MDS - an assessment tool), dated July 21, 2026, indicated a BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact).A review of the physicians order dated July 17, 2026, indicated, .Fluid restriction 1000 ml/day (milliliters per day - a unit of measurement), Dietary: 600 ml (B - (breakfast) 360ml, L - (Lunch) 120ml, D - (Dinner) 120ml.nursing: 400ml (AM (morning) 140 ml, PM (evening) 140 ml, NOC (nights) 120 ml to add total in 24 hours if over the fluid restriction. AM shift to notify MD (medical doctor) and dialysis (dialysis center) immediately.A review of the Fluid intake log dated from July 16, 2026, to July 31, 2026, indicated a total fluid intake over 1000 mls on three separate occasions:July 17, 2026.total fluid intake for 24 hours.1200 mls,July 19, 2026.total fluid intake for 24 hours.1290 mls,July 21, 2026.total fluid intake for 24 hours.1550 mls.There was no documented evidence the physician or dialysis was made aware of the total fluid intake over 1000 mls for 24 hours on July 17, 2026, July 19, 2026, and July 21, 2026.A review of the meal ticket for Resident 1 for the week of July 20, 2026 to July 24, 2026, indicated, .Alerts: >1000 ml fluid restriction.Breakfast.fluid restriction 360.Lunch fluid restriction 360.Dinner.fluid restriction 360.The physician orders for dietary fluid restrictions of 120 ml for lunch and dinner were not found to be reflected on the meal ticket for Resident 1.A review of Resident 4's medical record indicated, Resident 4 was admitted to the facility on [DATE], with a diagnoses which included aftercare following surgery of neoplasm (removal of a tumor) and ESRD with dependance on hemodialysis. The MDS, dated [DATE], indicated a BIMS score of 15 (cognitively intact).A review of the physicians order dated July 31, 2026, indicated, .Fluid restrictions 1000ml/day.Dietary: 720ml (B:240ml, L:240ml, D:240ml).nursing.(AM:100ml, PM:100ml, NOC:80ml). Monitor intake and output every shift. NOCs to total intake and output for 24 hours daily.Notify MD if over fluid intake.A review of the Fluid intake log dated from July 22, 2026, to August 6, 2026 indicated a total fluid intake over 1000 mls on four separate occasions:July 31, 2026.total fluid intake for 24 hours.1210 mls,August 1, 2026.total fluid intake for 24 hours.1175 mls,August 2, 2026.total fluid intake for 24 hours.1290 mls.August 4, 2026.total fluid intake for 24 hours.1200 mls.There was no documented evidence the physician or dialysis was made aware of the total fluid intake over 1000 mls for 24 hours on July 31, 2026, and August 1, 2, and 4, 2026.A review of the meal ticket for Resident 4 for the week of August 4, 2026, indicated, .Alerts: Blank.Breakfast.Blank.Lunch.Blank.Dinner.Blank.There were no notations on the meal ticket of Resident 4 which indicated a specific alert for a fluid restriction of 1000 ml and no distinction regarding the amount of fluids to be provided according to the physicians orders for breakfast, lunch and dinner meals.A review of the meal ticket for Resident 4 for the week of July 20, 2026 to July 24, 2026, indicated, .Alerts: >1000 ml fluid restriction.Breakfast.fluid restriction 360.Lunch fluid restriction 360.Dinner.fluid restriction 360.The physician orders for dietary fluid restrictions of 120 ml for lunch and dinner were not found to be reflected on the meal ticket for Resident 1.A review of Resident 6's medical record indicated, Resident 6 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses which included routine healing for rib fracture (broken rib bone) and ESRD with dependance on hemodialysis.The MDS dated [DATE], indicated a BIMS score of 12 (moderate cognitive impairment).A review of the physician's order dated July 30, 2026, indicated, .Fluid restriction as follows: 1000mL/24 hours. Dietary: breakfast 360 mL, lunch 120 mL, dinner 120 mL for a total of 600 ml. Nursing: Night shift 120 mL, Day shift 140 mL, Evening shift 140 mL for a total 400 mL.Monitor intake and output every shift. NOCs to total intake and output for 24 hours daily.Notify MD if over fluid intake.A review of the Fluid intake log dated from July 22, 2026, to August 6, 2026 indicated a total fluid intake over 1000 mls on two separate occasions:August 2, 2026.total fluid intake for 24 hours.1160 mls.August 3, 2026.total fluid intake for 24 hours.1440 mls.There was no documented evidence the physician or dialysis was made aware of the total fluid intake over 1000 mls for 24 hours on August 2, 2026, and August 3, 2026.A review of the meal ticket for Resident 6 for the week of August 4, 2026, indicated, .Alerts: Blank.Breakfast.Blank.Lunch.Blank.Dinner.Blank.There were no notations on the meal ticket of Resident 6 which indicated a specific alert for a fluid restriction of 1000 ml and no distinction regarding the amount of fluids to be provided according to the physicians orders for breakfast, lunch and dinner meals.On August 6, 2026, at 12:55 p.m., an interview and record review was conducted with Licensed Vocational Nurse (LVN 1) regarding Resident 1. LVN 1 reported that Resident 1 was scheduled for dialysis on Monday, Wednesday, and Friday (MWF). While reviewing the dialysis log sheet from July 17 to July 24, 2026, LVN 1 noted that Resident 1 refused dialysis treatments on both July 17 and July 24. Resident 1 received only two of the four expected treatments during that period, exercising their right to refuse. LVN 1 explained that the family had been informed of the associated risks, and the physician had also discussed these risks directly with Resident 1, who was encouraged but ultimately declined to attend the sessions. Regarding fluid restrictions, LVN 1 mentioned that Resident 1 frequently requested extra ice and snacks. LVN 1 added that daily staff meetings ensured all team members were aware of residents on fluid restrictions, and that the kitchen indicated these restrictions on meal tickets so nurses could provide appropriate meal trays.On August 6, 2026, at 2:05 p.m., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON indicated it was the responsibility of the nurse who received the physicians to communicate Resident 1's 1000 ml/24-hour fluid restriction to the nursing staff, registered dietitian (RD), and kitchen staff. After a review of the meal tickets from July 17-[DATE] with the ADON, the ADON indicated the meal tickets lacked specified lunch and dinner fluid limits (120 ml), and excess fluid intake wasn't reported to the MD. ADON stated Certified Nursing Assistants (CNA) were responsible for tracking and documenting total fluid intake and reporting overages to LVNs and that fluid restrictions were to be reviewed in daily nurse huddles with charge nurse and CNA oversight per policy. The ADON noted failures in nursing intake totals and poor communication between dietary, nursing, and electronic records increased risks of fluid overload and related symptoms. The ADON further stated the kitchen did not adhere to fluid limits for lunch and dinner, highlighting risks from inaccurate or incomplete meal tickets and nursing documentation. The ADON stressed the need for system improvements in communication and documentation.On August 6, 2026, at 3:10 p.m., an interview was conducted with LVN 2. LVN 2 stated residents on fluid restrictions are identified with a green dot sticker, shift huddles include discussion of fluid restriction lists, with new paper lists handed out to assigned staff. LVN 2 stated during meal service, LVNs check meal tickets to verify diet accuracy. RNs enter initial orders, and LVNs check these orders each shift and meal service staff would be made aware of any preferences adjustments. LVN 2 noted that MD orders for fluid restrictions are not rechecked after initial verification unless changes are made known and that nursing staff rely on kitchen meal tickets to accurately reflect MD orders.On August 6, 2026, at 4:28 p.m., an interview was conducted with the Dietary Manager (DM). DM noted no indications of fluid restriction on Resident 6's meal ticket and recommended that physician orders specifying ml amounts be documented in the notes and alert section. For Resident 1, DM observed that the 120 ml fluid restriction orders were not reflected on the meal ticket. For Resident 4, DM stated there was no indication of fluid restriction on the meal ticket. DM stated all dietary orders received from the nursing staff should be placed in the dietary logs (a document for tracking physicians orders) so that meal tickets would reflect the physicians orders correctly. The DM emphasized that nursing should communicate all fluid restriction orders (verbally and with the printed MD order) to ensure accurate meal ticket documentation and proper calculation of total fluid restrictions, reducing the risk of staff not knowing the resident's fluid limits.On August 6, 2026, at 4:54 p.m., an interview and record review was conducted with the Director of Nursing (DON). The DON reviewed the expectations for intake and output tracking (I&O) and stated the total inputs for Residents 1, 4, and 6 showed an overage of the fluid restriction without MD or dialysis notification for overages, which requires correction. The DON reviewed meal tickets for Resident 1, 4, and 6 and indicated the meal tickets did not reflect the physician's orders and they should. The DON emphasized that orders should be clearly communicated (written and verbal) between nursing staff and the kitchen so that the meal tickets would accurately reflect the residents fluid restriction orders. The DON further stated risks identified for residents on fluid restriction included shortness of breath, abnormal vital signs, and potential fluid overload leading to heart failure and respiratory problems.A review of the facility policy and procedure titled, Restricted Fluid Intake, dated October 2010, indicated, .the restriction of resident's fluid intake is determined and ordered by a physician.be accurate in recording fluid intake on the Intake and Output (I&O) record.dietary department will notify nursing on the amount of fluid that will be provided on the resident's tray.A review of the facility policy and procedure titled, Intake, Measuring and Recording, dated October 2021, indicated, to accurately determine the amount of liquid a resident consumes in a 24-hour period.Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy.at the end of your shift, total the amounts of all liquids the resident consumed.A review of the facility policy and procedure titled, Food and Nutrition Services, dated October 2017, indicated, .Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for , significant nutritional problems.a nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian.A review of the facility document titled, Job Description: LPN (Licensed Practical Nurse) LVN, dated November 2018, indicated, .record new/changed diet orders.forward information to the Food Services Department.perform routine charting duties as required and in accordance with established charting and documentation policies and procedures.

Based on interview and record review, the facility failed to complete an assessment, care planned a resident-to-resident intimate relationship for two of two residents reviewed (Residents 1 and 2). This failure had the potential to result in unmet psychosocial needs, inadequate monitoring of the relationship, and failure to identify risks requiring interventions to protect resident health, safety, and well-being.Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included morbid obesity (severely overweight) and urinary tract infection (an infection in the urinary system [body's waste removal system that makes and removes urine]). A review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated April 18, 2026, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a cognitive tool) score of 15, indicating no cognitive impairment. A review of Resident 1's progress notes, indicated the following: -Dated April 18, 2026, .another resident of opposite sex came inside and had a casual conversation with the resident. After the conversation ended, the two residents were noted to have a consensual relationship as they gave each other a kiss before the male resident left to go back to his own room. -Dated May 8, 2026, .Resident did not return from scheduled appointment. This writer contacted resident's father at approximately 2140 (9:40 p.m.) .regarding resident's whereabout. Father reported that resident .disclosed an alleged sexual assault by a male. -Dated May 9, 2026, .Allegation of sexual abuse raped by Resident #2 as reported by the resident#1's father yesterday evening when the Licensed nurse called him to ask where resident#1 was as she did not come back from her 3 PM appointment. Father said that resident #1 won't be coming back to the facility but will be going home as resident #1 claimed that she was raped by someone with one leg only and his name is resident#2. Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (long term lung disease which makes it difficult to breathe). Resident 2' MDS dated [DATE], indicated Resident 2 had a BIMS of 14 indicating no cognitive impairment. Further review of Resident 1 and 2's record indicated there was no documented evidence the facility completed its resident relationship assessment process after staff identified the relationship on April 18, 2026. In addition, there was no documented evidence of an Interdisciplinary team (IDT) review, assessment of both residents, completion of Sexual Consent Capacity Evaluation, or development of a care plan related to the relationship. On May 12, 2026, at 1:32 p.m., during an interview and record review with the Director of Nursing (DON), the DON stated Residents 1 and 2 were involved in a consensual relationship. The DON stated the facility's process required the IDT to conduct an assessment to determine whether residents were capable of entering into a consensual relationship. The DON stated no evaluation had been conducted for either resident. The DON stated both residents should have been evaluated. On May 12, 2026, at 5:01 p.m., the DON was again interviewed. The DON stated the licensed nurse should have reported the relationship when it was identified. The DON stated the IDT should have conducted an assessment, spoken with both residents, and developed an appropriate care plan. The DON stated the facility used a Sexual Consent Capacity Evaluation form when staff become aware of a resident relationship and confirmed the form had not been completed for either resident. A review of the facility's Sexual Consent Capacity Evaluation form indicated the form was used to assess and document a resident's capacity to consent to an intimate or sexual relationship. The form included evaluation of the resident's cognitive status and memory, decision-making ability, understanding of consent and associated risks, and determination of the resident's capacity to engage in the relationship. A review of the policy and procedure titled Resident Relationships Policy, dated September 2022, indicated .The purpose of a resident relationship policy is to affirm and respect the rights of all residents to engage in consensual relationships. The policy should uphold the belief that healthy consensual relationships are central to quality of life, and promote an environment that allows individuality, autonomy, dignity, and respect to thrive. A facility should welcome and respect all residents, whether lesbian, gay, bisexual, transgendered, or heterosexual. A policy should address the right of the resident to engage in any consensual relationship even if the relationship creates challenges to religious, doctrinal, family, or societal beliefs, including pertinent privacy and confidentiality issues. At the same time, the facility should acknowledge its responsibility to protect residents who may not be able to consent to sexual relationships. A policy provides guidance to the multi-disciplinary care team to carry out this balance of 1ights and protection in all relationships.

Based on observation, interview, and record review, the facility failed to implement an effective intervention to prevent resident-to-resident physical altercation for two of three sampled residents (Resident 2 and 3).This failure resulted in Resident 2 sustaining minor injuries from the physical altercation with Resident 3, and putting both residents (Res 2 and 3) and other residents at risk for further [NAME] January 20, 2026, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate an allegation of physical abuse.On January 20, 2026, 9:12 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated:- Resident 3 had a physical altercation with Resident 2 on January 11, 2026;- Resident 3 entered Resident 2's room and attempted to take Resident 2's personal belongings leading to the physical altercation;- Resident 2 sustained injuries after Resident 3 struck him in the face; and- A one on one (1:1 one staff member is assigned to watch and care for only one patient at all times) supervision was initiated on Resident 3 after the incident.On January 20, 2026, at 11:14 a.m., an observation with a concurrent interview was conducted with Resident 2. Resident 2 was in his room, alert, and interveiwable. Resident 2 stated:- On January 11, 2026, Resident 3 entered his room, and attempted to take his cup and blanket;- Resident 3 struck him twice punching him in the face when he tried to stop him. He sustained right upper lip swelling (puffiness or enlargement of a body part) and a nose scratch; and- He pressed the call light button for help but did not receive immediate staff response. He had to yell for help before the staff intervened.On January 20, 2026, at 11: 55 a.m., an observation with a concurrent interview was conducted with Resident 3. Resident 3 was observed in the activity room under staff supervision. Resident 3 did not recall the altercation incident with Resident 2 on January 11, 2026.On January 20, 2026, at 12:05 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was the CNA assigned to monitor Resident 3 on a 1:1 since after the incident on January 11, 2026. CNA 1 stated Resident 3 had a history of wandering behavior and occasional aggressive behavior by wandering into other resident's rooms and slapping the hands of staff.On January 20, 2026, at 3:21 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated:-She was the licensed nurse assigned to Resident 2 when the physical altercation occurred between Residents 2 and 3 on January 11, 2026 at 8:05 pm;- Resident 2 sustained right upper lip swelling and a scratch on the nose as a result of the physical altercation;-Resident 3 was removed from Resident 2's room and was placed on 1:1 supervision after the incident; and- Resident 3 had a history of wandering behavior, entering other resident's rooms and she was not aware of any written interventions to address his wandering behavior.On January 20, 2026, at 3:50 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated:- She was the RN assigned as charge nurse (team leader of nursing unit) on January 11, 2026 and was at the nurses station during the time of the altercation; and- She was not sure of the facility's policy and procedure on residents with wandering behavior and she was unaware of the interventions in place to address Resident 3's wandering behavior, prior to the incident with Resident 2 on January 11, 2026.On January 20, 2026, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE]Resident 2's Brief Interview for Mental Status (BIMS) dated October 10th, 2025, Indicated, Resident 2 had does have the capacity to understand and make medical decisions.The document titled, .Change of Condition, dated January 11, 2026, indicated, Signs and Symptoms identified .Resident 2 Punched in the face.Resident 2 stated Resident 3 came to his room and attempted to take his cup and upon stopping he was punched on his face, and then Resident 3 still tried to take Resident 2 blanket upon stopping he was punched on his face. Resident 2 wheeled Resident 3 out of his room and closed the door.Ice pack given on the lip of Resident 2.On January 20, 2026, Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE] with diagnoses including delusional disorder ( a mental health condition where a person holds a strong, fixed, and false belief that they refuse to give up, even when given clear, logical and factual evidence that they are wrong) and impulse disorder (a behavioral condition characterized by the inability to resist a powerful urge to act in a way that is harmful).The History and Physical, dated November 15, 2025, Indicated, Resident 3 was not able to make decisions.The electronic medication Administration Record (eMAR) dated January 1 to 31, 2026, indicated a physician's order to monitor Resident 3 for episodes for Impulse Control Disorder manifested by wandering and danger to self and others. The EMAR did not indicate Resident 3 exhibited these behaviors on January 11, 2026, when the incident occurred.The Care Plan dated October 9, 2025, indicated, .Elopement/Wandering: Resident is at risk for elopement/exit seeking/wandering related to altered cognitive status, forgetfulness.wanders aimlessly.Goal.Resident's safety will not be endangered related to behaviors.Resident 3's care plan for elopement/wandering indicated a general intervention that did not include the type of supervision or monitoring needed to address this behavior.The document titled, .Change of Condition. indicated, .Resident 2 punched in the face.no active bleeding noted .ice pack given on the lip of Resident 2.On January 20, 2026, at 4:15 p.m., an interview with a concurrent record review was conducted with the DON. The DON stated:- Resident 3's care plan for elopement and wandering lacked specific prevention intervention;- There was no documentation from the CNAs that monitoring on the wandering behavior was completed. In addition, the DON stated their internal communication board (a designated spot where a company shares important updates) did not list Resident 3 as a resident at risk for wandering prior to the incident on January 11, 2026; and- Resident 3 had a physician order to monitor for episodes of impulse disorder manifested by wandering and danger to self and others. The DON was unable to provide documented evidence a wandering or elopement prevention intervention was implemented on Resident 3 prior to the incident on January 11, 2026;On January 22, 2026, at 10:22 a.m., an interview was conducted with CNA 3. CNA 3 stated she was the CNA assigned to Resident 3 when the incident happened on January 11, 2026, during the pm shift. CNA 2 stated Resident 3 frequently wandered and needed to be checked every 15 to 30 minutes. CNA 3 stated she was on her lunch break when the altercation between Residents 2 and 3 occurred and no one was assigned to check on Resident 3 during her break.The facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation, revised April 2021was reviewed. The policy indicated .The facility must protect residents from abuse and take immediate action to ensure resident safety when abuse or risk of abuse is identified.The administrator is responsible for determining and implementing protective measures to prevent further harm to residents.The facility's policy and procedure titled, Wandering and Elopements, revised March 2019 was reviewed. The policy indicated, .Residents identified as at risk for wandering or elopement must have individualized strategies and interventions included in the care plan to maintain resident safety .The facility must identify residents at risk and implement interventions to prevent harm while maintaining the least restrictive environment.

Based on interview and record review, the facility failed to notify the resident's representative of a change in condition (COC) when one of three sampled residents (Resident 1) experienced deterioration of two lower extremity wounds. This failure resulted in the responsible party being unaware of Resident 1's change in condition.Findings: On January 21, 2026, April 14, 2021, at 9:00 a.m., an unannounced visit to the facility was conducted to investigate allegations of poor quality of care. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included acute osteomyelitis, left ankle and foot (bone infection). The History and Physical, dated October 7, 2025, indicated Resident 1 had a change in cognitive function which impacted her ability to make informed medical decisions. The resident's grandson was designated as the responsible party for medical decision-making. A review of Resident 1's COC from November through December 2025, indicated the following: -November 21, 2025, at 4:19 p.m., .COC.upon doing wound rounds, right heel DM (diabetic wound) and left heel DM wound noted to be deteriorating.Right heel deteriorating in size and quality. Left heel deteriorating in undermining in the wound. Treatment orders in place.primary care provider notified with orders in place.resident updated.-December 5, 2025, at 5:46 p.m., .COC .right heel diabetic wound noted deteriorating during wound rounds by wound specialist with updated treatment order.family or resident notified.self.-December 8, 2025, at 1:17 p.m., .COC .upon wound care right dorsum foot noted with dark brow/purple discoloration.MD notified.family or resident notified.self. There was no documented evidence the facility notified the resident's representative of Resident 1's change in condition on November 21, 2025, December 5, 2025, and December 8, 2025.On January 21, 2026, at 1:43 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she recalled providing wound care and completing the COCs for Resident 1. LVN 1 stated the process for communicating a change in condition was to notify the resident, family or resident representative, and the primary care and wound care physicians. LVN 1 stated a COC was completed when wound deterioration was observed. LVN 1 stated, on November 21, 2025, December 5, 2025, and December 8, 2025, she notified only the resident and did not notify the resident's representative. LVN 1 stated she should have communicated the change in condition to the resident representative so the representative would be aware of the resident's condition changes. On January 21, 2026, at 3:59 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 1 experienced changes in condition on November 21, 2025, December 5, 2025, and December 8, 2025, and that Resident 1's representative should have been notified of these changes. The DON stated facility policy required staff to notify the resident, resident representative, and physician when a change in condition occurred. A review of the policy and procedure titled Change in a Resident's Condition or Status, dated February 2021, indicated, .A significant change of condition is a major decline.that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.impacts more than one area of the resident's health status.a nurse will notify the residents representative when.there is a significant change in the resident's physical, mental, or psychosocial status.the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to ensure required personal protective equipment (PPE - specialized clothing or equipment worn by staff to protect themselves and others from exposure to infectious agents) was readily available on the PPE cart for one of one resident reviewed for infection control (Resident 8).This failure increased the risk of transmission of infection to residents and staff. Findings:A review of Resident 8's admission Record indicated Resident 8 was re-admitted to the facility on [DATE], with diagnoses including ESBL infection (Extended-Spectrum Beta Lactamases - a highly contagious bacterial infection requiring the resident to be on contact precaution (a type of precaution used to prevent the spread of infections that are transmitted to through direct physical contact).On September 24, 2025, at 3:38 p.m., during a concurrent observation and interview with the Housekeeping Supervisor (HS), Resident 8's PPE cart was observed without disposable gowns. The HS stated, she was responsible for stocking the PPE carts and stated the PPE cart was missing disposable gowns. The HS stated the cart should contain the proper PPE required for staff to prevent infection transmission.On September 25, 2025, at 2:01 p.m., during an interview with the Infection Preventionist (IP), the IP stated Resident 8 was on contact precautions, and the isolation cart should have disposable equipment available for staff to properly perform their duties. On September 25, 2025, at 3:10 p.m., during an interview with the Director of Nursing (DON), the DON stated, for contact precautions, required PPE, including gowns, gloves, masks, must be stocked and available for staff to use to prevent infection transmission. The DON stated any staff member who observed that the isolation cart was not fully stocked should restock it. A review of the facility policy and procedure titled, Infection Prevention and Control Program, dated December 2023, indicated, .important facets of infection prevention include.implementing appropriate enhanced barrier and transmission-based precautions when necessary .

Based on interview and record review, the facility failed to protect the resident's right to be free from abuse for one of three residents reviewed for abuse (Resident 127) when the staff member directed inappropriate and derogatory language toward the resident. This failure had the potential to cause psychological harm or emotional harm to Resident 127.Findings:A review of Resident 127's admission Record indicated Resident 127 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke).A review of Resident 127's History and Physical, dated July 17, 2025, indicated Resident 127 had the capacity to understand and make decisions.On September 24, 2025, at 4:58 p.m., during an interview with Resident 127, Resident 127 stated Licensed Vocational Nurse 3 (LVN 3) called him [NAME] [mother f***r],Come get your meds, [NAME]. Resident 127 stated, he was shocked, he could not react and thought that the licensed nurse was unprofessional.On September 25, 2025, at 2:51 p.m., during an interview with LVN 4, LVN 4 confirmed the incident occurred. LVN 4 stated she was at the nurse's station with Resident 127, when she heard LVN 3 said something inappropriate to Resident 127.On September 25, 2025, at 3:10 p.m., during an interview with the Director of Nursing (DON), the DON stated Resident 127 had reported to a staff member that a nurse said something inappropriate to him. The DON stated Resident 127 told her, he had been called a vulgar name by LVN 3. The DON stated staff were expected to speak respectfully to all residents and the language allegedly used by LVN 3 was inappropriate and inconsistent with facility expectations.On September 25, 2025, at 3:33 p.m., during an interview with LVN 3, LVN 3 stated, she was informed by the DON that the resident made an allegation of verbal abuse. LVN 3 stated, she and Resident 127 had good rapport and they would joke around, saying inappropriate things, sexual remarks and cuss too. LVN 3 stated on September 24, 2025, when Resident 127 was at the nurse's station and she was preparing to administer his medications, she could have said come on, [NAME], let me give your meds.On September 25, 2025, at 5:25 p.m., during an interview with Resident 127, he stated, he felt the language used by LVN 3 was inappropriate and derogatory, and he considered it verbal abuse.A review of the facility policy and procedures titled, Abuse, neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, indicate, .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Protect residents from abuse .from anyone including .facility staff .A review of the facility's policy and procedure titled, Resident Rights, revised February 2021, indicated, .Employees shall treat all residents with kindness, respect and dignity.be free from abuse, neglect, misappropriation of property, and exploitation .

Based on observation, interview and record review, the facility failed to ensure the resident's food preference was honored for one of three residents reviewed for nutrition (Resident 120). This failure had the potential to result in the resident refusing meals and experiencing decreased nutritional intake.Findings: On September 22, 2025, at 11:21 a.m. an observation and interview were conducted with Resident 120. Resident 120 stated she was prescribed a regular diet with large portions and disliked milk to drink. Resident 120 stated, they keep bringing me milk and I keep telling them I don't like it. A large note was observed on the resident's table that read in capital letters, .NO MILK PLEASE. Resident 1's meal ticket was observed to list the following: .Notes.Milk for cereal only.Standing.4fl oz (fluid ounce a unit of measure) milk 2% 4 fl oz juice.Orders.8 fl oz. Milk 2% .Dislikes.Milk to drink. On September 24, 2025, Resident 120's record was reviewed. Resident 120 was admitted on [DATE], with a diagnosis which included fracture of right femur (broken leg bone) and diverticulosis of the large intestine (a condition where small pouches [diverticula] form in the wall of the colon (large intestine). A review of the Minimum Data Set (an assessment tool), dated August 11, 2025, indicated Resident 120 had a Brief Interview of Mental Status (a tool to assess cognitive function of an individual) score of 14 (intact cognitive response). A review of the Dietary Interview dated August 8, 2025, indicated, .dislikes.cold cereal. A review of the Order Summary Report dated August 28, 2025, indicated, .NAS (no added salt) diet regular texture.thin consistency, Dislikes milk.Do not serve milk to drink. On September 24, 2025, at 11:47 a.m. an interview and record review was conducted with the Registered Dietitian (RD). The RD stated she was not aware Resident 120 received milk with meals after requesting no milk. The RD stated Resident 120 had an order which indicated don not serve milk to drink. The RD stated the staff serving meals should review the meal tickets prior to serving meals and provide the meals according to the orders, and preferences. The RD further stated Resident 120 should not be served milk. On September 25, 2025, at 8:37 a.m., an observation and interview was conducted with Certified Nursing Assistant CNA 2. CNA 2 was observed to serve milk to Resident 120 in her room. CNA 2 was observed to walk away from Resident 120's room with milk in hand. CNA 2 stated the resident told her to remove the milk from the tray. CNA 2 stated CNAs should check the meal tickets to ensure residents receive the correct diet and that the dislikes are honored. On September 25, 2025, at 8:39 a.m. a follow up interview was conducted with Resident 120. Resident 120 stated she was served milk and that she asked the staff to remove it from her tray before leaving the room. On September 25, 2025, at 8:58 a.m. a concurrent interview and record review was conducted with the Dietary Supervisor (DS). The DS stated the diet order for Resident 120 indicated Resident 120 did not want milk and dislikes milk. A review of the clinical dietary interview conducted by the DS on August 28, 2025, and the meal ticket dated September 25, 2025, was conducted with the DS. The DS stated there is cold cereal listed as a dislike and Resident 120 should not have received milk with her meals since cold cereal means milk, and the order on the meal ticket says 8floz of milk 2%. The DS stated, she should not have milk. A review of the facility's policy and procedure titled, Resident Food Preferences, dated July 2017, indicated, Individual food preferences will be assessed upon admission and as soon as practicable.modifications to diet will only be ordered with the resident's or representative's consent .staff.will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences.

Based on observation, interview, and record review, the facility failed to ensure the physician-ordered fortified diet (high calorie, high protein diet) were provided as prescribed for two of eight residents reviewed for nutrition (Residents 98 and 125).This failure had the potential to reduce calorie and protein intake, decrease palatability of meals, and negatively affect nutritional status for these residents, in a facility with a population of 140. Findings:A review of facility undated document titled Fortified Menu Plan, indicated .This plan provides an additional 300-400 calories and 3-4 grams of protein per day.Lunch and Dinner.Meat per menu.Possible Fortified Additions.Extra 1 oz (ounce- unit of measurement) of gravy or sauce. On September 24, 2025, at 1 p.m., during a lunch tray line observation, the meal trays for Resident 98 and Resident 125 were not provided with the required extra one ounce of gravy.On September 24, 2025, at 1:17 p.m., during a concurrent observation and interview with the Dietary Aid (DA) and the Dietary Supervisor (DS), the DA stated, the cart containing meals for Residents 98 and 125 was checked and ready for delivery. The DA with the DS compared the meal trays with the printed meal tickets, the DS stated Residents 98 and 125 trays did not contain the required extra ounce of gravy. The DS further stated that residents on a fortified diet must receive the added gravy per physician order and that additional protein assists with weight gain and wound healing. 1. A review of Resident 98's admission Record indicated Resident 98 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer stage 4 (full-thickness tissue loss extending into deep tissues, exposing muscle, tendon, or bone). A review of Resident 98's care plan dated October 28, 2024, indicated .Focus.Malnutrition (nutritional disorder) .Resident has a diagnosis of protein calorie malnutrition (a nutritional disorder) as evidenced by malnutrition .Interventions.Fortified Diet.Provide diet per physician order. A review of Resident 98's Physician Order dated August 23, 2025, indicated .Fortified Diet.2. A review of Resident 125's admission Record indicated Resident 125 was admitted to the facility on [DATE], with diagnoses which included generalized weakness. A review of Resident 125's care plan dated April 18, 2024, indicated .Focus.Malnutrition.Resident is at risk for Malnutrition/Weight Loss.Intervention.Fortified diet. A review of the facility's undated policy titled Diet Order indicated .Diet orders as prescribed by the Physician will be provided by the Food and Nutrition Services Department.

Based on observation, interview, and record review, the facility failed to ensure an assessment for safe self-administration of medication was conducted for two of three residents reviewed for choices (Residents 2 and 146). These failures had the potential for Residents 2 and 146 to self-administer the medications unsafely and without licensed nurse monitoring.Findings: 1.On September 22, 2025, at 11:35 a.m., a concurrent observation and interview were conducted with Resident 146. Resident 146 was observed lying on her bed, alert and oriented. An opened bottle of a 16oz (ounce) 3% hydrogen peroxide (an antiseptic [kills germs] solution used for disinfecting minor cuts and scrapes on skin and used as a gargle or rinse to help remove mucus and phlegm from the mouth and throat) was observed on the bedside table. Resident 146 stated her daughter bought the medication from a drug store and brought it to the facility to help her rinse her mouth after she ate. Resident 146 stated she had used the medication that morning after breakfast and had kept it at her bedside for few days. Resident 146 stated none of the staff asked her about it. On September 22, 2025, at 11:40 a.m., a concurrent observation and interview were conducted with Licensed Vocational Nurse (LVN) 1 inside Resident 146's room. LVN 1 stated she had provided care for Resident 146 but was not aware of any medication at the bedside. LVN 1 stated residents would need a self-administration assessment. LVN 1 stated she was unsure if Resident 146 had been evaluated. A review of Resident 146's records indicated Resident 146 was admitted to the facility on [DATE], with diagnoses including shortness of breath and nicotine dependence (a condition in which a person becomes physically and psychologically addicted to nicotine [substance found in tobacco products such as cigarettes]). A review of Resident 146's Minimum Data Set (MDS - an assessment tool) dated September 23, 2025, indicated a Brief Interview of Mental Status (a tool to assess cognitive function of an individual) score of 14 (cognitively intact). A review of Resident 138's History and Physical, dated September 18, 2025, indicated Resident 146 had the capacity to make decisions. Further review of Resident 146's records indicated there was no documentation Resident 146 had been assessed for medication self-administration. On September 22, 2025, at 3:34 p.m., a concurrent interview and record review of Resident 146's records were conducted with LVN 2. LVN 2 stated there was no documented evidence in Resident 146's records that she was assessed to self-administer any medications. LVN 2 stated, residents would need to be assessed to determine if they were capable of self-administering medications and for residents' safety. 2. On September 22, 2025, at 3:05 p.m., a concurrent observation and interview were conducted with Resident 2. Resident 2 was observed sitting on his bed watching television, alert and oriented. The following multiple over the counter (OTC - medicines which can be purchased without a prescription) medications were observed at his bedside:a. 16oz bottle of hydrogen peroxide topical solution (open)b. 1oz triple antibiotic ointment tube (topical first-aid medication containing three different antibacterial agents to treat minor skin irritations) (open)c. 3oz Medline Remedy Antifungal Powder (prevent fungal growth) (open)d. 10oz Gold Bond Medicated Body Powder (absorb moisture, control odor, and relieve itchiness) (open)Resident 2 stated he ordered the medications three weeks ago. Resident 2 stated he last used the antibiotic ointment 2 weeks ago for a pimple on his right cheek and have kept the medications on top of his drawer and no one had asked about them. On September 22, 2025, at 3:14 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated she has provided care for Resident 2 and have not noticed any medications in Resident 2's room. CNA 3 stated licensed nurses were supposed to check if they were safe to have medications at the bedside. On September 22, 2025, at 3:23 p.m., a concurrent observation and interview was conducted with LVN 2 in Resident 2's room. LVN 2 stated she was not aware that Resident 2 had been ordering medications and storing them in his room. LVN 2 stated residents were not allowed to keep medications at the bedside without a self-administration assessment. A review of Resident 2's records were conducted. Resident 2 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (abnormal heart rhythm) and low back pain. A review of Resident 2's MDS, dated [DATE], indicated a BIMS score of 15 (cognitively intact). Further review of Resident 2's records indicated there was no documentation that Resident 2 was assessed for medication self-administration. On September 22, 2025, at 3:30 p.m., a concurrent interview and record review of Resident 2's records were conducted with LVN 2. LVN 2 stated there was no documented evidence in Resident 2's records that he was assessed to self-administer the OTC medications. LVN 2 stated, without an assessment, Resident 2 should not have any medications at the bedside, as the staff would be unable to monitor whether the resident was using the medication safely. On September 25, 2025, at 2:04 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated without a self-administration assessment, Residents 2 and 146 should not have any medications at the bedside. The DON stated her expectations was for staff to inspect resident's rooms for medications at bedside and report right away. The DON stated both Residents 2 and 146 did not have self-administration assessments completed and further stated, they should have been evaluated to ensure they were using the OTC medications safely and the residents were being monitored. A review of facility's policy and procedure titled Self -Administration of Medications, dated 2001, indicated, .Residents have the right to self-administer medications if the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the residents.the resident is able to safely and securely store the medications.this is documented in the medical record and the care plan.

Based on observation, interview, and record review, the facility failed to ensure one oral relief sore throat spray stored in a medication cart was properly labeled. This failure had the potential for the residents to receive unnecessary medications or for medication error to occur. Findings:On September 25, 2025, at 11:32 a.m. a concurrent observation and interview were conducted with Licensed Vocational Nurse (LVN) 9 at the medication cart located in the East Station.An unlabeled bottle of Phenol 1.4 % (medications that temporarily induce a loss of sensation) oral relief sore throat spray was found in the cart, available for use. The bottle was half-full, the cap was broken, and there was no resident name, identifier or pharmacy label. LVN 9 stated she was unable to identify which resident the spray belonged to or when it was last used. LVN 9 stated the bottle had been opened and used, as half of the fluid in the bottle was visible. LVN 9 state she was unsure of how long the medication had been in the cart. LVN 9 stated it was the medication nurse responsibility to check the carts so that there were not unlabeled or expired medications available for use. LVN 9 stated I will check my carts normally at the beginning of each shift and I did not notice this; it should be removed because it has no label. LVN 9 stated unidentified items should be discarded and not be in the carts without a label because someone could use it unintentionally. LVN 9 stated residents were allowed to order over the counter medications but that the medications should be identified with a label indicating the residents name, orders for administration and authorized by a physician. A review of the facility policy and procedure titled, Storage of Medications dated April 2007 indicated, .the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.the nursing staff shall be responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner.resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to ensure the dialysis (a treatment which performs the work of the kidneys when they could no longer function properly) pressure dressing was removed two hours after arrival from dialysis as ordered, for one out of two residents reviewed for dialysis (Resident 148).This failure had the potential for infection and/or clotting to Resident 148's dialysis access site.Findings:On September 25, 2025, at 8:47 a.m., an observation and interview were conducted in Resident 148's room. Resident 148 was lying in bed, in a semi-upright position. His dialysis access site, located on his left upper arm, was covered with a pressure dressing. Resident 148 stated the dressing was to be removed the previous day upon returning from dialysis, they forgot.On September 25, 2025, at 9:00 a.m., a concurrent observation and interview was conducted with the Licensed Vocational Nurse (LVN 7). LVN 7 stated the pressure dressing should have been removed yesterday, within two hours of the resident's return from the dialysis clinic, in order to prevent infection. On September 25, 2025, at 3:10 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that the nursing staff should have removed the dialysis pressure dressing as ordered, within two hours post dialysis treatment to prevent further complications such as clotting and infection.A review of Resident 148's, admission Record indicated Resident 148 was admitted to the facility on [DATE], with diagnoses which included ESRD (End Stage Renal Disease-irreversible kidney failure).A review of Resident 148's, History and Physical, dated, September 12, 2025, indicated, .has the capacity to understand and make decisions.A review of Resident 148's Order Summary Report for the month of September 2025, indicated, . dialysis [name of facility] Mon [Monday]/Wed [Wednesday]/Fri [Friday] one time a day every Mon, Wed, Fri .remove bandage two hours after arrival from dialysis every shift.A review of the facility's policy and procedures (P&P) titled, Hemodialysis Access Care , dated September 2010, indicated, .to prevent infection and/or clotting: .keep the access site clean at all times.check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals .

Based on observation, interview and record review, the facility failed to ensure the necessary care and services to maintain a peripheral intravenous (PIV - the administration of fluids, medications directly into a vein) for one of three residents reviewed for parenteral/IV fluids (Resident 95) when: 1. A physician's order was not in place for the PIV.2. PIV site was not documented as assessed and the dressing was not changed per facility policy; and3. A care plan was not initiated to address care and monitoring of the PIVThese failures had the potential to place Residents 95 at risk for infection and injury.Findings: A review of Resident 95's records was conducted. Resident 95 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar) and urinary tract infection (UTI - kidney infection). A review of Resident 95's Minimum Data Set (MDS - an assessment tool) dated September 17, 2025, indicated a Brief Interview of Mental Status (a tool to assess cognitive function of an individual) score of 13 (cognitively intact). A review of the Physicians Order Summary for the month of September 2025, indicated, .NS (normal saline - a solution of salt and water) 1L (liter- a unit of measurement) IV (intravenous) Bolus (a single, large dose of medicine) .one time only for elevated blood sugar for 1 day. A review of the Nurses Progress Note dated September 13, 2025, at 12:27 a.m., indicated, .22g (gauge -needle thickness size) IV catheter (hollow tube inserted into a vein by a needle) inserted on the right wrist with one attempt.0.9% NS 1L bolus started.author: Registered Nurse (RN) Further review of Resident 95's records indicated, there was no documented evidence a physician's order was in place prior to PIV insertion and there was no documentation of assessment or monitoring of the IV site from September 13 to September 23, 2025. Additionally, there was no documented care plan initiated for the care of the PIV. On September 23, 2025, at 10:14 a.m., a concurrent observation and interview were conducted with Resident 95. Resident 95 was observed alert and lying in bed with a PIV line dressing on the right hand, dated September 13, 2025, with an illegible time and initials. Resident 95 stated he was unsure how long he had the PIV in place and stated he did not want to accidentally pull it out. On September 23, 2025, at 10:23 a.m., a concurrent observation and interview were conducted with Licensed Vocational Nurse (LVN 5) in Resident 95's room. LVN 5 stated Resident 95 had a 22g PIV on his right wrist dated September 13, 2025. LVN 5 stated the dressing was over 7 days, and per facility policy, the dressing should have been changed to prevent infection issues and ensure the IV remained intact. On September 23, 2025, at 10:27 a.m., a concurrent interview and record review of Resident 95's records were conducted with LVN 5. LVN 5 stated Resident 95 had a physician order for a 1L IV bolus due to Resident 95's elevated blood sugar. LVN 5 stated RNs were responsible for carrying out IV orders. LVN 5 stated there was no way to confirm whether the PIV site assessments were completed and further stated, the lack of monitoring posed a risk for infection. On September 23, 2025, at 3:10 p.m., a concurrent interview and record review of Resident 95's records were conducted with RN 2. RN 2 stated on September 12, 2025, Resident 95's blood sugar was elevated and there was a physician's order for a 1L NS bolus. RN 2 stated he inserted the PIV on the resident and forgot to verify whether a physician's order was in place for the PIV insertion. RN 2 stated there was no physician order for PIV insertion. RN 2 further stated, he should have initiated a care plan and monitoring for the PIV to avoid infection issues. On September 25, 2025, at 2:04 p.m., a concurrent interview and record review of Resident 95's records were conducted with the Director of Nursing (DON). The DON stated the facility had a standard order set for IV monitoring and it was not followed for Resident 95 because the physician order was not entered completely. The DON stated documentation should be indicated in the medical administration record (MAR) and/or in a progress note to confirm that the assessments for the PIV were completed. The DON stated there should have been a care plan to make sure the ongoing care and to prevent any infection issues. The DON stated, the RNs should make sure that a physician order was in place before inserting a PIV. A review of the facility's policy and procedure titled Peripheral and Midline IV Dressing, dated 2001, indicated, .The purpose of this procedure is to prevent complications associated with intravenous therapy.perform site care and dressing change.at least every 7 days for transparent semi permeable membrane (TSM).inspect the skin, dressing and securement of device for signs of complications.the following should be documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure physician-ordered nutritional interventions were implemented for two of three residents reviewed for nutrition (Residents 63 and 64) when:1.Resident 63 did not receive an ordered extra egg at breakfast; and2.Resident 64 did not receive Boost GC (Boost Glucose Control- blend of protein, carbohydrates and fat to help manage blood sugar levels as part of a balanced diet) as prescribed during medication administration. These failures had the potential to compromise the residents' nutritional status and delay healing in a resident population with identified nutritional risks. Findings:1.On September 24, 2025, a review of Resident 63's admission record indicated Resident 63 was admitted to the facility on [DATE], with diagnoses including pressure ulcer stage four (full-thickness tissue loss extending into deep tissues, exposing muscle, tendon, or bone). A review of Resident 63's Physician Order, dated August 24, 2025, indicated .Add one (1) extra egg at breakfast.for Nutrition and Decub (decubitus ulcer- damage skin and underlying tissue) Protocol. A review of Resident 63's Care Plan, initiated August 31, 2025, indicated .Focus-Nutritional Risk: Resident has the potential for altered nutrition.Goal: Will not have worsening in skin condition.Intervention-Provide diet.per physician order. A review of Resident 63's meal ticket, dated September 24, 2025, indicated the ordered extra egg was not included. On September 24, 2025, at 7:50 a.m., during a concurrent breakfast tray line observation and interview with the Dietary Service Supervisor (DSS), the DSS stated Resident 63's breakfast tray did not include the ordered extra egg. The DSS stated she was not notified by the nursing staff of the diet-related physician order for an extra egg for Resident 63. The DSS stated nursing was responsible for communicating diet orders to the kitchen. The DSS stated, failure to provide the extra egg could result in the resident not receiving needed protein to support wound healing. On August 25, 2025, at 11:04 a.m., during an interview with LVN 5, LVN 5 stated the expectation was that when licensed nurse received a diet-related physician order, the licensed nurse should complete a diet order slip and communicate verbally and in writing to dietary staff. On August 25, 2025, at 11:19 a.m., during an interview with LVN 6, LVN 6 stated she received the physician order for an extra egg and did not write the order on the diet slip nor did she notify dietary staff. LVN 6 further stated should have communicated the order as required. 2. A review of Resident 64's admission record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses which included unspecified protein calorie malnutrition (a nutritional disorder). A review of Resident 64's Physician Order, dated August 1, 2025, indicated .BOOST GLUCOSE CONTROL 1 CARTON two times a day for SUPPLEMENT .WITH MEDPASS. On September 24, 2025, at 8:41a.m., during an interview with LVN 7, LVN 7 stated she had finished administering medications to Resident 64. LVN 7 stated, Resident 64 had an order for Boost Glucose Control and she should have prepared and administered the ordered Boost Glucose Control during med pass. LVN 7 stated the supplement should have been given as ordered so that the resident could receive necessary nutrients to promote weight gain and improve nutritional status. A review of the undated facility policy and procedure titled Physician Orders, Accepting, Transcribing, Implementing, indicated .licensed nursing personnel will ensure written telephone and verbal order will be implemented .

Based on interview and record review, the facility failed to ensure incontinence care was provided in a timely manner, consistent with the resident's care needs, for one of one resident reviewed for dignity (Resident 116).This failure had the potential for Resident 116, to be prone to develop urinary tract infection, or increased risk for impaired skin integrity and to prevent her highest psychosocial wellbeing. On September 23, 2025, at 10:30 a.m., during a concurrent observation and interview with Resident 116, Resident 116 was in bed, alert, and interviewable. Resident 116 stated she used her call light during the night shift to request assistance for a brief change. Resident 116 stated, a staff member came in, turned off her call light, and did not return. Resident 116 stated, she again activated her call light, but no staff responded. Resident 116 stated, she remained soaked in urine from her shoulders to her toes, her pad and blanket were saturated. Resident 116 stated, she called her Responsible party last night (September 22, 2025), who in turn called the nurse's station, and only then did staff respond and provide incontinence care the following morning. A review of Resident 116's admission record indicated Resident 116 was admitted to the facility on [DATE], with diagnoses including fracture of right acetabulum (hip socket).Resident 116's History and Physical dated September 5, 2025, indicated .has fluctuating capacity to make decisions. A review of Resident 116's MDS (minimum data set- an assessment tool) dated September 11, 2025, indicated .Functional Abilities - admission .Toilet transfer .Dependent .A review of Resident 116's Care Plan dated September 11, 2025, indicated .The resident is frequently incontinent of bladder and increased risk for impaired skin integrity .Interventions.Brief Use: The resident uses disposable briefs. Change (q 2 hours- every two hours) and prn (as needed).On September 25, 2025, at 4:09 a.m., during an interview with Registered Nurse (RN) 1, RN 1 stated Resident 116 was non-ambulatory and dependent on staff for continence care. RN 1 further stated CNA assigned to Resident 116 should conduct brief check at least every two hours. On September 25, 2025, at 4:15 a.m., during an interview with CNA 1, CNA 1 stated he learned residents' need on his run during shift report. He further stated he worked the night shift, on September 22, 2025. CNA 1 stated he first changed Resident 116's brief at around 11:30 p.m., and he then last saw Resident 116 when he refilled her water pitcher at around 4:30 a.m. CNA 1 stated, he did not check or change her brief during that time. On September 25, 2025, at 8:36 a.m., during an interview with Licensed Vocational Nurse (LVN) 8, LVN 8 stated when she changed Resident 116' s patch earlier in the shift, the resident told her she was a bit wet. LVN 8 stated, she failed to inform the CNA that the resident required brief checks every two hours, per care plan. LVN 8 stated, the resident had increased risk for urinary tract infection and skin breakdown when left in a wet brief. On September 25, 2025, at 5:24 p.m., during an interview with Resident 116, Resident 116 stated it was wrong for anyone to be left soaking in urine all night. A review of facility policy and procedure titled Resident Rights, dated February 2021, indicated .Employee shall treat all residents with kindness, respect and dignity .

Based on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) to the resident or resident representative at the time of transfer to an acute care hospital for one of three residents reviewed for closed records (Resident 1). This failure had the potential for residents and/or their RPs not to be fully informed of their right to request a bed hold or to return to the facility after hospitalization, which could result in an inappropriate discharge.Findings: A review of Resident 1's records indicated Resident 1 was admitted on [DATE], with diagnoses including muscle wasting and atrophy (weakness of the muscles). A review of Resident 1's admission Agreement dated July 23, 2025, indicated, .Bed Holds and readmission If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You or your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you. A review of the Health Status Note dated August 25, 2025, at 9:28 a.m., indicated, .order to send resident to (acute hospital) for hernia/abd (abdominal) pain. Needs cannot be met at facility. Noted and carried out. A review of the Notice of Proposed Transfer/Discharge dated August 26, 2025, indicated, .notifications.my/our signature confirms that I/we have received a written copy of the Notice of Proposed Transfer/Discharge and, if applicable, the State Bed Hold Notice (including the facility's bed hold policy).Resident notification and verification of receipt of notice.(blank).date of resident representative notification and verification of receipt of notice.(blank). There was no documented evidence the facility provided a written bed hold notice for Resident 1 or their representative post discharge from the facility on August 25, 2025. On September 24, 2025, at 4:04 p.m., a concurrent interview and record review was conducted with the Social Service Director (SSD). He stated he was unsure of the process for a bed hold order but that his responsibility was to alert the family, resident or their representative and the Ombudsman regarding the notification of transfer and/or discharge. The SSD stated, he spoke to the ex-wife of Resident 1 and that a discharge notice was provided. The SSD further stated it was the responsibility of the nursing staff to provide the bed hold notice and such notice should be provided to the resident. On September 24, 2025, at 4:45 p.m. a concurrent interview and record review was conducted with the Licensed Vocational Nurse (LVN) 4, LVN 4 stated when a resident was hospitalized , a physician order or a seven-day bed hold was obtained. LVN 4 stated there was no other forms used to indicate a resident had a bed hold or that the resident or representative had been notified by the nursing staff. LVN 4 further stated the licensed nurses placed the orders and did not send the written bed hold notice to the resident or representative. On September 24, 2025, at 4:52 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the documentation of the notification of bed hold should have been noted in the medical record. The DON stated the nursing staff were responsible for communicating and sending the written bed hold notice to the resident or resident representative. The DON stated the written notice should have been sent to Resident 1 or Resident 1's representative which was the ex-wife, and the notification should have been documented. On September 24, 2025, at 4:58 p.m. an interview was conducted with the facility Administrator (FA). The FA stated that proper procedures for informing Resident 1's representative about the bed hold had not been followed. The FA stated although he had notified the ex-wife by phone, no notation was made, the required admission form outlining bed hold rights was not provided, and written documentation of the policy was missing from both the resident's records and the discharge/transfer form. The FA stated, the written notice should have been provided according to the facility protocols. A review of the facility policy titled Bed-Holds and Returns dated October 2022, indicated, .Residents and/or representatives are informed (in-writing) of the facility and state.bed hold policies.All residents/representatives are provided written information regarding the facility and stated bed -hold polices, which address holding or reserving a residents' bed during periods of absence.(hospitalization).residents, regardless of payer source, are provided written notice about these policies at least twice.notice 1.well in advance of any transfer.in admission packet.and.notice 2.at the time of transfer.within 24 hours.

Based on observation, interviews, and record review, the facility failed to make reasonable accommodations to meet the needs and preferences of two residents (Residents A and B) who required Hoyer lift (a mechanical device used to transfer residents who cannot bear weight) for transfers. This failure resulted in delays, missed activities, and disruption of established daily routines for two of three sampled residents (Residents A and B).Findings:On July 22, 2025, at 12:14 p.m., during an interview with Resident A, he stated everybody is fighting over two Hoyer lifts. Resident A stated, two Hoyer lifts were not enough to service more than 100 residents.1.A review of Resident A's admission Record indicated Resident A was admitted to the facility May 26, 2019, with diagnoses which included morbid obesity (extremely overweight), and chronic pain syndrome (persistent pain lasting longer than 3 months, often significantly impacting daily life and potentially leading to disability).On July 22, 2025, at 1:53 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated at least ten residents in the East station require a Hoyer lift for transfers. CNA 1 stated the facility needs four or five Hoyer lifts at that station to accommodate smokers who want to smoke at the same time.On July 22, 2025, at 1:58 p.m. during an interview with the Maintenance Supervisor (MS), the MS stated there were three functioning Hoyer lifts in the facility, one was disabled, and no replacement parts were available. On July 22, 2025, at 4:33 p.m. during another interview with Resident A, he stated it is hard for us to wait to be transferred and it screws up our daily routines. Resident A stated his routine is to be up at 10 a.m. daily and back to bed at 11:30 a.m. Resident A stated, this has happened more than once and sometimes he was told there was no available Hoyer lift and had to wait until other residents were finished. A review of Resident A's care plan dated February 18, 2025, indicated .Focus : Self Care Deficit at risk for poor hygiene R/T (related to) DX (diagnosis) - chronic pain syndrome.Needs total with 2 persons assistance with transfer .Intervention.CNA May sit up resident in wheelchair with Hoyer lift for transfer every day shift .On July 23, 2025, at 11:54 a.m., during an interview with CNA 2, CNA 2 stated she was regularly assigned to Resident A. CNA 2 stated it was facility practice to accommodate resident preferences. CNA 2 stated Resident A required the Hoyer lift for transfers and preferred to be up by 10 a.m., and 30 minutes earlier on shower days. CNA 2 stated, it often took longer than that to transfer him because there was no available Hoyer lift, requiring her to wait until other CNAs were finished. 2. A review of Resident B's admission Record, indicated Resident B was admitted to the facility on [DATE], with diagnoses which included hemiplegia (one sided paralysis) and hemiparesis (muscle weakness restricted to one side) following cerebral infarction (disrupted blood flow to the brain).A review of Resident B's care plan dated February 7, 2025, with target date of August 6, 2025, indicated Focus : ADL (activity of daily living)/Mobility: Resident has actual ADL/Mobility decline and requires assistance related to Dx of (L)left sided weakness s/p (status post) CVA (cerebrovascular accident -stroke) Intervention.Transfer.Use EZ (another brand) lift during transfer for safety every shift,,,On July 23, 2025, at 12:43 p.m., during an interview with CNA 1, CNA 1 stated Resident B preferred to be up at 9 a.m., for physical therapy at 9:30 a.m. and on other days at 1 p.m. to attend the 1:30 p.m. smoking schedule. CNA 1 stated Resident B would get upset when she had to wait for a Hoyer lift, and this wait time varied depending on how many other residents also needed the lift, especially smokers. On July 23, 2025, at 1:23 p.m., during an interview, Resident B stated she needed the Hoyer lift for transfers due to her medical condition. Resident B stated she preferred to be up by 1 p.m. to participated in the 1:30 p.m. smoking activity. Resident B stated in her stay at the facility, there were at least five occasions when she was not transferred to her wheelchair on time, including three occasions in the previous month (June 28, 29, and 30, 2025) when she missed the smoking activity entirely due to the unavailability of a Hoyer lift. On July 23, 2025, at 4:55 p.m. in a concurrent interview and record review of Smoker's Log with Activity Assistant (AA), AA stated Resident B did not attend smoking on June 28, June 29 & June 30, 2025.A review of facility policy and procedure titled, Activities of Daily Living (ADL), Supporting, dated April 2025, indicated, Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs.Appropriate care and services are provided for residents who are unable to carry out ADLs independently.in accordance with the plan of care, including appropriate support and assistance with.mobility.transfer.A review of the facility titled Accommodation of Needs, dated March 2021, indicated .The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered .

Based on interview and record review, the facility failed to assess and monitor one of four sampled residents (Resident 1) for signs and symptoms of circulatory insufficiency (decrease blood flow) in the right lower leg after testing positive for deep vein thrombosis (DVT - a blood clot). This failure had the potential to result in staff being unable to detect worsening circulatory insufficiency. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), end stage renal disease (kidney failure) and hemodialysis (special procedure done to remove wastes and excess fluids from the body). A review of Resident 1's History and Physical, dated April 6, 2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Radiology Results Report, dated May 1, 2025, indicated, .Venous Lower Extremity Unilat (unilateral - one side) .Interpretation .Significant findings .there is a clot in the right popliteal vein possibly chronic . A review of Resident 1's care plan indicated: - .Diabetes: Resident has a diagnosis of diabetes and is at risk for complications manifested by .peripheral vascular disease (decreased blood flow to lower extremities), skin breakdown .Interventions .monitor for skin changes or breakdown . - .Resident noted with right calf pain .5/1/25 .Venous Lower extremity unilateral US (ultrasound - medical tool that uses sound waves to produce images of the inside of the body) result: Chronic clot in the right popliteal vein (vein of the lower leg), MD (doctor) notified .potential for circulatory impairment (blood flow) manifested by pain, discoloration, swelling to R (right) foot .Interventions .Monitor for swelling, increasing to severe pain, discoloration and unable to move lower extremity . A further review of Resident 1's records did not indicate any documentation that Resident 1's right leg was assessed and monitored. A review of Resident 1's Change of Condition , dated May 9, 2025, indicated, .Resident noted with necrotic right foot, 2nd toe to 5th toe .Primary Care Provider Feedback .Recommendations .Send to ER (Emergency Room) . A review of Resident 1's hospital records dated May 10, 2025, indicated Resident 1 was admitted to the (local) hospital on May 9, 2025, with a diagnosis of gangrene of right foot 2nd through 5th toe. The records further indicated an ultrasound (type of test) of Resident 1's lower legs was conducted and indicated he had venous (veins) swelling and decreased arterial (artery) blood flow to the right leg. On July 7, 2025, at 9:45 a.m., a concurrent interview and record review of Resident 1's records were conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated after Resident 1's positive DVT diagnosis on May 1, 2025, it was standard care to monitor for pain, swelling, temperature changes, skin discoloratiion, and to check pedal pulses. LVN 1 stated there was no documentation in the resident's records these assessments were done for Resident 1. LVN 1 stated, lack of monitoring could result in unrecognized impaired blood flow, which could result to discoloration or necrosis (death of body tissue). On July 7, 2025, at 2:30 p.m., an interview was conducted with the Nurse Practitioner (NP). The NP stated, clinical best practice after a DVT diagnosis, was to monitor the affected area for swelling, pain, changes in color and pedal pulses and to report abnormal findings to the physician. On July 8, 2025, at 4:15 p.m., a concurrent interview and record review of Resident 1's records were conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated the facility protocol after a DVT diagnosis included monitoring for temperature, swelling, pain, and checking pedal pulses. LVN 2 stated, there was no documentation of monitoring for Resident 1. LVN 2 stated staff would not be able to identify if there was blood flow to the lower extremity which could lead to discoloration or tissue damage. On July 8, 2025, at 4:50 p.m., a concurrent interview and record review were conducted with the Director of Nursing (DON). The DON stated Resident 1 was tested positive for DVT on May 1, 2025. The DON stated the expectation for licensed nurses to monitor and document signs of circulatory issues, including swelling, discoloration, and pulse checks, and to notify the physician if abnormalities were found. The DON stated, there was no documentation that Resident 1's right lower extremity was monitored. The DON further stated, without monitoring, this could result in serious consequence such as tissue necrosis. The DON stated the facility did not have a policy for DVT management but stated its facility's standards of practice to assess and monitor accordingly for DVT follow up care for residents.

Based on interview, and record review, the facility failed to ensure resident's medical records were accurate and complete in accordance with the accepted professional standards and practices, for one of three sampled residents (Resident 1), when the nursing weekly summary and the skin evaluations did not reflect the skin changes from May 21, 2025, to May 31, 2025. These failures could negatively impact patient care and prevent staff or representatives from being aware of the potential changes in the resident's skin condition. Findings: On June 19, 2025, at 12:30 p.m., an unannounced visit was conducted to investigate a quality-of-care concern. Resident 1's record was reviewed. Resident 1 was admitted on [DATE] with diagnoses which included diabetes type two (inability to process and control glucose sugar levels in the body). A review of Resident 1's History and Physical, indicated, Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's skin/wound note, indicated: - Dated May 21, 2025, .Resident seen by Wound NP (nurse practitioner) for sacrum pressure wound. NP reclassified wound from unstageable to stage 4 pressure injury. New Tx (treatment) order to collagen (medication) and therahoney (medication) . - Dated May 28, 2025, .Resident seen by wound specialist NP with NNO (no new orders) for sacrum wound, wound worsen continue with treatment as indicated PRN if soiled or dislodge, two new skin condition noted upon skin assessment and treatment with new tx (treatment) orders as follow: .Right heel DTI (deep tissue injury), cleanse with wound cleanser, pat dry, apply betadine and cover with foam dressing .every day shift .Right lateral malleolus DTI, cleanse with wound cleanser, pat dry, apply betadine and cover with foam dressing A review of Resident 1's Skin & (and) Wound Evaluation, indicated: - Dated May 19, 2025, Sacrum pressure injury unstageable presenting about 40% slough (dead tissue) and 60% with very light serous drainage (fluid from wound) noted at this time, measuring 8 L (length) x9 W (width) cm (centimeters - unit of measure) with order for Medi honey (medication) and foam dressing . - Dated May 26, 2025, .Sacrum .Area 75.1 Length 10.8 Width 10.2 (change in size) .No c/o on wound but c/o generalized pain when turned or reposition .Sacrum pressure wound reclassified per NP as stage 4 presenting about 40% granulation, 20% slough and 40% epithelial tissue with light serious drainage noted with order for therahoney and collagen to wound bed . There were no skin and wound evaluations completed and no new measurements were obtained on May 21, 2025, and May 28, 2025, as required by facility protocol . A review of Resident 1's Nursing Weekly Summary, from May 15, 2025, to May 31, 2025, indicated the following: - May 15, 2025 .skin .any skin changes/breakdown? .NO (is checked) .other comments .continues tx to left lateral foot DTI, left lateral heel DTI, and coccyx . - May 22, 2025 skin .any skin changes/breakdown? .NO (is checked) .other comments .no new skin issues . - May 29, 2025 .skin .any skin changes/breakdown? .NO (is checked) .other comments NA . - May 31, 2025 .skin any skin changes/breakdown? .NO (is checked). Other comments .continues treatment to left lateral foot DTI, left lateral heel DTI and coccyx. No changes . There was no documented evidence that the nursing assessments described the progressive skin changes identified by the treatment team from May 22, 2025, to May 31, 2025. On June 19, 2025, at 2:00 p.m., a concurrent interview and record review was conducted with the Licensed Vocational Nurse (LVN). The treatment records (TAR), skin treatment evaluations, and progress notes of Residents 1 were reviewed. The LVN stated any skin changes found during the evaluation of the skin and wounds should reflect in the resident's record. The LVN stated, the treatment team performing skin and wound evaluations should obtain two sets of measurements: one manually and one using a digital tablet. The LVN stated when Resident 1's wound assessment was completed on May 21, 2025 and May 28, 2025, a skin evaluation should have been completed but it was not. The LVN further stated all skin evaluations should include both measurements and a wound description, especially when there is a change in the wound condition. On June 19, 2025, at 3:09 p.m. a concurrent interview and record review was conducted with the Director of Nursing (DON), she stated the licensed nurse should document in the TAR and skin evaluation that treatment was completed, including a description of the wound and measurements. The DON stated, the licensed nurse should have completed a skin evaluation on May 21, 2025, when the change in skin condition was identified. The DON stated, the weekly nursing summary for Resident 1 did not reflect the skin changes and should have been updated to include the most current description of the skin condition from May 21, 2025, to May 31, 2025. The DON stated if the skin condition is not documented accurately, there was a potential risk that the resident may not receive the necessary care and treatment, and the nursing staff and representative parities to be unaware of the changes and care provided. A review of the facility policy and procedure titled, Charting and Documentation, dated 2008 indicated, .All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record .all observations .services performed .must be documented in the resident's clinical record .the assessment data and/or any unusual findings obtained during the procedure/treatment .notification of family, physician or other staff .

Based on observation, interview and record review, the facility failed to report an allegation of physical abuse within two hours to the California Department of Public Health (CDPH), for one of three sampled residents (Resident 1). This failure had the potential to place Resident 1 at continued risk of abuse and negatively impact her emotional and psychosocial well-being. Findings: On April 1, 2025, at 2:31 p.m., CDPH received a fax (facsimile - telephonic transmission of scanned-in printed material) report involving an allegation of physical abuse for Resident 1. On April 4, 2025, at 12:30 p.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. 1. A review of Resident 1's Admission Record, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle weakness, pneumonia (a lung infection) and deaf nonspeaking. A review of Resident 1's History and Physical, dated December 31, 2024, indicated Resident 1 had capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (an assessment tool) dated January 7, 2025, indicated a Brief Interview for Mental Status (used to identify the cognitive condition of a resident) score of 6 (severe cognitive impairment). A review of Resident 1s eINTERACT Change in Condition Evaluation, dated March 28, 2025, indicated, . At 2200 (10pm) on 3/28/25 (Resident 3) was outside their room when allegedly they saw (Resident 2) enter room of (Resident 1) and hit them in the back of the head. (Resident 3) then saw that (Resident 2) leave the room of (Resident 1). After the alleged witnessed abuse, Resident 3 came over to [NAME] side nurses' station and explained what she allegedly saw to the RN supervisor and LVN for the P.M. shift. No staff witnessed this event, only Resident 3 . A Review of Resident 1's Progress Notes, dated March 28, 2025, at 10:08 p.m., indicated .neuro checks for this resident for 72 hrs d/t (due to) allegedly being hit in the head by another resident .no new orders from MD .resident refused ice pack, severe pain was not present after the event occurred .will continue to monitor . A review of Resident 1's Progress Notes, dated March 28, 2025, at 3 a.m., indicated .resident resting in bed .no c/o (complaint of) pain or discomfort at this time .no acute distress noted .call light within reach . 2. A review of Resident 2's Admission Record, indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included Schizoaffective disorder, bipolar type (a mental health condition). A review of Resident 2's History and Physical, dated January 15, 2025, indicated Resident 2 had capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (an assessment tool) dated March 31, 2025, indicated a BIMS score of 9 (moderate cognitive impairment). A Review of Resident 2's Progress Notes, dated March 28, 2025, at 10:08 p.m., indicated .at 2200 (10 p.m.) (Resident 3) informed this LVN that she witnessed (Resident 2) going into room [ROOM NUMBER]. When (Resident 2) entered the room, she hit (Resident 1) in the (resident's room) in the head and proceeded to leave the room. CNAs and other staff members redirected (Resident 2) back to her room. This nurse evaluated (Resident 1) after she was hit and had little to no pain after (Resident 2) had hit her. Will continue to watch resident for this behavior . A review of Resident 2's Progress Notes, dated March 29, 2025, at 3:00 a.m., indicated .(Resident 2) sitting on wheelchair at the station. No s/sx (sign and symptoms) of agitation at this time. No reports of pain or discomfort. No acute distress noted. Kept the environmental calm and quiet . A review of Resident 2's Progress Notes, dated March 29, 2025, at 8:00 a.m., indicated .(Resident 2) has been wheeling herself around facility, calmly asking for breakfast and coffee. Educated her of breakfast times and resident went back to her room. Will continue to monitor and follow POC . A further review of Residents 1 and 2's record indicated, there was no documented evidence that the facility reported the alleged abuse to CDPH or facility Ombudsman on March 28, 2025, at 10 p.m. On April 4, 2025, at 12:55 p.m. an interview was conducted with Resident 3. Resident 3 stated on March 28, 2025, at approximately 10 p.m., she was in her room and observed Resident 1, who was sitting in her wheelchair and facing the window, when Resident 2 entered Resident 1's room and hit her on the back of the head. Resident 3 stated, she went to check on Resident 1, who appeared tearful and scared. Resident 3 stated, she assisted Resident 1 to the nurses' station and reported the incident to the Licensed Vocational Nurse (LVN) 1. On April 4, 2025, at 1:15 p.m., a concurrent observation and interview were conducted with Resident 1. Although nonverbal, Resident 1 was able to communicate in writing. Resident 1 wrote that Resident 2 had hit her on the head at night. Resident 1 also wrote that she was scared. Resident 1 indicated that Resident 3 witnessed the incident and helped her report the incident to the staff. On April 4, 2025, at 1:47 p.m., an interview was conducted with LVN 1. LVN 1 stated, she was assigned to both Residents 1 and 2 on the evening shift of March 28, 2025. LVN 1 stated, at 10 p.m., Resident 3 brought Resident 1 to the nurse's station and reported the witnessed incident. LVN 1 stated, she informed Registered Nurse (RN 1) and relied on RN 1 for direction and did not receive further assistance. LVN 1 stated, the incident was a physical abuse and should have been reported to CDPH within two hours. LVN 1 stated, the failure to report in a timely manner could have exposed Resident 1 to further abuse and emotional distress. On April 4, 2025, at 2:15 p.m., an interview was conducted with RN 1. RN 1 stated, she was informed of the incident by LVN 1 around 10 p.m. RN 1 stated, she assumed LVN 1 would handle the reporting of the alleged abuse to CDPH. RN 1 stated, she should have followed up and ensured the report was made within the required timeframe to CDPH, the Ombudsman, law enforcement, the physician, and the resident's representative. On April 4, 2025, at 4:02 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was first informed of the incident on March 29, 2025, at approximately 9:50 a.m. by LVN 2. The DON stated, the incident between Residents 1 and 2 should have been reported to CDPH and other required entities within two hours of staff awareness. The DON stated, all staff are mandated reporters and must report allegations of abuse promptly to ensure resident safety and prevent emotional or physical harm. A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation, dated September 2022, indicated, . All reports of resident abuse .are reported to local, state, and federal agencies .immediately .within two hours of an allegation involving abuse or result in serious bodily injury .

Based on interview and record review, the facility failed for one of three sampled residents (Resident 1), to report Resident 1's total right shoulder prosthesis dislocation [the artificial component of a shoulder replacement entirely come out of their proper position], an injury of unknown source, within 2 hours to California Department of Public Health (CDPH) after the facility was made aware of the injury, for one of three sampled residents (Resident 1). This failure had potential to result in further injury for Resident 1, affecting the resident physical, emotional, and psychosocial well-being. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's History and Physical, dated January 24, 2025, indicated Resident 1 had fluctuating capacity to make medical decisions. A review of Resident 1 Admission/Readmission Evaluation/Assessment, dated January 21, 2025, indicated, .Extremities (arms and legs) .No limited ROM (range of motion - a measure of joint function and flexibility) .No Edema (swelling) Present .Resident has no wounds or skin .concerns . A review of Resident 1 Nurse's Note, dated January 27, 2025, indicated, .R (sic) (right) shoulder xray (a test used to take pictures of areas inside the body) d/t (due to) c/o (complaints of) pain and swelling . A review of Resident 1's Radiology Interpretation, dated January 27, 2025, indicated, .Right Shoulder, 2 Views .Impression .Dislodgement of the glenoid fossa portion of the right shoulder prosthesis as well as a dislocation of the total right shoulder . A review of Resident 1's eINTERACT Change in Condition Evaluation, dated January 27, 2025, indicated, .Dislodgement of glenoid fossa portion of R (sic) (right) shoulder prosthesis as well as a dislocation of the total R (right) shoulder prosthesis .Pain, swelling to R (right) shoulder .Sent to ER .Xray: New or unsuspected finding . On February 24, 2025, at 1:56 p.m., during a concurrent interview and review of Resident 1 medical records with Registered Nurse (RN) 1, she stated, any injuries of unknown source should be reported to CDPH, police, and the Ombudsman [resident's advocate who investigates and addresses complaints ensuring their rights and well-being are protected] immediately or within 2 hours after the facility became aware of the injury. RN 1 further stated it was important to report these types of injuries because they could be related to abuse. RN 1 stated on January 27, 2025, during the afternoon shift, Resident 1 was sent to the hospital due to a right shoulder prosthesis dislocation. RN 1 further stated Resident 1's right shoulder dislocation was of unknown source and a sudden event. RN 1 stated Resident 1's injury was not reported to CDPH, police, or the Ombudsman. RN 1 further stated, after the X-ray results were received on January 27, 2025, Resident 1's injury should have been reported within two hours to CDPH to ensure resident safety and prevent any further injuries or abuse. On February 24, 2025, at 3:39 p.m., during a concurrent interview and review of Resident 1's medical records with the Director of Nursing (DON), she stated, Resident 1 was transferred to the hospital on January 27, 2025, due to right shoulder dislocation and prosthesis dislodgement. The DON further stated the facility does not know how Resident 1 dislocated his right shoulder and described it as an injury of unknown source and cause. The DON stated, the facility's process for reporting injuries of unknown source requires notification to the Ombudsman, police, and CDPH within two hours of the facility becoming aware of the injury to rule out abuse. The DON stated, Resident 1's right shoulder dislocation was not reported to CDPH, the Ombudsman, or the police. The DON further stated, Resident 1's injury should have been reported for the resident safety and to rule out any possible abuse. A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated April 2021, indicated, . All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies .Immediately .within two hours . A review of the facility policy and procedure titled, Recognizing Signs and Symptoms of Abuse/Neglect, dated 2021, indicated, .All personnel are expected to report any signs and symptoms of abuse/neglect .immediately .Signs of physical abuse: Injuries that are non-accidental or unexplained .Fractures, dislocations or sprains .

Based on observation, interview and record review, the facility failed to ensure three of 29 residents (Residents 23, 31, and 83) received necessary care and services to achieve and maintain their highest practicable physical, mental, and psychosocial well-being as follows: 1. For Resident 23, the facility failed to ensure staff promptly responded, assessed and provided immediate care and treatment on [DATE], when the resident's pain level increased from ,[DATE] (severe pain) at 8:00 a.m., to level ,[DATE] (very severe/worst pain) at 8:43 a.m., and the resident was displaying signs of respiratory distress without staff intervention. The facility also failed to notify the physician timely of the changes/decline in Resident 23's medical condition. Resident 23 was transported to the acute care hospital approximately nine (9) hours after the resident had a change in condition despite having full-code status (desire to receive all life saving measures). This facility failure resulted in Resident 23 suffering prolonged level 10 pain, worsening difficulty breathing, expression of anxiety and fear, and delay in receiving a higher level of care at the hospital. Resident 23 was treated in the emergency room and later admitted to the hospital with [REDACTED]. If untreated can lead to death), urinary tract infection (UTI- infection of the bladder) and dysuria (pain urination). An Immediate Jeopardy (IJ -A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident) was called on [DATE], at 4:54 p.m. in the presence of the facility Administrator and Director of Nursing (DON). On [DATE], at 4:33 p.m., the Administrator and DON were notified the IJ was removed after the facility submitted an acceptable plan of correction, and began to implement corrective interventions to prevent further occurrences. 2. For Resident 31, the facility staff failed to provide adequate supervision and assistive devices for the resident who had a history of [REDACTED].). This facility failure resulted in Resident 31 falling on [DATE], sustaining a left [MEDICAL CONDITION] (broken hip bone), and requiring hospitalization /surgery. 3. For Resident 83, the facility failed to assess, monitor and revise interventions when the resident refused to wear Ted Hose (long tight fitting stockings that place mild static pressure on the legs to prevent blood clots) and ace wraps (an elastic bandage) to lower extremities to treat [MEDICAL CONDITION] (swelling caused by excess fluid trapped in body tissues). This had the potential to result in painful swelling to the legs and delayed healing of [MEDICAL CONDITION] (a bacterial infection of the skin and tissues beneath the skin) to the right foot. Findings: 1. Resident 23's record was reviewed. The resident was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. ones ability to breathe well). A review of the Physician Orders for Life-Sustaining Treatment (POLST-describes patient wishes and physician orders for medical treatment), dated [DATE], indicated Resident 23 was a full-code (to attempt cardiopulmonary resuscitation (CPR- provide chest compression and rescue breathing if no pulse and not breathing) and full medical treatment including long term artificial nutrition). Resident 23 was alert and able to verbalize her needs. Resident 23's Brief Interview for Mental Status (BIMS - a screening tool used to get a quick snapshot of cognitive functioning at that moment in time) score was 9. (A score between ,[DATE] means moderately impaired, while a score of ,[DATE] means cognitively intact). On [DATE], at 8:43 a.m., Resident 23 was observed in her room, sitting in a wheelchair next to her bed, with her bedside table positioned in front of the wheelchair. Resident 23 was receiving oxygen via nasal cannula (a tube placed in the nostrils to deliver oxygen) at a rate of 3 liters a minute. The end of the tubing was attached to oxygen concentrator (machine). During a concurrent interview, Resident 23 complained of left hip pain. Resident 23 was restless and moving around in her wheelchair, trying to lift herself to a standing position. The resident was asked about her pain level on a scale of ,[DATE] (0-meaning no pain and 10-meaning severe/worst pain). The resident stated her pain level was 10. Resident 23 was asked if she notified the nurse and the resident stated, Not lately. The resident was asked by the Surveyor to put her call light on. The resident stated, Where is it? I don't see it. At 8:44 a.m., the Surveyor called for Certified Nursing Assistant (CNA) 1 to the resident's room. CNA 1 verified the call light was not within reach of the resident, and CNA 1 positioned the call light next to the resident. Resident 23 told CNA 1 she was in a lot of pain. CNA 1 then left the room. At 9:08 a.m., no staff were observed to assist Resident 23 since 8:44 a.m. The resident continued to be restless and moving around in the wheelchair stating she could not get comfortable. Resident 23 stated, I am having lots of pain. Resident 23 stated her pain level was still ,[DATE]. The resident's call light was on with no staff response. Resident 23 then yelled out, I am gasping for breath, please help me. At 9:09 a.m., CNA 2 knocked on the resident's door and stated, Can I help you? Resident 23 told CNA 2 she was in a lot of pain and gasping for air. Resident 23 was mouth breathing in between her speech. CNA 2 told Resident 23 that she (Resident 23) had received pain medication and the next dose was not due until around lunchtime, but he would check with the nurse. CNA 2 then told Resident 23 to call if she need anything. CNA 2 then left the room. Resident 23 was observed mumbling and fidgeting in her wheelchair. At 9:18 a.m., Resident 23 yelled out, I am in a lot of pain, I am in a lot of pain. The resident kept repeating, I am in a lot of pain. I am in a lot of pain. I am sitting on the area in the chair that is hurting. The pain is not going away, maybe if I stand up. Resident 23's call light was on. At approximately 9:21 a.m., CNA 2 responded to the call light. Resident 23 stated she was in a lot of pain and gasping for air. The resident continued to mouth breathe in between her speech. CNA 2 told the resident he could take her to activities to distract her from the pain. CNA 2 asked, Do you want to go to activities? I can take you now. Resident 23 stated, I don't know what to do. I am having terrible pain in my hip. I do not complain much but I am in a lot of pain. CNA 2 stated he would tell the nurse. Resident 23 kept mumbling and fidgeting stating, I am gasping for air, please help me. CNA 2 then left the room. At approximately 9:27 a.m., Resident 23 got louder, yelling out that she was in a lot of pain. Resident 23 was gasping for breaths during periods of yelling out. Her head was moving up and down. Her fists were clenched and her arms were shaking. Resident yelled out, Oh God, help me. I'm scared. The Surveyor summoned CNA 2 from across the hall to come into the resident's room. CNA 2 told Resident 23 the nurse would bring her pain medication. Resident 23 stated, I am gasping for breath. Resident 23 asked CNA 2 for a number to call for help. CNA 2 gave resident a piece of paper. At approximately 9:32 a.m., LVN 1 entered the room and asked Resident 23 where her pain was. Resident 23 stated her rear end and hip was hurting. Observed Resident 23's head moving up and down as she talked, and opening her mouth to catch her breath while talking. LVN 1 told the resident the CNA would put her to bed so he could assess the area. LVN 1 then left the room. (This was the first time LVN 1 came into the room since 8:43 a.m.) At approximately 9:34 a.m., CNA 2 entered the room and told Resident 23 that he was putting her to bed. Resident 23 stated, Don't let me lie down, I am gasping for air. The resident asked CNA 2 to open the window so fresh air could come in and she could breathe. Resident 23 stated, I am scared, I am gasping for breath. CNA 2 told the resident to try and stay calm and then left the room. At approximately 9:37 a.m., CNA 3 knocked and entered the resident's room. CNA 3 stated he was there to change the resident's oxygen tubing. CNA 3 walked over to resident and replaced the oxygen tubing. Resident 23 stated, I am gasping for breath, please help me. CNA 3 then left the room. At approximately 9:42 a.m., the Surveyor observed Resident 23's breathing becoming more labored. Resident 23 was swaying back and forth with her arms flailing (moving about wildly), appearing to have a frantic expression and verbalizing ongoing complaints of being fearful. The Surveyor went to nurse's station and requested assistance from a licensed nurse to help Resident 23. LVN 2 stated he would get LVN 1, the resident's assigned nurse. LVN 1 and CNA 3 came into Resident 23's room. LVN 1 placed a respiratory mask (oxygen mask that covers the nose and mouth) on the resident's face, connected the mask to a nebulizer machine (a medical device that turns liquid medicine into a mist to help patient breathe) and then left the room. From approximately 9:42 a.m. to 9:49 a.m., the Surveyor observed Resident 23 taking off the mask and placing the mask on the bed. The resident kept saying, Please help me, please help me, I am scared, don't leave me. The resident was observed to not receive the breathing medication coming from the nebulizer machine. At approximately 9:49 a.m., LVN 1 returned to the resident's room and asked the resident why she took the mask off. LVN 1 then reapplied the mask and stayed with the resident until her breathing treatment had completed. At approximately 9:53 a.m., LVN 1 stated to the resident, Your oxygen level went up to 94%. LVN 1 asked the resident how she felt and the resident stated she was breathing better. An interview was conducted with LVN 1 on [DATE], at 11:18 a.m. LVN 1 was asked what the expectation was for responding to a resident that was complaining of ,[DATE] pain and gasping for air. LVN I stated Resident 23 was medicated at 8 a.m. for a level ,[DATE] pain. Informed LVN 1 that at 8:43 a.m., Resident 23 began complaining of level ,[DATE] pain, and at 9:08 a.m. the resident was gasping for air. LVN 1 stated the CNAs did not tell him (LVN 1) about Resident 23's respiratory distress. LVN 1 was asked if Resident 23 experienced this kind of episode frequently. LVN 1 stated No, but the resident gets confused. During the same interview with LVN 1, Resident 23's Medication Administration Record [REDACTED]. The resident had orders to receive [MEDICATION NAME] (medication to improve breathing) every 4 hours routine, and every 4 hours as needed (prn) for shortness of breath (SOB). LVN 1 stated Resident 23's oxygen saturation level (amount of oxygen in the blood) was 96% at 8:00 a.m. (Normal levels range from 95 to 100%). LVN was asked what the acceptable oxygen saturation level was for Resident 23. LVN 1 stated 90% and over was okay. LVN 1 was asked what happens when the oxygen saturation level was 91% and resident was having problems breathing. LVN 1 responded, You give the prn [MEDICATION NAME]. LVN 1 further stated Resident 23 was given routine [MEDICATION NAME] (a narcotic pain medication used to treat severe pain) ,[DATE] milligrams (mg) for level ,[DATE] (severe) left hip pain, and [MEDICATION NAME] breathing medication at 8:00 a.m. On [DATE], at 11:42 a.m., an interview was conducted with LVN 3. LVN 3 was asked if she was aware of Resident 23's pain and breathing difficulty that occurred earlier. LVN 3 stated, No. LVN 3 was asked what the expectation was for licensed nurses to respond to a resident experiencing level ,[DATE] pain, and progressive/prolonged respiratory distress. LVN 3 stated the licensed nurse should respond right away and render necessary service. During the same interview at approximately 11:50 a.m., Resident 23 was observed without oxygen in place, and a staff was wheeling the resident past the nurse's station and down the hallway towards the resident's room. LVN 3 acknowledged Resident 23 did not have oxygen on (despite a physician's order for the resident to be on continuous oxygen at 3 liters/minute). On [DATE] at 2:57 p.m., the survey team identified an Immediate Jeopardy (IJ - A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident) due to changes in Resident 23's condition, for complaints of severe level ,[DATE] pain and signs of respiratory distress, without prompt nursing response, assessment and intervention. On [DATE], at 4:54 p.m., an IJ was called in the presence of the Administrator and Director of Nursing (DON) related to Resident 23's change of condition for complaints of severe level ,[DATE] pain and signs of respiratory distress, without prompt nursing response, assessment and intervention. On [DATE], at 6:55 p.m., the following Plan of Action was received by the Administrator and DON and was acceptable. The Plan of Action included sending Resident 23 to the acute hospital for evaluation, RN assessments to be performed of other residents with respiratory conditions, pain and use of oxygen, notifying the physician or Medical Director as necessary, inservicing licensed nurses and CNAs, ongoing monitoring of the residents' conditions, ongoing staff education and review of staff competency, compliance review by the DON during weekly meeting with licensed nurses, and with the Medical Director during quarterly Quality Assurance Meetings. An interview was conducted on [DATE], at 5:05 p.m., with LVN 3, the day shift charge nurse. Stated she did not notify Resident 23's physician of the resident's change of condition because, She gets like this sometimes. LVN 3 stated she did not feel it was a sudden change of condition that needed to be reported to the physician. LVN 3 stated LVN 1 told her the resident, Gets like that if she has too many people around. LVN 3 stated she did not complete a change of condition report, or notified anyone of the incident because she did not feel it was an unusual incident that required special attention for Resident 23. On [DATE], at 6:30 p.m., a second interview was conducted with LVN 3. She stated Resident 23 was assessed by Registered Nurse 1 (RN) at approximately 5:50 p.m., and the resident complained of shortness of breath (SOB). LVN 3 stated the resident's oxygen saturation level was between 85% - 88%. LVN 3 stated Resident 23 was transported to the emergency room via 911 (emergency response) transport for evaluation and treatment. (This was approximately nine hours after Resident 23 experienced the first episode of SOB on [DATE], at 9:08 a.m.) A review of Resident 23's Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. A review of the hospital's Emergency Department Record, dated [DATE], at 6:43 p.m., indicated Resident 23 was diagnosed with [REDACTED]. It can be caused by not being able to breathe properly, not getting enough fresh oxygen into the lungs or getting rid of carbon [MEDICATION NAME]). A review of the acute hospital's, Admission History and Physical, dated [DATE], indicated Resident 23 was diagnosed with [REDACTED]. Resident 23 was admitted to the hospital for further evaluation and treatment. An interview was conducted with RN 1 on [DATE], at 3:45 p.m. regarding Resident 23. RN 1 stated she was not made aware of Resident 23's pain and respiratory distress on [DATE], until after the IJ was called. RN 1 stated LVN 1 should have notified the RN Supervisor in charge to assess the resident and direct the resident's care. RN 1 stated RN 4 was the supervisor in charge on on [DATE], at the time of Resident 23's change in condition. An interview was conducted with the Director of Nursing (DON) on [DATE], at approximately 4:15 p.m. The DON stated she was not made aware of Resident 23's condition until the IJ was called. The DON stated the LVNs should have responded immediately and notify the RN to assess the resident. The DON stated the resident's physician should have been notified right away regarding the resident's change of condition, and transported the resident out to the acute hospital. The DON stated the LVN should have stayed with the resident. The following care plans for Resident 23 were reviewed and indicated the following: a. Ineffective airway clearance/potential for SOB (shortness of breath) associated with [DIAGNOSES REDACTED]. (Initiated [DATE]). Interventions included: Monitor for episodes of SOB and be present to render support to prevent anxiety if episode of SOB occurs. Monitor for restlessness, [MEDICAL CONDITION](fast heart rate), and anxiety related to use of [MEDICATION NAME] (breathing medication). b. Potential for alteration in comfort secondary to pain.(Initiated [DATE]) Interventions included: Assess pain symptoms, identify frequency, location, quality, onset and manner of expressing pain. Monitor effectiveness of non-pharmacologic interventions and pain medications. Notify MD (physician) of increasing pain or condition change(s). Monitor pain level every shift; rate ,[DATE]/being worst pain (,[DATE] = mild, ,[DATE] = moderate, ,[DATE] = severe, ,[DATE] = very severe) c. Potential for SOB, chest pain, irregular pulse and elevate blood pressure related to heart problems. (initiated [DATE]) Interventions included: Be present to render support to prevent anxiety if SOB occurs (LVN/RN), Monitor for episodes of SOB and notify MD accordingly (LVN/RN). Oxygen at 3 liters per minute via nasal cannula continuously every shift. On [DATE], at 4:25 p.m., the facility's Plan of Action (accepted on [DATE]) was reviewed with the Administrator and the DON present. The facility showed documentation of progress towards completing staff in-services and resident assessments. On [DATE] at 4:33 p.m., the Administrator and DON were notified the IJ was removed. An interview was conducted on [DATE], at 9:18 a.m., via telephone with Resident 23's Physician. The Physician stated Resident 23 was fragile with unique medical diagnoses/allergies [REDACTED]. The Physician stated he was not notified on [DATE], of Resident 23's change of condition. The Physician stated the expectation was the licensed staff should immediately provide needed medical care and contact the physician, or Medical Director if the physician was not available. An interview was conducted on [DATE], at 9:36 a.m., via telephone with the Respiratory Therapist (RT). RT stated she was familiar with Resident 23, who had been on respiratory service in the past. RT stated staff should have addressed the resident's concerns right away, evaluated the causes of pain and anxiety, stayed with the resident and calmed her down, and completed a physical assessment. An interview was conducted on [DATE], at 10:05 a.m. with RN 4 who was on duty [DATE], at the time of Resident 23's change of condition. RN 4 stated on [DATE], he was not notified by the nursing staff of Resident 23's SOB or change in condition. 2. The record for Resident 31 was reviewed. Resident 31 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS - a comprehensive screening assessment) completed [DATE], indicated Resident 31 had a decline in her Brief Interview for Mental Status (BIMS - evaluate thinking, reasoning, memory status) from a score of 13 to 12. (,[DATE] means cognitively intact; ,[DATE] means moderately impaired). The resident also declined from limited assistance with bed mobility, transfers and walking in room and corridor to extensive assistance with one person physical assist. A review of the Fall Risk Assessment completed [DATE], indicated the resident had intermittent confusion and balance problems when standing. The resident required use of assistive devices (wheel chair, walker) and was chair bound. Resident 31's fall risk score was 17. (A score of 10 and above meant the resident was risk for falls). An interview was conducted with Registered Nurse (RN) 1 on [DATE], at 10:50 a.m., who stated she investigated Resident 31's fall on [DATE]. RN 1 stated Licensed Vocational Nurse (LVN) 1 medicated Resident 31 a few minutes prior to the fall, and was two door down when he heard a thud and the resident yelling. RN 1 stated Resident 31 was returning from the bathroom and fell . RN 1 stated the resident should have called for assistance. RN 1 stated the resident complained of extreme pain in left extremity (leg). RN 1 further stated on [DATE], (prior to fall) Resident 31 was independent walking in her room with supervision only and no physical assistance from staff. An interview was conducted on [DATE], at 12:25 p.m. with Registered Nurse (RN) 1. RN 1 stated the fall was unwitnessed but it was seen on facility's video surveillance camera. RN 1 stated she viewed the video after the fall occurred and it appeared that Resident 31 was coming out of the bathroom and fell near the doorway. RN 1 stated Resident 31 was not using the call light to call for help due to the resident's confusion, and the resident would get up by herself so the bed alarm was implemented to alert staff to the resident's movement. RN 1 stated the bed alarm increased Resident 31's confusion because when the alarm sounded the resident thought it was a telephone ringing and the resident would look all over for it. RN 1 further stated this was upsetting to the resident and the resident began turning off the alarm. RN 1 was asked if staff were aware Resident 31 was turning off the alarm. RN 1 stated, Yes, staff were to check the alarm status frequently. RN 1 was asked what new interventions were implemented once Resident 31 began turning off the alarm. RN 1 stated after the the resident's fall and return from the hospital, the bed alarm was discontinued. Staff were to provide more frequent visual checks, and staff education was provided. RN 1 further stated the alarm did not sound at the time of the fall because the resident had turned it off. RN 1 did not indicate any new interventions were implemented prior to the resident's fall and [MEDICAL CONDITION] once staff became aware that Resident 31 was turning off the alarm. A review of the Certified Nursing Assistant (CNA) daily flow sheets from [DATE] to 17, 2017, was conducted with RN 1. The flow sheets indicated Resident 31's mobility and ambulation in her room varied over different shifts from requiring supervision only, requiring physical assist of staff, to independently walking in room. The CNA flow sheets also indicated the resident's transferring ability varied from requiring supervision only to independent with no help from staff. A review of the licensed nursing notes completed by LVN 1, who was assigned to care for Resident 31 at the time of her fall on [DATE], indicated at 0645 (6:45 a.m.) heard a thud and a scream from (resident's room), went and investigate and found resident lying on her right side by the doorway. Upon assessment, resident noted in fetal position, holding her left leg and appears in pain and crying. When asked what happened resident unable to recall how she fell . Resident has difficulty moving her left leg and was screaming in pain when touched. Resident was not moved from present position because of possible body injury. 911 was called. The nursing notes further indicated the physician was called, and Resident 31 was transferred to the hospital on [DATE], at 7:05 a.m. An interview was conducted on [DATE], at 10:18 a.m. with RN 2 and LVN 5, (MDS Coordinators). RN 2 stated the Significant Change MDS completed on [DATE], was due to Resident 31's decline in BIMS score from 13 to 12, and decline in transfers and walking from limited assistance to extensive assist with one person physical assist. RN 2 and LVN 5 stated they were not aware Resident 31 was turning off the alarm. The following care plans in place prior to the fall were reviewed with LVN 2: a. At risk for falls or injuries: related to impaired physical mobility; Use of [MEDICAL CONDITION] (medications to treat mood and behavior) medications; history falls - 2 X (times) past 6 months. [DATE] resident found lying on floor-trying to go to BR and lost her balance. Goal: No fall with injury in next 3 months. Interventions included: Bed alarm for safety. Educate and remind resident to utilize call light when in need of assistance prior to attempting to self-transfer for safety purposes. Educate and remind staff for checking of alarms as ordered and replacement as indicated for any alarm malfunctions. Ensure safe transfers at all possible times. Place call lights within reach of the resident. Low bed for safety. W/C alarm for safety. Remind resident to call for assistance. There were no documentation of any new interventions implemented on the care plan addressing Resident 31 turning off the alarms. b. Altered thought process: Compromised memory recall ability and impaired decision making ability as manifested by: forgetfulness, noted intermittent confusion and disorientation (BIMS: ,[DATE]). Goal: Resident will maintain sense of identity by being able to state name when asked X 3 months. There were no documented evidence the care plan was revised with new interventions after the MDS completed on [DATE], indicated a decline in BIMS score from 13 to 12. An interview was conducted on [DATE], at approximately 8:30 a.m. with the restorative nursing aide (RNA) 1. She stated she was familiar with Resident 31 and provided care to her prior to the fall. RNA 1 stated Resident 31 walked with walker and stand by assist. Resident 31 was alert but forgetful. RNA 1 further stated Resident 31 had a bed and chair alarm. RNA 1 further stated she was not aware Resident 31 was turning off the alarms. An interview was conducted on [DATE], at 11:25 a.m., with LVN 1, who was assigned to care for Resident 31 at the time of her fall on [DATE]. LVN 1 stated on [DATE], at 6:35 a.m., he left Resident 31 sitting on the side of the bed after he administered her medication. LVN 1 stated he was two doors down from the resident's room when at 6:45 a.m., he heard a thump and the resident scream. Went to the room and found Resident 31 on the floor. LVN 1 stated he did not hear the bed alarm sound. LVN 1 stated he knew there was a problem with the bed alarm; the resident would become agitated when alarm went off. LVN 1 stated he was not aware the resident turned off the alarm. LVN 1 stated prior to the fall, Resident 31 would call when she needed to go to the bathroom or would walk to the bathroom by herself. LVN 1 further stated Resident 31 complained of pain on a scale of ,[DATE] (meaning worst/severe pain) after the fall. An interview was conducted with certified nursing assistant (CNA) 4 on [DATE], at 8:02 a.m. CNA 4 stated she was familiar with Resident 31, and was assigned to care for the resident at the time of the fall on [DATE]. CNA 4 stated the resident could go to bathroom with assistance. CNA 4 further stated Resident 31 would remove the alarm from under the mattress and pull the wires apart (causing the alarm not to sound when the resident got up). A review of the facility policy and procedure titled, Fall Prevention Program, dated amended on [DATE], indicated the following documentation: Policy: Each resident shall be assessed for propensity for falls and each resident shall be with adequate supervision and assistance devices as necessary to prevent accidents. Procedures: .1. Each resident shall be comprehensively assessed by the IDT (Interdisciplinary Team) for predisposition for falling and the assessment shall be documented in the FALL ASSESSMENT FORM and in the MDS. Each resident shall be assessed initially upon admission, quarterly thereafter and as often as necessary .7. Based on the comprehensive assessments, a plan of care shall be developed by the IDT for each resident to prevent falls .11. Residents assessed to be high risk for fall and appropriate for use of wheelchair alarms, bed alarms, perimeter mat will be ordered. The use of wheelchair alarms, bed alarms, and as needed perimeter mat will be assessed quarterly by the IDT .14. Residents with physician orders for the use of perimat (perimeter mat- place around the resident's bed), bed or wheelchair alarms will be entered in the point of care -HER (electronic health record) and signed for by CNA (Certified Nursing Assistant) assigned, to make sure that it has been properly applied and the alarms are properly working. 3. A review of the Resident 83's record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. for blood and oxygen), [MEDICAL CONDITION] ([MEDICAL CONDITION]- a lung disease that obstructs the lung airflow and interferes with breathing), dependent on oxygen and [MEDICAL CONDITION] to right lower leg. A review of the Minimum Data Set (MDS - a comprehensive assessment of the resident) dated [DATE], indicated Resident 83's Brief Interview for Mental Status (BIMS - evaluates thinking, reasoning, memory status) score was 9 (,[DATE] means moderately impaired; ,[DATE] means cognitively intact). Resident 83 was dependent on staff and required two person physical assist for transfers. Resident was Spanish speaking an(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure an effective Quality Assessment and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) plan was in placed for identifying and responding to resident care concerns, by implementing, monitoring, and evaluating action plans for pain management, respiratory care, and answering call lights. This failure put multiple residents' health and safety at risk including delayed and inappropriate provision of care and treatment for [REDACTED]. Findings: During the course of the facility survey on December 11-19, 2017, multiple residents with care concerns were observed regarding appropriate provision of respiratory care, pain management and answering call light promptly. On December 18, 2017, at 9:56 a.m., a review of facility documents such as the QAPI/QAA meeting minutes and Resident Census and Conditions of Residents (Form CMS-672) was conducted with the Quality Assurance (QA) Nurse/Registered Nurse (RN) 1. The committee meeting minutes dated July 19, 2017 and October 25, 2017, was attended by the Interdisciplinary Team including QA Nurse/RN 1, Physician/Medical Director, Director of Nursing (DON), Administrator, Pharmacy Consultant, and department heads for Dietary, Social Services, Activities, and Maintenance. The documents indicated 35 of 121 residents were receiving respiratory care such as continuous and as needed (PRN) oxygen therapy and inhalation treatment. In addition, 45 of 121 residents were on pain management program such as routine and/or PRN administration of narcotic (potent pain medication) and/or non-narcotic pain medication. There was no current program plan developed and implemented for pain management, respiratory care and answering call lights promptly. A concurrent interview with QA Nurse/RN 1 regarding the facility's QAPI program was conducted. QA Nurse/RN 1 stated her responsibility as the head of the QAPI/QAA committee included making sure all potential resident care concerns and problems were identified and action plans developed, implemented and evaluated. QA Nurse/RN 1 stated the facility had developed and was currently implementing improvement programs for fall prevention of all residents residing in the facility. QA Nurse/RN 1 was asked if there was written evidence the QAPI/QAA team had identified potential concerns/problems of residents for pain management, respiratory care, and promptly answering call lights. QA Nurse/RN 1 stated, No and acknowledged there was no current program plan developed for pain management, respiratory care and answering call lights promptly.

Based on interview and record review, the facility failed to ensure accurate documentation, ongoing pain assessments, and pain management was being provided for three of 29 sampled residents (Residents 102, 23, and 322) to address the pain management needs of the residents. This failed practice had the potential for the residents to have unrelieved and/or uncontrollable pain, and lack of individualized resident centered pain control care plans to meet the specific needs of the residents. Findings: 1. A review of Resident 102's medical record was conducted. Resident 102 was readmitted to the facility October 22, 2017. Resident 102's [DIAGNOSES REDACTED]. Further review of Resident 102's medical record indicated a physician order [REDACTED]. A review of the medication administration records (MARs) for the months of November and December 2017, indicated for November 2017, the pain level documented for Resident 102 was zero (indicating no pain). For December 1 through December 12, 2017, the pain level was zero (indicating no pain); however, the facility continued to administer [MEDICATION NAME] 10-325 mg four times a day to Resident 102. Additional review of the NMAR (narcotic MAR) dated November 30, 2017, through December 13, 2017, indicated a Pre-Analysis Pain Scale of zeros (indicating no pain); however, the facility continued to administer [MEDICATION NAME] four times a day to Resident 102. In an interview with Resident 102 on December 12, 2017, at 11 a.m., Resident 102 stated he was in pain with a pain scale of 7/10 (meaning severe pain). The Resident stated he received the pain medication four times a day because he was always in pain. In an interview and a concurrent record review with Licensed Vocational Nurse (LVN 10) on December 12, 2017, at 12 p.m., LVN 10 stated he gave Resident 102 [MEDICATION NAME] 10-325 mg. The LVN was asked if the resident was in pain. LVN 10 stated Resident 102 was in pain; however, LVN 10 documented no pain for Resident 102 on the MAR and a pain level of 1 on the NMAR. LVN 10 reviewed the MAR and the NMAR and confirmed the information on the MARs and the NMAR did not accurately reflect Resident 102's pain levels. A concurrent interview and record review was conducted with the Minimum Data Set Nurses (MDS 1 and MDS 2) on December 15, 2017, at 4:30 p.m. MDS 1 and 2 reviewed the MARs for November 2017 and December 2017, and the NMAR dated November 30, 2017, through December 13, 2017. MDS 2 confirmed that the information on the MARs and the NMAR did not accurately reflect Resident 102's pain levels. MDS 1 further stated if the pre-and post-assessments were zeros for a month, Resident 102's Physician should have been called to consider tapering or discontinuing the pain medication. There was no documentation in Resident 102's record indicating tapering or discontinuing the pain medication since the resident was no longer in pain according to the pain assessment. The facility's undated policy and procedure titled, Pain and Behavior Management Program, was reviewed. The policy indicated, Every shift the nurse will document on pain flow sheet the effectiveness of pain management. 2. Resident 23's record was reviewed. The resident was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. ones ability to breathe well). A review of the Physician order [REDACTED]. Resident 23 was alert and able to verbalize her needs. Resident 23's Brief Interview for Mental Status (BIMS - a screening tool used to get a quick snapshot of cognitive functioning at that moment in time) score was 9. (A score between 8-12 means moderately impaired, while a score of 13-15 means cognitively intact). On December 14, 2017, at 8:43 a.m., Resident 23 was observed in her room, sitting in a wheelchair next to her bed, with her bedside table positioned in front of the wheelchair. Resident 23 was receiving oxygen via nasal cannula (a tube placed in the nostrils to deliver oxygen) at a rate of 3 liters a minute. The end of the tubing was attached to oxygen concentrator (machine). During a concurrent interview, Resident 23 complained of left hip pain. Resident 23 was restless and moving around in her wheelchair, trying to lift herself to a standing position. The resident was asked about her pain level on a scale of 0-10 (0-meaning no pain and 10-meaning severe/worst pain). The resident stated her pain level was 10. Resident 23 was asked if she notified the nurse and the resident stated, Not lately. The resident was asked by the Surveyor to put her call light on. The resident stated, Where is it? I don't see it. At 8:44 a.m., the Surveyor called for Certified Nursing Assistant (CNA) 1 to the resident's room. CNA 1 verified the call light was not within reach of the resident, and CNA 1 positioned the call light next to the resident. Resident 23 told CNA 1 she was in a lot of pain. CNA 1 then left the room. At 9:08 a.m., no staff were observed to assist Resident 23 since 8:44 a.m. The resident continued to be restless and moving around in the wheelchair stating she could not get comfortable. Resident 23 stated, I am having lots of pain. Resident 23 stated her pain level was still 10/10. The resident's call light was on with no staff response. Resident 23 then yelled out, I am gasping for breath, please help me. At 9:09 a.m., CNA 2 knocked on the resident's door and stated, Can I help you? Resident 23 told CNA 2 she was in a lot of pain and gasping for air. Resident 23 was mouth breathing in between her speech. CNA 2 told Resident 23 that she (Resident 23) had received pain medication and the next dose was not due until around lunchtime, but he would check with the nurse. CNA 2 then told Resident 23 to call if she need anything. CNA 2 then left the room. Resident 23 was observed mumbling and fidgeting in her wheelchair. At 9:18 a.m., Resident 23 yelled out, I am in a lot of pain, I am in a lot of pain. The resident kept repeating, I am in a lot of pain. I am in a lot of pain. I am sitting on the area in the chair that is hurting. The pain is not going away, maybe if I stand up. Resident 23's call light was on. At approximately 9:21 a.m., CNA 2 responded to the call light. Resident 23 stated she was in a lot of pain and gasping for air. The resident continued to mouth breathe in between her speech. CNA 2 told the resident he could take her to activities to distract her from the pain. CNA 2 asked, Do you want to go to activities? I can take you now. Resident 23 stated, I don't know what to do. I am having terrible pain in my hip. I do not complain much but I am in a lot of pain. CNA 2 stated he would tell the nurse. Resident 23 kept mumbling and fidgeting stating, I am gasping for air, please help me. CNA 2 then left the room. At approximately 9:27 a.m., Resident 23 got louder, yelling out that she was in a lot of pain. Resident 23 was gasping for breaths during periods of yelling out. Her head was moving up and down. Her fists were clenched and her arms were shaking. Resident yelled out, Oh God, help me. I'm scared. The Surveyor summoned CNA 2 from across the hall to come into the resident's room. CNA 2 told Resident 23 the nurse would bring her pain medication. Resident 23 stated, I am gasping for breath. Resident 23 asked CNA 2 for a number to call for help. CNA 2 gave resident a piece of paper. At approximately 9:32 a.m., LVN 1 entered the room and asked Resident 23 where her pain was. Resident 23 stated her rear end and hip was hurting. Observed Resident 23's head moving up and down as she talked, and opening her mouth to catch her breath while talking. LVN 1 told the resident the CNA would put her to bed so he could assess the area. LVN 1 then left the room. (This was the first time LVN 1 came into the room since 8:43 a.m.) At approximately 9:34 a.m., CNA 2 entered the room and told Resident 23 that he was putting her to bed. Resident 23 stated, Don't let me lie down, I am gasping for air. The resident asked CNA 2 to open the window so fresh air could come in and she could breathe. Resident 23 stated, I am scared, I am gasping for breath. CNA 2 told the resident to try and stay calm and then left the room. At approximately 9:37 a.m., CNA 3 knocked and entered the resident's room. CNA 3 stated he was there to change the resident's oxygen tubing. CNA 3 walked over to resident and replaced the oxygen tubing. Resident 23 stated, I am gasping for breath, please help me. CNA 3 then left the room. At approximately 9:42 a.m., the Surveyor observed Resident 23's breathing becoming more labored. Resident 23 was swaying back and forth with her arms flailing (moving about wildly), appearing to have a frantic expression and verbalizing ongoing complaints of being fearful. The Surveyor went to nurse's station and requested assistance from a licensed nurse to help Resident 23. LVN 2 stated he would get LVN 1, the resident's assigned nurse. LVN 1 and CNA 3 came into Resident 23's room. LVN 1 placed a respiratory mask (oxygen mask that covers the nose and mouth) on the resident's face, connected the mask to a nebulizer machine (a medical device that turns liquid medicine into a mist to help patient breathe) and then left the room. From approximately 9:42 a.m. to 9:49 a.m., the Surveyor observed Resident 23 taking off the mask and placing the mask on the bed. The resident kept saying, Please help me, please help me, I am scared, don't leave me. The resident was observed to not receive the breathing medication coming from the nebulizer machine. At approximately 9:49 a.m., LVN 1 returned to the resident's room and asked the resident why she took the mask off. LVN 1 then reapplied the mask and stayed with the resident until her breathing treatment had completed. At approximately 9:53 a.m., LVN 1 stated to the resident, Your oxygen level went up to 94%. LVN 1 asked the resident how she felt and the resident stated she was breathing better. An interview was conducted with LVN 1 on December 14, 2017, at 11:18 a.m. LVN 1 was asked what the expectation was for responding to a resident that was complaining of 10/10 pain and gasping for air. LVN I stated Resident 23 was medicated at 8 a.m. for a level 7/10 pain. Informed LVN 1 that at 8:43 a.m., Resident 23 began complaining of level 10/10 pain, and at 9:08 a.m. the resident was gasping for air. LVN 1 stated the CNAs did not tell him (LVN 1) about Resident 23's respiratory distress. LVN 1 was asked if Resident 23 experienced this kind of episode frequently. LVN 1 stated No, but the resident gets confused. During the same interview with LVN 1, Resident 23's Medication Administration Record (MAR) was reviewed. LVN 1 stated Resident 23 was on continuous oxygen at 3 liters a minute. The resident had orders to receive [MEDICATION NAME] (medication to improve breathing) every 4 hours routine, and every 4 hours as needed (prn) for shortness of breath (SOB). LVN 1 stated Resident 23's oxygen saturation level (amount of oxygen in the blood) was 96% at 8:00 a.m. (Normal levels range from 95 to 100%). LVN was asked what the acceptable oxygen saturation level was for Resident 23. LVN 1 stated 90% and over was okay. LVN 1 was asked what happens when the oxygen saturation level was 91% and resident was having problems breathing. LVN 1 responded, You give the prn [MEDICATION NAME]. LVN 1 further stated Resident 23 was given routine [MEDICATION NAME] (a narcotic pain medication used to treat severe pain) 5/325 milligrams (mg) for level 7/10 (severe) left hip pain, and [MEDICATION NAME] breathing medication at 8:00 a.m. On December 14, 2017, at 11:42 a.m., an interview was conducted with LVN 3. LVN 3 was asked if she was aware of Resident 23's pain and breathing difficulty that occurred earlier. LVN 3 stated, No. LVN 3 was asked what the expectation was for licensed nurses to respond to a resident experiencing level 10/10 pain, and progressive/prolonged respiratory distress. LVN 3 stated the licensed nurse should respond right away and render necessary service. During the same interview at approximately 11:50 a.m., Resident 23 was observed without oxygen in place, and a staff was wheeling the resident past the nurse's station and down the hallway towards the resident's room. LVN 3 acknowledged Resident 23 did not have oxygen on (despite a physician's orders [REDACTED]. An interview was conducted on December 14, 2017, at 5:05 p.m., with LVN 3, the day shift charge nurse. Stated she did not notify Resident 23's physician of the resident's change of condition because, She gets like this sometimes. LVN 3 stated she did not feel it was a sudden change of condition that needed to be reported to the physician. LVN 3 stated LVN 1 told her the resident, Gets like that if she has too many people around. LVN 3 stated she did not complete a change of condition report, or notified anyone of the incident because she did not feel it was an unusual incident that required special attention for Resident 23. On December 14, 2016, at 6:30 p.m., a second interview was conducted with LVN 3. She stated Resident 23 was assessed by Registered Nurse 1 (RN) at approximately 5:50 p.m., and the resident complained of shortness of breath (SOB). LVN 3 stated the resident's oxygen saturation level was between 85% - 88%. LVN 3 stated Resident 23 was transported to the emergency room via 911 (emergency response) transport for evaluation and treatment. (This was approximately nine hours after Resident 23 experienced the first episode of SOB on December 14, 2017, at 9:08 a.m.) A review of Resident 23's Medication Administration Record (MAR) indicated from December 1 to 14, 2017, the resident's oxygen saturation levels averaged between 90-96% with routine breathing treatments. Review of the MAR indicated an order dated November 13, 2017, to administer [MEDICATION NAME] 5-325 mg, one tablet two times per day routinely for pain management at 8 a.m. and 5 p.m. An order dated November 29, 2017, indicated to administer [MEDICATION NAME] 5-325 mg one table every 8 hours as needed (prn) for very severe pain (8-10). A review of the hospital's Emergency Department Record, dated December 14, 2017, at 6:43 p.m., indicated Resident 23 was diagnosed with [REDACTED]. It can be caused by not being able to breathe properly, not getting enough fresh oxygen into the lungs or getting rid of carbon [MEDICATION NAME]). A review of the acute hospital's, Admission History and Physical, dated December 15, 2017, indicated Resident 23 was diagnosed with [REDACTED]. Resident 23 was admitted to the hospital for further evaluation and treatment. An interview was conducted with RN 1 on December 15, 2017, at 3:45 p.m. regarding Resident 23. RN 1 stated she was not made aware of Resident 23's pain and respiratory distress on December 14, 2017, until after approximately 4:54 p.m. RN 1 stated LVN 1 should have notified the RN Supervisor in charge to assess the resident and direct the resident's care. RN 1 stated RN 4 was the supervisor in charge on on December 14, 2017, at the time of Resident 23's change in condition. An interview was conducted with the Director of Nursing (DON) on December 15, 2017, at approximately 4:15 p.m. The DON stated she was not made aware of Resident 23's condition on December 14, 2017, until approximately 4:54 p.m. The DON stated the LVNs should have responded immediately and notified the RN to assess the resident. The DON stated the resident's physician should have been notified right away regarding the resident's change of condition, and transported the resident out to the acute hospital. The DON stated the LVN should have stayed with the resident. The following care plans for Resident 23 were reviewed and indicated the following: a. Ineffective airway clearance/potential for SOB (shortness of breath) associated with [DIAGNOSES REDACTED]. (Initiated 7/7/16). Interventions included: Monitor for episodes of SOB and be present to render support to prevent anxiety if episode of SOB occurs. Monitor for restlessness, [MEDICAL CONDITION](fast heart rate), and anxiety related to use of [MEDICATION NAME] (breathing medication). b. Potential for alteration in comfort secondary to pain.(Initiated 7/7/16) Interventions included: Assess pain symptoms, identify frequency, location, quality, onset and manner of expressing pain. Monitor effectiveness of non-pharmacologic interventions and pain medications. Notify MD (physician) of increasing pain or condition change(s). Monitor pain level every shift; rate 0-10/being worst pain (1-2 = mild, 3-5 = moderate, 6-8 = severe, 9-10 = very severe) c. Potential for SOB, chest pain, irregular pulse and elevate blood pressure related to heart problems. (initiated 7/6/16) Interventions included: Be present to render support to prevent anxiety if SOB occurs (LVN/RN), Monitor for episodes of SOB and notify MD accordingly (LVN/RN). Oxygen at 3 liters per minute via nasal cannula continuously every shift. An interview was conducted on December 18, 2017, at 9:18 a.m., via telephone with Resident 23's Physician. The Physician stated Resident 23 was fragile with unique medical diagnoses/allergies [REDACTED]. The Physician stated he was not notified on December 14, 2017, of Resident 23's change of condition. The Physician stated the expectation was the licensed staff should immediately provide needed medical care and contact the physician, or Medical Director if the physician was not available. 3. On December 13, 2017, at 4:05 p.m., Resident 322 was observed lying in bed. In a concurrent interview with Resident 322, the resident was asked if he was able to attend activities. Resident 322 stated he could not attend activities when he could not transfer to the wheelchair due to pain on both knees. Resident 322's record was reviewed. Resident 322 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician order [REDACTED]. The physician order [REDACTED]. QD (daily)/BID (twice a day) 6/(per)WK (week) X 30 DAYS . The document titled, PT DAILY TREATMENT NOTE, dated November 30, 2017, indicated, .PPt (patient/resident) c/o (complain of) constant pain on both knees; right worse than the left. States that left knee is 5/10 (moderate pain) and right knee is 8-9/10 pain (severe pain). He was provided pain medication prior to PT evaluation and treatment but still c/o pain on both knees. He is unable to tolerate standing well and is unable to ambulate d/t (due to) pain on both knees. On December 13, 2017, at 4:08 p.m., the Occupational Therapist (OT) was interviewed. OT stated Resident 322 had been medicated for pain prior to therapy. OT stated Resident 322 was still complaining of pain during therapy. OT further stated pain medication was not helping. On December 14, 2017, at 10:36 a.m., Licensed Vocational Nurse (LVN) 15 was interviewed. LVN 15 stated Resident 322 had his therapy usually in the morning. LVN 15 stated he administered Tylenol (pain medication) two tablets prior to therapy. LVN 15 stated he was not aware resident was complaining of pain during therapy. LVN 15 reviewed the progress notes and stated there was no documentation the therapist reported Resident 322's pain during therapy. On December 14, 2017, at 11:53 a.m., LVN 16 was interviewed. LVN 16 stated the physician should have been made aware of resident's pain during therapy. LVN 16 further stated the pain should have been addressed. The facility policy and procedure titled, Pain and Behavior Management Program, undated, indicated, .Facility will implement an established program to address resident's pain and behavioral concerns by which resident will experience enhanced quality of life and care .

Based on observation, interview and record review, the facility failed to ensure the physician and responsible party were promptly notified for two of 29 sampled residents (Residents 23 and 122) when the residents experienced a change of condition as follows: 1. Resident 23 complained of prolonged level 10 (very severe /worst pain) pain and increased complaints of difficulty breathing on December 14, 2017. 2. Resident 122 had episode of low blood sugar on September 19, 2017, without staff notifying the physician and responsible party. This failure had the potential for the residents to not receive necessary care and treatment, and had the potential for the residents to develop further exacerbated medical complications [REDACTED]. Findings: 1. The record for Resident 23 was reviewed. Resident 23 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. The POLST also indicated the resident desired full medical treatment including long term artificial nutrition (tube feeding). Resident 23 was alert and able to verbalize her needs. The Brief Interview for Mental Status (BIMS - a screening tool used to get a quick snapshot of cognitive (memory) functioning at that moment in time) score was 9. (A score of 8-12 means moderately impaired, while 13-15 means cognitively intact). On December 14, 2017, at 8:43 a.m., Resident 23 was observed sitting in her wheelchair next to her bed with a bedside table positioned in front of the wheelchair. The resident was receiving oxygen via nasal cannula (tubing used to deliver oxygen thru the nose) at a rate of 3 liters per minute from an oxygen concentrator (machine that delivers oxygen). During a concurrent interview with Resident 23, she complained of left hip pain. The resident was observed to be uncomfortable and moving around in the wheelchair trying to lift herself to a standing position. The resident was asked what her pain level was from a scale of 0-10, with 10 being the worst/severe pain. Resident said, 10. The resident was asked to press her call light to alert a nurse. The resident's call light was not easily accessible or within reach. Resident 23 then asked, Where is it, I don't see it, referring to her call light. At 8:44 a.m., the Surveyor alerted the Certified Nursing Assistant (CNA) 1, who was in the hallway, that Resident 23 needed assistance. CNA 1 entered the resident's room, verified the call light was not within reach of the resident, and positioned the call light next to the resident. Resident 23 told CNA 1 she was in a lot of pain. CNA 1 then left the room. At 9:08 a.m., Resident 23 was again observed moving around in the wheelchair and stated she could not get comfortable. She said, I am having lots of pain. Resident 23 stated her pain level was still 10/10. The resident's call light was on. Resident yelled out, I am gasping for breath, please help me. At 9:09 a.m., CNA 2 knocked on the resident's door and said, Can I help you? CNA 2 came into the room and went over to Resident 23. Resident 23 told CNA 2 she was in a lot of pain and gasping for air. Resident was mouth breathing in between her speech. CNA 2 told Resident 23 she had received pain medication earlier and the next dose was not due until around lunchtime, but he (CNA 2) would check with the nurse. CNA 2 further told Resident 23 to call if she need anything and then CNA 2 left the room. Resident 23 was observed to be restless by mumbling and fidgeting in the wheelchair. At 9:18 a.m., Resident 23 yelled out, I am in a lot of pain, I am in a lot of pain. The resident then kept repeating, I am in a lot of pain. I am in a lot of pain. I am sitting on the area in the chair that is hurting. The pain is not going away, maybe if I stand up. The resident's call light was on. At approximately 9:21 a.m., CNA 2 responded to the resident's call light. Resident 23 stated she was in a lot of pain and gasping for air. The resident continued to mouth breathe in between her speech. CNA 2 told the resident he could take her to activities to distract her from the pain. CNA 2, asked, Do you want to go to activities? I can take you now. Resident 23 stated, I don't know what to do. I am having terrible pain in my hip. I do not complain much but I am in a lot of pain. CNA 2 stated he would tell the nurse. Resident 23 kept mumbling and stating, I am gasping for air, please help me. CNA 2 then left the room. At approximately 9:27 a.m., Resident 23 started yelling louder that she was in a lot of pain. Resident 23 was observed gasping for air during periods of yelling out. Her head was moving up and down. Her fists were clenched and her arms shaking. Resident yelled out, Oh God, help me; I'm scared. The Surveyor alerted CNA 2 from across the hall to come to the resident's room. CNA 2 told Resident 23 the nurse would bring her pain medication. Resident 23 stated, I am gasping for breath. Resident 23 asked CNA 2 for a number to call for help. CNA 2 gave resident a piece of paper. At approximately 9:32 a.m., Licensed Vocational Nurse (LVN) 1 entered the resident's room. LVN 1 asked Resident 23 where her pain was. Resident 23 stated her pain was in her rear end and her hip was hurting. Observed Resident 23's head moving up and down as she talked, opening her mouth to catch her breath while talking. LVN 1 told resident the CNA would put her to bed so he (LVN 1) could assess the area. LVN 1 left the room without assessing Resident 23. (This was the first time LVN 1 came into the resident's room since 9:08 a.m. when the resident was gasping for air). At approximately 9:34 a.m., CNA 2 entered the room and told Resident 23 he was putting her to bed. Resident 23 stated, Don't let me lie down, I am gasping for air. Resident 23 asked CNA 2 to open the window so fresh air could come in and she could breathe. Resident 23 stated, I am scared, I am gasping for breath. CNA 2 told the resident to try and stay calm and then left the room. Resident 23 was observed sitting on the side of the bed, hands at her side on the bed with her feet touching the floor. Both ankles were swollen. Resident was chanting, muttering and moving her upper body back and forth. At approximately 9:37 a.m., CNA 3, knocked and entered the resident's room. CNA 3 stated he was there to change the resident's nasal cannula for her oxygen. CNA 3 replaced the nasal cannula. Resident 23 said, I am gasping for breath, please help me. CNA 3 left the room. At approximately 9:42 a.m., Resident 23's breathing was observed to become more labored. Resident 23 was swaying back and forth with her arms flailing (moving sporadically). The resident was expressing ongoing complaints of being fearful. The Surveyor went to nurse's station and requested nursing assistance to Resident 23's room. LVN 2 stated he would get LVN 1 (the resident assigned nurse). LVN 1 went to the resident's room and placed a respiratory mask (a device worn over the mouth and nose to administer oxygen or breathing treatment) on the resident's face, turned on the nebulizer machine (a medical device that turns liquid medicine into a mist to help patient breathe) and left the room. Resident 23 was observed taking off the mask, placing the mask on the bed, and not receiving the treatment . Resident 23 kept saying, Please help me, please help me, I am scared, don't leave me. At approximately 9:49 a.m., LVN 1 returned to the resident's room and stayed with the resident until 9:53 a.m. to receive the breathing treatment until it was complete. At 9:53 a.m., LVN 1 stated, Your oxygen level went up to 94%, and asked the resident how she felt. The resident stated she was breathing better now. An interview was conducted with LVN 1 on December 14, 2017, at 11:18 a.m. LVN 1 was asked what the expectation was for nursing response when a resident was complaining of 10/10 level pain and gasping for air. LVN I responded that Resident 23 was medicated at 8 a.m. for level 7 pain. LVN 1 was informed that Resident 23 began complaining of level 10 pain at 8:43 a.m., and at 9:08 a.m., the resident was gasping for air. LVN 1 stated the CNAs did not tell him (LVN 1) about Resident 23's respiratory distress. LVN 1 was asked if Resident 23 experienced this kind of episode frequently. LVN 1 stated no, but the resident gets confused. Resident 23's Medication Administration Record [REDACTED].m LVN 1 stated Resident 23 was on continuous oxygen at 3 liters per minute. The resident received [MEDICATION NAME] (medication to improve breathing) every 4 hours and as needed (prn) for shortness of breath (SOB). Resident 23's oxygen saturation level was documented at 96% at 8:00 a.m. LVN 1 was asked what the acceptable oxygen saturation level was for Resident 23. LVN 1 stated 90% and above was okay. LVN 1 was asked what happens when the oxygen saturation level was 91% and resident was having problems breathing. LVN 1 responded, You give the prn [MEDICATION NAME]. LVN 1 further stated Resident 23 was given routine [MEDICATION NAME] (a narcotic pain medication used to treat severe pain) 5/325 milligrams (mg) for level 7 (severe pain) pain to the left hip, and breathing medication at 8 a.m. On December 14, 2017, at 11:43 a.m., an interview was conducted with LVN 3. LVN 3 stated she was not aware of Resident 23's episode of severe pain and difficulty breathing. LVN 3 was asked what the expectation was for nursing response when a resident was experiencing a pain level of 10, and progressive and prolonged respiratory distress. LVN 3 stated the licensed nurse should respond right away and render necessary service. An interview was conducted on December 14, 2017, at 4:45 p.m., with LVN 14. LVN 14 was asked about Resident 23's condition. LVN 14 stated she was not aware that anything had happened with Resident 23, had not been notified the resident change of condition during change of shift report. An interview was conducted on December 14, 2017, at 5:05 p.m., with LVN 3. LVN 3 stated she had not notified Resident 23's physician about what happened earlier in the morning because she (Resident 23) gets like this from time to time. LVN 3 stated she did not feel it was a sudden change of condition that needed to be reported to the physician. LVN 3 stated LVN 1 told her (LVN 3) that Resident 23, Gets like that if she has too many people around her. LVN 3 acknowledged she did not complete the change of condition report or notify anyone about the resident's condition. LVN 3 states she did not feel it was an unusual incident for Resident 23 that required special attention. On December 14, 2016, at 6:30 p.m., a second interview was conducted with LVN 3. LVN 3 stated Resident 23 was assessed by Registered Nurse 1 (RN) at around 5:50 p.m., and complained SOB. The resident oxygen saturation (concentration of oxygen in the blood) was between 85% - 88% (low), and resident was transferred to the acute hospital emergency room . (This was more than nine hours after the resident initially complained of severe pain and difficulty breathing). A review of Resident 23's emergency room record dated December 14, 2017, indicated Resident 23 was treated in the emergency room and later admitted to the hospital with [REDACTED]. An interview was conducted on December 18, 2017, at 9:18 a.m., via telephone with Resident 23's Physician. The Physician stated Resident 23 was fragile with unique medical diagnoses/allergies [REDACTED]. The Physician stated he was not notified on December 14, 2017, of the change in Resident 23's condition. The Physician further stated the expectation was the licensed nursing staff should immediately provide needed medical care, and contact the alternate Physician or the Medical Director if the regular Physician was not available. A review of the facility's policy and procedure titled, Change of Condition, undated, indicated the following: PURPOSE: To assure the appropriate care and documentation occurs when residents experience a change of condition. POLICY: Facility shall promptly notify the resident his or her attending physician and resident's legal representative of changes in the resident's condition or status. In case of a medical emergency or life threatening condition; if attending physician or alternate physician is not available, notify the medical director . 2. Resident 122's record was reviewed. Resident 122 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The progress notes dated September 19, 2017, at 6:10 a.m., indicated, Resident 122 was administered [MEDICATION NAME] due to a blood sugar level of 36 (low). (Normal blood sugar for someone without diabetes ranges from 77-99). There was no documentation the physician and the responsible party were notified of Resident 122's low blood sugar. On December 15, 2017, at 9:34 a.m., the Director of Nursing (DON) was interviewed. The DON stated low blood sugar was a change of condition so the staff should have notified the physician and the responsible party. The DON stated there was no documentation the physician and responsible party were notified of Resident 122's change of condition. The facility policy and procedure titled, CHANGE OF CONDITION, undated, indicated, .To assure the appropriate care and documentation occurs when residents experience a change of condition .Facility shall promptly notify the resident his or her attending physician and resident's legal representative of changes in the resident's condition .