Every finding on record at Surprise Valley Community Hospital D/P SNF

Based on interviews and record reviews the facility failed to develop and implement a care policy for residents that required end of life care. This had the potential for residents not to receive compassionate, dignified, and personalized care during their final days. Findings:During a concurrent interview and record review on 1/15/26 at 8:50 am, with Medical Records Manager (MRM), the undated policy and procedure (P&P) titled, Comfort Care and End-of-Life was reviewed. MRM indicated the facility did not have an official P&P in place and stated, we just started the development of the comfort care policy, it's developed, but has not been approved.During an interview on 2/26/26 at 3:58 pm, the Director of Nursing indicated they were unaware if the facility had a policy on end-of-life care before developing the Comfort Care and End of Life policy.

Based on observation, interview, and record review, the facility failed to report to the California Department of Public Health (CDPH), a physical abuse allegation immediately or within two (2) hours for one of three sampled residents (Resident 1), when Resident 1 made an allegation that she was treated rough during a shower and this was not reported to the facility's Abuse Coordinator or to CDHP in accordance with the facility's Abuse Policy.This failure had the potential of creating an environment where abuse allegations are not timely reported to the appropriate agencies, and result in all residents being at risk of physical and emotional abuse without appropriate investigations, leading to an unsafe environment for residents and no consequences for an actual abuser.During a review of the facility's Policy and Procedure titled, Abuse Reporting and Investigation, dated 5/12/22, indicated, All reports of resident abuse.are reported to local, state (CDPH), and federal agencies.and thoroughly investigated by facility management. Findings of all investigations are documented and reported.If resident abuse. is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.During a review of Resident 1's medical record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills, leading to severe impairment in daily functioning), Dementia (progressive organic brain disorder with persistent loss of intellectual functioning, memory impairment, and personality change) with agitation and Mood Disturbances, and Depression.Resident 1's most recent Minimum Data Set (MDS, tool for evaluating and implementing a standardized general assessment of residents), dated 11/19/25, was reviewed. Section C, Brief Interview for Mental Status (BIMS, assessment of cognitive function), reflected Resident 1 scored 99, which equates to cognition being severely compromised. Resident 1 was not their own Representative (RP) and does not make their own medical decisions but is able to express needs and desires verbally.During a review of the document titled, Report of Suspected Dependent/Elder Abuse, State of California (SOC-341), was completed by the facility on 12/9/25 and not submitted to CDPH until 12/10/25 at 1:43 pm. The form indicated the Director of Nursing (DON) was informed by Activities Director (AD) that Resident 1 complained that Certified Nursing Assistant (CNA) B, has been rough with Resident 1 during a shower. AD documented she had heard people talking about this allegation for a couple of weeks. During an interview on 12/18/25 at 1:15 pm, with AD on the telephone, AD stated that during Resident Council (monthly meeting of residents to discuss issues and concerns regarding the facility) Resident 1 stated she was treated roughly in the shower, but she did not recall when. AD concurred there were rumors among staff about the allegation for a few weeks. AD confirmed she had not reported the allegation to the Abuse Coordinator or to the DON, until 12/9/25. During an interview on 12/18/25 at 2:15 pm, with Licensed Vocational Nurse (LN) A in the conference room, LN A stated, I made a mistake. I did not report the allegation when it initially was reported to me [by CNA C]. I should have reported the allegation when it occurred. I do not recall when it occurred but it was awhile back. During an interview on 12/18/25 at 2:45 pm, with CNA C in the conference room, CNA C stated they informed LN A of the abuse allegation from Resident 1 regarding an incident in the shower, but they did not follow up and make sure the LN Ae formally reported the allegation. CNA C could not recall when the allegation was made but thought perhaps it was at the end of October 2025.During an interview on 12/19/25 at 7:40 am, with DON in the conference room, DON confirmed staff did not report the abuse allegation in accordance with the facility's Abuse Policy. The DON confirmed the notification of alleged abuse was made late to CDPH.

Based on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food was stored, prepared and served under sanitary conditions when: 1. Stainless-steel prep area was unsanitary 2. Large mixer was difficult to sanitize 3. Walk-in freezer had ice build-up 4. Coffee station was uncleanable 5. Kitchenware had burnt-on food 6. Painted center island were difficult to sanitize 7. Painted wood cabinets were difficult to sanitize 8. Ceiling above the stove was damaged 9. Area above laminate splash guard was difficult to sanitize 10. Kitchen and dishwashing room walls were dirty 11. Dry storage entryway was uncleanable 12. Dry storage shelving was uncleanable 13. Dry storage area ceiling was damaged 14. Divider wall had broken tile 15. Stainless-steel storage table was uncleanable 16. Dishwashing room wall was uncleanable These failures had the potential to spread infection and cause food borne illness for residents consuming food in the facility. Findings: A review of a facility document titled, Infection Control- Dietary, undated, indicated, All kitchenware .shall be cleaned after each use and thoroughly cleaned after each meal preparation. A review of a facility document titled, Infection Control- Dietary, undated, indicated, Non-food contact surfaces of equipment shall be cleaned to such intervals as to keep them in a clean and sanitary condition. 1. During an observation and concurrent interview on 5/5/25 at 11:19 a.m., the stainless-steel prep area had a small painted wood ledge with dried food debris, dried fluid debris and hair, and chipped paint, with wood exposed. The painted wood legs were with chipped, worn paint. The sealant between the stainless steel counter-top and abutted stainless steel counter-top (creates an L-shaped stainless steel counter-top) had dirty build-up and was stained. Dietary Supervisor (DS) confirmed these issues can be an infection control issue. 2. During an observation and concurrent interview on 5/5/25 at 11:20 a.m., a large metal mixer was noted to have chipped paint. DS confirmed this is a potential infection control issue because bacteria and food could get lodged between the metal and chipped paint. 3. During an observation and concurrent interview on 5/5/25 at 11:20 a.m., the walk-in freezer was noted to have ice build-up at the back of the condenser, on the condenser pipe, on the fan guard, on the ceiling, and on the floor. The DS stated she does inventory and cleaning of the freezer everything Tuesday and Wednesday. She indicated she cleans up the ice on Tuesdays. DS confirmed the danger of slipping and falling, and a possible malfunction of the unit, which could create an infection control issue. 4. During an observation and concurrent interview on 5/5/25 at 11:23 a.m., an observation of the coffee station noted the laminate edges of the top counter were chipped or missing, and uncleanable. The body and doors of the wood cabinet had edges and sides with chipped, worn paint. DS confirmed that these conditions could cause an infection control issue because bacteria could be present and paint chips could get into the food. 5. During an observation and concurrent interview on 5/5/25 at 11:24 a.m., an observation of two muffin tins, two cake pans, one large pot, and six out of eight sheet pans had burnt-on food present. The muffin tins had burnt-on food on the top, and the cake pans, large pot, and sheet pans had burnt-on food on the sides. DS confirmed that the burnt-on foods could cause an infection control issue. 6. During an observation and concurrent interview on 5/5/25 at 11:54 a.m., an observation of the center island noted edges of cabinet doors and drawers with chipped, worn paint. The left cabinet door is missing a part of the top edge, with chipped and worn paint. DS confirmed these conditions are difficult to clean and are an infection control issue. During an interview with the Maintenance Supervisor (MS) on 5/5/25 at 2:41 p.m., he indicated that he was aware of the condition of the kitchen and the walk-in freezer, but they were low on the priority list. He confirmed that the condition of the kitchen and freezer can potentially be an infection control issue. 7. During an observation and concurrent interview on 5/7/25 at 8:15 a.m., an observation of wood cabinets to the left and right of the stove noted cabinet and door edges to have chipped and worn paint, with exposed wood and is uncleanable. The drawer beneath the left wooden cabinet also with chipped and worn paint. The Dietary Manager (DM) confirmed that these conditions can hide bacteria and cause an infection control issue. 8. During an observation and concurrent interview on 5/7/25 at 8:16 a.m., an observation of the ceiling above the stove noted an open, chipped and unpainted area, exposing ceiling materials. DM confirmed a potential infection control issue. 9. During an observation and concurrent interview on 5/7/25 at 8:17 a.m., an observation of the area above the laminate splash guard noted orange discoloration which could harbor bacteria. DM confirmed the potential infection control issue. 10. During an observation and concurrent interview on 5/7/25 at 8:22 a.m., an observation of the kitchen and dishwashing room walls noted grimy, dark areas, streaks, and old repairs. DM indicated the kitchen and dishwashing room have not been painted in years and the build-up of grime can potentially be an infection control issue. 11. During an observation and concurrent interview on 5/7/25 at 8:35 a.m., an observation of the dry storage entryway noted peeling paint in three spots. DM confirmed peeling paint could cause an infection control issue. 12. During an observation and concurrent interview on 5/7/25 at 8:36 a.m., an observation of the dry storage shelving, both metal and wood, noted chipped, worn paint and exposed wood. DM confirmed wood and paint particles can create an infection control issue. 13. During an observation and concurrent interview on 5/7/25 at 8:37 a.m., an observation of the dry storage ceiling with water damage. DM indicated it happened about a year ago. DM confirmed not sure what could be hidden under the damage, for instance mold, creating an infection control issue. 14. During an observation and concurrent interview on 5/7/25 at 11:26 a.m., an observation of the dividing wall of the dishwashing area and kitchen had two broken perimeter tiles. DM confirmed that bacteria and insects could be harbored, proper cleaning is not possible and can cause an infection control issue. 15. During an observation and concurrent interview on 5/7/25 at 12:53 p.m., the stainless-steel storage table had rust on the bottom shelf and on the legs. DS confirmed cleaning is not possible and can potentially cause an issue for infection control. 16. During an observation and concurrent interview on 5/7/25 at 12:46 p.m., an observation of the dishwashing room wall noted laminate cracked and repaired but some of the wall was still exposed, and laminate was cracked along the top of stainless-steel splash. There was also exposed sheet rock to the right of the dishwasher. DM confirmed these areas would be hard to clean and can cause an infection control issue. During an interview with the Infection Preventionist (IP) on 5/7/25 at 1:52 p.m., he confirmed that there are potential infection control issues with the kitchen.

Based on interview and record review the facility failed to ensure the care plan was developed and revised to reflect the current status of the resident for three of four sampled residents (Residents 51, 57 and 157) when: 1. Resident 51's care plan was not revised to include a rash. 2. Resident 57's care plan was not revised to include skin breakdown. 3. Resident 157's care plan was not revised to include comfort care. These failures had the potential to result in the residents' needs not being identified, and resident's feeling depressed with poor self-esteem, and had the potential for the residents to acquire new pressure ulcers and/or worsen current pressure ulcers, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 8/19/18, the P&P indicated, 1. Baseline Care Plans will be initiated within 4 hours of admission and no later than 48 hours of admission. 2. Comprehensive Person-Centered Care Plans will be developed with in 7 days after the completion of the required MDS and no more than 21 dys after admission. 3. All SNF care plans will be reviewed and or revised by the licensed nurse: with every Weekly Summary; new order; and any change in condition. 1. During a review of Resident 51's clinical record, Resident 51 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation (memory loss), back pain, long term drug therapy, and major depression. A review of Resident 51's most recent Minimum Data Set (MDS, a standardized resident assessment) dated 12/6/24, indicated Resident 51 had severely impaired cognition (significant trouble with their thinking, memory, and ability to make decisions). During a record review of Resident 51's, Skin & Wound Evaluation, dated 4/30/25, the Skin & Wound Evaluation indicated that Resident 51 had a rash on the right ankle. During a review of Resident 51's, Clinical Care Plan Detail (CP), dated 3/15/25, the CP did not indicate that Resident 51's had a rash to the bony bump on the inside of the right ankle. During an interview on 5/7/25 at 11:00 a.m., with the Director of Nursing (DON), DON confirmed Resident 51's CP was not revised to include a rash on the ankle. 2. During a review of Resident 57's clinical record, Resident 57 was admitted to the facility on [DATE] with diagnosis that included stroke and left sided weakness, difficulty swallowing, and pressure ulcer on the tail bone. During a record review of Resident 57's, Skin and Wound Evaluation, dated 5/2/25, the Skin and Wound Evaluation indicted that Resident 57 had skin damage to the tail bone. During a record review of Resident 57's CP, dated 3/15/25, the CP indicated that Resident 57 did not have any skin breakdown. During an interview on 5/8/25 at 11:00 a.m., with the DON, DON confirmed the CP was not revised to include the skin breakdown on Resident 57's tail bone. 49934 3. A review of Resident 157's Admission Record indicated Resident 157 was admitted to the facility on [DATE], with diagnoses of dementia, (affects memory, thinking and social abilities) bed confinement status (unable to tolerate any activity out of bed), and pain. A review of the most recent Minimum Data Set (MDS, a resident assessment tool), for Resident 157, dated 4/19/25, indicated that Resident 157 had a severe cognitive deficit (poor memory and decision making skills), with a brief interview for mental status (BIMS) score of 00 out of 15. A review of Resident 157's Admission Record, dated 5/8/25, indicated that the Resident's daughter was the Responsible Party, indicating Resident 151 is unable to make healthcare decisions for herself. During a review of Resident 157's Physician's Orders on 5/8/25, indicated she was on comfort care (provides relief from symptoms and stress of a serious illness for the terminally ill). During a review of Resident 157's Care Plans on 5/8/25, indicated that a care plan was not created for Resident 157's physician ordered comfort care. During a concurrent care plan review and interview with the DON on 5/8/25 at 10:15 a.m., the DON confirmed that a care plan for the comfort care order for Resident 157 was not developed.

Based on observation, interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS). The failure to submit the required data, staffing hours and census information, can prevent determining whether or not an adequate level of staff is working at a given time, leading to inadequate care of residents and adverse clinical outcomes. Findings: On 04/18/24 at 10:10 AM, the PBJ reporting data was reviewed with the Facility Administrator (FA). FA stated, I am not sure who is doing it. It maybe the Director of Nursing (DON). The DON was present and stated, I believe it is done in payroll. It is not nursing that has that information. Human Resources was also present and added that, It is not being done in HR. On 04/18/24 at 10:15 AM, the PBJ reporting data was reviewed with the Accounting Clerk (AC). AC stated, We don't submit this. I think it is nursing. I have not done it before. There was no evidence offered by the facility that the facility was in compliance with submitting the PBJ data and report to CMA, as required by regulation.

Based on interview and record review, this regulation was not met when the facility failed to have a program in place to prevent an outbreak by testing their water for legionella bacteria, (Legionaire's Disease, a potentially fatal lung infection). This had the potential for residents, staff and visitors to become infected with legionella bacteria and cause illness and possibly death. Findings: In an interview and concurrent record review on 4/15/24 at 1:23 PM, Maintenance Manager (MM) provided the facility's water testing logs from a professional testing laboratory. MM stated that he was unaware of a requirement to test for or prevent legionella. Review of a record titled Analytical Report water monitoring dated 2/5/24, indicated that testing was done for coliform and e. Coli (two bacteria from sewage that can be present in water), but legionella testing was absent. MM confirmed that legionella was not listed on the vendor's report of tests performed on the water. Similarly, a contracted laboratory's microbiology testing report for the facility, dated 2/2/24 did not indicate testing for legionella. Similarly, review of a record titled, County Water District report 2022 indicated no legionella testing was performed at the municipal source of the facility's water. In an interview on 4/17/24 at 1:30 PM, Facility Administrator (FA) stated that she was unaware of requirement for Legionella/Management and water testing or that this was required by the Centers for Medicare and Medicaid Services (CMS). In a follow-up interview and concurrent record review on 4/17/24 at 11:35 AM, MM stated that he will develop a written plan for legionella prevention and can add testing to current water testing being done by a lab for the facility.

Based on interview and record review, the facility failed to follow policy requirements of the facility policy titled, Weight Assessment & Interventions for one of twelve residents sampled by not reweighing Resident 13 (R13) when weight loss was discovered. The failure to follow the policy requirement affected one resident creating the potential for additional unaddressed weight loss and a detrimental clinical outcome for residents. Findings: The facility policy titled, Weight Assessment & Interventions was reviewed. Under the policy section titled, Weight Assessment numeral 3 states, Any weight change of 5 pounds more or less since the last weight assessment will be retaken the next day for confirmation. According to the policy, over 3 months a weight loss of greater than 7.5% is significant. Resident 13 was admitted on [DATE] with diagnoses that included Alzheimer disease. On 4/15/2025 at 10:30 AM, during a concurrent interview with the Director of Nursing (DON) and record review of weight documentation for Resident 13 (R13) was performed. The documented weight on 2/2/2024 was 132 pounds. The weight on 3/3/2024 had dropped to 125 pounds for a total loss of 7 pounds. The recorded weight loss was more than required for a reweigh. The DON provided documentation of weights for R13 and stated that, The weight should have been retaken for March (3/3/24) because it was more than 5 pounds per policy. The DON confirmed, There should be another weight for the next day on the sheet (Vital Signs Grid). The CNA's (Certified Nursing Assistants) do the weights and write them in. They should have done it again the next day. During an interview with CNA 3 on 4/17/2024 at 3:30 PM, CNA 3 stated, The residents are weighed on Sundays. If they are below 5 pounds from the last time, we weight them again on Mondays. There aren't many. When asked if R13 would have been reweighed on 3/3/2024, CNA 3 stated, If we know we do it. On 4/18/2024 at 8:15 AM CNA 4 was interviewed regarding reweighing residents. CNA 4 stated, We get the weights and when they are not right we reweigh then. Sometimes it is the chair. We weigh them first then the chair after and subtract. If there is blankets it can make it wrong. CNA4 was not aware resident 13 needed reweighed on 3/3/2024.

Based on interview, observation and record review, the facility failed to meet this requirement when a medication for one (Resident 10) of nine sampled residents did not match Resident 10's current physician order, and did not meet professional pharmacy standards of practice for drug labeling. This resulted in the potential for overdosing medication and harm to the resident. Findings: Resident 10 was admitted to the facility in November, 2019 and was recently being treated with the antibiotic Sulfametoxazole/trimethoprim (SMZ/TMP or Septra) for a urinary tract infection. Review of the facility's policy titled, ER Medication Dispensing and Prescribing, revised 4/6/24, indicated that Medications to be dispensed will be unit dose whenever possible . [Unit dosing is the pharmacy practice of providing no more or no less medication than will be administered to the resident to lessen the risk of under or overdosing]. A review of the facility's record titled, prescribing order dated 7/22/22, indicated that the facility's physician ordered 400 millligrams (a unit of measure) of sulfamethoxazole/80 milligrams of trimethoprim in a single dose. In an observation on 4/16/24 at 11:00 AM, Licensed Vocational Nurse (LVN 1) was observed taking Resident 10's medication from a blister pack (pre-packaged medication doses in individual plastic bubbles on a multi-dose card) labeled SMZ/TMP DS TAB 800/160, indicating 800 milligrams of sulfamethoxazole, 160 milligrams of trimethoprim tablets. The tablets were provided in a form that was double the dose to be administered to Resident 10, requiring the nurse to split the tablet in half, therefore the medication was not unit dosed per pharmacy policy. The package was not labeled by pharmacy with the new dose, and handwriting in blue ball point pen indicated, 1/2 tablet, 400mg/80mg. In an interview on 4/16/24 at 1:32 PM, Director of Nursing (DON) stated that staff cannot re-label medications on the blister pack; pharmacy must label all medications. DON stated that it is not an acceptable practice to re-write dose changes by handwritten instructions. In a telephone interview on 4/16/24 at 1:00 PM, Pharmacy Consultant (PC) stated that the facility's blister pack medication is designed to be dose-specific and contain the dose to be delivered to the resident to avoid medication errors, and that the best practice is for pharmacy to provide a pharmacy-printed label according to the current dose. PC stated that only pharmacy technicians or pharmacists can re-label medications and red alert stickers are to be used to note dosing changes.

Based on observation, interview and record review, the facility failed to prevent the willful neglect of one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 intentionally neglected to check Resident 1's blood sugars and administer insulin (a medication to lower blood sugar) as ordered by the physician, then LVN 1 falsified Resident 1's medication record by recording blood sugar results that she never obtained and insulin coverage that she never provided, nine times between November and December, 2023. This failure resulted in abnormal blood sugar levels requiring additional insulin to stabilize Resident 1's blood sugars and had the potential to have serious negative outcomes to Resident 1's health, by not monitoring and controlling his blood sugars with insulin. Findings: The facility's policy titled, Abuse Identification dated 5/25/22, was reviewed. The policy indicated that, Abuse is defined as: a. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; and b. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being; and c. Having the knowledge and ability to provide care and services, but choosing not to, constitutes abuse. Resident 1 (R1), was admitted to the facility with a diagnoses that included diabetes and dementia. R1 required blood sugar monitoring four times daily and administration of insulin. A review of R1's Physician's Orders for the month of December 2023, reflected that R1's physican had ordered; a. Blood sugar checks three times a day before meals. b. Novalog (a regular fast acting insulin) 100 units (U-100)subcutaneous (SQ, just into the superficial fat layer under the skin), to be given per a sliding scale (SS- insulin is given according to the level of the blood sugar), as followed: for blood sugars between 150-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, 401-450 give 12 units and notify the physician. c. Victoza (a long lasting insulin), 1.2 milligrams (mg) SQ, every morning. On 12/06/23 at 1:15 PM, during a concurrent interview and record review with the Director of Nursing (DON), R1's Medication Administration Records (MARs) for November and December 2023, were reviewed. LVN 1 had recorded blood sugar results as well as recorded amounts of insulin that had been given to R1, for the months of November and December, 2023. The DON indicated that during an audit, the DON initially found that R1 had high blood sugars when LVN 1 was on duty and assigned to R1's care. Upon further investigation, the DON indicated that the Glucometer (a hand held device to check blood sugars and records the date, time and results of blood sugars), had no recorded blood sugars for R1 which matched the blood sugar numbers that LVN 1 had recorded, on November 8, 9, 10, and 11, or on December 22, 23, 24, 25 and 26 of 2023, when LVN 1 had worked. The DON stated she interviewed LVN 1 and, I couldn't believe what she [LVN 1] told me. When I confronted her [LVN 1], she openly admitted to not checking [R1's] blood sugars or giving him insulin and stated that she had just made up the numbers and wrote them in because she said that she just did not have time. The DON then provided the facility's policy titled, Adverse Drug Reaction and Medication Errors. Under the heading, Policy Interpretation and Implementation section 6a. Omission- a drug is ordered but not administered. is one of the Examples of medications errors . Under the same heading, section 9 the policy requires that, Nursing staff will document appropriately detailed accounts of any incidents on an appropriate form.

Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse when Certified Nursing Assistant (CNA) 1 slapped Resident 1 in the face. This resulted in anger, frustration and emotional distress for Resident 1 and had the potential for all residents under the care of CNA 1 to be subjected to mistreatment. Findings: A review of the facility's policy titled, Identification Types of Abuse dated 5/25/22, indicated that, Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and suppo1t, and a facility-wide culture of compassion and caring. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. On 11/01/23 at 3:30 PM, during an interview Licensed Practical Nurse (LPN) stated, .I heard a sharp scream sound and then I heard his [CNA 1] voice, it was low and about four or five words, an angry voice. According to the LPN two other staff heard and investigated the scream. At that time they were not able to determine what occurred. The LPN went on to state, [Resident 1] came to the nurses station and motioned at him [CNA 1], which is totally out of her normal self and was yelling and waiving her arms around yelling, He hit me, he hit me and that's not right. He hit me right here and pointed to her neck. She is not normally so animated and she was so upset I separated them by taking her to the other nurses station. She kept saying, he gets so mad. He hit me hard. She was tearful and adamant that he [CNA 1], hit her. On 11/02/23 at 11:20 AM, in a concurrent interview and record review, the Director of Nursing (DON) stated, She [Resident 1] said she didn't want to do what he [CNA 1] wanted, and he slapped her. She said not with a fist, but open handed. She said he was trying to take her clothes off and she didn't want to so he slapped her. The whole time her story hasn't changed. She knew he slapped her on the left side of her face . The DON also provided photos taken about an hour after the incident which showed some redness to the left side of Resident 1's face. On 11/02/23 at 12:15 PM, Resident 1 was interviewed and stated, Yes, he slapped me on the face .on the side here. Pointing to the left side of her face. Resident 1 stated, it was a while back. Resident 1 was very clear on the account of the incident and did not need any assistance in providing the information. As she relayed the facts, she would at time squint her eyes and her lips would tremble indicating stress in recollection of the event. During an interview on 11/2/23 at 1:50 PM, CNA 1 was interviewed and stated, She [Resident 1] asked why she had to change, I said because she wore the same shirt yesterday. So, she grumbled and put on the top I gave to her. Sometimes she doesn't understand so I had her sit, and I changed her pants. So, I unbraided her hair and brushed it. I went out and made coffee for her and sat at the nurse station and Resident 1 came up and said I slapped her . So, when she said that I was smiling. They said when abuse is reported by anyone, we must report it. I was doing what I was supposed to do. She was dirty and shoes were on wrong and she needed clean clothes. All that I know is that she was not happy because I had to change her. On 11/2/23 at 1:55 PM, CNA 2 was interviewed. CNA 2 stated, It was Sunday night/Monday morning. I was in another room down the hall heard a scream, I wrapped up what I was doing and asked the nurse if she heard it. She said she did and I went down and looked. No continuing commotion. So, I went back to doing what I needed to do.

Based on interview and record review, the facility failed to track controlled substances (medications that have a high risk for abuse such as opioid medications) when facility staff failed to count the medications upon receipt for one resident (Resident 1) and failed to keep a narcotic sheet for the oxycodone. This resulted in a discrepancy in the number of pills received for two controlled medications, oxycodone (a controlled narcotic mediation) and Lorazepam (anti-anxiety medication) and resulted in a lack of accountability for these medications and possible diversion of the controlled substances by staff. Findings: The facility's Controlled Substance policy, dated 4/2019, was reviewed. The policy statement was, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. 1. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on the premises. 3. Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications. 4. Access to controlled medications remains locked at all times and access is recorded. Upon receipt: a. The nurse receiving the medication and the individual delivering the medication verify the name. dose and quantity of each controlled substance being delivered. b. Both individuals sign the controlled substance record of receipt. c. An individual resident controlled substance record is made for each resident who is receiving a controlled substance. The record contains: (1) name of the resident; (2) name and strength of the medication; (3) quantity received; (4) number on hand; (5) name of physician; (6) prescription number; (7) name of issuing pharmacy; and (8) date and time received. The facility's Accepting Delivery of Medications policy, dated 2/2021, was reviewed. The policy statement was, All staff shall follow a consistent procedure in accepting medications. 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/order receipt. A review of Resident 1's record indicated she was admitted on [DATE] with diagnoses that included severe dementia, anxiety, and depression. She suffered a fall and fracture (break) of her left femur (thighbone) and was transferred to an acute care hospital for treatment. She returned to the facility on [DATE] around 7:30 pm. The California Department of Public Health (CDPH) received notification on 10/18/22, from the Interim Director of Nurses (IDON) A that there were missing narcotics and staff were being drug tested . The facility indicated four tablets were missing of Oxycodone and Lorazepam (in a class of drugs called benzodiazepines). Documentation from the acute care hospital indicated the medications were picked up from their pharmacy ad were stapled shut with the patient's identification sticker and placed in the patient's belonging bag. The transport team reported they never opened the belongings bag and were not aware it contained medications. A review of the staff drug tests included one nurse who tested positive for opiates and benzodiazepines but negative for oxycodone. During an interview on 4/27/23 at 10:25 am, IDON A said she no longer worked at the facility, but recalled Resident 1 had been sent out to a hospital and returned to their facility around 7:30 pm. The Skilled Nursing Facility (SNF) night shift Licensed Nurse (LN) A put the narcotics in the bottom of the medication cart. She said although the medication cart itself is locked, narcotics are supposed to be kept under double lock and there was a separate locked area within the medication cart where they were supposed to be placed. The narcotics, which were supposed to be sealed, since they had come from the pharmacy in the hospital where Resident 1 had been treated, were not counted. She said the narcotics should have been counted when the resident was brought back to the facility by the ambulance. IDON A said in the morning the count was done and it was off by four tablets of Lorazepam and Oxycodone each, if she recalled correctly. She was notified and a drug test was done on staff who had worked and may have had access to the medications. She said there was a Registered Nurse (RN) on the acute side of the facility for the emergency room (ER), RN A who tested positive for opioids and benzodiazepines but this nurse later produced a prescription for Tylenol with codeine and said she had a dental procedure and received a benzodiazepine medication. She said she never did found out where the drugs were or who took them. LN A was terminated and had issues other than the ones involved with not counting the narcotics. She said she filed a report with CDPH, DEA (Drug Enforcement Agency) and the Sheriff. During an interview on 5/2/23 at 5 pm, RN A said she was working in the ER and LN A was working in the SNF when Resident 1 returned to the facility. She said she opened the front door for the ambulance and then opened the ER door for Resident 1's daughter. She said she did not have anything else to do with Resident 1. She said all of Resident 1's medications and belongings were given to LN A and she did not even even know what was given to him. RN A said she takes care of ER patients and does not get involved with the SNF residents. She said she later found out some of the narcotics were missing and she was drug tested . RN A said her drug screen tested positive for benzodiazepines but she had received Valium (a benzodiazepine that can be detected weeks after the last dose) in a procedure she had recently, and it can be detected in a drug screen for two months after ingestion. She said she also had a prescription for Tylenol with codeine (shows as opiates during a drug screen). She said her drug screen was negative for oxycodone. RN A said she left to take a traveling assignment for three months but has since returned to work at the facility. During an interview on 5/1/23 11:50 am, the Administrator (Admin) said staff who had access to the medications were tested and RN A tested positive for opiates and benzodiazepine. Admin advised RN A of the test results who provided a prescription for Tylenol with codeine. RN A later said she had eye surgery two weeks prior and had received valium at that time which could stay in her system and account for the positive benzodiazepine drug screen. RN A provided a record of the procedure, (done 10/5/22) as well as the medication she had received. Admin said they never did find the narcotics and don't know what happened to them. She said LN A was let go because there were a lot of complaints that he was rude to other employees, unprofessional and did not count these narcotics, when he knew he should have done so because it's in our policies. Admin said Resident 1 received her medications as needed so there was no issue with the resident being deprived of her medication. She said two RNs now count, like we're supposed, to from each shift. The narcotic sheets were requested for the Oxycodone and the Lorazepam. The narcotic sheet for the Lorazepam was provided which indicated there were 26 tablets when first counted. The Oxycodone narcotic sheet could not be located at this time. During a follow up interview on 5/3/23 10:40 am, the Director of Staff Development (DSD) said she had looked through all narcotic sheets and could not find the one for the oxycodone. She said this was the only one missing. Admin also confirmed she was unable to find it. Based on interview and record review, the facility failed to track controlled substances (medications that have a high risk for abuse such as opioid medications) when facility staff failed to count the medications upon receipt for one resident (Resident 1) and failed to keep a narcotic sheet for the oxycodone. This resulted in a discrepancy in the number of pills received for two controlled medications, oxycodone (a controlled narcotic mediation) and Lorazepam (anti-anxiety medication) and resulted in a lack of accountability for these medications and possible diversion of the controlled substances by staff. Findings: The facility's Controlled Substance policy, dated 4/2019, was reviewed. The policy statement was, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. 1. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on the premises. 3. Controlled substances are stored in the medication room in a locked container, separate from containers for any non-controlled medications. 4. Access to controlled medications remains locked at all times and access is recorded. Upon receipt: a. The nurse receiving the medication and the individual delivering the medication verify the name. dose and quantity of each controlled substance being delivered. b. Both individuals sign the controlled substance record of receipt. c. An individual resident controlled substance record is made for each resident who is receiving a controlled substance. The record contains: (1) name of the resident; (2) name and strength of the medication; (3) quantity received; (4) number on hand; (5) name of physician; (6) prescription number; (7) name of issuing pharmacy; and (8) date and time received. The facility's Accepting Delivery of Medications policy, dated 2/2021, was reviewed. The policy statement was, All staff shall follow a consistent procedure in accepting medications. 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/order receipt. A review of Resident 1's record indicated she was admitted on [DATE] with diagnoses that included severe dementia, anxiety, and depression. She suffered a fall and fracture (break) of her left femur (thighbone) and was transferred to an acute care hospital for treatment. She returned to the facility on [DATE] around 7:30 pm. The California Department of Public Health (CDPH) received notification on 10/18/22, from the Interim Director of Nurses (IDON) A that there were missing narcotics and staff were being drug tested . The facility indicated four tablets were missing of Oxycodone and Lorazepam (in a class of drugs called benzodiazepines). Documentation from the acute care hospital indicated the medications were picked up from their pharmacy and were stapled shut with the patient's identification sticker and placed in the patient's belonging bag. The transport team reported they never opened the belongings bag and were not aware it contained medications. A review of the staff drug tests included one nurse who tested positive for opiates and benzodiazepines but negative for oxycodone. During an interview on 4/27/23 at 10:25 am, IDON A said she no longer worked at the facility, but recalled Resident 1 had been sent out to a hospital and returned to their facility around 7:30 pm. The Skilled Nursing Facility (SNF) night shift Licensed Nurse (LN) A put the narcotics in the bottom of the medication cart. She said although the medication cart itself is locked, narcotics are supposed to be kept under double lock and there was a separate locked area within the medication cart where they were supposed to be placed. The narcotics, which were supposed to be sealed, since they had come from the pharmacy in the hospital where Resident 1 had been treated, were not counted. She said the narcotics should have been counted when the resident was brought back to the facility by the ambulance. IDON A said in the morning, the count was done and it was off by four tablets of Lorazepam and Oxycodone each, if she recalled correctly. She was notified and a drug test was done on staff who had worked and may have had access to the medications. She said there was a Registered Nurse (RN) on the acute side of the facility for the emergency room (ER), RN A who tested positive for opioids and benzodiazepines but this nurse later produced a prescription for Tylenol with codeine and said she had a dental procedure and received a benzodiazepine medication. She said she never did found out where the drugs were or who took them. LN A was terminated and had issues other than the ones involved with not counting the narcotics. She said she filed a report with CDPH, DEA (Drug Enforcement Agency) and the Sheriff. During an interview on 5/2/23 at 5 pm, RN A said she was working in the ER and LN A was working in the SNF when Resident 1 returned to the facility. She said she opened the front door for the ambulance and then opened the ER door for Resident 1's daughter. She said she did not have anything else to do with Resident 1. She said all of Resident 1's medications and belongings were given to LN A and she did not even even know what was given to him. RN A said she takes care of ER patients and does not get involved with the SNF residents. She said she later found out some of the narcotics were missing and she was drug tested . RN A said her drug screen tested positive for benzodiazepines but she had received Valium (a benzodiazepine that can be detected weeks after the last dose) in a procedure she had recently, and it can be detected in a drug screen for two months after ingestion. She said she also had a prescription for Tylenol with codeine (shows as opiates during a drug screen). She said her drug screen was negative for oxycodone. RN A said she left to take a traveling assignment for three months but has since returned to work at the facility. During an interview on 5/1/23 11:50 am, the Administrator (Admin) said staff who had access to the medications were tested and RN A tested positive for opiates and benzodiazepine. Admin advised RN A of the test results who provided a prescription for Tylenol with codeine. RN A later said she had eye surgery two weeks prior and had received valium at that time which could stay in her system and account for the positive benzodiazepine drug screen. RN A provided a record of the procedure, (done 10/5/22) as well as the medication she had received. Admin said they never did find the narcotics and don't know what happened to them. She said LN A was let go because there were a lot of complaints that he was rude to other employees, unprofessional and did not count these narcotics, when he knew he should have done so because it's in our policies. Admin said Resident 1 received her medications as needed so there was no issue with the resident being deprived of her medication. She said two RNs now count, like we're supposed, to from each shift. The narcotic sheets were requested for the Oxycodone and the Lorazepam. The narcotic sheet for the Lorazepam was provided which indicated there were 26 tablets when first counted. The Oxycodone narcotic sheet could not be located at this time. During a follow up interview on 5/3/23 10:40 am, the Director of Staff Development (DSD) said she had looked through all narcotic sheets and could not find the one for the oxycodone. She said this was the only one missing. Admin also confirmed she was unable to find it.

Based on interview and record review, the facility failed to protect seven of nine sampled residents (Residents 1, 2, 3, 4, 5, 6 and 7) from potential further abuse, when they did not summarize the outcome of four of their resident to resident abuse investigations and report those results to the Department within 5 working days from the date the incidents occurred . This had the potential to subject these residents to further abuse and cause a decline in these residents' physical, emotional and psychosocial status and ability to attain or maintain their highest practicable level of well-being. Findings: A review of the facility's Abuse Reporting and Investigation policy, dated 5/12/22, indicated, The administrator or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation with five (5) working days of the occurrence of the incident. 1. On 10/13/22, Admin (Administrator) reported to the Department that during an altercation, Resident 2 hit Resident 1 in the face. 2. On 11/2/22, Licensed Nurse (LN) 2 reported to the Department that during an altercation, Resident 2 Resident 3 in the face. 3. On 10/25/22, LN 3 reported to the Department that during an altercation, Resident 5 grabbed Resident 4's left arm and Resident 4 swung at Resident 5. 4. On 10/16/22, Interim Director of Nurses A reported to the Department that during an altercation, Resident 7 pushed Resident 6 causing her to fall. On 5/1/23, Admin presented the documentation of the facility's investigations for these resident to resident altercations. None of them contained evidence that a 5 day conclusion to their investigations had been done or submitted to the Department. There was no evidence that the facility evaluated and summarized whether or not the actions that they had taken were effective in maintaining the safety and preventing further abuse altercations for these residents. During an interview on 5/3/23 at 9 am, any investigation five day reports for these resident to resident altercations were requested from Admin, who confirmed she was unable to find that any had been done and submitted to the Department.

Based on observation, interview and record review, the facility failed to ensure that 11 of 16 sampled residents (Residents 3, 4, 5, 7, 12, 11, 12, 14, 16, 21, and 22) had interdisciplinary (interventions from all departments) and comprehensive person-centered care plans that addressed their preferences (choices), goals (measurable expected outcomes) and interventions (care and services necessary to achieve those goals) when; 1. Resident 4 was taking [MEDICATION(S)] (an antidepressant medication) and [MEDICATION(S)] (an antipsychotic medication) and a care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using each medication, potential unwanted adverse side effects, or resident specific interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological (non-medication) interventions, in order for Resident 4 to achieve her goals. 2. 2. Resident 7 was taking as needed (PRN) [MEDICATION(S)] (an anti-anxiety medication), [MEDICATION(S)] (a chemical compound use for depression), [MEDICATION(S)] (an SSRI antidepressant, these types of antidepressants have the potential to cause Serotonin Syndrome a potentially serious clinical condition resulting from overstimulation of serotonin receptors. It is commonly related to the use of multiple serotonin-stimulating medications e.g., SSRIs, SNRIs, triptans, certain antibiotics. Symptoms may include restlessness, hallucinations, confusion, loss of coordination, fast heartbeat, rapid changes in blood pressure, increased body temperature, overactive reflexes, nausea, vomiting and diarrhea), [MEDICATION(S)] (an SSRI antidepressant medication) and [MEDICATION(S)] (an antipsychotic medication which can cause serious adverse and irreversible side effects in the elderly, especially with dementia). A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from each medication, potential unwanted adverse side effects including Serotonin Syndrome, or resident specific interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological interventions, in order for Resident 7 to achieve her goals. 3. Resident 16 had two PRN [MEDICATION(S)] orders, one by injection and the other in a pill form. A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using each medication, potential unwanted adverse side effects, or resident specific interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological (non-medication) interventions, in order for Resident 16 to achieve his goals. 4. Resident 21 was taking [MEDICATION(S)] (an SSRI antidepressant medication), [MEDICATION(S)] (a [NAME], like an SSRI, antidepressant) and [MEDICATION(S)] (a long acting anti-anxiety medication). A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using each medication, potential unwanted adverse side effects including Serotonin Syndrome, or resident specific interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological (non-medication) interventions, in order for Resident 21 to achieve her goals. 5. Resident 22 was taking three antipsychotic medications; [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] at the same time. A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from using three medications from the same drug class, potential unwanted adverse side effects, or resident specific interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological (non-medication) interventions, in order for Resident 22 to achieve his goals. 6. Resident 3 was taking [MEDICATION(S)] (an SSRI antidepressant medication). A care plan was not developed which included the specific medication being used, the specific target behavior for the medication, the expected goals to be achieved from using the medication, potential unwanted adverse side effects including Serotonin Syndrome, or resident specific interventions that included approaches from all disciplines and described the care and services necessary, including non-pharmacological interventions, in order for Resident 3 to achieve her goals. 7. Resident 11 had no care plan for [MEDICATION(S)], a [CONDITION(S)] medication (any drug that affects brain activities associated with mental processes and behavior), and [MEDICATION(S)] for for aggressive behaviors. 8. Resident 12 received three antipsychotic medications, but his care plan did not include the target behaviors for these medications. 9. Resident 14 received an antipsychotic medication and had no care plan for the medication or the target behaviors. 10. Resident 5 had a fall on 1/3/22, and his care plan was not updated with interventions to prevent future falls. 11. Resident 10 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures had the potential for necessary care and services to go unrecognized and prevent the residents from attaining or maintaining their highest practicable level of medical and psychosocial well-being. Findings: The facility's policy titled, Care Plans-Comprehensive revised December 2010, directed the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice from problem areas and conditions. 1. Resident 4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had orders for [MEDICATION(S)] and [MEDICATION(S)]. On 5/2/22 at 1:30pm, Resident 4 was observed in her room, alert and able to answer simple questions, well-groomed and dressed in her own clothes. On 5/4/22 at 12:22pm, an interview and concurrent care plan review was conducted with Medical Records staff (MR) B. A care plan was developed that indicated Resident 4 was at risk for adverse side effects from [CONDITION(S)] medications but did not specify what medications she was taking, or the specific side effects for each medication. There was a care plan developed for Chronic Depression but no target behavior or interdisciplinary interventions, including non-pharmacological interventions, were in place to manage her depression. MR B confirmed the above. 2. Resident 7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 1:50pm, Resident 7 was observed in the dining room in a Merry Walker. Nicely dressed and well groomed. On 5/4/22 at 3:44pm, an interview and concurrent care plan review was conducted with MR B. Resident 7 was taking [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and PRN [MEDICATION(S)]. A care plan was developed for Episodes of Aggression but had not described the specific target behavior or interventions, pharmacological and non-pharmacological, to manage her behaviors. There were no care plans developed with specific target behaviors and what medications were being used for each behavior and their specific side effects, including her risk for Serotonin Syndrome, and there were no interdisciplinary non-pharmacologic interventions. MR B confirmed the above. 3. Resident 16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 2:10pm, Resident 16 was observed in his room. He was alert and oriented, pleasant and well groomed. On 5/4/22 at 2:34pm, an interview and a concurrent care plan review was conducted with MR B. Resident 16 was taking [MEDICATION(S)] IM and PO on a PRN basis. There was a care plan developed for At Risk for Aggression that had not included the target behavior, specific medication, specific medication adverse side effects, or interdisciplinary non-pharmacologic interventions. MR B confirmed the above. 4. Resident 21 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 2pm, Resident 21 was observed in her room. She was well groomed and nicely dressed. On 5/4/22 at 5:12pm, an interview and care plan review was conducted with MR B. Resident 21 was taking [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. There were no care plans developed for the use of these medications which included a specific target behavior, specific medication, adverse side effects of the medications, including her risk for Serotonin Syndrome, or interdisciplinary interventions, including non-pharmacological interventions. MR B confirmed the above. 5. Resident 22 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 2:15pm, Resident 22 was observed in the dining room in a Merry Walker. He is nicely dressed and well groomed. On 5/4/22 at 2:43pm, an interview and concurrent care plan review was conducted with MR B. Resident 22 was taking [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. There was no care plan developed for the specific target behaviors for these medications, what the adverse side effects were, what his goals were, or interdisciplinary approaches to meet his goals, including non-pharmacological interventions. MR B confirmed the above. 6. Resident 3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/22 at 1:40pm, Resident 3 was observed in her room. She was pleasant, nicely dressed and well groomed. She was sitting in her recliner. On 5/4/22 at 5:41pm, an interview and concurrent care plan review was conducted with MR B. Resident 3 was taking [MEDICATION(S)] for depression. There was an At Risk for Major Depression care plan but had not included the specific medication she was taking, the specific target behavior, the specific adverse side effects of [MEDICATION(S)], what her goals were, or interdisciplinary approaches, including non-pharmacological interventions. MR B confirmed the above findings. 7. A review of Resident 11's record indicated he was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 5/4/22 at 9:30 am, Medical Records and Quality Assurance staff (MR A) confirmed the above medications. She confirmed there was not a care plan for the antipsychotic medication [MEDICATION(S)] or a care plan for [MEDICATION(S)]. Aggressive behaviors were noted as the target behavior on the Medication Administration Record (MAR) for both [MEDICATION(S)] and [MEDICATION(S)]. MR A confirmed there was no care plan regarding these types of behaviors. 8. A review of Resident 12's record indicated he was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 5/4/22 at 10:44 am MR A confirmed Resident 12 was taking [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] all for paranoid [CONDITION(S)] with the behavior of [CONDITION(S)] to be monitored on the MAR, and [MEDICATION(S)] for panic disorder with the behaviors of panic to be monitored on the MAR. During a concurrent interview and record review on 5/5/22 at 9:35 am, MR A confirmed there was a care plan for antipsychotic medications with an intervention to monitor target behaviors but does not specify or list those target behaviors. 9. A review of Resident 14's record indicated she was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 5/11/22 at 12:05 pm, MR A reviewed the MAR and confirmed there were no target behaviors listed for [MEDICATION(S)] and no care plan for this medication or any target behaviors. 10. A review of the facility's Managing Falls and Fall Risk policy, dated 12/2007, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. A review of Resident 5's record indicated he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 5/11/22 at 12:36 pm, MR A said Resident 5's last fall was on 1/3/22. Prior to that he had slipped and fallen while trying to get into his wheelchair. He suffered no injuries after either fall. The nursing note, dated 1/3/11 at 5 am, indicated Resident 5 was found on the bathroom floor, sitting on his bottom. The raised toilet seat was noted on the floor and bent. There were no other notes regarding an investigation into how the fall happened. MR A confirmed the falls care plan was updated with interventions to prevent a future fall after the fall on 3/30/21, but it had not been updated after Resident 5's last fall on 1/3/22. During an interview on 5/12/22 at 7:36 am, the DON said they thought the resident got up and was confused and somehow bent the toilet riser seat, where it was attached to the toilet. During an observation with the DON at 7:40 am, there was no riser on the toilet, and it was a low sitting toilet. The DON said the low sitting toilet would be hard for Resident 5 to get up from because it was so low. Maintenance staff was then contacted and installed a raised toilet seat. 11. A review of Resident 10's record indicated she was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 5/5/22 at 9:43 am MR A confirmed Resident 10 had a [CONDITION(S)] in 1/2022 and 4/2022. No permanent care plan had been developed for Resident 10 relating to the [CONDITION(S)]'s and there was no short term, temporary care plan, for the [CONDITION(S)], Resident 10 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview, record, and policy review, the facility failed to ensure that 20 of 20 residents (Residents 1, 3, 4, 5, 7, 8, 9, 10, 14, 16, 17, 18, 21, 22, 23, 24, 25, 26, 27, and 28) who were over the age of 65, were educated, offered and/or received the pneumococcal (a serious pneumonia in the lungs caused by [CONDITION(S)] bacteria) vaccine according to the facility's policy. This widespread failure represented a systemic failure which resulted in substandard quality of care for the facility residents and had the potential for vulnerable residents to be unprotected from pneumococcal pneumonia which could result in increased risk for contracting pneumonia with its associated complications. Findings: The facility's policy titled, Pneumococcal Vaccine revised 4/2013, indicated that all residents would be offered the pneumococcal vaccine to aid in preventing infectious diseases (pneumonia). Policy implementation directed that: 1. Residents will be assessed for eligibility to receive the pneumococcal vaccine prior to or upon admission and will be offered the vaccine within 30 days of admission. 2. Assessment of the resident's pneumococcal vaccination status will be conducted within 5 working days of admission. 3. Before receiving the vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the vaccine as outlined in the CDC vaccine publications. Such education will be documented in the resident's medical record 5. Residents/representatives have the right to refuse vaccination. If refused, documentation in the medical record will include the date and reason for refusal. 6. For residents who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's medical record. 7. Administration of the pneumococcal vaccine or revaccinations will be made in accordance with current CDC recommendations at the time of the vaccination. A review of CDC website for Pneumococcal vaccine recommendations, as of 1/24/22, indicated adults of age 65 or older who have never received a pneumococcal vaccine or those who have an unknown vaccination history, should be offered a PCV15 ([MEDICATION(S)]) or PCV20 (Prevnar20). If the [MEDICATION(S)] is used, then this should be followed by a PPSV23 ([MEDICATION(S)]) in one year. If the Prevnar20 is used, the vaccination is complete. If the resident had already received the [MEDICATION(S)] first, then it should be followed with a [MEDICATION(S)] or Prevnar20, in one year. If the resident had received the PCV13 (Prevnar13), regardless of age, then at [AGE] years of age or older, they should receive a [MEDICATION(S)]. On 5/3/22 at 8:15am, an interview and resident vaccination status review was conducted with the Infection Preventionist (IP). The IP presented an undated and untitled log of residents who had received pneumococcal vaccines. Of the 20 residents in the facility over the age of 65, the IP showed that only Resident 18 was recently (6/30/21) vaccinated, but had not indicated which pneumococcal vaccine was used, Resident 21 had refused the vaccine and the reasons were not documented, Residents 3, 4, 5, 8, 9, 24 and 26 had vaccine dates that were far more than one year old and did not describe which vaccine they were given, the IP did not have the pneumococcal vaccine status of Residents 1, 7, 10, 14, 16, 17, 22, 23, 25, 27 and 28. There was no evidence that education had been provided to the residents according to CDC vaccine publications. The IP indicated that he has been in his position for 3 months. He stated, I'm trying to get organized and get caught up. I need someone to advise me. I did not get any training for this position. The IP indicated that he did not know the current CDC guidelines and timeframes for administering pneumococcal vaccines. The IP was not familiar with the different types of pneumococcal vaccines or in what order they were to be given. He indicated that he was not familiar with the facility's policy regarding pneumococcal vaccinations. The IP did not know that residents should be reviewed and offered the vaccine annually, even if they had previously refused. The IP indicated that he was not aware of the CDC educational materials that residents were supposed to receive.

Based on interview, record and policy review, the facility failed to provide a safe, sanitary, and comfortable environment when they failed to ensure that there was a dedicated facility-wide Infection Control Program (ICP) that prevented, identified, reported, investigated and controlled infections based on national standards; (Centers for Disease Control (CDC), Society for Healthcare Epidemiology of America (SHEA), McGeer's Criteria and National Healthcare Safety Network (NHSN) are examples of nationally accepted standards), and failed to review their ICP policies annually. This had the potential not to control infectious and communicable diseases before they spread to residents, staff, and visitors. Findings: The facility's policy titled, Infection Preventionist revised January 2012, was reviewed. The policy indicated that the Infection Preventionist (IP) .shall coordinate the development and monitoring of our facility's established Infection control policies and practices and .collect, analyze and provide infection data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidence-based infection control practices. On 5/11/22 at 5:01pm, an interview and review of the facility's ICP and ICP policies was conducted with the IP. The IP stated that he reviews facility infections under the Infections tab in the electronic health records however, that was not an accurate account of the infections in the facility because, the nurses don't always fill that out. The IP confirmed that he had not established a current system for infection surveillance (a process for reviewing staff implementation of the ICP and analyzing compliance), based upon national standards of practice. The IP confirmed that he did not have a routine, ongoing, and systematic way to collect information about infections and communicable diseases (such as conducting a facility risk assessment, what and when to report, reviewing orders and care plans for antibiotic therapy and reviewing laboratory cultures). The IP stated that he had no system for analyzing and interpreting facility infections (such as maintaining tracking documentation about the types of infections, organisms, symptoms, locations, antibiotic treatment, resolution, or the facility's overall infection rate percentages) and stated, I don't know how to do that yet. I need guidance. The IP confirmed that the ICP policies had not been reviewed since August 2019, three years ago, and should have been reviewed annually.

Based on interview and record review the facility's pharmacy consultant failed to identify drug irregularities which included duplicate therapy (According to the Centers for Medicare and Medicaid Services or CMS, Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking), the CMS requirement to limit as needed (PRN) antipsychotic (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking) and [CONDITION(S)] (any drug that affects brain activities associated with mental processes and behavior) medications to 14 days, unless there was a re-evaluation of the resident and drug and rationale as to why the medication needed to be extended past 14 days, necessary indications for each [CONDITION(S)] drugs, and necessary gradual dose reductions (GDR) for 13 of 16 sampled residents (Residents 3, 4, 7, 9, 10, 11, 12, 14, 16, 17, 18, 21, and 22). The facility's consultant pharmacist did not send his monthly medication regimen reviews (MRR) to the physician or the Director of Nurses (DON). The facility had no process for ensuring timely follow up on a recommendation of the pharmacist by the physician. 1. Resident 11 received the following medications in combination that were contraindicated due to risk of serious clinical deterioration: [MEDICATION(S)] (an anti-depressant and monoamine oxidase type B, MAO-B drug), [MEDICATION(S)] (an anti-depressant and a selective serotonin reuptake inhibitor, SSRI), and [MEDICATION(S)] (used to treat [CONDITION(S)] and major depressive disorder), the necessary labs were not done to assess the levels of the [MEDICATION(S)] medication in the blood, which could have led to toxicity, and these issues were not noted by the pharmacist. 2. Resident 12 received duplicate therapy when he received [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)]), [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)]), and [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)]) for the same diagnosis of paranoid [CONDITION(S)] with the same behavior of [CONDITION(S)] to be monitored, and these issues were not noted by the pharmacist during the past year. 3. Resident 17 received PRN [MEDICATION(S)], since 1/9/22, in excess of 14 days, without a re-evaluation and rationale documented by the physician, and this was not noted by the pharmacist in the past year. 4. Resident 14 received [MEDICATION(S)] ([CONDITION(S)] drug used to treat anxiety), since 12/29/20, in excess of 14 days without a re-evaluation and rationale documented by the physician, and this was not noted by the pharmacist in the past year. 5. Resident 9 had received [MEDICATION(S)] PRN since 12/19/19, in excess of 14 days, without a re-evaluation and rationale documented by the physician and this was not noted by the pharmacist in the past year. A recommendation, on 4/26/21 (more than one year ago), by the facility's pharmacy consultant for a GDR for [MEDICATION(S)] (ordered 12/28/18) was not acted upon by the facility. 6. Resident 10 had received [MEDICATION(S)] PRN since 1/5/22, in excess of 14 days, without a re-evaluation and rationale documented by the physician, and this was not noted by the pharmacist. 7. Resident 18 had received [MEDICATION(S)] PRN since 8/4/21, in excess of 14 days, without a re-evaluation and rationale documented by the physician and this was not noted by the pharmacist. A recommendation, on 12/31/21, by the facility's pharmacy consultant for a GDR for [MEDICATION(S)] (an anti-depressant ordered 6/22/21) was not acted upon by the facility. 8. Resident 4 received [MEDICATION(S)] (an antidepressant) and [MEDICATION(S)] for 3 years without a GDR. 9. Resident 7 had an order for PRN [MEDICATION(S)] (an anti-anxiety) for 3 years without being reevaluated every 14 days and [MEDICATION(S)] (a chemical compound use for depression) for 3 years without an indication for use (target behavior), and this was not noted by the pharmacist. 10. Resident 16 had two PRN [MEDICATION(S)] orders (duplicate therapy) that exceeded the 14-day limit and without an inadequate indication for use, adequate monitoring (a target behavior and side effects) and in an excessive dose), and this was not noted by the pharmacist. 11. Resident 21 received [MEDICATION(S)] without an indication for use and adequate monitoring. [MEDICATION(S)] (an antidepressant) and [MEDICATION(S)] (a long-acting anti-anxiety) were ordered PRN without adequate indications for use, adequate monitoring and exceeded the 14-day limit), and this was not noted by the pharmacist. 12. Resident 22 received three antipsychotics (duplicate therapy); [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] at the same time without adequate indications for use and adequate monitoring, and this was not noted by the pharmacist. 13. Resident 3 received [MEDICATION(S)] (an antidepressant) without an adequate indication for use and adequate monitoring and had no GDR in 3 years. Omeprazole (a PPI stomach acid reducer intended for short term use) has been taken for 4 years and the medication change recommended a year ago, was not followed. This resulted in or had the potential to result in residents receiving unnecessary medication or inappropriate dosages with adverse side effects, some of which could be permanent. Findings: The facility's pharmacy services agreement required their consultant pharmacist to review the drug regimen for all skilled nursing patients monthly, review use of [CONDITION(S)] drugs with a letter to the physician every three months requesting consideration of a gradual dose reduction as appropriate and ensure the pharmacy services were in compliance with all state and federal regulations regarding pharmaceutical services. 1 a. A review of Resident 11's record indicated he was admitted on [DATE] with diagnoses that include mood disorder, major depressive disorder and dementia with behavioral disturbance. A review of the current physician's orders included [MEDICATION(S)] 5 milligrams (mg) every morning, [MEDICATION(S)] 40 mg every day at bedtime, [MEDICATION(S)] 40 mg every 12 hours (antipsychotic medication use to treat [CONDITION(S)] and [CONDITION(S)]), [MEDICATION(S)] (treats anxiety and panic disorders) 1 mg every day at bedtime, and [MEDICATION(S)] 300 mg every day at bedtime, which had been started on 6/11/21. During a concurrent interview and record review on 5/4/22 at 9:30 am, Medical Records and Quality Assurance staff (MR A) confirmed the above medications. Lexi-comp (a nationally recognized drug reference) included a warning for the following drug interactions, the use of [MEDICATION(S)] and [MEDICATION(S)] (SSRI) could lead to serotonin syndrome. As defined by the Centers for Medicare and Medicaid Services (CMS): Serotonin Syndrome is a potentially serious clinical condition resulting from overstimulation of serotonin receptors. It is commonly related to the use of multiple serotonin-stimulating medications (e.g., SSRIs, SNRIs, triptans, certain antibiotics). Symptoms may include restlessness, hallucinations, confusion, loss of coordination, fast heartbeat, rapid changes in blood pressure, increased body temperature, overactive reflexes, nausea, vomiting and diarrhea. Lexi-comp also included a warning Risk X: avoid combination for the use of [MEDICATION(S)] and [MEDICATION(S)]. MAO-B may enhance the serotonergic effects of Serotonergic Agents. Avoid concomitant use of Type B MAOs with [MEDICATION(S)]. At least 14 days should elapse between discontinuance of Type B MAOs and initiation of [MEDICATION(S)]. During an interview on 5/4/22 at 7:04 pm, a pharmacist (Pharm F) with the pharmacy that supplies the facility its medications, confirmed the combination of [MEDICATION(S)] and [MEDICATION(S)] was a Risk X - avoid combination and other information from Lexi-comp, including the risk of Serotonin Syndrome from the use of [MEDICATION(S)] and [MEDICATION(S)]. During an interview on 5/05/22 at 8:10 am, the facility's consultant pharmacist (Pharm E) confirmed he had performed monthly medication reviews for Resident 11. He said the combination of [MEDICATION(S)] and [MEDICATION(S)] could result in serotonin syndrome and he said he did not inform the facility staff or physicians about this in his medication reviews. Pharm E said he uses Lexi-comp but disagreed that the combination of [MEDICATION(S)] and [MEDICATION(S)] was a Risk X. He admitted that the combination of [MEDICATION(S)] and [MEDICATION(S)] could cause clinical deterioration of the resident. He also confirmed he did not inform the facility's staff or physician about this in his medication reviews. b. The following was also noted in Lexicomp, regarding [MEDICATION(S)]. ALERT: US Boxed Warning - Monitoring: [MEDICATION(S)] toxicity is closely related to serum [MEDICATION(S)] levels and can occur at doses close to therapeutic levels. Facilities for prompt and accurate serum [MEDICATION(S)] determinations should be available before initiating therapy. Only prescribe in settings where serum concentration monitoring is available. Toxic effects occur with serum concentrations =1.5 mEq/L and may be seen in some patients with serum concentrations as low as 1.2 mEq/L (Janicak 2021); . serum electrolytes (baseline, then periodically); ECG with rhythm strip (baseline for all patients >[AGE] years of age or if underlying cardiac risk factors, repeat as clinically indicated); . serum [MEDICATION(S)] levels (twice weekly until both patient's clinical status and levels are stable, then repeat levels every 1 to 3 months or as clinically indicated; closely monitor in patients with significant renal or cardiovascular disease, debilitation, dehydration, sodium depletion, or those taking concomitant medications that impact renal function); . signs of [MEDICATION(S)] toxicity (e.g., diarrhea, vomiting, tremor, mild ataxia, drowsiness, muscular weakness). Toxic concentrations: >1.5 mEq/L (SI: >1.5 mmol/L): Early signs and symptoms of intoxication may include marked tremor, nausea, diarrhea, blurred vision, [CONDITION(S)], confusion, and decreased deep tendon reflexes (APA 2002). >2.5 mEq/L (SI: >2.5 mmol/L): Intoxication symptoms may progress to include severe neurological complications, seizures, coma, cardiac [CONDITION(S)], and permanent neurological impairment (APA 2002). >3.5 mEq/L (SI: >3.5 mmol/L): Potentially lethal toxicity ([NAME] 2001). During an interview on 5/4/22 at 9:30 am, MR A said there had been only one [MEDICATION(S)] level done on 8/17/21 which was 1.0. During a concurrent interview and record review on 5/4/22 at 4 pm, MR B confirmed baseline labs were done (as indicated in Lexicomp) and repeated every two to three months, except no EKG had been done when [MEDICATION(S)] was initiated or afterwards. During an interview on 5/05/22 at 8:10 am, Pharm E confirmed he did not make a recommendation about a [MEDICATION(S)] level during his medication reviews for Resident 11. 2. A review of Resident 12's record indicated he was admitted on [DATE] with diagnoses that included paranoid [CONDITION(S)], anxiety disorder, and panic disorder. The current physician's orders included [MEDICATION(S)] 50 mg every day, [MEDICATION(S)] 8 mg every morning and 16 mg every evening, [MEDICATION(S)] 8 mg every evening, and [MEDICATION(S)] 1 mg every evening. During a concurrent interview and record review on 5/4/22 at 10:44 am MR A confirmed Resident 12 was taking [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] all for paranoid [CONDITION(S)] with the behavior of [CONDITION(S)] to be monitored, and [MEDICATION(S)] for panic disorder with the behaviors of panic to be monitored. The pharmacist's medication regimen reviews (MRR) from 5/29/21 - 4/30/22 were reviewed. On the MRR dated 10/24/21, Pharm E recommended a gradual dose reduction (GDR) for all of the four meds above due on 10/31/21. There was no mention by the pharmacist during the past year in his MRR's of duplicate/triplicate therapy for the same diagnosis and behaviors. There was no mention by the pharmacist during the past year of his MRR's of triplicate therapy for the same diagnosis and behaviors. There was a MRR dated 4/30/22 wherein a GDR for [MEDICATION(S)] PRN was recommended. MR A said this medication was no longer ordered for this resident and he hadn't received it since 2/1/21. During an interview on 5/05/22 at 8:20 AM, Pharm E was asked if he had advised the facility that this resident was receiving duplicate therapy, since he was receiving three antipsychotic medications for the same diagnosis and behavior. He said, in a review on 10/23/19, he advised the facility that this resident was on three antipsychotic meds and asked for a risk benefit statement. He said he had not included this recommendation since that time although he had since recommended GDRs for these medications. He said he does not repeat the same recommendations month to month so those MRRs will indicate that there are no irregularities. He said he tries to give the physicians time to respond and repeat the recommendation quarterly or at least yearly. He said he sent the MRRs to the medical records manager not the DON. Pharm E was asked why his 4/2022 review asked for a GDR for the [MEDICATION(S)] PRN order when it was discontinued in 2/2021. He said he did not have remote access to the residents' records and explained this drug was on the pharmacy profile as an active order or he may not have taken it off his list and schedule, probably the latter. He said he does not have remote access and it would be easier if he did. He talked to one of the nurses who told him he would need access to the facility server and had to talk to the facility's Information Technology manager. During a concurrent interview and record review on 5/5/22 at 9:35 am, MR A confirmed the first MRR done by the pharmacist was 11/26/19 which indicated no irregularities. She said there was not a MRR done in October 2019 and said Resident 12 was admitted on [DATE]. b. During a concurrent interview and record review on 5/4/22 at 10:44 am, MR A confirmed on the MRR dated 10/24/21, the Pharmacist recommended a GDR was due on 10/31/21, for [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)], all of which had been ordered on 10/18/19. This MRR was signed by Resident 12's physician on 11/1/21 and indicated I reviewed this resident's current medication regimen and agree with the consultant pharmacist's medication review. However, there was no note or order from the physician that actually noted which medication and dosage should be changed or no risk benefit statement as to why a GDR should not be done. MR A said she thought the DON was supposed to follow up on that. During an interview on 5/5/22 at 11:16 am, the DON confirmed if the physician signed he agreed with the pharmacist's recommendation but does not make a change in the medication dosage, they have no process at this time to follow up to see what changes the physician wants to make. 3. A review of Resident 17's record indicated he was admitted on [DATE], with diagnoses that included major depressive disorder and dementia without behavioral disturbance. A review of the current physician's orders included an as needed PRN order for [MEDICATION(S)] 25 mg for agitation at bedtime, dated 1/9/22. During a concurrent interview and record review on 5/04/22 at 10:30 am, MR A confirmed the [MEDICATION(S)] PRN order had started on 1/9/22. The pharmacy consultant noted during his MRR on 1/31/22, that CMS restricts prn use of antipsychotics for 14 days. There was no physician signature or response on this MRR. There was no re-assessment by the physician for this med. The pharmacy consultant did not mention this issue in subsequent MRRs done from 2/2022 through 4/2022. During an interview on 5/5/22 at 8:30 am, Pharm E said he does not repeat the same recommendations month to month so those MRR's will indicate that there are no irregularities. He said he tries to give the physicians time to respond and repeat the recommendation quarterly or at least yearly. Pharm E said he sent the MRRs to the medical records director (MRD) not the DON. During an interview on 5/05/22 at 11:07 am, the DON said he had not received the MRRs, and they have been sent to MRD. He said Pharm E did not have his email address and he just found out about that today. 4. A review of Resident 14's record indicated she was admitted on [DATE], with diagnoses that included anxiety and mood disorder. The current physician's orders included [MEDICATION(S)] 25 mg twice per day and [MEDICATION(S)] 1 mg twice per day PRN for panic and anxiety. During a concurrent interview and record review on 5/4/22 at 10:55 am, MR A reviewed the MRRs done by the pharmacy consultant over the past year. There was no mention of the PRN [MEDICATION(S)] although the MRRs did include a GDR recommendation for [MEDICATION(S)]. Resident 14 had not received this medication for several months. During an interview on 5/5/22 at 8:30 am Pharm E said the [MEDICATION(S)] 1 mg PRN BID was started on 12/29/20. He said he recommended the re-evaluation after 14 days for the [MEDICATION(S)] on 2/26/21. He was unable to say if he had repeated this recommendation in later reviews during the past year. He said he tries to repeat the recommendations quarterly or at least yearly. 5. A review of Resident 9's record indicated she was admitted on [DATE], with diagnoses that included major depressive disorder, dementia with behavioral disturbance, and restlessness. A review of the current physician's orders included [MEDICATION(S)] 100 mg at bedtime and [MEDICATION(S)] 0.5 mg twice per day PRN. During a concurrent interview and record review on 5/5/22 at 9:59 am, MR A confirmed the above medication orders. She said Resident 9 had not received any [MEDICATION(S)] in the past eight months. A review of the MARs showed no [MEDICATION(S)] was given from 12/2021 through the present. MR A reviewed the MRR's from the past year and confirmed there was no report from the pharmacist regarding the CMS restriction of PRN psychotropics to 14 days and the need to document the rational to extend the drug beyond 14 days. MR A confirmed there was no rationale or risk benefit statement documented by the physician to extend the use of the [MEDICATION(S)] after 14 days. b. During a concurrent interview and record review on 5/5/22 at 9:59 am, MR A confirmed the pharmacy consultant included a GDR recommendation for [MEDICATION(S)] on 4/30/22. The prior GDR recommendation was on 4/26/21 and the physician signed he agreed with pharmacist's recommendation on 5/10/21, but no changes in the dose were made at that time. During an interview on 5/12/22 at 7:27 am, the DON reviewed the MRR dated 4/26/21 and signed 5/10/21 and said they had no process for following up when the physician signs the MRR from pharmacist but did not change the dosage. He said the MRRs went to MRD and he not get them, but after last week, the pharmacy consultant would now be sending them to him. 6. A review of Resident 10's record indicated she was readmitted on [DATE] with diagnoses that included major depressive disorder, dementia without behavior disturbance, and lung disease. The current physician's orders included [MEDICATION(S)] 0.5 mg every six hours PRN for anxiety and restlessness. During an interview on 5/4/22 at 3:55 pm, Pharm E said he made a recommendation regarding the use of prn [MEDICATION(S)] on 1/31/22. During a concurrent interview and record review on 5/5/22 at 9:43 am, MR A confirmed the [MEDICATION(S)] PRN order. She said this resident was admitted with this order. The pharmacy consultant's MRRs for 2/22, 3/22, 4/22 indicated there were no medication irregularities. A review of the physician notes did not include a re-evaluation of this drug and why it needed to continue after 14 days. During an interview on 5/11/22 at 11:45 am, MR A reviewed the copy of the MRR dated 1/31/22. It asked for a GDR of [MEDICATION(S)] but did not mention PRN use and CMS restriction of PRN psychotropics to 14 days and the need to document the rational to extend the drug beyond 14 days. 7. A review of Resident 18's record indicated she was admitted on [DATE], with diagnoses that included anxiety disorder, depressive disorder, and dementia with behavioral disturbance. Her current orders included [MEDICATION(S)] (anti-depressant) 10 mg daily and [MEDICATION(S)] (treats anxiety) 0.5 mg every 12 hours PRN. During a concurrent interview and record review on 5/05/22 at 10:07 am, MR A confirmed the [MEDICATION(S)] 0.5 mg PRN was ordered on 8/4/21. A review of the pharmacy consultant's MRRs, each month since 8/8/21, did not mention the CMS restriction of PRN psychotropics to 14 days and the need to document the rational to extend the drug beyond 14 days. A MRR dated 10/24/21 included a GDR recommendation for [MEDICATION(S)] and its PRN use should be considered and a [MEDICATION(S)] GDR due 11/30/21. This was signed by the MD that he was in agreement with the pharmacist's recommendation on 11/1/21. The MRR dated 12/31/21 included a recommendation for a GDR for [MEDICATION(S)]. This was not signed by a physician. Subsequent MRRs through 3/2022 contained no irregularities. MRR dated 4/30/22 included a recommendation for GDR for [MEDICATION(S)]. MR A confirmed there was no rationale or risk benefit documented by the physician to extend the use of the [MEDICATION(S)] after 14 days. A review of the MARs showed no [MEDICATION(S)] was given from 12/2021 through the present. During an interview on 5/5/22 at 11:16 am, the DON confirmed if the physician signs he agrees with the pharmacist's recommendation but does not make a change in the medication dosage, they have no process at this time to follow up to see what changes the physician wants to make. 8. On 5/4/22 at 12:22pm, an interview and a concurrent review of Resident 4's MRRs was conducted with Medical Records staff (MR) B. MR B described that the facility's process for managing the Consultant Pharmacist's (Pharm) D's monthly MRRs was that Pharm D emailed the reviews to the MR Director (MRD). The MRD then brought them to the weekly clinical IDT meeting for the physicians to review and address. MR B stated, the DON is not involved in this process. MR B stated the MR department will give the nurses any MRRs that have order changes and then the MR department scans the completed MRRs into the residents' records. Resident 4 was admitted on [DATE] with diagnoses that included, major depressive disorder (severe depression) and emotional lability (uncontrollable laughing, crying or irritability). A review of Resident 4's MRRs for the past year showed that [MEDICATION(S)] (an antipsychotic) 0.5mg was ordered on 3/18/19. The MRRs requested that a GDR be done from May 2021 to December 2021, but one was never done and there was no rationale documented by her physician for not following the recommendation. The GDR was not recommended again, until the March 2022 MRR and Resident 4's physician documented that a GDR was contraindicated. The physician had not documented a resident specific clinical rationale for not doing a dose reduction at that time. Therefore, a GDR had not been attempted for 3 years. [MEDICATION(S)] (an SSRI antidepressant) 100mg QD was ordered on 5/15/19. The MRRs requested that a GDR be done from May 2021 through December 2021, but one was never done. The April 2022 MRR indicated no irregularities and had no further recommendations for a GDR. MR B confirmed the above findings. 9. On 5/4/22 at 3:44pm, an interview and a concurrent review of Resident 7's MRRs was conducted with MR B. Resident 7 was admitted on [DATE] with diagnoses that included, dementia with behavior problems, [CONDITION(S)] depression with manic episodes (episodes of extreme mood changes with states of depression lows and high energy and excitement), restlessness and agitation, and [CONDITION(S)] (episodes of hallucinations, delusions or paranoia). The April and September 2021, MRRs indicated that Resident 7 had been on [MEDICATION(S)] (an anti-anxiety) 1mg every 24 hours PRN since 6/24/19, and that CMS regulations limits all PRN [CONDITION(S)] use to 14 days and cannot be continued unless the prescriber evaluates the resident for appropriateness and documents rationale for continuation. This recommendation was not addressed, and Pharm D did not make that recommendation again. [MEDICATION(S)] (a salt chemical used for depression) 150mg at bedtime was ordered on 8/5/18. The August 2021 MRR indicated that a required annual GDR was due. This was not done and not recommended again. Pharm D had not identified that a target behavior was not being monitored [MEDICATION(S)]. MR B confirmed the above findings. On 5/4/22 at 3:40pm, an interview was conducted with Pharm D. He was asked what his process was for ensuring that PRN orders did not exceed the 14-day limit. Pharm D indicated that if he made the recommendation to re-evaluate and the facility did not do that, at some point he would stop recommending it. 10. On 5/4/22 at 2:34pm, an interview and a concurrent review of Resident 16's MRRs was conducted with MR B. Resident 16 was admitted on [DATE] with diagnoses that included, restlessness and agitation, [CONDITION(S)], dementia and Wernicke's [CONDITION(S)] (confusion, incoordination and eye abnormalities caused from a lack of B vitamins). MRRs from May 2021 through April 2022, showed no irregularities and had no recommendations, even though Resident 16 had two PRN [MEDICATION(S)] (an anti-anxiety) orders without specific indications for use (target behaviors) or monitoring done for adverse side effects and were ordered in an excessive dose. [MEDICATION(S)] 2mg IM PRN QD had been ordered since 1/19/22. [MEDICATION(S)] 1mg orally (PO) every 8 hours PRN was ordered on 7/22/21. Both orders were to treat, restlessness and agitation (not specific). Neither of these PRN medications had been reviewed within the 14-day limit and were still available for use. According to LexiComp, the recommended dose limit for [MEDICATION(S)] for adults aged 65 or older is 2mg. Resident 16 had the potential to receive up to 5mg of [MEDICATION(S)] per day. MR B confirmed all of the above findings. 11. On 5/4/22 at 5:12pm, an interview and a concurrent review of Resident 21's MRRs was conducted with MR B. Resident 21 was admitted on [DATE] with diagnoses that included, major depressive disorder, anxiety disorder, restlessness and agitation, dementia with behaviors, and irritability and anger. [MEDICATION(S)] (an SSRI antidepressant) 40mg QD was ordered on 1/4/22. There was no target behavior monitored (indication for use) or monitoring done for adverse side effects. [MEDICATION(S)] 100mg PRN was ordered on 1/4/22. There was no 14-day re-evaluation. No target behavior was identified (reason for use) or monitored. No monitoring had been done for adverse side effects. [MEDICATION(S)] 0.25mg every 12 hours PRN was ordered on 1/4/22. There was no 14-day reevaluation done. A target behavior was not identified or monitored. No monitoring was done for adverse side effects. These irregularities were not identified on the MRRs from January 2022 to April 2022. The MRR for February 2022 was missing. MR B confirmed the above findings. On 5/4/22 at 3:40pm, during an interview with Pharm D, he confirmed that the January, March and April 2022 MRRs for Resident 21, had not included any irregularities or recommendations. Pharm D confirmed that the MRR for February 2022 was missing, I may have missed one. 12. On 5/4/22 at 2:43pm, an interview and a concurrent review of Resident 22's MRRs was conducted with MR B. Resident 22 was admitted on [DATE] with diagnoses that included, [CONDITION(S)], dementia with behaviors, psychotic disorder with delusions, and [CONDITION(S)] (a brain damage or malfunction with a broad spectrum of symptoms). [MEDICATION(S)] (an antipsychotic) 100mg every morning and [MEDICATION(S)] 150mg at bedtime was ordered on 2/28/22. There was no target behavior (reason for use) or side effect monitoring being done. A second antipsychotic, [MEDICATION(S)] 5mg QD was ordered on 2/28/22. There was no target behavior or side effect monitoring being done. A third antipsychotic [MEDICATION(S)] 20mg QD was added on 3/10/22. There was no target behavior or side effect monitoring being done. There was no documented clinical rationale by Resident 22's physician to justify the use of three antipsychotic medications (duplicate therapy). The March 2022 MRR indicated that, the resident is taking more than one antipsychotic .Please evaluate this combination for duplication of therapy and, if no changes, document risk vs. benefit for taking multiple antipsychotics. The physician did not document a resident specific clinical rationale and responded, Patient is stable only on both these meds and had not recognized that Resident 22 was actually taking three antipsychotics. The April 2022 MRR identified, no irregularities and had no recommendations and Resident 22 continues to take three antipsychotic medications without an adequate indication for use or adverse side effect monitoring. MR B confirmed the above findings. 13. On 5/4/22 at 5:41pm, an interview and a concurrent review of Resident 3's MRRs was conducted with MR B. Resident 3 was admitted on [DATE] with diagnoses that included, gastroesophageal reflux disease (GERD), major depressive disorder, and vascular dementia (brain damage caused by multiple strokes) without behaviors. [MEDICATION(S)] (an SSRI antidepressant) 10mg QD was ordered on 9/29/19. The target behavior and adverse side effects were not being monitored. There was no evidence that a GDR had been done since the [MEDICATION(S)] was ordered, 3 years ago. On the September 2021 MRR, Pharm D recommended a dose reduction. This was never done and not recommended again. Omeprazole (a proton pump inhibitor (PPI) stomach acid reducer) 20mg QD was ordered on 5/18/18. According to LexiComp, PPI medications should not be taken long term. They can cause kidney damage, vitamin B-12 deficiency, [CONDITION(S)] (bone mineral depletion) and stomach cancer. On the May 2021 MRR, Pharm D recommended changing Omeprazole to Pepcid (a stomach acid reducer that is not a PPI), this was never done and Resident 3's physician had not documented a reason for not following the recommendation. The MRRs from October 2021 to April 2022, showed no irregularities or recommendations. MRB confirmed the above findings. On 5/5/22 at 8:10am, Pharm D was interviewed. Pharm D indicated that he did not have remote access to the resident's records, which made his ability to do the MRRs, more difficult and possibly less thorough. Pharm D indicated that he did not have the email addresses of the Administrator, DON or Medical Director, therefore, those individuals did not get the MRRs. Pharm D indicated that he does not attend the facility's QA/QAPI (Quality Assurance) meetings, there's not enough time in the day (the facility is in a rural area more than 3 hours from any city). Pharm D confirmed that he was aware that residents in the facility were receiving duplicate [CONDITION(S)] drugs and PRNs over the 14-day limit. Pharm D added, when they lost their previous DON things changed and I did not change my routine when things stopped working. Pharm D confirmed that has not tried to meet with the Medical Director to discuss a plan to reduce the use of unnecessary drugs in the facility.

Based on interview and record review, the facility failed to ensure 15 of 16 sampled residents (Residents 3, 4, 5, 7, 8, 9, 10, 11, 12, 14, 16, 17, 18, 21, and 22) who received [CONDITION(S)] drugs (any drug that affects brain activities associated with mental processes and behavior), received the necessary monitoring of labs (tests used to evaluate the level of medications in the body), adverse side effects, target behaviors to assess effectiveness, gradual dose reductions (GDR); and did not receive duplicate therapy (Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking) and as needed (PRN) [CONDITION(S)] and antipsychotic drugs (drugs that work by altering brain chemistry to help reduce psychotic symptoms including hallucinations, delusions, and disordered thinking) past 14 days, without the necessary re-evaluation and rationales by the physician. 1. Resident 11 received the following medications in combination that were contraindicated due to risk of serious clinical deterioration: [MEDICATION(S)] (an anti-depressant and monoamine oxidase type B, MAO-B drug), [MEDICATION(S)] (an anti-depressant and a selective serotonin reuptake inhibitor, SSRI), and [MEDICATION(S)] (used to treat [CONDITION(S)] and major depressive disorder), the necessary labs were not done to assess the levels of the [MEDICATION(S)] medication in the blood, which could have led to toxicity, adverse side effects of [MEDICATION(S)] were not monitored, and behaviors were not monitored to assess the effectiveness of the medications. 2. Resident 12 received duplicate therapy when he received [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)]), [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)]), and [MEDICATION(S)] (antipsychotic medication used to treat [CONDITION(S)]) for the same diagnosis of paranoid [CONDITION(S)] with the same behavior of [CONDITION(S)] to be monitored without a rationale by the physician as to why three were necessary, and no gradual dose reductions for these medications. 3. Resident 17 received PRN [MEDICATION(S)], since 1/9/22, in excess of 14 days, without a re-evaluation and rationale documented by the physician. 4. Resident 14 received [MEDICATION(S)] ([CONDITION(S)] drug used to treat anxiety), since 12/29/20, in excess of 14 days without a re-evaluation and rationale documented by the physician and received no behavior monitoring for [MEDICATION(S)]. 5. Resident 9 had received [MEDICATION(S)] PRN, since 12/19/19, in excess of 14 days, without a re-evaluation and rationale documented by the physician. A recommendation, on 4/26/21 (more than one year ago), by the facility's pharmacy consultant for a GDR for [MEDICATION(S)] (ordered 12/28/18) was not acted upon by the facility. 6. Resident 10 had received [MEDICATION(S)] PRN since 1/5/22, in excess of 14 days, without a re-evaluation and rationale documented by the physician. 7. Resident 18 had received [MEDICATION(S)] PRN since 8/4/21 in excess of 14 days, without a re-evaluation and rationale documented by the physician. A recommendation, on 12/31/21, by the facility's pharmacy consultant for a GDR for [MEDICATION(S)] (an anti-depressant ordered 6/22/21) was not acted upon by the facility. There were no target behaviors to monitor the effectiveness of [MEDICATION(S)] and [MEDICATION(S)]. 8. Resident 5 received [MEDICATION(S)] (anti-depressant) since 12/11/19, without a GDR or statement by the physician as to why the GDR was contraindicated. 9. Resident 8 received [MEDICATION(S)] (an anti-depressant) since 10/8/21, without a re-evaluation, when the order was for a trial for two weeks and then re-evaluate. 10. Resident 4 received [MEDICATION(S)] (an antidepressant) and [MEDICATION(S)] (an antipsychotic) for 3 years without a GDR. 11. Resident 7 had an order for PRN [MEDICATION(S)] (an anti-anxiety) for 3 years without being reevaluated every 14 days. [MEDICATION(S)] (an antipsychotic medication) was given without an adequate indication for use as there was no specific behavior identified. There was no documented evidence that a GDR had been attempted since the [MEDICATION(S)] was ordered, 4 years ago. [MEDICATION(S)] (a chemical compound use for depression) for 3 years, without an indication for use (target behavior). 12. Resident 16 had two PRN [MEDICATION(S)] orders (duplicate therapy) that exceeded the 14-day limit and without an inadequate indication for use, adequate monitoring (a target behavior and side effects) and in an excessive dose. 13. Resident 21 received [MEDICATION(S)] without an indication for use and adequate monitoring. [MEDICATION(S)] (an antidepressant) and [MEDICATION(S)] (a long-acting anti-anxiety) were ordered PRN without adequate indications for use, monitoring and exceeded the 14-day limit. 14. Resident 22 received three antipsychotics (duplicate therapy); [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] at the same time without adequate indications for use and monitoring. 15. Resident 3 received [MEDICATION(S)] (an antidepressant) without an adequate indication for use and adequate monitoring and had no GDR in 3 years. Omeprazole (a PPI stomach acid reducer intended for short term use) had been taken for 4 years and the medication change recommended a year ago, was not followed. This widespread failure resulted in substandard quality of care for the facility residents and had the potential to result in permanent neurological side effects and a deterioration in the clinical condition of these residents. Findings: During a document review of the facility's Antipsychotic Medication Use policy, dated 4/2007, was reviewed. It indicated, Antipsychotic mediation therapy shall be used only when it is necessary to treat a specific condition 3. Nursing staff will document in detail an individual's target symptom(s). 4. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. 6. The staff will observe, document and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. During a document review of the facility's Tapering Medication and Gradual Drug Dose Reduction policy, dated 4/2007, was reviewed. It indicated, Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 11. Within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. During a document review of the facility's pharmacy services agreement, dated 5/8/18, required their consultant pharmacist to review the drug regimen for all skilled nursing patients monthly, review use of [CONDITION(S)] drugs with a letter to the physician every three months requesting consideration of a gradual dose reduction as appropriate and ensure the pharmacy services were in compliance with all state and federal regulations regarding pharmaceutical services. 1 a. A review of Resident 11's record indicated he was admitted on [DATE], with diagnoses that included mood disorder, major depressive disorder and dementia with behavioral disturbance. A review of the current physician's orders, dated 5/2022, included [MEDICATION(S)] 5 milligrams (mg) every morning, [MEDICATION(S)] 40 mg every day at bedtime, [MEDICATION(S)] 40 mg every 12 hours (antipsychotic medication use to treat [CONDITION(S)] and [CONDITION(S)]), [MEDICATION(S)] (treats anxiety and panic disorders) 1 mg every day at bedtime, and [MEDICATION(S)] 300 mg every day at bedtime, which had been started on 6/11/21. During a concurrent interview and physician orders record review on 5/4/22 at 9:30 am, Medical Records and Quality Assurance staff (MR A) confirmed the above medications and doses. A review of Lexi-comp (a nationally recognized drug reference) on 5/4/2022, included a warning for the following drug interactions, the use of [MEDICATION(S)] and [MEDICATION(S)] (SSRI) could lead to serotonin syndrome. As defined by the Centers for Medicare and Medicaid Services (CMS): Serotonin Syndrome is a potentially serious clinical condition resulting from overstimulation of serotonin receptors. It is commonly related to the use of multiple serotonin-stimulating medications (e.g., SSRI's, SNRIs, triptans, certain antibiotics). Symptoms may include restlessness, hallucinations, confusion, loss of coordination, fast heartbeat, rapid changes in blood pressure, increased body temperature, overactive reflexes, nausea, vomiting and diarrhea. Lexi-comp also included a warning Risk X: avoid combination for the use of [MEDICATION(S)] and [MEDICATION(S)]. MAO-B may enhance the serotonergic effects of Serotonergic Agents. Avoid concomitant use of Type B MAOs with [MEDICATION(S)]. At least 14 days should elapse between discontinuance of Type B MAOs and initiation of [MEDICATION(S)]. During an interview on 5/4/22 at 7:04 pm, a pharmacist (Pharm F) with the pharmacy that supplies the facility its medications, confirmed the combination of [MEDICATION(S)] and [MEDICATION(S)] was a Risk X - avoid combination and other information from Lexi-comp included the risk of Serotonin Syndrome from the use of [MEDICATION(S)] and [MEDICATION(S)]. During an interview on 5/05/22 at 8:10 am, the facility's consultant pharmacist (Pharm E) confirmed he had performed monthly medication reviews for Resident 11. He said the combination of [MEDICATION(S)] and [MEDICATION(S)] could result in serotonin syndrome and he said he did not inform the facility staff or physicians about this in his medication reviews. Pharm E said he uses Lexi-comp but disagreed that the combination of [MEDICATION(S)] and [MEDICATION(S)] was a Risk X. He admitted that the combination of [MEDICATION(S)] and [MEDICATION(S)] could cause clinical deterioration of the resident. He also confirmed he did not inform the facility's staff or physician about this in his medication reviews. b. The following was also noted in Lexicomp on 5/4/22, regarding [MEDICATION(S)]. ALERT: US Boxed Warning (a type of warning that appears on the package insert for certain prescription drugs)- Monitoring: [MEDICATION(S)] toxicity is closely related to serum [MEDICATION(S)] levels and can occur at doses close to therapeutic levels (concentration usually expected to achieve the desired effect). Facilities for prompt and accurate serum [MEDICATION(S)] levels should be available before initiating therapy. Only prescribe in settings where serum concentration (the amount of a given medication present in the blood at the time of testing) monitoring is available. Toxic effects occur with serum concentrations =1.5 mEq/L and may be seen in some patients with serum concentrations as low as 1.2 mEq/L (Janicak 2021); . serum electrolytes (baseline, then periodically); ECG with rhythm strip (baseline for all patients >[AGE] years of age or if underlying cardiac risk factors (particular habits, behaviors, circumstances or conditions that increase a person's risk of developing cardiovascular disease), repeat as clinically indicated); . serum [MEDICATION(S)] levels (twice weekly until both patient's clinical status and levels are stable, then repeat levels every 1 to 3 months or as clinically indicated; closely monitor in patients with significant renal or cardiovascular disease, debilitation, dehydration, sodium depletion, or those taking concomitant medications that impact renal function); . signs of [MEDICATION(S)] toxicity (e.g., diarrhea, vomiting, tremor, mild ataxia, drowsiness, muscular weakness). Toxic concentrations: >1.5 mEq/L (SI: >1.5 mmol/L): Early signs and symptoms of intoxication may include marked tremor, nausea, diarrhea, blurred vision, [CONDITION(S)] (a sensation of whirling and loss of balance), confusion, and decreased deep tendon reflexes (an involuntary reaction of a muscle to being passively stretched by percussion of the tendon) (APA 2002). >2.5 mEq/L (SI: >2.5 mmol/L): Intoxication symptoms may progress to include severe neurological complications, seizures, coma, cardiac [CONDITION(S)], and permanent neurological impairment (APA 2002). >3.5 mEq/L (SI: >3.5 mmol/L): Potentially lethal toxicity ([NAME] 2001). During an interview on 5/4/22 at 9:30 am, MR A said there had been only one [MEDICATION(S)] level done on 8/17/21 which was 1.0, since the medication was ordered on 6/11/21. During a concurrent interview and record review on 5/4/22 at 4 pm, MR B confirmed baseline labs were done (as indicated in Lexicomp) and repeated every two to three months, but no EKG had been done when [MEDICATION(S)] was initiated on 6/11/21 or afterwards. During an interview on 5/05/22 at 8:10 am, Pharm E confirmed he did not make a recommendation about a [MEDICATION(S)] level during his medication reviews for Resident 11. c. A review of Resident 11's medication administration record (MAR) listed the adverse side effects for all the [CONDITION(S)] medications and included a place for the licensed nurses to document such, except for [MEDICATION(S)]. During a concurrent interview and physician orders record review on 5/4/22 at 9:30 am, MR A confirmed the adverse side effects for [MEDICATION(S)] were not listed on the MAR. During an interview on 5/04/22 at 5:30 pm, Licensed Nurse (LN) C reviewed the MAR and said the adverse side effects for [MEDICATION(S)] were added today and prior to today, they did not appear on the MAR. She said she would not have known the side effects of [MEDICATION(S)], unless they were listed on the MAR, or she looked it up in a drug reference book. d. Further review of Resident 11's MAR listed the target behaviors that were being monitored for both [MEDICATION(S)] and [MEDICATION(S)], as aggressive combative behaviors. During a concurrent interview and record review on 5/05/22 at 9:24 am, MR A confirmed the target behaviors for both [MEDICATION(S)] and [MEDICATION(S)] were the same and were for aggressive behaviors. 2 a. A review of Resident 12's record indicated he was admitted on [DATE] with diagnoses that included paranoid [CONDITION(S)], anxiety disorder, and panic disorder. The current physician's orders included [MEDICATION(S)] 50 mg every day, [MEDICATION(S)] 8 mg every morning and 16 mg every evening, [MEDICATION(S)] 8 mg every evening, and [MEDICATION(S)] (used to treat anxiety and panic disorders) 1 mg every evening. During a concurrent interview and record review on 5/4/22 at 10:44 am MR A confirmed Resident 12 was taking [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] since 10/18/19, all for paranoid [CONDITION(S)] with the behavior of [CONDITION(S)] to be monitored, and [MEDICATION(S)] for panic disorder with the behaviors of panic to be monitored. The pharmacist's medication regimen reviews (MRR) from 5/29/21 - 4/30/22 were reviewed. On the MRR dated 10/24/21, Pharm E recommended a gradual dose reduction (GDR) for all of the four medications above due on 10/31/21. There was no mention by the pharmacist during the past year in his MRR's of duplicate/triplicate therapy for the same diagnosis and behaviors. During an interview on 5/05/22 at 8:20 AM, Pharm E was asked if he had advised the facility that this resident was receiving duplicate therapy since he was receiving three antipsychotic medications for the same diagnosis and behavior. He said, in a review on 10/23/19, he advised the facility that this resident was on three antipsychotic medications and asked for a risk benefit statement (a comparison between the risks of a situation and its benefits). He said he has not included this recommendation since that time, although he has since recommended GDRs for these medications. He said he does not repeat the same recommendations month to month, so those MRR's will indicate that there are no irregularities. He said he tries to give the physicians time to respond and repeat the recommendation quarterly or at least yearly. During a concurrent interview and record review on 5/05/22 at 9:35 am MR A confirmed the first MRR done by the pharmacist was 11/26/19 which indicated no irregularities. She said there was not a MRR done in October 2019 and said Resident 12 was admitted on [DATE]. b. During a concurrent interview and record review on 5/4/22 at 10:44 am MR A confirmed on the MRR dated 10/24/21, the Pharmacist recommended a GDR was due on 10/31/21, for [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)], all of which had been ordered on 10/18/19. This MRR was signed by Resident 12's physician on 11/1/21 and indicated I reviewed this resident's current medication regimen and agree with the consultant pharmacist's medication review. However, there was no note or order from the physician that actually noted which medication and dosage should be changed or no risk benefit statement as to why a GDR should not be done. MR A said she thought the Director of Nurses (DON) was supposed to follow up on that. During an interview on 5/05/22 at 11:16 am, the DON confirmed if the physician signed, he agreed with the pharmacist's recommendation but does not make a change in the medication dosage, they have no process at this time, to follow up to see what changes the physician wants to make. c. During a concurrent interview and clinical record review on 5/11/22 at 11:14 am MR A said the only target behavior to be documented for the three antipsychotic medications was [CONDITION(S)]. She said the MAR included the behaviors documented for 5/1/22 for [CONDITION(S)], as well as the other behaviors of panic and anxiousness, and all indicate Resident 12 had 20 episodes for each behavior for that day. She said they have not been tallying the total number of behaviors for psychotropics (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) each month, but they are going to start doing this. A review of the MAR for 4/2022 included numbers of episodes of behaviors that were all documented by the same nurse and the same numbers for all behaviors that were being monitored. On the other days when other nurses were working this resident had no behaviors documented on the MAR. During an interview on 5/12/22 at 7:13 am, the DON reviewed the MARs for 4/2022 that included numbers of behaviors every shift. Every Friday, Saturday, and Sunday the same nurse documented the same number of behaviors for the antipsychotic medications and for the behaviors for the [MEDICATION(S)]. The other nurses working Monday through Thursday did not document any behaviors on any days. He said he did not think the numbers of behaviors documented from Friday through Sunday were accurate because he had worked during some of those days and has not seen these behaviors from the resident. DON said he had not observed an episode of [CONDITION(S)], inability to sleep, or panic with this resident. 3 a. A review of Resident 17's record indicated he was admitted on [DATE], with diagnoses that included major depressive disorder and dementia without behavioral disturbance. A review of the current physician's orders included a PRN order for [MEDICATION(S)] 25 mg for agitation at bedtime, dated 1/9/22. During a concurrent interview and record review on 5/04/22 at 10:30 am, MR A confirmed the [MEDICATION(S)] PRN order had started on 1/9/22. The pharmacy consultant noted during his MRR on 1/31/22, that CMS restricts PRN use of antipsychotics to 14 days. There was no physician signature or response on this MRR. There was no re-assessment by the physician for this medication. The pharmacy consultant did not mention this issue in subsequent MRR's done from 2/2022 through 4/2022. During an interview on 5/05/22 at 8:30 am, Pharm E said he does not repeat the same recommendations month to month so those MRR's will indicate that there are no irregularities. He said he tries to give the physicians time to respond and repeat the recommendation quarterly or at least yearly. Pharm E said he sent the MRR's to the medical records director (MRD) not the DON. During an interview on 5/05/22 at 11:07 am, the DON said he had not received the MRR's, and they have been sent to MRD. He said Pharm E did not have his email address and he just found out about that today. During a later interview on 5/12/22 at 8:05 AM, the DON said he did have an email with an attachment from MRD that included the pharmacist's MRR's dating back to at least 12/2021. He said had he received an email from the pharmacist he would have opened it right away. During an interview on 5/12/22 at 9 am, MRD she gets the MRR's from the pharmacist then sends them to the DON, MR A, MR B, and the Director of Staff Development. She said MR A and MR B then forward the MRR's to the physicians for their review. b. During an interview on 5/12/22 at 7:09 am, the DON reviewed the facility's last survey from 2019 wherein PRN antipsychotic medications were written for the same issue. The facility's plan of correction (POC) at that time was to revise its [CONDITION(S)] drug policy to include the CMS requirements regarding PRN [CONDITION(S)] and antipsychotic medications but the DON said this had not been done. 4 a. A review of Resident 14's record indicated she was admitted on [DATE] with diagnoses that included anxiety and mood disorder. The 5/2022 physician's orders included [MEDICATION(S)] 25 mg twice per day and [MEDICATION(S)] 1 mg twice per day PRN for panic and anxiety. During a concurrent interview and physician orders record review on 5/4/22 at 10:55 am, MR A reviewed the MRR's done by the pharmacy consultant over the past year. There was no mention of the PRN [MEDICATION(S)] although the MRR's did include a GDR recommendation for [MEDICATION(S)]. MR A confirmed Resident 14 had not received this medication for several months. During an interview on 5/05/22 at 8:30 am, Pharm E said the [MEDICATION(S)] 1 mg PRN BID was started on 12/29/20. He said he recommended the re-evaluation after 14 days for the [MEDICATION(S)] on 2/26/21. He was unable to say if he had repeated this recommendation in later reviews during the past year. He said he tried to repeat the recommendations quarterly or at least yearly. b. During a concurrent interview and record review on 5/11/22 at 12:05 pm, MR A reviewed the 5/2022 MAR and confirmed there were no target behaviors listed for [MEDICATION(S)] so there has been no monitoring of the effectiveness for this drug. 5 a. A review of Resident 9's record indicated she was admitted on [DATE] with diagnoses that included major depressive disorder, dementia with behavioral disturbance, and restlessness. A review of the 5/2022 physician's orders included [MEDICATION(S)] 100 mg at bedtime and [MEDICATION(S)] 0.5 mg twice per day PRN. During a concurrent interview and clinical record review on 5/5/22 at 9:59 am, MR A confirmed the above medication orders. She said Resident 9 had not received any [MEDICATION(S)] in the past eight months. A review of the MARs showed no [MEDICATION(S)] was given from 12/2021 through the present. MR A reviewed the MRR's from the past 12 months and confirmed there was no report from the pharmacist regarding the CMS restriction of PRN psychotropics to 14 days and the need for the physician to document the rational to extend the drug beyond 14 days. MR A confirmed there was no rationale or risk benefit statement documented by the physician in the clinical record to extend the use of the [MEDICATION(S)] after 14 days. b. During a concurrent interview and clinical record review on 5/5/22 at 9:59 am, MR A confirmed the pharmacy consultant included a GDR recommendation on 4/26/21 and the physician signed he agreed with pharmacist's recommendation on 5/10/21, but no changes in the dose were made at that time. The target behaviors for why this resident was receiving [MEDICATION(S)] was listed on the MAR as, worrying and becoming angry, worried about cats. During an interview on 5/12/22 at 7:27 am, the DON reviewed the MRR dated 4/26/21 and signed by the physician on 5/10/21, and said they had no process for following up when the physician signs the MRR from pharmacist but did not change the dosage. The DON stated the MRR's went to MRD, and he does not get them, but after last week, the pharmacy consultant would now be sending them to the DON. During an interview on 5/12/22 at 11:34 am. the behaviors listed on the MAR for [MEDICATION(S)] were discussed with the DON. He said those were not the target behaviors that should be listed on the MAR and monitored. 6. A review of Resident 10's record indicated she was readmitted on [DATE] with diagnoses that included major depressive disorder, dementia without behavior disturbance, and lung disease. The current physician's orders included [MEDICATION(S)] 0.5 mg every six hours PRN for anxiety and restlessness. During an interview on 5/4/22 at 3:55 pm, Pharm E said he made a recommendation regarding the use of PRN [MEDICATION(S)] on 1/31/22. During a concurrent interview and record review on 5/05/22 at 9:43 am MR A confirmed the [MEDICATION(S)] PRN order. She said this resident was admitted with this order. The pharmacy consultant's MRR's for 2/22, 3/22, 4/22 indicated there were no medication irregularities. A review of the physician notes did not include a re-evaluation of this drug and why it needed to continue after 14 days. During an interview on 5/11/22 at 11:45 am, MR A reviewed the copy of the MRR dated 1/31/22. It asked for a GDR of [MEDICATION(S)] but did not mention PRN use and CMS restriction of PRN psychotropics to 14 days and the need for the physician to document the rational to extend the drug beyond 14 days. 7 a. A review of Resident 18's record indicated she was admitted on [DATE] with diagnoses that included anxiety disorder, depressive disorder, and dementia with behavioral disturbance. Her current orders included [MEDICATION(S)] 10 mg daily and [MEDICATION(S)] (treats anxiety) 0.5 mg every 12 hours PRN. During a concurrent interview and record review on 5/5/22 at 10:07 am, MR A confirmed the [MEDICATION(S)] 0.5 mg PRN was ordered on 8/4/21. A review of the pharmacy consultant's MRR's, each month since 8/8/21, did not mention the CMS restriction of PRN psychotropics to 14 days and the need for the physician to document the rational to extend the drug beyond 14 days. A MRR dated 10/24/21 included a GDR recommendation for [MEDICATION(S)] and its PRN use should be considered and a [MEDICATION(S)] GDR due 11/30/21. This was signed by the MD that he was in agreement with the pharmacist's recommendation on 11/1/21. The MRR dated 12/31/21 included a recommendation for a GDR for [MEDICATION(S)]. This was not signed by a physician. Subsequent MRR's through 3/2022 contained no irregularities. MRR dated 4/30/22 included a recommendation for GDR for [MEDICATION(S)]. MR A confirmed there was no rationale or risk benefit documented by the physician to extend the use of the [MEDICATION(S)] after 14 days. A review of the MARs showed no [MEDICATION(S)] was given from 12/2021 through the present. During an interview on 5/05/22 at 11:16 am, the DON confirmed if the physician signs he agrees with the pharmacist's recommendation but does not make a change in the medication dosage, they have no process at this time to follow up on, to see what changes the physician wants to make. During a concurrent interview and record review on 5/11/22 at 1 pm, MR A reviewed the MAR and confirmed there were no target behaviors listed for [MEDICATION(S)] or [MEDICATION(S)]. so there has been no monitoring of the effectiveness for these drugs. 8. A review of Resident 5's clinical record indicated he was admitted on [DATE] with diagnoses that included major depressive disorder and chronic pain syndrome. His current physician's orders included [MEDICATION(S)] 30 mg daily, started on 12/11/19. During a concurrent interview and record review on 5/05/22 at 10:20 am, MR A reviewed the pharmacy consultant's MRR's for the past 12 months. The MRR dated 10/24/21, included a GDR date for this medication due on 12/31/21. The physician signed he was in agreement with this recommendation on 11/1/21 but did not change the dosage of the medication. This GDR recommendation was not repeated in later MRR's and there was no GDR or risk benefit statement from the physician as to why the GDR should not be done. During an interview on 05/05/22 at 11:39 am, the above was discussed with the DON. He said they had no process to follow up when the physician signs he agrees but does not make a change in the dose. 9. A review of Resident 8's medical record indicated she was admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, and heart disease. Her current physician's orders included an order, dated 10/8/21, for [MEDICATION(S)] (anti-depressant) 30 mg daily, trial for two weeks and re-evaluate. During a concurrent interview and record review on 5/05/22 at 10:30 am, MR A confirmed the above order had continued, there was no stop date after two weeks which would have been 10/23/21, and there was no re-evaluation by the physician. She said Resident 8's pain was monitored on the MAR, but no depression symptoms or behaviors were monitored. During an interview on 5/05/22 at 11:52 am, the DON said a stop date for this medication should have been entered into their system two weeks after the medication started. He said he would follow up with the physician regarding this medication. On 5/3/22 at 2:12 pm, an interview was conducted with the Director of Staff Development (DSD). The DSD stated that the facility does not have a [CONDITION(S)] drug committee (staff members who provide oversight of the use of [CONDITION(S)] medications including, care planning, required dose reductions, evaluating target behaviors to determine the effectiveness and/or ineffectiveness of the medications and present these findings to the physicians), I'm working on that. The DSD stated that resident [CONDITION(S)] drug use was discussed at their weekly Clinical Interdisciplinary Team (IDT- facility managers and supervisors) meeting. The DSD stated that she recognized that there was a problem with [CONDITION(S)] drug use and dual therapy usage but the [Medical Director] refuses to discontinue any medications. The DSD confirmed that behavior symptoms are not being tallied or presented to the physicians so that a determination can be made as to whether or not the [CONDITION(S)] medications are effective, ineffective, causing adverse side effects, or due for a gradual dose reduction (GDR). The DSD stated, I have no clue whether or not GDRs are getting done we are not keeping track or monitoring that, and we don't tally up the behaviors for the doctors. 10. Resident 4 was admitted on [DATE] with diagnoses that included, major depressive disorder (severe depression) and emotional lability (uncontrollable laughing, crying or irritability). On 5/4/22 at 12:22 pm, a review of Resident 4's Physician's Orders for May 2022, and a concurrent interview was conducted with Medical Records staff (MR) B. [MEDICATION(S)] (an SSRI antidepressant) 100 milligrams (mg) was ordered to be given once a day (QD) on 12/10/19, for isolating self and not eating. Failure to eat and withdrawn behaviors were being monitored on the Electronic Treatment Administration Record (ETAR) together therefore, there was no way to determine how many episodes of each behavior Resident 4 was having, which would indicate whether or not the [MEDICATION(S)] was effective. There were no non-pharmacological interventions (any type of health intervention which is not primarily based on medication) identified t

Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement a plan of action to correct deficiencies related to unnecessary [CONDITION(S)] medications (any drug that affects brain activities associated with mental processes and behavior) and infection control (Refer to F 756, 758, 880, 881, and 883). As a result, widespread deficiencies were present regarding unnecessary [CONDITION(S)] medications and infection control that had the potential to harm all residents who resided in the facility. Findings: A review of the facility's last survey included deficiencies relating to unnecessary [CONDITION(S)] medications, inadequate drug regimen reviews by the pharmacist and the necessary follow up, infection control, antibiotic stewardship, and immunizations. The plan of correction the facility submitted had not been implemented and the same deficiencies were found during the present survey. During a concurrent interview and document review on 5/11/22 at 2 pm, the above was discussed with the Quality Assurance Coordinator (MR A). She said she sends reminders to department heads, and they turn in reports monthly that go over past deficiencies. MR A said around 12/2021, she recognized problems with pharmacy related Medication Regimen Review (MRR) issues due to no follow up on the pharmacist's recommendations but had not yet brought it to the QAA committee's attention and no plan had been made to correct the issues. She and Medical Records staff (MR B) came up with a plan to discuss with the interdisciplinary team (IDT) but it was not taken to the QAA committee. She said she had a calendar from the pharmacist with due dates for Gradual Dose Reductions for residents' [CONDITION(S)] medications, that he started sending in 11/2021, but no other information from him. The pharmacist does not attend QAA meetings. The QAA committee had no specific drug/pharmacy related quality indicators to monitor. MR A said there was no Infection Preventionist (IP) for about three months (10/15/21 - 1/15/22). She said the prior IP was not on top of things, but after she left, there was a lag before the new IP started and completed his training. MR A said she was unaware of any infection control issues.

Based on interview and record review, the facility failed to ensure that 6 of 15 sampled residents (Residents 4, 7, 11, 12, 16, and 22) were provided with sufficient information, in advance, by their physicians which informed them of the risks, benefits, options and alternatives to treating their behaviors with psychotherapeutic drugs (drugs that affect mood, behavior, thoughts, and perception). The facility used a [CONDITION(S)] Medication Informed Consent (ICO) which contained all of the necessary information about the psychotherapeutic medication's reason for use, risks, benefits, adverse side effects, and non-pharmacological (non-medicine) interventions that had been tried unsuccessfully prior to offering medication. The form required a signature from either the resident or their responsible party acknowledging that they were informed and understood, however, the ICOs were late, incomplete or non-existent. This had the potential for those residents who received psychotherapeutic drugs, not to have received the information necessary to make an informed decision and residents were given psychotherapeutic medications prior giving consent. Findings: The facility's Informed Consent policy, reviewed 6/2007, indicated, Before initiating the administration of psychotherapeutic drugs, or physical restraints, or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function, facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent for the proposed treatment or procedure. 1. Resident 4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/22 at 12:22pm, a review of Resident 4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] (an antidepressant medication) 100 milligrams (mg) was ordered to be given once a day (QD) on 12/10/19, the [CONDITION(S)] Medication Informed Consent (ICO) was not provided to the resident's responsible party (RP) until 4/25/19, four months after she had been taking the medication. [MEDICATION(S)] (an antipsychotic medication) 0.5 mg twice a day (BID) was ordered on 12/10/19, and the ICO was not provided to her RP until 2/4/19, two months after she had been taking the medication. MR B confirmed the above and stated that, [CONDITION(S)] medications cannot be given until there is evidence that the resident or RP, have received the information on the ICO from their physicians. 2. Resident 7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/22 at 3:44 pm, an interview and concurrent record review was conducted with MR B. A review of Resident 7's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ICO was not provided to her RP until 4/21/22, and the information about what behavior they were treating and what non-pharmacological interventions had been tried and failed, was left blank. [MEDICATION(S)] (a chemical salt compound that is used for [CONDITION(S)] depression) 150 mg at bedtime (HS) was ordered on 8/5/18. The ICO was not provided to Resident 7's RP until 4/22/22, and the behavior symptom and non-pharmacologic interventions sections were left blank. [MEDICATION(S)] (an antipsychotic medication) 1 mg BID was ordered on 4/9/18, and the ICO was not provided to her RP until 4/21/22, and the behavior symptom and non-pharmacological interventions were left blank. [MEDICATION(S)] (an anti-anxiety medication) 1 mg QD as needed (PRN) was ordered on 12/19/19. The ICO was not provided to her RP until 6/14/19. MR B confirmed the above. 3. Resident 16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/22 at 2:34 pm, an interview and concurrent record review was conducted with MR B. Resident 16's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no ICO for this medication. [MEDICATION(S)] 1 mg every 8 hours PRN was ordered on 7/22/21. The ICO was not provided to his RP until 3/10/22, and the behavior symptom and non-pharmacological sections were left blank. MR B confirmed the above. 4. Resident 22 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/22 at 2:43pm, an interview and concurrent record review was conducted with MR B. A review of Resident 22's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ICO section to describe the target behavior was [CONDITION(S)] with psychotic features which is not a specific target behavior. The non-pharmacological intervention section was blank. [MEDICATION(S)] (an antipsychotic medication) 5 mg QD was ordered on 2/28/22. The ICO section for the behavior symptom was for confusion which is not a specific target behavior. The non-pharmacological intervention section was blank. [MEDICATION(S)] (an antipsychotic medication) 20mg QD was ordered on 3/10/22. The behavior symptom was psychotic features which is not a specific target behavior. The non-pharmacological intervention section was blank. MR B confirmed the above findings. On 5/3/22 at 2:12pm, during an interview with the Director of Staff Development (DSD), she indicated that she was aware that some residents had missing and/or old ICOs. She stated, I have been in the process of cleaning that up. The DSD added that the facility does not have a dedicated [CONDITION(S)] Drug Committee to oversee the use of psychotherapeutic drugs in the facility. 5. A review of Resident 11's record indicated he was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 5/11/22 at 11:54 am, MR A confirmed the ICO for [MEDICATION(S)] was mailed to Resident 11's RP for signature and they were waiting to get it back. According to the consent form the RP had been called on 4/8/22 and a message left. 6. A review of Resident 12's record indicated he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and review of the consents for antipsychotic medications on 5/11/22 at 11:22 am, MR A confirmed no dose, no behaviors, and no non-pharmacological interventions were listed on the consent for [MEDICATION(S)]. There were no behaviors or non-pharmacological interventions listed on the consent for [MEDICATION(S)]. There were no non-pharmacological interventions listed on the consent for [MEDICATION(S)].

Based on interview, record review and policy review, the facility failed to ensure that they thoroughly assessed the needs of their resident population as a foundation to ensure that they had the necessary resources to provide quality care to their residents, when they had not conducted a facility-wide risk assessment. This failure contributed to substandard quality of care findings, an extended survey, unnecessary use of [CONDITION(S)] drugs (drugs that alter mood and behavior), implementation of standardized immunization practices, competent nurses and the unrealized resident care areas that needed improvement. Refer to F758 and F883 Findings: The facility's policy titled, Safety and Supervision of Residents revised December 2008, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. On 5/5/22 at 12:30pm, an interview was conducted with the facility's Administrator (Admin) regarding their development of a facility-wide assessment. The Admin confirmed that a facility assessment had not been done and she was not familiar with that requirement.

Based on interview and record review, the facility failed to implement routine bowel care (a medical approach to manage fecal constipation) for two of 10 sampled residents (Residents 7, and 10) when; 1. Resident 10 did not receive bowel care for a period of nine days, during the month of ,[DATE]. 2. Resident 7 did not receive bowel care for a period of eight days. These periods without bowel care resulted in, for Resident 10, and had the potential to result in, for Resident 7, constipation, increased pain, and bowel obstruction. Findings: A review of the facility policy titled, Bowel Protocol, dated [DATE], indicated that all residents admitted to the facility will have the following order for bowel care on their admission orders [REDACTED] A. If no bowel movement in three days give Milk of Magnesia (a laxative that draws water into the intestines) 30 milliliters (ml) by mouth at bedtime. B. If no results by 9 am, give one [MEDICATION NAME] (stimulant Laxative) rectal suppository. C. If no results by 4 pm, give fleets (a saline laxative) enema. D. If no results by 9 pm, call physician. 1. A review of Resident 10's record, indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized resident assessment) dated [DATE], indicated that Resident 10 was cognitively impaired, independent with Activities of Daily Living (ADLs, daily self-care activities), and she was always continent of bowel movements. A review of Resident 10's physician's orders, for the month of ,[DATE], indicated that Resident 10 did not have orders for the facility's Bowel Protocol. The Certified Nursing Assistants recorded the number of all bowel movements (BM) on the BM log and charted a 0 if the resident did not have a BM. A review of the BM list, for the month of ,[DATE], indicated that Resident 10 did not have a BM from [DATE] through [DATE]. A review of the Nurse's Notes, dated ,[DATE] through [DATE], did not contain any documentation that Resident 10's physician was notified that there were no recorded BMs for nine days. A review of the Nurse's Notes, dated [DATE] at 6:40 pm, indicated that Resident 10 had a change of condition. Resident 10 was noted to be nauseated and dizzy in the bathroom and vomited two times. A review of the Nurse's Notes, dated [DATE] at 7:30 pm, indicated that Resident 10 was lying in bed, eyes closed, and not easily aroused. A review of the Interdisciplinary Team's (IDT) note, dated [DATE], indicated that Resident 10 was septic (infected with bacteria), The IDT note indicated, MD will have another talk with (Responsible Party (RP)) about transport for testing and acute care A review of Resident 10's Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], indicated DNRDo Not Resuscitate, (DNR, a legal order to withhold cardiopulmonary resuscitation, CPR) with limited additional interventions including medical treatment. A review of the Nurse's Notes, dated [DATE] at 6:15 am, indicated that Resident 10 was barely audible and her abdomen was soft and distended (swollen due to pressure from inside). A review of the Nurse's Notes, dated [DATE] at 2:50 pm, indicated that Resident 10 received a saline enema. A review of the Nurse's Notes, dated [DATE] at 3:30 pm, indicated that Resident 10 had a large bowel movement. A review of the Physician's Progress Note, dated [DATE], indicated that Resident 10 was Essentially non-responsive. The physician's impression was that Resident 10 [MEDICAL CONDITION], and she would receive supportive care and comfort measures. The physician's note indicated that Resident 10's RP agrees that Resident 10 would not be transferred to a higher level of care. During an interview, on [DATE] at 2:50 pm, the RP stated that the facility never told her that Resident 10 was constipated. The RP stated that this would have concerned her because Resident 10 has had problems with constipation in the past. The RP stated that when the physician discussed Resident 10's prognosis, she did not refuse for Resident 10 to be transferred. The RP stated that it was explained to her that Resident 10 had less than a one percent chance of survival and a transfer to an acute hospital would be stressful for Resident 10. A review of the Nurse's Notes, dated [DATE] at 9:10 am, indicated that Resident 10 passed away at 8:23 am. A review of the Certificate of Death, dated [DATE], indicated the causes of Resident 10's death were cardiopulmonary arrest,[MEDICAL CONDITION], and perforated large intestine. 2. A review of Resident 7's record indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders indicated the physician had discontinued all laxatives (medication to treat constipation) on [DATE]. The Certified Nursing Assistants recorded the number of all bowel movements on the BM log and charted a 0 if the resident did not have one. A review of this log for Resident 7 indicated she had no BMs for four days, from ,[DATE] - [DATE]. A review of the Medication Administration Record [REDACTED]. The BM log for ,[DATE] indicated Resident 7 did not have a BM for eight days, from ,[DATE] - [DATE], and for five days, from ,[DATE] - [DATE]. A review of the MAR for ,[DATE], indicated she did not receive any laxatives to treat constipation. During an interview on [DATE] at 12:10 pm, Licensed Nurse (LN) A stated the nurses were supposed to check to see if the residents had not had a BM in three days, but now they don't have bowel protocol orders for laxatives since one of their physicians had discontinued the laxative orders. The Director of Nurses (DON), who was also present, stated that after a resident has had no BM for three days, the facility's bowel protocol should have been implemented. DON stated if there were no order for laxatives, the physician should have been called. During an interview on [DATE] at 11:30 am, the DON stated he had discussed the above issue with the Physician's Assistant who reported he had been unaware that residents were not having bowel movements for four days and longer.

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 1) was free from abuse, when Certified Nursing Assistant B (CNA B) slapped the right side of his face. This failed practice resulted in dark purple bruising to the right side of Resident 1's face and increased anxiety demonstrated by the resident's statement, She's trying to kill me and two and a half hours later by the resident's statement, Please don't let that lady kill me. Findings: A review of a faxed document titled, Incident report, dated 12/16/16, and received by the California Department of Public Health (CDPH) from the facility on 12/17/16 indicated, Observed CNA slapping resident in face( right side cheek). Resident 1's clinical record was reviewed. A document titled, History and Physical, dated 3/2016, was reviewed and indicated that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nursing note dated 12/16/16, at 11 pm, from Resident 1's record was reviewed and indicated, This writer (LN A) heard CNA (CNA B) asking resident to let go and to stop. Prompting this writer to go into the resident's room. Upon entering the room, I witnessed the CNA attempting to move the resident's hand off of the diaper he was holding onto. The CNA freed the resident's hand from the diaper at which time the resident became combative and hit the CNA. The CNA then hit the resident across the face with the back of her hand. The Resident looked at this writer and stated, 'Help me, she is trying to kill me ' Resident 1's record contained a nursing note dated 12/17/16, 1:30 am, which indicated, Resident calling out for help. This writer went into his room. Resident lying in bed with hands reaching out to me. Held resident's hand, resident stated, 'Please do not let that lady kill me.' During an interview on 12/21/16, at 10:30 am, the Chief Nursing Officer (CNO) reported that after CNA B had been observed slapping Resident 1 across the face,physically abusing the resident, she was immediately removed from resident care and sent home. CNA B was subsequently terminated from employment on 12/19/16 The CNO stated that this incident had left Resident 1's right cheek red which had progressed into a small area of bruising. During a and observation on 12/21/16, at 10:50 am, Resident 1 was sitting in the Day Room with his Family Member. Resident 1 had a small purplish bruise on his right cheek. During a concurrent interview with Resident 1 and his Family Member; Resident 1, when asked, was unable to recall how he had obtained the injury to his face. Family Member stated she had had not pushed Resident 1 to remember the episode of physical abuse, because she did not want to stress him (Resident 1) further. During an interview, on 12/21/16 at 11:55 am, the Acting Human Resource Director stated that CNA B's action, physical abuse of a resident, was inappropriate and this facility had zero tolerance when it came to abuse. On 12/22/16, at 9:30 am, an attempt was made to interview CNA B by telephone. CNA B did not answer and the voice mail recording indicated that the user was unavailable and the voice mailbox had not been set up. During a telephone interview on 12/22/16, at 11:40 am, LN A stated that she responded to verbal commotion inside Resident 1's room on the night of 12/16/16. LN A stated that as she entered the room, she could see CNA B and Resident 1 playing what looked like tug-of-war with an absorbent brief. Then Resident 1 released the absorbent brief and raised up his hand as if to hit CNA B. This was when CNA B slapped Resident 1 across the right-side of his face. LN A stated, She (CNA B) slapped the[***]out of that poor old man (Resident 1)! LN A stated that she (LN A) immediately sent CNA B out of Resident 1's room. Resident 1 then grabbed her (LN B) hand and begged her not to let CNA B come back into his room. LN A stated that Resident 1 kept repeating, Please do not let her come back in here, she is trying to kill me. LN A stated that Resident 1 was restless throughout the night. LN A stated that this slap was not an accident, it was purposeful and with intent. LN A reported that the right-side of Resident 1's face was visibly red following this incident. On 1/3/17, at 11 am, during a telephone interview, CNA B confirmed her identity, but stated that she did not have time to talk and would call back. As of 1/6/17, CNA B had not called back. The facility's policy and procedure titled, Elder Abuse, dated 9/2011, indicated that the purpose of the policy and procedure was, the on-going safety and freedom from abuse of all . residents The facility's policy and procedure titled, Resident Rights, dated 8/2016, indicated that the facility's employees shall treat all residents with kindness, respect and dignity.

Based on observation, interview, and record review, the facility failed to ensure that one of three sampled resident's right to refuse treatment was upheld (Resident 1), when staff were bathing and providing incontinence hygiene care and administered an influzenza (flu) immunization injection, against Resident 1's wishes. This denied Resident 1's right to refuse treatment, which resulted in increased levels of agitation, causing him to strike out at staff, attempt to spit on staff and bite staff. Staff proceeded to then place their hands over his arms, restraining his hands on his chest, and applying a face visor (a staff personal protective item) or a face mask to prevent being bitten or spit upon. On 11/9/16 at 1:55 pm, an Immediate Jeopardy (IJ) was called with the facility's Director of Nursing (DON) for Resident 1's right to refuse treatment (the facility's Administrator was not present in the building at this time). The facility's immediate plan of action was received 11/10/16 at 4:40 pm and accepted, to remove the immediacy. The facility IJ was abated with the DON and Adminstrator on 11/15/16 at 4 pm with onsite verification of their implemented plan of action. The plan of action included to provide a no hands-on management plan including providing Resident 1 with a calendar to establish his scheduled care, scheduling a tele-medicine mental health evaluation and providing education to staff on treating Resident 1 with dignity, respect and kindness and maintaining his rights. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Social Service Assessment, dated 3/21/16, read Resident 1 was responsible for self. A nurse practitioner note written 3/23/16 read Spoke with Public Guardian regarding conservatorship, public guardian states she is for financial only. Resident can sign his own consents and make his own decisions per public guardian. Resident 1's conservatorship papers in the record, filed 8/23/13, were noted incomplete, the court findings read Probate Conservator of the person and estate . that (Resident 1) is unable to properly provide for his or her personal needs for physical help, food, clothing, shelter . On page three of the orders the court granted conservatorship over estate only. In an interview on 11/9/16 at 2:50 pm, Resident 1's public guardian acknowledged that the court orders were confusing and incorrectly prepared. She stated that she thought the court had granted power over his estate and medical decisions. The public guardian stated she had given a verbal authorization for a flu shot to be given to Resident 1, which was administered on 11/4/16. She stated that at no time did she consent to medical care and treatment that required a hands on approach against Resident 1's wishes. She stated that she would have had to consult with a county attorney to consider removing his right to refuse treatment. A nurse's note in Resident 1's record dated 11/4/16 at 3:45 pm, contained domentation that the flu vaccine was given on 11/4/16. The month of 10/2016 Resident 1's Activities of Daily Living (ADL) record had multiple documented (almost daily) refusals for incontinence care, showers, soiled bed changes. The record contained documentation that Resident 1 was verbally, and physically abusive to staff and his physician. In an interview on 9/29/16 at 11:15 am, Resident 1's physician (Medical Doctor MD) A stated that Resident 1 had attempted to bite him during care. He is attempting to be as bad and dirty as possible. MD A stated that his refusal have been worse in the last few months. On 9/29/16 at 11:45 am, Resident 1 was observed in his room, had his door closed, answered to the knock on door, and agreed to be interviewed. Resident 1 had his light off, and drapes closed. Urine odor was apparent. In a concurrent interview, Resident 1 complained about his assigned public guardian not sending him clothes that fit. He complained that both of his doctors did not believe in using narcotic (strong medication for pain) medication. He stated his pain starts at the top of his head to tip of his toe. He rated his pain at 8 out of 10. During the interview, Resident 1's assigned Certified Nursing Assistant (CNA) B was observed coming in to the room. He allowed her to empty his urinal, kept between his legs, but not to do a bed change. He told her he would shower later after lunch, and the bed change could occur at that time. On 10/5/16 at 5:15 pm, the facility staff were observed rewarding Resident 1 with compliance with showers and bed changes by giving him a beer. During review of Resident 1's record, this program was not specifically documented in the care plan and no physician's order was obtained for the beer. Resident 1's record contained the following Care Plans, updated 9/27/16, which included the following: 1. Alteration in Activities-Self Concept Disturbance with approaches that included encourage activities and to verbalize feelings; 2. Urinary Incontinence with approach to maintain environment free of skin irritants; 3. Alteration in ADL function: bathing hygiene with approaches that included active/passive range of motion as tolerated and allow for expression of loss and verbalization of feelings. 4. Psychosocial Well Being: self esteem disturbance with approaches that included allow time to answer questions. 5. Potential for alteration in mood related to refusing ADL care daily with approaches that included 1:1 with social services and include resident in care planning sessions. 6. Impaired Mobility that included approach to turn every two hours. 7. Pain: shoulder neck and leg pain with pain medication as only approach. 10. Potential for alteration in skin integrity related to three reddened areas on back, due to refusals to be changed and cleaned regularly after voiding and BM's. Has poured his urinal on his bed with interventions that include validate his cooperation with care and validate his cooperation with rewards. 11. [MEDICAL CONDITION] Drug Use: Takes [MEDICATION NAME] for anxiety with intervention that includes one on one conversations whenever possible regarding fears, anger issues, and anxieties. 12. Behavior anxiety/[MEDICAL CONDITION], depression, anger with intervention that included praise his good choices. 13. Non -compliance:related to refusing to get out of bed, refusing to be turned frequently, anger issues with approaches 1. Explain to resident in gentle way the reason for turning frequently and getting out of bed, and 2. approach resident calmly and non threatening manner for care due to [MEDICAL CONDITION] and anger issues. In an interview on 10/6/15 at 9:45 am, DON acknowledged that Resident 1's care plan interventions had been ineffective thus far, in ensuring he complied with care. On 10/31/16 at 2 pm, a nursing note by the DON, read Was called into residents room by CNAs. The CNAs were attempting to change the linen and clean the resident. The resident is resistant to care. The odor emitting from his room is so strong with an acidic odor that your eyes water. The resident began spitting on staff, threw Pepsi on staff, and attempted to throw urine. The DON held the residents hands and he was given a bed bath and linen change . On 11/8/16 at 11 am, Resident 1 was observed in his room without a roommate, window shades open, and was watching television and looking outside. His room was much brighter than when last observed on 9/29/16. A strong urine odor was present. In a concurrent interview, Resident 1 stated I want to be out of here more than ever. He stated he was held down by nurses for them to wipe his butt, clean urine, and change his chucks (disposable under pad). He stated they cannot do that. Resident 1 stated It's up to me if anyone does anything. He stated that he had agreed to care with one staff, and the next thing that happened was a group of four staff came in. He stated these staff disregarded his refusals, holding his head down and doing his care and bed change. Resident 1 also stated that he refused a flu shot and it was given without his consent. He was told that his conservator had agreed, and he was given the injection. In an interview on 11/9/16 at 10:30 am, Assistant DON stated that she had been in Resident 1's room and giving hygiene care despite his refusals. Resident 1 had been refusing incontinence care all morning. She stated his bed was soaked with urine and feces, at about 1 pm (unknown date) and she explained it was necessary that he be cleaned up. Assistant DON stated that Resident 1 stated he did not care, in response to her encouragement. I like certain people and they are the only ones I will allow to care for me. Assistant DON stated that the conservator had authorized hands on care. Assistant DON further stated the physician and DON had stated We have to take care of him no matter what. In an interview on 11/9/16 at 10:45 am, DON stated You provide the solution. There are no effective interventions. I am not sure when I made the decision to hold his hands as he was cleaned. His head was moved to put on a plastic face shield. DON stated that she trained other staff on this intervention. DON acknowledged Resident 1's statement made on 11/8/16 at 11 am, that an approach with four staff members holding him down was done, and that Resident 1 was spouting out profanities and threats. She stated that staff had to hold his hands to his chest to protect themselves. In an interview on 11/9/16 at 1:20 pm, MD A stated, related to Resident 1, I think he should be getting the hell out of here, we can't ignore him. I am proud of what we did. In an interview on 11/9/16 at 1:15 pm, Licensed Nurse (LN) B stated if Resident 1 refused care that sometimes you just have to do it. The facility policy titled Resident Rights was reviewed. The policy directed that residents are entitled to exercise their rights and privileges to the fullest extent possible. It also directed that the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. On 11/9/16 at 1:55 pm, an Immediate Jeopardy (IJ) was called with the facility's Director of Nursing (DON) for Resident 1's right to refuse treatment. In an interview on 11/10/16 at 8:30 am, CNA C stated that she was involved with a bed bath where Resident 1's hands were held. We explained that he needed to be changed. He said yes then tried to kick us. CNA C stated that another Nursing Assistant (NA) D and the Assistant DON were present during this instance of holding him down to provide care. In an interview on 11/10/16 at 8:40 am, NA D stated that she was involved with a four person staff altercation with Resident 1 when he kept refusing care. He was mad because we were going to change him. The Assistant DON instructed us to hold his arms and hands. We switched places to do the care. A mask was used due to spitting. I did not agree with that. A review of Resident 1's record showed that the interventions to proceed with care by holding him down despite his refusals was not documented in his multiple care plans (refer to F279). In an interview on 11/10/16 at 9:20 am the Administrator was notified of the IJ but he indicated that he did not want to discuss this any further and did not want to hear the details to justify the IJ. The facility's immediate plan of action was received 11/10/16 at 4:40 pm and accepted to remove the immediacy. The facility IJ was abated with the DON and Adminstrator on 11/15/16 at 4 pm with onsite verification of their implemented plan of action. The plan of action included to provide a no hands-on management plan including providing Resident 1 with a calendar to establish his scheduled care, scheduling a tele-medicine mental health evaluation and providing education to staff on treating Resident 1 with dignity, respect and kindness and maintaining his rights.

Based on interview, and document review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 2) when licensed facility staff did not provide Cardio [MEDICAL CONDITION] Resuscitation (CPR, an emergency lifesaving procedure that is done when someone's breathing or heartbeat stops). This failure resulted in life sustaining interventions not being taken to save her life, when she stopped breathing, and her heart stopped, in the presence of the licensed nurse, and she passed away. An Immediate Jeopardy (IJ) was called with the physician (Medical Doctor MD) A, and the Director of Nursing (DON), on [DATE] at 2:25 pm (the Adminstrator was not present in the building at this time). An immediate plan of action was accepted on [DATE] at 5:32 pm to remove the immediate threat. The plan of action included ensuring all Registered Nurses had current ACLS certification, orienting all nursing staff to the Code Blue policy, identifcation on each shift of the staff who are responsible to respond to a Code Blue, mock Code Blue situations to be performed quarterly including a mock Code on [DATE] with all current staff. The IJ was abated on [DATE] at 4 pm with the DON and Admininstrator, with onsite verification of the implementation of their plan. Findings: Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Physician Attestation, signed [DATE], listed the immediate cause of death was Cardio [MEDICAL CONDITION] Arrest (heart and lungs stop working). Resident 2 had a Physician order [REDACTED]. The POLST identified that she desired to have Attempted Resuscitation/CPR. A Charge Registered Nurse (CRN) wrote in Resident 2's Nurse's Notes that on [DATE], at approximately 6 am, he was called to Resident 2's room to assist another staff , Licensed Vocational Nurse (LN) A, to position her up in her bed, so her oxygen could be applied. Resident 2 was upset and stated that she wanted to go outside and smoke a cigarette, even though she had just received a treatment for [REDACTED]. CRN wrote that after raising the head of Resident 2's bed up and applying oxygen that she suddenly stopped breathing, and slumped down in her bed. CRN documented that he checked for breathing and pulse and verified that she was not breathing and had no pulse. CRN wrote Pt (patient) was on a soft spring mattress without back support so it was not possible to do chest compressions. CRN's note read that Resident 2's physician (MD) called her death at 6:04 am [DATE]. A facility Code Blue (an emergency situation announced in a facililty in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a 'code team') to rush to the specific location and begin immediate resuscitative effort) Policy: Hospital, dated ,[DATE], read that the first person on scene calls the code so staff can respond, then begins CPR, the North Station Nurse gets the crash cart (cart with emergency life saving supplies and medications) to the location immediately. In an interview on [DATE] at 7 pm, LN A stated she had been working with Resident 2 much of the evening on [DATE]. LN A further stated that at about 5:30 am on [DATE] Resident 2 was given a breathing treatment, then was taken outside, where Resident 2 stated that the fresh air felt good and that she wanted a cigarette. LN A explained to Resident 2 that her difficulties with breathing would make smoking impossible, and that the doctor had been called and wanted her on oxygen. LN A stated that she then took Resident 2 to her room. Resident 2 had slumped back in her bed but was still breathing. She asked CRN to help her as Resident 2 was difficult to position. CRN asked LN A to call the physician and she was asked to get a mask for Resident 2's oxygen. LN A stated that when she returned to the room Resident 2 was not breathing. LN A stated that she did not know Resident 2's code status (what type of intervention a health care team will conduct should a patient's heart stop beating or lungs stop moving air in the event of a medical emergency). In an interview on [DATE] at 7:30 pm, CRN stated that the emergency crash cart (with a back board, and ambu-bag for ventilation, and oxygen) was not obtained for Resident 2 and no code blue was announced for Resident 2, though the doctor was called to come in. CRN stated he was not aware of Resident 2's code status. CRN stated he made a judgement call that any resuscitation would be futile (of no use). CRN stated that he had back problems that prevented him from lowering Resident 2 to the floor. CRN also stated that his Advanced Cardiac Life Support (ACLS) Training (which included his CPR certification) had just expired a few days ago, on [DATE]. In an interview on [DATE] at 10:15, Interim Human Resources Staff (IHRS) stated that there was not a system to ensure that CPR, ACLS, Pediatric Advanced Life Support (PALS) was being tracked to ensure that staff had current training. IHRS stated that she had discovered this upon taking over the interim position. A facility provided job description for Registered Nurse, dated [DATE], read Essential Duties and Responsibilities include the following . ACLS certification is required . Is responsible as Charge Nurse for Acute, including ER, and SNF . Will initiate all emergency treatments and protocol according to Surprise Valley Hospital policy . In an interview on [DATE] at 12 pm, DON stated that she was aware of the problem with CRN not performing CPR (coding her) when she came in to work on [DATE], the morning of Resident 1's death. DON stated that she had not completed an unusual occurrence report, but had done her own unwritten investigation. DON stated that she educated staff on the crash cart and discovered that the wheels on the cart were frozen in place and could not be moved. DON stated that Resident 1 should have been transferred to the emergency room or that she should have peen placed on the floor to do CPR. An Immediate Jeopardy (IJ) was called with the physician (MD), and the Director of Nursing (DON), on [DATE] at 2:25 pm. An immediate plan of action was accepted on [DATE] at 5:32 pm to remove the immediate threat. The plan of action included ensuring all Registered Nurses had current ACLS certification, orienting all nursing staff to the Code Blue policy, identifcation on each shift of the staff who are responsible to respond to a Code Blue, mock Code Blue situations to be performed quarterly including a mock Code on [DATE] with all current staff. In an interview on [DATE] at 9:20 am the Administrator was notified of the IJ but he indicated that he did not want to discuss this any further and did not want to hear the details to justify the IJ. The IJ was abated on [DATE] at 4 pm with the DON and Admininstrator, with onsite verification of the implementation of their plan.

Based on interview and record review, the facility failed to operationalize their Elder Abuse Policy and Procedure for one of 10 sampled residents (Resident 1). On 4/3/12, Resident 1 had been physically detained at a sink in the dining room, wearing only a t-shirt and pants, by three staff members, Licensed Vocational Nurse (LVN) G, Certified Nursing Assistant (CNA) K, and CNA L, while they searched him for cigarettes against his will, in front of fell ow residents. On 5/7/12, Resident 1 was physically held in a headlock by LVN G in the dining room, which was witnessed by another resident, when she took an unlit cigarette away from him. 1. The facility Interim (temporary) Administrator, Director of Nurses (DON), Human Resources Director (HRD) and the Ombudsman had knowledge of the 4/3/12 abuse and mistreatment of [REDACTED]. Additionally, each staff member who had knowledge of the mistreatment and abuse of Resident 1, failed to individually report the incidents, per Mandated Reporter law. 2. The DON failed to conduct a complete investigation of the abuse and mistreatment of [REDACTED]. 3. The DON had not included resident abuse and mistreatment as a quality deficiency in the facility's Quality Assessment and Assurance (QA&A) agenda. 4. The facility failed to provide training that ensured staff reported abuse without fear of reprisal. 5. The facility failed to prevent abuse when the DON had not ensured that Resident 1's needs were met, and that staff assigned had knowledge of Resident 1's care needs. 6. The facility's nursing staff failed to monitor, assess, and care plan Resident 1's behaviors which might have led to conflict or neglect. 7. The facility failed to protect Resident 1 from further opportunities for abuse and mistreatment by not suspending employees that had abused and mistreated him. 8. The facility's HRD failed to screen potential new hires by not contacting applicants current or previous employers. This systems failure had to potential for all residents to receive substandard quality of care and subjection to abuse and mistreatment, and required immediate correction. (Refer to F223) Findings: Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 2/9/12, reflected that Resident 1 had some cognitive impairments. Resident 1 was conserved by a public guardian who was responsible for his healthcare and financial decisions. 1. The Interim Administrator stated in an interview on 5/11/12 at 9:30 am, that he became aware of the 4/3/12 abuse and mistreatment of [REDACTED]. The Administrator confirmed that he had not reported the abuse to the CDPH or investigated, per the facility's Elder Abuse policy. a. The HRD confirmed in an interview on 5/9/12 at 4:35 pm, that he had knowledge of Resident 1's 4/3/12 abuse and mistreatment on 5/3/12, when another resident told him. The HRD stated that he had not reported to the Administrator or to the CDPH and had not "had time" to initiate an investigation, per the facility's Elder Abuse policy. b. On 5/11/12 at 3:16 pm, the DON maintained that she had no knowledge that Resident 1 had been abused and mistreated on 4/3/12. c. On 5/16/12 at 2:45 pm, the Ombudsman stated that she informed the DON in person on 4/4/12, of the abuse and mistreatment of [REDACTED]. The Ombudsman stated that the DON assured her that she would investigate, which she had not done. The Ombudsman confirmed that she had not reported the incident to the CDPH. d. On 5/10/12 at 2:30 pm, the facility's Nurse Practitioner (NP) was interviewed. The NP confirmed that on 4/6/12, Resident 1 told had her that he had felt mistreated and humiliated during a search that occurred on 4/3/12. The NP confirmed she had not reported that incident to a supervisor, or to the CDPH, per the facility's Elder Abuse policy and Mandated Reporter laws. e. On 5/9/12 at 2:20 pm, LVN C, who is also the Social Service Director, confirmed that she had not reported her knowledge of the on-going abuse and mistreatment of [REDACTED]. LVN C confirmed that she had not followed the facility's Elder Abuse policy and Mandated Reporter laws. f. On 5/9/12 at 3:10 pm, Medical Records staff (MR) X, stated that she had not reported her knowledge of LVN G's on-going "snotty and humiliating" treatment of [REDACTED]. g. On 5/9/12 at 3:30 pm, MR Y confirmed that she had knowledge of LVN G's on-going mistreatment of [REDACTED]. MR Y stated that she had not reported the abuse and mistreatment of [REDACTED]. h. On 5/9/12 at 4:10 pm, CNA F stated that she had knowledge that LVN G was "very rude" to Resident 1, and that it had been of an "on-going" nature. CNA F confirmed that she had not reported her observations to her supervisor or to the CDPH, and had not followed the facility's Elder Abuse policy and Mandated Reporter laws. i. On 5/10/12 at 3:45 pm, Activity Assistant (AA) D confirmed that she witnessed Resident 1's abuse and mistreatment by LVN G and CNA's K and L on 4/3/12, and had knowledge that LVN G frequently mistreated and humiliated Resident 1. AA D stated that she had not reported that knowledge to her supervisor, the DON, or the CDPH, per facility Elder Abuse policy and Mandated Reporter laws. j. On 5/10/12 at 10 am, CNA E confirmed that he had knowledge that LVN G, "abuses, goads, bullys, and provokes" Resident 1, and had not reported that to his supervisor, the DON, or to the CDPH. CNA E confirmed that he had not followed the facility's Elder Abuse policy or Mandated Reporter laws. On 5/9/12, the facility's policy and procedure titled, "Elder Abuse," revised 8/06, was reviewed. The section titled, "Investigation" instructed that: 1. "When abuse, mistreatment or neglect of a resident is observed by, reported to, or suspected on any employee at the facility, staff immediately notifies their supervisor on duty. The supervisor assumes responsibility for taking the following steps during the investigation." 2. "Immediately notify the Director of Nurses and Administration/HR, by telephone if necessary." 3. "Immediately investigate the alleged incident during the shift on which the alleged abuse occurred..." 4. "Initiate steps to protect the resident..." 6. "Notify the Ombudsman..." 7. "Complete SOC-341 form." 8. "Call Department of Health..." 10. "The supervisor completes the SNF investigation tool. Send ...to Director of Nurses who then reports to the Administrator." 11. "Administration and DON complete a written statement as a summary of the incident and includes conclusions reached." 13. "Administration faxes investigation documentation, written statements and investigation summary including actions taken to DHS...within 48 hours." The section titled, "Training" instructed that: 4. "All staff will be made familiar with the telephone reporting for alleged abuse to express all concerns of legal, ethical, or quality issues." 2. On 5/11/12 at 3:16 pm, the DON was unable to provide evidence that she had adequately conducted an abuse investigation on 5/7/12, for Resident 1. The DON had the contents of the facility's investigations in an unorganized and overflowing folder, which contained only one piece of the 5/7/12 investigation. The DON confirmed that she had not "followed through" with investigating Resident 1's abuse on 5/7/12, per the facility's Elder Abuse policy, "I did not interview him or get his side of the story." The facility's policy titled, "Elder Abuse", revised 8/06, "Identification" section instructed that: 1. "All events or incidents meeting the definition of abuse will be recorded on the Unusual Circumstance Documentation Form... This form will be kept at both nurse's stations and is to be filled out by the Nurse Supervisor on duty at the time of the incident." 2. "The completed Unusual Circumstance Form will be given to the Director of Nurses for follow-up and investigation if necessary." The "Investigation" section instructed that: 3. "Immediately investigate the alleged incident during the shift on which the alleged abuse occurred. Obtain written statements from all parties involved and have them signed and dated. Written statements should include facts, conversations and observations. Use quotes whenever possible." 3. (numbered 3 again) "Interview the resident or other witnesses. This interview is to be dated, documented and signed by the supervisor. 3. On 5/16/12 at 10:45 am, the Medical Records Supervisor, also QA&A coordinator, confirmed that the DON had not brought any quality deficiencies to the QA&A committee regarding resident abuse and mistreatment or resident abuse reporting and investigating. The facility's policy titled, "Elder Abuse", revised 8/06, "Identification" section instructed that: 3. "The Director of Nurses will bring these forms to the PI committee for review." 4. On 5/10/12 at 10 am, CNA E confirmed that although he had knowledge that Resident 1 had been abused by LVN G, he had not reported for fear of, "getting fired." The facility's policy titled, "Elder Abuse", revised 8/06, instructed under the "Training" section: 3. "Staff will be encouraged to report any knowledge of the allegations of abuse without fear of reprisal." 5. On 5/8/12 at 2 pm, the DON stated that due to Resident 1 collecting and bringing cigarette butts into the facility, she had directed that her staff "search" him. The DON stated that she had not provided staff with an inservice on how to appropriately conduct a resident "search", nor had she observed while they conducted one. The DON stated that there had not been adequate staff to meet Resident 1's individual care needs. The facility's policy titled, "Elder Abuse," revised 8/06, directed under the "Prevention" section that: 2. "Nursing management will use all means necessary to supply sufficient numbers of staff, on each shift, to meet the needs of the residents and that staff assigned has knowledge of individual residents' care needs." 6. On 5/15/12 at 1 pm, the DON confirmed that Resident 1's plan of care had not identified through an interdisciplinary approach, potential behaviors or how to monitor those behaviors which could lead to abuse and mistreatment. The DON confirmed that Resident 1 had a [DIAGNOSES REDACTED]." The DON confirmed that Resident 1 had not been monitored or assessed for his response to being searched, therefore, the care plan had not been revised to prevent the abuse and mistreatment of [REDACTED]. The facility's policy titled, "Elder Abuse," revised 8/06, directed under the "Prevention" section that: 5. "The nursing staff will monitor, assess, and care plan residents with needs and behaviors which might lead to conflict or neglect." 7. On 5/9/12 at 4:35 pm, the HRD confirmed that Resident 1 had not been protected from the possibility of future abuse. The HRD confirmed that LVN G, CNA K, and CNA L had not been suspended and were available/scheduled to provide care to Resident 1. The facility's policy titled, "Elder Abuse", revised 8/06, instructed under the "Protection" section that: 1. "The facility will protect the resident from harm during an investigation..." 4. "When a staff member is implicated in a potential resident abuse situation, the employee is to be sent home immediately..." 5. "The employee will be instructed that they are being placed on suspension pending the outcome of the investigation..." 8. On 5/9/12 at 4:35 pm, the HRD stated that he had not contacted potential employees' or newly hired employees' current or previous employers. The HRD confirmed that he had not screened new employees, per the facility's Elder Abuse policy, "for years." The facility's policy titled, "Elder Abuse", revised 8/06, instructed under the "Screening" section that: 1. "The Human Resources Manager will attempt to contact current employers and/or previous employers on all applications considered for hiring. Notations regarding information received will be made on the application next to the appropriate employer listing. All employees will be subject to a criminal background check through the Office of Inspector General." On 5/11/12 at 3:16 pm, the interim Administrator, Human Resources Director, and the Director of Nurses were informed that the survey team had determined that an Immediate Jeopardy situation existed for the following reasons: 1. Resident 1 was abused and mistreated when LVN G, CNA K, and CNA L conducted a search of his person on 4/3/12. 2. Resident 1 was physically abused on 5/7/12, when LVN G held him in a "headlock" during another search of his person. 3. Staff members, NP, MR Y, MR X, LVN C, CNA F, CNA E, and AA D, had knowledge of on-going abuse and mistreatment to Resident 1, and failed to follow the facility's Elder Abuse policy and procedures and report to their supervisors, DON, or the CDPH. 4. All seven of the facility staff with knowledge of Resident 1's abuse and mistreatment, failed to follow Mandated Reporter Laws. 5. The DON had knowledge of Resident 1's abuse and mistreatment on 4/4/12, and failed to implement the facility's Elder Abuse procedures of reporting to Administration and QA&A, reporting to the CDPH, investigation, and protection of the resident. 6. The HRD had knowledge of Resident 1's abuse and mistreatment on 5/3/12, and failed to implement the facility's Elder Abuse procedures of reporting to Administration and the CDPH, screening, investigation, and protection of the resident. 7. The interim Administrator had knowledge of Resident 1's abuse and mistreatment on 5/9/12, and failed to ensure that the facility's Elder Abuse policy and procedures had been operationalized. On 5/11/12 at 4:40 pm, the Administrator, HRD, and DON, confirmed that the facility's system for preventing and reporting elder abuse had failed, and confirmed that the residents were in immediate jeopardy. On 5/11/12 at 5:45 pm, the Administrator presented a plan of immediate corrective action that was not acceptable. At 6 pm, a teleconference was held by the CDPH Supervisor and survey team with the Interim Administrator, DON, and HRD to discuss the concerns identified during survey related to resident abuse and the facility's unacceptable plan of corrective action. The facility's administrative team was asked to provide the survey team with a revised plan of corrective action. On 5/11/12 at 10:07 pm, the interim Administrator presented another plan of immediate corrective action which included: The Administrator, or designee, will conduct in-service training for the entire staff regarding legal requirements for mandated reporting of mistreatment or abuse. The in-service will include a complete review of mandated reporting requirements to the CDPH and a complete review of the District Policy of Patient Abuse and Mistreatment. All staff will watch the Department of Justice video, "YOUR LEGAL DUTY" and each staff member will acknowledge in writing, understanding of the procedure. The in-service will commence immediately on the night of 5/11/12, and continue daily with each shift change. The entire staff will be in-serviced no later that 5/18/12. For continued awareness, the Director of Staff Development will continue with in-service training quarterly. The DON will post mandated reporting requirements throughout the facility and ensure the District Policy is readily available to staff. A quality indicator will be developed by the DON no later than 5/18/12, to assess the effectiveness of the initial in-service with monthly reviews, and will report directly to the Administrator. LVN G has been suspended. CNA L will resume to work after counseling, in-service, and under direct supervision and will not care for Resident 1. CNA K is only a "casual" employee and will not be utilized. The DON will complete a comprehensive care plan that protects Resident 1 and prevents future risk of abuse and mistreatment. The Administrator will conduct QA oversight of the DON. The Administrator, or designee, will follow up and investigate any concerns of suspected, alleged, or potential abuse communicated by residents. The Administrator, or designees, will conduct ongoing oversight of all staff concerning the reporting of abuse. On 5/11/12 at 10:20 pm, the interim Administrator was informed by the survey team that the immediate plan of corrective action had been accepted, and the Immediate Jeopardy was abated.

Based on observation, interview, and record review, the facility failed to ensure that one of 10 sampled residents (Resident 1) was free from abuse and mistreatment by staff. On 4/3/12, a Licensed Vocational Nurse (LVN) G and two male Certified Nursing Assistants (CNAs) K and L, physically detained Resident 1 against his will at a sink in the dining room wearing only a t-shirt and trousers, and in the presence of visitors and fell ow residents searched him for cigarettes. On 5/7/12, the same LVN physically held Resident 1 against his will in a headlock, in front of his peers, to take his cigarettes away. The unprofessional and abusive manner by which the staff had mistreated Resident 1, with disregard to fell ow residents, staff, and visitors, caused him fear and humiliation. After the 4/3/12 incident, the facility noted Resident 1 was refusing to eat, exhibited self isolation, and expressed feelings of sadness and depression. This practice violated Resident 1's right to be free from abuse, mistreatment, and humiliation in his home, and created an adverse effect on his ability to obtain his highest practicable level of emotional well-being. (Refer to F226, F279, F323, F329, F490, and F520 for additional information regarding Resident 1). Findings: On 5/8/12 at 2 pm, an interview was conducted with the Director of Nurses (DON) regarding an entity reported incident ( 7) that the facility had filed with the California Department of Public Health (CDPH). The facility reported that Resident 1 shoved LVN G, when she tried to take his cigarettes away. The DON stated that she had no knowledge of the staff being abusive to Resident 1, but "he's abusive to my staff, I've asked his conservator to move him." Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Sets (MD'S, assessment tools) were reviewed for 5/24/11, 11/18/11, and 2/9/12, and all reflected that Resident 1 had cognitive impairments, but no behavior problems. Resident 1 had a public guardian that made his financial and healthcare decisions. On 5/8/12 at 5:20 pm, Resident 1 was observed in the dining room. He was pleasant, calm, and friendly with fell ow residents and staff. On 5/9/12 at 9 am, the survey team conducted confidential interviews with a group of eight residents. When the group was asked if they had ever been, or knew of anyone else who had been abused or mistreated, two of eight in the group stated that Resident 1, "was being abused." An alert and oriented resident expressed that she had been, "sickened" by the way Resident 1 had been mistreated by LVN G. The resident stated that LVN G had been "abusive" to Resident 1, "for months." The resident stated that on 4/3/12, Resident 1 had been out of the facility all day. When he returned, at about 5 pm, he came through the dining room door, where "we were having an activity event with staff, other residents, and some visitors." The resident described that, LVN G and CNAs K and L, "took him to the sink" and "patted down and ganged up on" Resident 1, "the second he got through the door." The resident stated that Resident 1's hat, coat, shirt, and shoes had been removed and that CNA's K and L were digging in Resident 1's pockets. The resident heard CNA's K and L shouting out, "I found a cigarette - Oh! here's another" and that Resident 1 had said, "stop!" The resident stated that everyone in the dining room was watching, "it was very emotionally disturbing." A second confidential interview was held with the same resident in her room, on 5/15/12 at 11 am. The resident stated that LVN G, "argues with us when we want something" and is "not a patient advocate." The resident stated that LVN G's "presence makes me uncomfortable" and added, "we don't have a happy home anymore." On 5/9/12 at 9 am, in response to the same question of abuse and mistreatment, another alert resident from the group stated that he had witnessed the search of Resident 1, on 4/3/12, as well, and stated, "it was down right humiliating." The resident stated, "he's being abused." The resident stated that he had witnessed another search on 5/7/11, that LVN G had conducted in the dining room, "we all watched again", "she ripped his hat off of his head and put him in a headlock trying to take his cigarettes away." The resident stated that Resident 1, "shoved her (LVN G) to get her off of him", "then she called the Sheriff and wanted him (Resident 1) arrested." A second confidential interview was held with the same resident in his room, on 5/15/12 at 11:05 am. The resident stated, "I don't want her (LVN G) taking care of me." The resident added, "She's (LVN G) dangerous and should not be taking care of old people." On 5/9/12 at 2:50 pm, Resident 1 was interviewed. Resident 1 stated that his quality of life in the facility was that of a "prison." Resident 1 stated that he had been abused, humiliated, and intimidated by LVN G, "everyday she works." Resident 1 stated that in order to preserve his emotional well-being he goes out of his way to avoid LVN G, "she's bossy and mean to me." Resident 1 described that on 4/3/12, LVN G and CNA's K and L "attacked me as soon as I walked through the door." Resident 1 stated, "they had no reason to search me, I hadn't been smoking, I was gone all day in Klamath Falls (Oregon) for my doctors appointment." Resident 1 went on to describe that "without warning and against my will" LVN G and CNA's K and L, "ganged up on me and had me "pinned" up against the dining room sink and began searching me and digging in my pockets, I was down to my t-shirt and pants, they even made me take my shoes off." Resident 1 stated he was "scared." Resident 1 was shaking his head with a sad facial expression and stated, "I was so humiliated in front of all those people in the dining room, I hadn't done anything wrong, this is supposed to be my home." Resident 1 described that LVN G had conducted a second traumatic search on him in the dining room, on 5/7/12. Resident 1 stated, "the minute "she (LVN G) saw me coming in from outside she ripped my hat off my head." Resident 1 stated that LVN G was aggressively trying to take a cigarette away from him, "it was brand new and I wanted to keep it" but "she (LVN G) put me in a headlock an took it from me." Resident 1 stated that the manner in which LVN G had approached him was provoking and intimidating and that he had shoved LVN G's shoulder to, "get myself out of the headlock." Resident 1 stated that after LVN G had wrestled him for the cigarette, she called the Sheriff, "she attacked me- then wanted me arrested for protecting myself." Resident 1 stated that he now feared going to jail if he "crossed" LVN G. Resident 1 had been very kind and soft spoken during the interview. On 5/9/12 at 10:20 am, LVN G was interviewed. LVN G confirmed that although she had searched Resident 1 on 4/3 and 5/7/12, she had not recognized that her conduct was abusive, "I do what I have to do for the safety of others." LVN G stated that she had enlisted the help of CNA's K and L on 4/3/12, because "he (Resident 1) gets aggressive with me." LVN G confirmed that it had not been appropriate to search Resident 1 in the dining room while others watched, "that was wrong." LVN G had documented in the nurses notes on 3/2/12 at 6 am, "I further told him (Resident 1) if he felt he was being treated unfairly by nurses he needed to speak to (name) DON on Monday." On 4/22/12 at 1:30 pm, LVN G documented, "Res was irritated he did not get (lunch) tray. Res then wanted coffee, explained that aides were busy feeding and asked him to wait until they were done. Res very irritated stating (to his visitor) Oh thank God (name of visitor) get me out of here away from these people that are so bad to me!" On 5/9/12 at 2:20 pm, LVN C, who acts as Social Service Director twice a month, was interviewed. LVN C stated that LVN G treated Resident 1, "terrible." LVN C stated that LVN G's approach with Resident 1 was "rude, snotty, and harassing." LVN C stated that LVN G, "mistreated and abused" Resident 1. LVN C had documented in her progress notes on 5/3/12, that LVN G told Resident 1, "you better be nice to us, because if no one agrees to take you out at your smoking times, you're out of luck." On 5/9/12 at 3:10 pm, Medical Records staff (MR) X, was interviewed. MR X stated that LVN G spoke to Resident 1 in a "snotty and humiliating" manner. MR X stated, "I would be very upset if that was my dad." On 5/9/12 at 3:30 pm, MR Y was interviewed. MR Y stated that on 4/3/12 at about 5 pm, she heard a "commotion" that was loud enough to be heard through her closed office door. When she came out to see what was going on, she observed that LVN G and "a few CNAs" had Resident 1 "pinned up against the sink in the dining room." MR Y stated that they were "yelling" at Resident 1 to take his coat off and that his, "pant pockets were hanging out." MR Y stated that Resident 1 was "quite agitated" and that "the scene was humiliating." On 5/9/12 at 4:10 pm, CNA F stated during an interview that LVN G, "is always rude" to Resident 1, "it's on-going." CNA F stated that she had heard LVN G tell Resident 1, "this is all your fault!", when LVN G called the Sheriff on 5/7/12, to report that Resident 1 had shoved her. On 5/10/12 at 10 am, an interview was conducted with CNA E. CNA E stated that LVN G was "abusive" to Resident 1. CNA E stated that, "She (LVN G) "goads, bullys, and provokes him (Resident 1)." CNA E stated that during a conversation he had with LVN G, she stated, "I hope he (Resident 1) hits me so I can get him out of here." On 5/10/12 at 2:30 pm, the facility's Nurse Practitioner (NP) was interviewed. The NP stated that LVN G was, "not treating him (Resident 1) right." The NP had documented in Resident 1's history and physical report, dated 4/6/12, "There was some question by some of the other residents regarding his (Resident 1) treatment ... The patient (Resident 1) was searched by the staff the other day in the common room which was somewhat humiliating, in his words." On 5/10/12 at 3:45 pm, Activity Assistant (AA) D was interviewed. AA D described that on 4/3/12 at 5 pm, LVN G and CNA's K and L, "were on him (Resident 1) the minute he walked through the dining room door and had him over by the counter, pinned up against the dining room sink." AA D stated that LVN G had not asked for Resident 1's permission to search him, before she "attacked." AA D stated that LVN G was loud, demeaning, aggressive, and intimidating toward Resident 1. AA D stated that the male CNA's, K and L, had their hands in Resident 1's pant pockets and that Resident 1 was "down to his t-shirt, pants, and socks." AA D stated that she had been conducting an activity which had been disrupted by LVN G and CNA's K and L, "the way they searched him was ugly and appalled the other residents and family members." AA D stated, "poor (Resident 1), he was so down looking when they were done with him." On 5/11/12 at 1:32 pm, CNA K was interviewed. CNA K confirmed that he had participated in searching Resident 1, on 4/3/12, at the direction of LVN G and the DON. CNA K confirmed that the search was conducted in the resident dining room in front of other residents and visitors. CNA K confirmed that Resident 1's hat, coat, and shoes had been removed. CNA K confirmed that he, LVN G, and CNA L had detained Resident 1 "at the sink" in the dining room and that Resident 1, "didn't like it and was very quiet afterward." CNA K expressed concern that the facility would know that he had spoke with a surveyor. On 5/11/12 at 1:40 pm, CNA L was interviewed. CNA L confirmed that he, LVN G, and CNA K had searched Resident 1 for cigarettes in the dining room on 4/3/12, in front of other residents and visitors. CNA L stated, "the situation was under control," but remained quiet when asked to describe what "situation" had been "under control." On 5/9/12, the facility's policy and procedure titled, "Elder Abuse", revised 8/06, was reviewed. The policy described the following: ABUSE: "Physical abuse (includes sexual abuse), neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering, deprivation, by custodian of goods or services that are necessary to avoid physical harm or mental suffering." PHYSICAL ABUSE: "Is any of the following willful acts: assault, battery, assault with a deadly weapon or force likely to produce great bodily injury, unreasonable physical constraint or continual deprivation of food or water, sexual assault, use of a physical or chemical restraint or [MEDICAL CONDITION] medication under any of the following conditions; for punishment, for a period beyond that for which the medication was ordered, for any purpose not authorized by the physician." SUBTLE RESIDENT ABUSE: "...careless, thoughtless, tactless and insensitive actions. Subtle abuses are destructive because they undermine self-esteem." On 5/11/12 at 9 am, the Human Resources Director confirmed that Resident 1's treatment was "abuse" per the facility's Elder Abuse Policy and Procedure.