Every finding on record at The Redwoods Post-Acute

Based on observation, interview, and record review, the facility failed to ensure to maintain infection prevention and control practices to prevent the spread of infection when:Certified nursing assistant (CNA) staff failed to wear a gown (to cover staff's clothing and skin to prevent the spread of infection [part of the personal protective equipment, PPE]) when they transferred a resident with enhanced barrier precautions (EBP, an infection control strategy used with residents with high risk infections or devices in place to prevent the spread of infections or to protect from infections); and,Occupational Therapist (OT, a healthcare expert who helps residents do everyday tasks and gain independence) failed to discard gloves appropriately after removed.These failures had the potential for disease transmission among residents residing in the facility. Findings:1.During an observation on 7/28/2026 at 12:20 p.m., noted posted sign for EBP on the wall outside room for Resident 1. Observed CNA A transferred Resident 1 from wheel chair (W/C, a chair with wheels used by residents who cannot walk or have mobility concerns) to bed with no gown to cover her clothing and skin on.Review of Resident 1's face sheet (FS, a document that gives resident's information at a quick glance) indicated, Resident 1 was admitted to facility on 2/16/2024.Review of Resident 1's diagnoses included end stage renal disease (permanent kidney [a bean shaped organ, filters blood, removes waste and balances body fluids] failure) and dependence on renal dialysis (a life-saving medical treatment that liters waste, and extra fluids from blood when kidneys fail).Review of Resident 1's order summary report indicated, Enhanced Barrier Precautions during high contact time secondary to: RUC (right upper chest) PERMACATH (a flexible medical tube placed permanently under the skin on chest, used for dialysis treatment) every shift, dated 2/19/2026.Review of EBP sign posted on wall outside Resident 1's room indicated, PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Transferring.During an interview with CNA A on 7/28/2026 at 12:31 p.m., CNA A confirmed did not wear gown when transferred Resident 1 from W/C to bed. CNA A also confirmed Resident 1 needed EBP including gloves and gown while providing care to follow infection control precautions. CNA A stated should have had wore gown before transferred Resident 1.During an interview with facility's infection preventionist (IP) on 7/28/2026 at 2:10 p.m., IP stated CNA A should have followed PPE for EBP as posted when transferred Resident 1 for infection control practices. IP also stated all staff should follow infection control practices to prevent the risk for spreading infections among residents and staff.During an interview with facility's director of nursing (DON) on 7/28/2026 at 2:45 p.m., DON stated all staff should follow infection control practices and required PPE for residents with EBP.2.During an observation on 7/28/2026 at 1:10 p.m., noted OT came out to hallway from Resident room [ROOM NUMBER] with both gloves on and holding cell phone in her right hand. OT placed cell phone in her uniform right pocket, removed gloves, placed removed gloves in her uniform's left pocket and did hand hygiene with alcohol gel.During an interview with OT on 7/28/2026 at 1:17 p.m., OT confirmed above observation. During an interview, observed OT removed gloves from her uniform's left pocket and discarded in garbage bin attached to Medication Cart (movable workstation used to store, organize, transport and dispense medications to residents) 1 at Nurse's Station 1. OT stated she should have removed gloves, discarded in assigned garbage bin and provided hand hygiene before came out of Resident room [ROOM NUMBER] for infection control. OT also stated she should not have kept used gloves in uniform pocket to prevent the risk for infection. OT provided hand hygiene after completed the interview.During an interview with IP on 7/28/2026 at 2:10 p.m., IP stated OT should have discarded used gloves in garbage bin instead of placing in her uniform's pocket to prevent the risk of spreading infection. IP also stated will educate staff today for safe infection control practices.During an interview with facility's director of nursing (DON) on 7/28/2026 at 2:45 p.m., DON stated all staff should follow infection control practices for discarding gloves after each use. Review of facility's policy and procedure (P&P) titled, Enhanced barrier Precautions, revised 6/28/2024, the P&P indicated, Enhanced barrier precautions (EBPs) are used as an infection prevention and control interventions to reduce the spread of multi-drug resistant organisms (MDROs) to residents. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . c. transferring;Review of facility's P&P titled, Personal Protective Equipment-Gloves, revised July 2009, the P&P indicated, Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed.

Based on interview and record review, the facility failed to maintain a complete medical record for one of three sampled residents (Resident 1) when:There were multiple days for which there was no documentation that Resident 1's scheduled skin treatments were provided;There were multiple days for which there was no documentation that Resident 1 was provided assistance for certain activities of daily living (ADLs); andThere were multiple days for which there was no documentation of Resident 1's meal intake (percentage of food the resident ate during each meal).These failures had the potential to compromise the facility's ability to ensure adequate care and monitoring were provided to maintain Resident 1's health and well-being at the highest practicable level.Findings:1.) Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including Huntington's disease (a disorder that destroys the areas of the brain that control movement, thinking, and mental health).Review of Resident 1's Order Summary Report indicated she had a physician's order, dated 7/18/24, to cleanse cellulitis (a skin infection) to LUE (left upper extremity) with NS (normal saline, a sterile salt water solution), pat dry, apply hydrocortisone 1% cream (medication used to relieve skin irritations), and leave open to air BID (two times a day). Resident 1 also had a physician's order, dated 7/18/24, to cleanse rash to entire body with NS, pat dry, and apply zinc oxide (a skin protectant) and hydrocortisone 1% cream BID.Resident 1's treatment administration record (TAR) was reviewed. From 7/18/24 to 8/24/24, there were nine days (ten scheduled treatments) for which there was no documentation that the facility provided treatment to Resident 1's LUE cellulitis as ordered. Further review of the TAR indicated that from 7/18/24 to 9/16/24, there were 11 days (12 scheduled treatments) for which there was no documentation that the facility provided treatment to Resident 1's entire body rash as ordered.During an interview and concurrent record review with licensed nurse A (LN A) on 5/18/26, at 12:49 p.m., LN A confirmed that when nurses provide skin treatments, they should document this on the TAR. LN A confirmed there were multiple days for which there was no documentation that the facility provided treatments to Resident 1's LUE cellulitis and entire body rash as ordered. 2.) Resident 1's Documentation Survey Report was reviewed. There was a section on this report designated for staff to document the type of assistance they provided to Resident 1 for eating, oral hygiene, and toileting hygiene. From 4/1/24 to 4/28/25, there were 63 days (67 shifts) for which staff did not document that assistance was provided to Resident 1 for these ADLs.During an interview and concurrent record review with LN B on 5/18/26, at 12:32 p.m., LN B confirmed that when staff provide ADL assistance to a resident, they should document this in the electronic health record (EHR). LN B confirmed there were multiple days/shifts for which there was no documentation that staff provided Resident 1 with assistance for the ADLs mentioned above. 3.) Resident 1's Documentation Survey Report was reviewed. There was a section on this report designated for staff to document the percentage of food Resident 1 ate during each meal. From 4/1/24 to 4/28/25, there were 36 days (67 meals) for which staff did not document the percentage of food Resident 1 ate.During an interview and concurrent record review with LN B on 5/18/26, at 12:35 p.m., LN B reviewed Resident 1's Documentation Survey Report and confirmed there were multiple days/meals for which staff did not document the percentage of food Resident 1 ate.Review of the facility's policy titled Charting and Documentation, revised 7/2017, indicated all services provided to the resident shall be documented in the resident's medical record. The policy further indicated, Documentation in the medical record will be objective (not opinionated or speculative ), complete, and accurate.

Based on interview and record review, the facility failed to ensure three out of 31 sampled residents (Residents 92, 307, and 400) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 92 received four psychotropic medications without documented evidence of attempted or contra-indicated non-pharmacological (non-drug) interventions prior to initiating or increasing these medications. Also, there was no monitoring for side effects of aripiprazole (Abilify, an antipsychotic medication to treat mental illnesses) since July 2024; 2. Resident 307 received a PRN (as needed) prochlorperazine (antipsychotic medication which can be used for short term psychotic disorders or nausea/vomiting) without a 14-day limit; and 3. Resident 400 received trazodone (an anti-depressant medication) without effectiveness monitoring. The failures resulted in unnecessary medications for the residents, and had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: 1. A review of Resident 92's clinical record indicated she was admitted to the facility in June 2024 with diagnoses including anxiety and depression. A review of her physician's orders indicated, on 7/3/24, she received three new psychotropic medication orders, as follows: a. Aripiprazole (Abilify, an antipsychotic) 5 milligrams (mg, unit of measurement), give 1 tablet by mouth one time a day for Schizoaffective disorder Bipolar Type [a mental disorder with extreme highs (mania) and severe lows (depression)] for 1 Week m/b [manifested by] angry outburst, demeaning staff, calling staff names, cursing staff. b. Cymbalta (an antidepressant) 30 mg, give 1 capsule by mouth one time a day for depression m/b verbalization of sadness; and c. Clonazepam (an anti-anxiety medication) 0.5 mg, give 1 tablet two times a day for ANXIETY m/b verbalization of nervousness or expression of feeling panicky. Also, on the same day, 7/3/24, her trazodone (an antidepressant) was increased from 50 mg to 100 mg, to be administered at bedtime for depression m/b inability to sleep. Despite the three new psychotropic medication orders and an increase in trazodone, there was no documented evidence in Resident 92's clinical record of attempted or contraindicated non-drug interventions prior to initiating and increasing these medications. Furthermore, there was no documented evidence the facility staff monitored for the side effects of aripiprazole since it was started. During a concurrent interview and record review with the Director of Nursing (DON) and Assistant DON C (ADON C) on 1/16/25 at 10:20 a.m., they reviewed Resident 92's clinical record and confirmed there had been no monitoring for the side effects of aripiprazole. The DON stated the side effects should be documented on the MAR but it was not there. During a follow-up interview with the DON on 1/16/25 at 3:58 p.m., she stated the non-drug interventions were documented only on the activity assessment and care plan but there was nothing documented to show non-drug interventions were implemented prior to starting the medications. 2. Resident 307 was admitted to the facility with diagnoses including depression, dysphagia (swallowing difficulties), and nasogastric (NG) tube (a small, flexible tube inserted through the nose and into the stomach for delivery of nutrition and medications) status. A review of Resident 307's clinical record indicated a physician's order, dated 1/6/25, for Prochlorperazine [an antipsychotic medication] .10 mg Give 1 tablet via NG-Tube every 8 hours as needed for Nausea or Vomiting. There was no 14-day limit to this order. During a concurrent interview and record review with the DON on 1/16/25 at 2:22 p.m., she confirmed there was no 14-day limit for Resident 307's prochlorperazine order. 3. A review of Resident 400's clinical record indicated she was admitted to the facility with diagnoses including insomnia (inability to sleep). On 1/3/25, she had a physician's order for trazodone 50 mg, 1 tablet by mouth at bedtime for insomnia m/b inability to sleep. During an interview with Resident 400 at her bedside on 1/16/25 at 8:40 a.m., Resident 400 stated she had not been sleeping well and would like to have stronger medication to help her sleep better. A review of Resident 400's January 2025 MAR indicated the nursing staff had been monitoring, since 1/2/25, for inability to sleep and placing a check mark for each shift; however, there was no monitoring for the hours of sleep (total amount of time the resident sleeps during a given period). During a concurrent interview and record review with the DON on 1/16/25 at 2:26 p.m., she reviewed Resident 400's MAR and stated the staff should be monitoring the hours of sleep in order to see whether the trazodone was effective in helping the resident sleep. A review of the facility's policy and procedures titled Psychotropic Medication Use, dated July 2022, indicated in part: Psychotropic medication management includes . adequate monitoring for efficacy and adverse consequences . Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications . PRN orders for psychotropic medications are limited to 14 days . For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication .

Based on observation, interviews, and record review, the facility had a medication error rate of 11.11% when three medication errors occurred out of 27 opportunities during the medication administration for three out of seven residents (Residents 81, 118, and 133). The failure resulted in the residents not receiving the medications as prescribed, and had the potential for complications such as unnecessary pain or medication side effects. Findings: 1. During the medication administration observation on 1/13/25 at 8:41 a.m., Licensed Vocational Nurse (LVN) D was observed preparing and administering 5 medications to Resident 81. The medications did not include a lidocaine patch (a topical medication applied to the skin for pain management). A review of Resident 81's clinical record indicated a physician's order, dated 11/26/24, for Lidocaine Patch 5% Apply to right shoulder topically one time a day for pain management. It was scheduled to be administered daily at 9 a.m. During an interview with LVN D on 1/13/25 at 2:09 p.m., she stated, We have only 4% but not 5% [patches]. We called pharmacy for delivery. She confirmed the patch was due this morning but it was not administered to the resident. A review of Resident 81's January 2025 Medication Administration Record (MAR) indicated a 4 (meaning other, see nurse notes') with LVN D's initials in the 1/13/25 at 9 a.m. entry for lidocaine 5% patch. A review of the nurse's notes, written on 1/13/2025 at 10:24 a.m. by LVN D, indicated: Lidocaine Patch 5 % . On order Call the the pharmacy, MD and family aware. Will fallow up with pharmacy. 2. During a medication administration observation on 1/13/25 at 10:08 a.m., LVN E was observed preparing 8 medications, including a lidocaine 4% patch, for Resident 133. On 1/13/25 at 10:26 a.m., at Resident 133's bedside, LVN E was observed removing a patch from the resident's left upper shoulder and applying the newly-prepared lidocaine 4% patch on the same location. During a concurrent interview and record review with LVN E on 1/13/25 at 10:30 a.m., she confirmed she removed the previous day's lidocaine patch before applying a new one. When asked whether the used patch should have been removed the night before, she reviewed Resident 133's clinical record and stated, They didn't remove at 9 p.m. but they were supposed to remove it. On 1/13/25 at 10:35 a.m., LVN E advised the surveyor, The resident refused to remove the patch. A review of Resident 133's clinical record indicated a physician's order, dated 12/24/24, for Lidocaine Patch 4% Apply to Left Shoulder topically one time a day for pain management Apply at 9am and remove at 9 pm. On 1/13/25, a review of the nursing progress notes, from 1/12 to 1/13/25, did not have any documentation regarding the resident refusing for the previous day's patch to be removed at 9 p.m. on 1/12/25. On 1/13/25 at 2:35 p.m., an interview was conducted with Resident 133 at his bedside with LVN E present. Resident 33 stated the staff had been applying the lidocaine patch daily in the morning and removing it at night. LVN E asked the resident why the one from last night was not removed, Resident 133 stated, I don't remember. LVN E asked whether he would be okay with them removing the patch tonight, he stated, Yeah, ok. I don't have a problem with that. 3. During a medication administration observation with LVN F on 1/13/25 at 10:36 a.m., she was observed preparing and administering 5 medications to Resident 118. Included in the medications was a tablet of aspirin chewable 81 milligrams (mg, unit of measurement). A review of Resident 118's clinical record indicated a physician's order for Aspirin EC [enteric coated - a coating formation that allows aspirin to pass through the stomach to the small intestine before dissolving] Low Dose Oral Tablet Delayed Release 81 mg Give 1 tablet by mouth one time a day for CVA ppx [cerebrovascular accident or stroke prevention]. During a concurrent interview and record review with LVN F on 1/13/25 at 2:26 p.m., she reviewed Resident 118's physician's order for aspirin and confirmed she administered the chewable (or immediate release) aspirin while the physician's order indicated for the enteric-coated, delayed release formulation. A review of the facility's policy and procedures titled Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when two of the ceiling exhaust fans above the food preparation area were dirty and dusty with grey lint. These failures had the potential to cause food borne illness for 143 residents consuming food in the facility. Findings: During a kitchen tour observation on 1/13/25 at 1:58 p.m. two ceiling exhaust fans above the food preparation area were observed dirty and dusty with grey lint. During a concurrent observation and interview on 1/14/25 at 3:30 p.m., with the Maintenance Director (MDR), the MDR used the ladder to reach the ceiling exhaust fan above the food preparation area and wiped it, then he confirmed the dust. The MDR stated maintenance did the cleaning of the kitchen monthly. During a concurrent observation and interview on 1/14/25 at 3:35 p.m., with Registered Dietitian H (RD H), she confirmed two of ceiling exhaust fans above the food preparation area were dirty and dusty with grey lint. She stated that the food preparation area should be clean. She further stated, they would clean it before preparing the next meal. During a review of the facility's P&P titled Sanitization, Care of Residents revise date, 11/2022 indicated, 1. All kitchens, Kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects .

Based on observation, interview, and record review, the facility failed to ensure one of two trash dumpsters had the lid closed completely. This failure had the potential to attract pests (like flies and rodents) that could spread diseases and bacteria to the 150 residents residing at the facility. Findings: During a concurrent observation and interview on 1/14/2025 at 3:24 p.m., with the Dietary Supervisor (DS), the lid of one trash dumpster behind the kitchen was open and not closed completely flat. The DS stated, that trash container lids should be closed completely. During a concurrent observation and interview on 1/14/2025 at 3:28 p.m., with the Maintenance Director (MDR), he confirmed, one of two trash dumpster's lid was not completely closed. The MDR stated all the facility garbage goes to those trash dumpsters. He stated, trash dumpster lid should be closed. During an interview on 1/16/2025 at 9:06 a.m., with the Infection Preventionist Nurse (IP), the IP stated that the trash dumpsters should be fully closed and should have no space in between the lid to prevent any animals from going in and to control the infection. During a review of the facility's policies and procedures (P&P) titled, Food-Related Garbage and Refused Disposal, Revised 10/2017, the P&P indicated . 2. All garbage and refuse containers are provided with tight-fitting lid or covers and must be kept covered when stored or not in continuous use . 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests .

Based on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care for when the individual becomes incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was completed for 3 of 31 sampled residents (Residents 29, 31, and 32). These failures could lead to the delivery of unnecessary or inappropriate medical services, which are against the residents' goals and wishes. Findings: Review of Resident 29's clinical record indicated he was initially admitted to the facility on [DATE]. Review of Resident 29's POLST form, dated 8/20/24, indicated the AD section of the POLST form was blank. The POLST form did not indicate if there was an advance directive in placed or it was not available. Further review of Resident 29's POLST form indicated the section titled Artificially Administered Nutrition was blank. The POLST form did not indicate Resident 29's choices regarding feeding tubes and artificial nutrition. Review of Resident 31's clinical record indicated she was initially admitted to the facility on [DATE]. Review of Resident 31's POLST form, dated 11/28/23, indicated the AD section of the POLST form was blank. The POLST form did not indicate if there was an advance directive in placed or it was not available. Review of Resident 32's clinical record indicated she was initially admitted to the facility on [DATE]. Review of Resident 32's POLST form, dated 8/7/24, indicated the AD section of the POLST form was blank. The POLST form did not indicate if there was an advance directive in placed or it was not available. During an interview and concurrent record review with the director of nursing (DON) on 1/17/25 at 12:01 p.m., the DON reviewed the POLST forms for Residents 29, 31, and 32. She stated the admission nurse reviews the POLST form with the resident or their responsible party (RP) and discusses their wishes regarding medical treatment. The DON confirmed The POLST forms for Residents 29, 31, and 32 were incomplete. The DON stated all sections of the POLST forms should be completed and signed by the physician and the resident or their RP. A review of the facility's policy titled Advance Directives, revised 9/2022, indicated the advanced directives would be honored in accordance with state and facility policy. Upon admission, the resident would be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for one out of eleven sampled residents, (Resident 301), when Resident 301's refusals to participate in the activities that were being offered was not care planned. This failure had the potential to result in the resident not receiving the intervention and monitoring necessary to maintain his highest level of well-being. Findings: During a concurrent observation and interview of Resident 301 on 1/14/25 at 9:30 a.m., Resident 301 was laying in his bed, alert, calm and verbally responsive. He was refusing to participate in activities. During another concurrent observation and interview of Resident 301 on 1/15/25 at 8:50 a.m., Resident 301 was in his bed and appeared calm and comfortable. He was still refusing to participate in activities. Review of Resident 301's admission record (document that contains information about a resident's admission to a healthcare facility) indicated, Resident 301 was readmitted to the facility on [DATE] with diagnoses including unspecified parkinsonism (group of neurodegenerative conditions that manifest with motor symptoms, including rigidity, tremors and bradykinesia), unspecified schizoaffective disorder (mental health condition that includes symptoms of both schizophrenia and mood disorders) and generalized muscle weakness (decreased strength in the muscles). Review of Resident 301's order listing report (list of orders for a resident, including the details of each order) indicated, Resident 301 may participate in activity program if not in conflict with treatment plan, revised on 12/27/24. During an interview with the activity assistant I (AA I) on 1/17/25 at 9:35 a.m., AA I verified that the resident refused to participate in activities and there was no care plan about his refusal to participate in activities and this behavior was not monitored and followed up. During a concurrent record review of Resident 301's care plans and interview with the assistant director of nursing A (ADON A) on 1/17/25 at 12:31 p.m., ADON A verified that there was no care plan of Resident 301's refusal to participate in activities and this behavior of refusing to participate in activities should have been care planned, monitored and followed up. During an interview with the director of nursing (DON) on 1/17/25 at 12:55 p.m., DON verified that Resident 301's refusal to participate in activities should have been care planned, monitored and followed up. Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan . reflects currently recognized standards of practice for problem areas and conditions . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change .

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for two of thirty-one sampled residents, (Residents 8 and 400), when: 1. for Resident 8, there was no care plan, monitoring and follow-up of her hand contractures, and 2. for Resident 400, the staff took the blood pressure (BP, the force of blood pushing against the walls of the arteries) on the same arm where the resident has the AV fistula (arteriovenous fistula, connection that's made between an artery and a vein for dialysis access.) These failures had the potential for the residents, not to attain or maintain their highest practicable physical, mental, psychosocial well-being, and potential to cause injury. Findings: During a concurrent observation and interview of Resident 8 on 1/14/25 at 8:45 a.m., Resident 8 was laying in her bed, alert, calm, comfortable and verbally responsive. Resident 8's hands were contracted and she verbalized that she's not getting therapy of her contracted hands anymore which could be very helpful. Review of Resident 8's admission record (document that contains information about a resident's admission to a healthcare facility) indicated, Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia (complete paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (type of stroke that occurs when the brain tissue dies due to lack of blood flow) affecting right dominant side, type 2 diabetes mellitus (chronic condition characterized by high levels of sugar in the blood) with diabetic chronic kidney disease (condition that occurs when diabetes damages the kidneys over time) and generalized muscle weakness (decreased strength in the muscles). Review of Resident 8's clinical records indicated that the hand contractures of Resident 8 were not care planned, monitored and followed up. During another concurrent observation and interview of Resident 8 with assistant director of nursing A (ADON A) on 1/16/25 at 3:35 p.m., Resident 8 was laying in her bed, calm and comfortable. Resident 8 stated that therapy and follow-up of her hand contractures will be good for her. During an interview with ADON A on 1/16/25 at 3:48 p.m., ADON A verified the hand contractures of Resident 8 and stated that they should have been care planned, monitored and followed up to prevent deterioration of the hand contractures. During an interview with the director of nursing (DON) on 1/17/25 at 12:50 p.m., DON acknowledged that the hand contractures of Resident 8 should have been care planned, monitored and followed-up to avoid the hand contractures, from getting worse. Review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), revised March 2018, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate . 50855 2.During a review of Resident 400's clinical record indicated, Resident 400 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids.) Review of Resident 400's admission record Inpatient Nephrology Consult Follow Up Note indicated, Resident 400 has left AV fistula and chest permacath (a flexible tube that's inserted into a blood vessel in the neck or chest). During a review of Resident 400's Blood Pressure Summary indicated, Resident 400 had the blood pressure taken on the left arm on the following dates: - 1/3/2025 at 02:00; - 1/3/2025 at 10:23; - 1/4/2025 at 09:05; - 1/5/2025 at 01:29; - 1/6/2025 at 09:32; - 1/7/2025 at 09:52; - 1/8/2025 at 10:11; - 1/10/2025 at 00:14; - 1/102025 at 16:20; - 1/11/2025 at 11:16; - 1/12/2025 at 05:29; - 1/12/2025 at 08:26; - 1/13/2025 at 08:34; - 1/14/2025 at 08:10; - 1/14/2025 at 12:45; - 1/14/2025 at 22:23; - 1/15/2025 at 10:13 and - 1/17/2025 at 08:21. During a concurrent interview and record review on 1/17/2025 at 11:41 a.m., with the Director of Nursing (DON), the DON reviewed Resident 400's clinical record and she stated, Resident 400 had chest permacath and left AV fistula. The DON confirmed, Resident 400's BP summary dated January 3,4,5,6,7,8,10,11,12,13,14,15, and 17/2025, that were recorded were taken on left arm. The DON stated that nurses, should not check the blood pressure on the AV fistula, because it could interfere with the blood flow. Review of the facility's P&P titled Hemodialysis, Care of Residents, dated 11/2017, indicated, Standard . 4. Blood pressures or venous punctures will not be performed and physical restraint will not be applied on the extremity where access site is located.

Based on observation, interview, and record review, the facility failed to ensure the adequate provision of pharmaceutical services when: 1. Three medications were not available for administration x 4 days, for one of 36 sampled residents (Resident 311). The failure had the potential for worsening and/or complications of the resident's medical conditions; and 2. Two of two nursing staff did not don appropriate personal protective equipment (PPE) during the preparation and administration of hazardous drugs (HDs; medications with potential to cause cancer and/or for causing other toxic effects on humans). The failure had the potential for staff and/or resident exposure to dangerous medications. Findings: 1. During a medication administration observation on 1/13/25 at 9:11 a.m., Licensed Vocational Nurse D (LVN D) was observed administering 3 medications, including an eye drop called Cosopt 2%-0.5% (medication to treat glaucoma) ophthalmic (eye) solution, to Resident 311. Upon review of Resident 311's clinical record, it indicated she was admitted to the facility on [DATE] with diagnoses including glaucoma and unspecified vision loss. The clinical record indicated the resident was to receive 3 eye medications, as follows: a. Cosopt ophthalmic solution 2%-0.5%, 1 drop in both eyes two times a day for glaucoma, dated 1/9/25; b. Vyzulta ophthalmic solution (to treat increased eye pressure in adults with ocular hypertension or open-angle glaucoma) 0.024%, 1 drop in both eyes two times a day for vision impairment, dated 1/9/25; and c. Xiidra ophthalmic solution (to treat signs and symptoms of dry eye disease) 5%, 1 drop in both eyes two times a day for vision impairment, dated 1/9/25. Resident 311 also had a physician's order for levothyroxine (medication to treat underactive thyroid gland) 75 micrograms, give 1 tablet daily in the morning for hypothyroidism, dated 1/9/25. On 1/13/25, a review of Resident 311's January 2025 Medication Administration Record (MAR) showed the resident had not been receiving the Vyzulta, Xiidra, and levothyroxine since 1/10/24 (or 4 days). During an interview with LVN D and Assistant Director of Nursing B (ADON B) on 1/13/25 02:11 p.m., ADON B stated the Xiidra and Vyzulta were put on hold (not administered) because I was told we don't have them available. A review of the nursing progress notes, from 1/9/25 to 1/13/25, indicated the nursing staff did not call or follow up with the pharmacy on the missing levothyroxine. For four consecutive days, from 1/10/25 to 1/13/25, the nursing staff wrote four times of Med in transit each day. For the Xiidra and Vyzulta eye drops, there was only one nursing notes, dated 1/10/25 at 22:36 (10:36 p.m.), indicating the nursing staff called the pharmacy and was told by a pharmacy staff that medication will arrive 1/11/25 with 5am medication run. There were no documentation of further follow-up with the pharmacy when these medications did not arrive on 1/11/25. During a follow-up interview with ADON B on 1/14/25 at 2:21 p.m., she stated she called the pharmacy and was told the Xiidra eye drop was not delivered because it was a high cost medication. ADON B confirmed the pharmacy should have communicated with the facility why it did not send the medication. ADON B was asked to find out the reason why the other two medications were not delivered. In a concurrent interview and record review with ADON B on 1/14/25 at 3:00 p.m., ADON B stated the facility faxed Resident 311's admission orders twice on 1/9/25 at 9:02 p.m. and again at 9:05 p.m., on the evening the resident was admitted . However, she showed an email from the pharmacy, dated 1/14/25, indicating: Investigation found that the 3 medications delayed til 1/13/25 were cut off on initial admit fax and pharmacy tech missed them on initial admit papers as a result . ADON B confirmed the facility staff should have followed up with the pharmacy each day they did not receive the medications for the resident. She also confirmed the 3 medications did not arrive until the afternoon of 1/13/25 (day of survey), and the resident did not receive them for 4 days. A review of the facility's policy and procedures (P&P) titled Pharmacy Services Overview, dated 4/2019, indicated: The facility shall accurately and safely . obtain pharmaceutical services, including the provision of routine and emergency medications . Residents have sufficient supply of the prescribed medications and receive medications .in a timely manner . Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. 2. During a medication administration observation with LVN D on 1/13/25 at 9:11 a.m., the 3 medications administered to Resident 311 included two tablets of megestrol (an anti-cancer medication that can also be used for loss of appetite) 40 milligrams (mg, unit of measurement). During the preparation, LVN D was observed punching 2 megestrol tablets from the blister pack (a card that packages doses of medication within small, clear plastic bubbles [or blisters]) into a small medication cup. Then she transferred them into a small plastic bag and crushed them into a fine powder using the crushing device. After finished, she transferred the crushed powder back into the medication cup and mixed it with applesauce. Observation of the pharmacy label revealed a dark red auxiliary label indicating: HAZARDOUS DRUGS. During this preparation process, LVN D did not wear gloves or had any special PPE. On 1/13/25 at 9:19 a.m., LVN D administered the medications to the resident with water. During an interview, on 1/13/25 at 9:29 a.m., when shown HAZARDOUS DRUGS sticker on the pharmacy label for megestrol tablets, LVN D stated she did not know if there was any special handling and administration procedures for HDs. During a follow-up interview on 1/13/25 at 11:17 a.m., LVN D stated she was supposed to wear gloves during handling and preparing HDs. During a medication administration observation with LVN J on 1/13/25 at 4:26 p.m., she was observed preparing and administering 3 medications, including 3 tablets of divalproex (medication to treat seizure or mood disorders) delayed release 125 mg, to Resident 25. The same dark red HAZARDOUS DRUGS sticker was affixed by the pharmacy label of the divalproex blister pack. LVN J did not wear gloves or had any special PPE for this preparation and administration. Shortly after the medication administration, on 1/13/25 at 4:37 p.m., when asked whether she should have worn special PPE when handling HDs, LVN J stated she did not know and I will need to ask the supervisor. During an interview with ADON B on 1/13/25 at 4:42 p.m., in the presence of LVN J, ADON B stated nurses should be wearing gloves when handling HDs. During an interview with the DON on 01/14/25 at 1:45 p.m., she stated the consultant pharmacist had given an in-service last year regarding handling and administering HDs. She stated, for HDs, The staff should handle more carefully by not touching them and wearing gloves during handling and administration. A review of the facility's P&P titled Policies and Procedures for the Safe handling of Hazardous Drugs, dated 10/3/2019, indicated, Hazardous Drugs may have special handling procedures in place that must be adhered to by all nursing staff that receive, handle, prepare, administer and destroy the HDs. It is the responsibility of all staff to know these procedures . and adhere to these policies and procedures when handling HD and Appropriate PPE must be worn when handling HDs including during . handling . preparation/mechanical manipulation . administration .

Based on interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 400) was free from unnecessary medications when there was no monitoring for signs and symptoms of bleeding while Resident 400 was receiving two medications with increased risk for bleeding: apixaban(an anticoagulant or blood thinner, to prevent blood clots) and clopidogrel (an antiplatelet medication which has potential to increase the risk of internal bleeding or gastrointestinal hemorrhaging). The failure resulted in inadequate monitoring, and had the potential for untimely recognition and intervention for adverse effects related to these medications. Findings: A review of Resident 400's clinical record indicated she was admitted to the facility with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm, a condition that can lead to blood clots in the heart) and percutaneous coronary Intervention (PCI, a minimally invasive procedure used to open blocked coronary [heart] arteries that are narrowed or clogged by fatty deposits). A review of Resident 400's physician's orders included the following: - Eliquis (apixaban) 5 milligrams (mg, unit of measurement), 1 tablet by mouth two times a day for atrial fibrillation, dated 1/3/25; and - Clopidogrel 75 mg, 1 tablet by mouth one time a day for PCI, dated 1/3/25. A review of an online resource, www.drugs.com, it indicated, Using apixaban together with clopidogrel may increase the risk of bleeding, including severe and sometimes fatal hemorrhage (accessed 1/16/25). There was no documentation in Resident 400's clinical record indicating the nursing staff was monitoring for adverse effects (i.e. bleeding, bruising, etc) related to the use of apixaban and clopidogrel. A review of Resident 400's care plan, dated 1/2/25, indicated to monitor and report to the physician signs and symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, ,diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs]. During a concurrent interview and record review with the Director of Nursing (DON) on 1/16/25 at 2:26 p.m., she reviewed Resident 400's clinical and stated the monitoring for signs and symptoms related to anticoagulants should be monitored on the MAR [medication administration record]. She reviewed the resident's MAR and confirmed there was no monitoring for bleeding and other symptoms related to use of apixaban and clopidogrel. A review of the facility's policy and procedure titled Anticoagulant, revised 9/2017, indicated, The staff and physician will monitor for possible complications in individuals who are being anticoagulated .

Based on interview and record review, the facility failed to provide services to promote healing of pressure ulcers (damage to the skin and underlying tissue as a result of prolonged pressure) for one of 3 residents (Resident 1) when the licensed nurse did not obtain pressure ulcer measurements and no treatment order was obtained for 6 days for Resident 1's pressure ulcer. These failures had the potential to delay treatment and potentially lead to new or worsening pressure ulcers. Failure to obtain measurements had the potential to compromise the facility's ability to determine whether Resident 1's pressure ulcer was increasing or decreasing in size. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including fracture of second and third lumbar vertebrae (small bones forming the backbone in the lower back), hemiplegia and hemiparesis (paralysis and weakness) affecting left side, obesity (too much body fat), type 2 diabetes (a condition which affects blood sugar), history of diabetic foot ulcer (open sore or wound), congestive heart failure (heart cannot pump enough blood to meet the body's needs), anemia (low levels of healthy red blood cells, hypertension (increase in blood pressure),muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Review of Resident 1's Braden scale assessment (tool used in wound assessment) dated 6/18/24 indicated she had a score of 16 (a score of 15-18 represents a risk for developing pressure ulcers). Review of Resident 1's pressure injury skin assessment dated [DATE], indicated a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure wound to Resident 1's bilateral buttocks. There were no measurements of Resident 1's bilateral buttocks pressure injury on the skin assessment form. Review of Resident 1's Order Summary Report indicated there was no physician order for treatment to the pressure ulcer on Resident 1's bilateral buttocks until 6/24/24, and six days after the facility identified the pressure ulcer on admission on 6/18/24. During an interview and concurrent record review with the treatment nurse (TN) on 9/5/24 at 1:15 p.m., she stated she performs treatments and wound assessments every week for residents in the facility, and stated she first assessed Resident 1's skin and wounds on 6/18/24. The TN reviewed Resident 1's Pressure Injury Skin Assessment document from 6/18/24 and confirmed there were no measurements of Resident 1's wounds. The TN stated she completed the form and identified the wounds but did not measure anything. The TN confirmed the measurements should be there and further stated all wounds should be measured during the weekly skin review to assess if treatments are effective. The TN reviewed Resident 1's physician orders and confirmed there was no treatment order for Resident 1's pressure ulcer until 6/24/24, 6 days after admission, when she first identified the Stage II pressure ulcer. The TN stated there should be a treatment order obtained from the physician when the pressure ulcer is first identified. During an interview and concurrent record review with the director of nursing (DON) on 9/5/24 at 1:45 p.m., she reviewed Resident 1's pressure injury skin assessment dated [DATE] and confirmed there were no measurements documented for Resident 1's stage II pressure ulcer. The DON stated all wounds should have been measured on admission, or when first identified, and recorded on the skin assessment document. The DON reviewed Resident 1's physician orders and confirmed there was no treatment order obtained until 6/24/24 to treat Resident 1's pressure ulcer. The DON stated the MD should have been notified and a treatment order obtained when a pressure ulcer was first identified. A review of the facility's undated policy, Pressure Injury Risk Assessment indicated to Conduct a structured pressure injury risk assessment using a facility-approved tool. The risk assessment should be conducted as soon as possible after admission. In addition, the policy indicated Documentation . The following information should be recorded in the resident's medical record utilizing facility forms .5. The condition of the resident's skin (i.e., the size and location of any red or tender areas) if identified.

Based on interview and record review, the facility failed to provide written notice prior to multiple room changes for one of four sampled residents (Resident 1). This failure had the potential to compromise Resident 1's rights. Also, there was no documentation that the facility monitored Resident 1 after one room change. This failure had the potential to compromise the facility's ability to identify complications related to the room change and implement interventions accordingly. Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE]. Further review of the clinical record indicated the facility implemented room changes for Resident 1 on 11/15/23, 11/17/23, and 1/2/24. During a telephone interview and concurrent record review with social services staff C (SS C) on 6/25/24, at 1:13 p.m., SS C reviewed Resident 1's clinical record remotely (from a location outside of the facility) and confirmed Resident 1 had room changes on the dates mentioned above. SS C explained when the facility implements room changes, they should complete a Room Transfer form (document that explains the reason for the room change and that must be signed by the resident), complete a consent form, and do behavior/psychosocial monitoring for 72 hours. SS C confirmed for Resident 1's room changes on 11/15/23, 11/17/23, and 1/2/24, there was no documentation that indicated the facility completed a Room Transfer form or a consent form prior to the room changes. SS C also confirmed for Resident 1's room change on 1/2/24, there was no documentation that indicated the facility did behavior/psychosocial monitoring for 72 hours. Since SS C was reviewing Resident 1's clinical record remotely, licensed nurse D (LN D) was also asked to review the record. During an interview and concurrent record review with LN D on 6/25/24, at 1:43 p.m., LN D reviewed Resident 1's medical record and confirmed for the room changes on 11/15/23, 11/17/23, and 1/2/24, there was no documentation that indicted the facility completed a Room Transfer form or a consent form prior to the room changes. LN D also confirmed for Resident 1's room change on 1/2/24, there was no documentation that indicated the facility did behavior/psychosocial monitoring for 72 hours. The facility's policy titled Room Change/Roommate Assignment, revised 3/2021, indicates the resident is given advanced written notice prior to a room change.

Based on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS, an assessment tool) for one of four sampled residents (Resident 1). The failure to accurately assess had the potential to compromise the facility's ability to develop and implement interventions to meet the resident's needs. Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including congestive heart failure (a condition in which the heart does not pump blood as well as it should), ascites (fluid in the abdominal cavity that causes swelling), muscle weakness, and abnormalities of gait (walking) and mobility (ability to move freely). Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication form), dated 12/21/23, indicated Resident 1 was seen on the floor. During an interview and concurrent record review with MDS nurse A (MDSN A) on 6/25/24, at 10:46 a.m., MDSN A reviewed Resident 1's clinical record and confirmed the resident fell on [DATE]. MDSN A stated this fall should have been coded on Resident 1's MDS, dated [DATE]. MDSN A reviewed Resident 1's MDS, dated [DATE], and confirmed section J1800 was coded No, indicating Resident 1 did not fall during the specified time frame. MDSN A confirmed section J1800 should have been coded Yes, to indicated Resident 1 fell during the specified time frame. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2023, indicated for section J1800, Code 1, yes if the resident has fallen during the specified time frame.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards for one of four residents (Resident 1) when: 1. There were multiple days for which there was no documentation that the facility obtained Resident 1's daily weight as ordered by the physician, and 2. There were multiple days for which there was no documentation that the facility notified Resident 1's physician of an abdominal girth (measurement of distance around the abdomen) increase of more than three centimeters (cm, unit of measurement). These failures had the potential to negatively affect the resident's health and well-being. Findings: 1. Review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including congestive heart failure (a condition in which the heart does not pump blood as well as it should) and ascites (fluid in the abdominal cavity that causes swelling). Review of Resident 1's Order Summary Report indicated he had a physician's order, dated 10/30/23, for daily weights and to inform the physician if Resident 1 gained two pounds or more in a day. Further review of the clinical record indicated the facility was documenting Resident 1's daily weights on the medication administration record (MAR). Resident 1's MAR was reviewed. From 11/1/23 to 2/29/24, there were 29 days for which the section designated to document Resident 1's daily weight was left blank. Further review of Resident 1's electronic and paper clinical record (aside from the MAR) indicated there was no documentation that the facility obtained Resident 1's daily weight on those 29 days. There was also no documentation that indicated Resident 1 refused to be weighed on those days. During an interview and concurrent record review with licensed nurse B (LN B) on 6/25/24, at 12:03 p.m., LN B reviewed Resident 1's clinical record and confirmed there were several days on the MAR for which the section designated to document Resident 1's daily weight was left blank. LN B stated if the resident refused to be weighed, this should be documented either on the MAR or a nurse's note. LN B further reviewed Resident 1's clinical record and confirmed there was no documentation that the facility obtained Resident 1's daily weight on the days for which the designated section on the MAR was left blank. LN B also confirmed there was no documentation that indicated Resident 1 refused to be weighed on those days. The facility's policy titled Charting and Documentation, revised 7/2017, indicated all services provided to the resident shall be documented in the resident's clinical record. The policy further indicated that documentation will include whether the resident refused a procedure or treatment. 2. Review of Resident 1's clinical record indicated he had a physician's order, dated 1/17/24, to measure abdominal girth every day and notify the physician of an increase of more than three cm. Further review of the clinical record indicated the facility was documenting Resident 1's abdominal girth measurements on the MAR. Resident 1's MAR was reviewed. On 3/2/24, 3/7/24, 3/14/24, 3/25/24, and 4/7/24, the documentation on the MAR indicated Resident 1's abdominal girth increased by more than three cm compared to the previous day. There was no documentation in the clinical record that indicated the facility notified Resident 1's physician of the increase in abdominal girth on the above dates. During an interview and concurrent record review with LN B on 6/25/24, at 12:03 p.m., LN B reviewed Resident 1's clinical record and confirmed there was a physician's order to measure abdominal girth every day and notify the physician of an increase of more than three centimeters. LN B confirmed that the documentation on the MAR indicated Resident 1's abdominal girth increased by more than three cm compared to the previous day on the dates mentioned above. LN B confirmed there was no documentation in the clinical record that indicated the facility notified Resident 1's physician of the increase in abdominal girth on those dates.

Based on interview and record review, the facility failed to follow their policy and procedure to develop a comprehensive person-centered care plan (plan that identifies residents' needs and outlines the care and services to be provided to meet those needs) for one of two sampled residents (Resident 1) to address management of onychomycosis (fungal infection of the nails). This failure had the potential to result in Resident 1 not receiving necessary care and services. Findings: Review of Resident 1's face sheet indicated the following diagnoses: paraplegia (the lower body is paralyzed), schizoaffective disorder (a mental health condition that can cause hallucinations, delusions, and mood disorder), and tinea unguium (onychomycosis). During an interview and concurrent record review with the Director of Nursing (DON) on 12/14/23 at 2:02 p.m., the DON reviewed Resident 1's clinical record and confirmed there was no care plan to address management of onychomycosis. The facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse. Resident 1 sustained facial injuries when Resident 2 hit her in the face with a water bottle. Despite both residents being cognitively impaired, Resident 2's act of hitting Resident 2 in the face was deliberate to inflict harm or injury, not accidental; therefore her action is deemed as a willful act and considered abuse.The facility was aware Resident 2 had a history of both physical and verbal behaviors. This failure has the potential of both physical and emotional harm to all residents. Findings: On 3/4/2023, the facility submitted a facsimile (FAX) to the California Department of Public Health (CDPH) about an incident between Residents 1 and 2. The FAX showed Resident 2 hit Resident 1 with a water bottle and Resident 1 sustained redness around her left eye and a small cut on the right side of her nose. Review of the facility's Policy and Procedure (P&P) titled Resident to Resident Altercations (revised date December 2016) showed facility staff will monitor residents for aggressive/inappropriate behavior towards other residents Make any necessary changes in the care plan approaches to any or all the involved individuals; document in the resident ' s clinical record all interventions and their effectiveness and consult psychiatric services as needed . Review of the facility's Investigative Summary dated 3/8/2023, showed on 3/4/2023 at approximately 12:45 p.m., Resident 1 entered Resident 2's room to look for something in Resident 2's draw. Resident 2 got upset apparently hit Resident 1 with a water bottle. Resident 1 was noted to have redness around her left eye with a small cut on the right side of her nose. Resident 1 was put on every hour monitoring system for her whereabouts. 1. Clinical record review for Resident 1 was conducted on 6/7/2023. Resident 1 was admitted to the facility with diagnoses including traumatic subdural hemorrhage (brain injury resulting from a fall) with loss of consciousness, cognitive communication deficit and adjustment disorder with anxiety. Her Minimum Data Set (MDS-an assessment tool) dated 2/1/2023, showed a Brief Interview for Mental Status (BIMS) score of 3 (severely impaired cognition). Review of Resident 1's Physician Order dated 2/3/2022, showed an order for a psychiatry and/or psychology evaluation and treatment as needed. Review of Resident 1's Psychiatry Diagnostic Interview note dated 10/28/2022, showed Resident 1 had a history of adjustment disorder with anxiety, currently not prescribed psychotropic medications. The Nurse Practitioner (NP) documented the resident had cognitive communication deficit with poor attention/concentration, insight/judgment, and poor memory capabilities. Review of Resident 1's care plan problems dated 3/4/2023 showed a problem to address an altercation with another resident. The interventions included monitoring every hour for her whereabouts. Additional problems dated 3/4/2023 showed a problem to address her small cut on the right side of her nose and a problem to address redness around her left eye. Review of Resident 1's Interdisciplinary Department Team (IDT) Altercation/Abuse/Incident Notes dated 3/6/2023 showed on 3/4/2023 at 12:45 p.m., a licensed nurse (LN) heard yelling and went to assess the situation in Resident 2's room. The LN documented she saw Resident 1 sitting in her wheelchair while trying to get access to Resident 2's draws. Resident 2 was standing in front of Resident 1 with a water bottle raised in her hand. She documented Resident 1 had redness around her left eye and a small four centimeter (cm) cut on the right side of her nose. Resident 1's bleeding was stopped with pressure, cleansed with normal saline, triple antibiotic ointment was applied to the cut and a dry dressing was applied. The Care Plan was completed and the preventive measures in place were to put the resident on every hour monitoring for her whereabouts. Review of Resident 1's Social Services Note dated 3/6/2023 at 12:52 showed day 1 of 72-hour monitoring, Resident 1 was unable to recall the incident on 3/4/2023 and the nursing department had implemented for both residents (Residents 1 and 2) to be under every hour monitoring for whereabouts. 2. Clinical record review for Resident 2 was conducted on 6/7/2023. Resident 2 was admitted to the facility with diagnoses including vascular dementia (changes to memory, thinking and behavior, decline in thinking skills), severe with other behavioral disturbances, major depressive disorder, and unspecified mood (affective) disorder. Review of Resident 2's hospital Discharge Summary dated 9/14/2022 showed Resident 2 had vascular dementia and was in the hospital for about five months prior to discharge on 8/22/2022 back to a skilled nursing facility (SNF). The SNF was unable to handle her behavior and sent Resident 2 back to the emergency room for placement the very next day. The discharge instructions included to crush Resident 2's medications and give them with chocolate ice cream since this is the only way the resident takes her medication. Review of Resident 2's Doctor's Progress Note dated 9/15/2022 showed the resident was admitted to the SNF with diagnoses including vascular dementia. He documented on 3/12/2022, Resident 2 was sent to the emergency room due to being agitated, combative and throwing/smashing laptops, printers, and potted plants. An attempt was made to transfer her another SNF on 8/22/2022; however, the transfer was unsuccessful due to their inability to handle her behaviors and Resident 2 was sent back to the emergency room . The physician documented Resident 2 has been calm if the staff can give medications (needs to hide the medications in the foods that she likes). He documented Resident 2 does not have the capacity to make decisions and easily gets upset and agitated. Review of Resident 2's Psychiatry Diagnostic Interview note dated 11/18/2022 showed documentation Resident 2 was alert, angry and confused. The staff reported the resident displays angry outbursts which are often difficult to redirect. The NP documented the staff continue to monitor and document the resident's episodes of severe agitation, yelling and verbal abuse towards the staff. She documented the resident had aggressive, and verbal behaviors, was irritable, angry, poor impulse control, insight/judgment. The plan and recommendations included monitoring for mood and behavior for verbal aggression and anger. Review of Resident 2's MDS dated [DATE], shows a BIMS score of 2 (severely impaired cognition) with inattention and disorganized thinking. Review of Resident 2's Situation, Background, Assessment and Recommendations (SBAR) note dated 3/4/2023 at 12:45 p.m., showed no recommendations or monitoring. Review of Resident 2's IDT Altercation/Abuse/Incident Notes dated 3/6/2023 at 3:22 p.m., showed on 3/4/2023 at 12:45 p.m., a LN heard yelling and went to assess the situation in Resident 2's room. The LN documented she saw Resident 1 sitting in her wheelchair while trying to get access to Resident 2's draws. Resident 2 was standing in from of Resident 1 with a water bottle raised in her hand. Resident 1 was noted to have redness around her left eye and a small 4 cm cut on the right side of her nose. The nurse documented the staff would continue to monitor for emotional distress due to the incident. The Care Plan was completed and the Preventive Measures that were put in place to prevent re-occurrence were to put Resident 1 on every hour monitoring for her whereabouts and for Resident 2 to be monitored for emotional distress. The conclusion included to educate Resident 2 to call for assistance with the staff to help her redirect the other resident. On 6/7/2023 at 11:30 a.m., an interview was conducted with Certified Nursing Assistant (CNA) A. She stated Resident 1 was alert and oriented and able to make her needs known. CNA A stated Resident 1 has no behavior problems, and just stays in her wheelchair by the nurse's station. She stated she was unaware of Resident 1 entering another resident's room before the incident on 3/4/2023. Continued interview with CNA A regarding Resident 2. She stated Resident 2 had intermittent confusion and had no behavior problems. CNA A stated Resident 1 was happy all the time and ambulated independently. On 6/7/2023 at 11:40 a.m., an interview was conducted with CNA B. She stated Resident 1 was confused, sometimes able to make her needs known and had no behavioral problems. CNA B stated she was unaware of Resident 1 wandering into other residents' room, except with Resident 2. When she was asked about Resident 2, she stated Resident 2 was alert, and sometimes confused. CNA B stated Resident 2 yells and curses at staff and residents but was unaware of any physical altercations. On 6/7/2023 at 12:15 p.m., an interview was conducted with the Social Service Director (SSD). He stated Resident 1 was alert but not oriented and was able to make her needs known. The SSD stated he was unaware of Resident 1 wandering into other residents' room, she just sits outside her room in a wheelchair. He stated Resident 1 did not have any behavioral problems. When the SSD was asked about Resident 2's behaviors, he stated she was verbally abusive to the staff and was delusional. He stated Resident 2 is alert and oriented to her name only and ambulates independently in the hallways. The SSD stated he was unaware of Resident 2 having any physical behaviors. During an interview with the Assistant Director of Nurses (ADON) on 6/7/2023 at 1 p.m., she stated Resident 1's words do not make sense and she was unable to communicate. The ADON stated Resident 1 can self-propel herself in her wheelchair but was unaware of Resident 1 wandering into any other residents' rooms except Resident 2's room. She stated she was aware of the incident on 3/4/2023 when Resident 2 hit Resident 1 with a water bottle. The ADON stated the staff were monitoring Resident 1's behavior every hour to determine her whereabouts to keep her aware from Resident 2. When the ADON was interviewed about Resident 2, she stated Resident 2 was alert and oriented to name only and was able to make her needs known. She stated Resident 2's behaviors included angry outbursts and verbally abusing the staff, calling the staff idiots, useless, worthless and racial slurs. The ADON stated she was unaware of any physical aggressive behavior with Resident 2, except the incident on 3/4/2023. She stated the staff were monitoring Resident 2 for angry outbursts but was unable to locate any monitoring related to her physical aggressive behavior with Resident 1. On 6/7/2023 at 2:45 p.m., Resident 2 was observed lying in her bed, awake and alert. Multiple water bottles were visible on her bedside table. She was confused and unable to answer simple questions. On 6/7/2023 at 2:50 p.m., Resident 1 was observed sitting in her wheelchair in the hallway, two doors away from Resident 2. She was confused and unable to answer simple questions. A telephone interview was conducted on 6/7/2023 at 4:40 p.m., with Resident 1's responsible party (RP). He stated he was unaware of Resident 1 wandering into other residents' rooms. He stated she probably went into Resident 2's room because she thought Resident 2 had stolen something from her. Resident 1's RP stated Resident 1 is very happy there and feels she is safe there. A telephone interview was conducted on 6/7/2023 at 5:17 p.m., with Resident 2's RP. He stated he was aware of the incident on 3/4/2023. The RP stated in the past, Resident 2 had physical behaviors in the past due to a urinary tract infection but was unaware of any other recent behaviors.

Based on observation, interview and record review, the facility failed to develop and implement individualized, resident-centered care plans for one of four sampled residents (Resident 2). Resident 2 had a history of physical aggression. On 3/4/3023, Resident 2 hit Resident 1 with a water bottle in her face. The facility failed to develop and implement a care plan to monitor Resident 2's physical aggression following the incident with Resident 1. This deficient practice has the potential for placing other residents at risk for injury and/or harm. Findings: Clinical record review for Resident 2 was conducted on 6/7/2023. Resident 2 was admitted to the facility with diagnoses including vascular dementia (changes to memory, thinking and behavior, decline in thinking skills), severe with other behavioral disturbances, major depressive disorder, and unspecified mood (affective) disorder. Review of Resident 2's hospital Discharge Summary dated 9/14/2022 showed Resident 2 had vascular dementia and was in the hospital for about five months prior to discharge on 8/22/2022 back to a skilled nursing facility (SNF). The SNF was unable to handle her behavior and sent Resident 2 back to the emergency room for placement the very next day. Review of Resident 2's Doctor's Progress Note dated 9/15/2022 showed the resident was admitted to the SNF with diagnoses including vascular dementia. He documented on 3/12/2022, Resident 2 was sent to the emergency room due to being agitated, combative and throwing/smashing laptops, printers, and potted plants. An attempt was made to transfer her to another SNF on 8/22/2022; however, the transfer was unsuccessful due to their inability to handle her behaviors and Resident 2 was sent back to the emergency room . The physician documented Resident 2 had been calm if the staff can give medications (needs to hide the medications in the foods that she likes). He documented Resident 2 does not have the capacity to make decisions and easily gets upset and agitated. Review of Resident 2's Psychiatry Diagnostic Interview note dated 11/18/2022 showed Resident 2 was alert, angry and confused. The staff reported the resident displays angry outbursts which are often difficult to redirect. The NP documented the staff continued to monitor and document the resident's episodes of severe agitation, yelling and verbal abuse towards the staff. She documented the resident had aggressive, and verbal behaviors, was irritable, angry, with poor impulse control, insight/judgment. The plan and recommendations included monitoring for mood and behavior for verbal aggression and anger. Review of Resident 2's MDS dated [DATE], shows a BIMS score of 2 (severely impaired cognition) with inattention and disorganized thinking. Review of Resident 2's IDT Altercation/Abuse/Incident Notes dated 3/6/2023 at 3:22 p.m., showed on 3/4/2023 at 12:45 p.m., a LN heard yelling and went to assess the situation in Resident 2's room. The LN documented she saw Resident 1 sitting in her wheelchair while trying to get access to Resident 2's draws. Resident 2 was standing in front of Resident 1 with a water bottle raised in her hand. Resident 1 was noted to have redness around her left eye and a small 4 cm cut on the right side of her nose. The nurse documented the staff would continue to monitor for emotional distress due to the incident. The Care Plan was completed and the Preventive Measures that were put in place to prevent re-occurrence were to put Resident 1 on every hour monitoring for her whereabouts and for Resident 2 to be monitored for emotional distress. The conclusion included to educate Resident 2 to call for assistance with the staff to help her redirect the other resident. Review of Resident 2's Care Plan Problems showed: 1. a problem dated 12/28/2022 (revised date 4/20/2023)-potential to demonstrate physical behaviors related to dementia, cognitive impairment, history of throwing plants, laptops and refusing medications. The goal: will not harm self or others (initial date 12/28/2022, revised date 3/17/2023). Two interventions: monitor/document/report to the physician of danger to self and others and Psychiatric/Psychogeriatric consult as indicated. 2. a problem with an altercation with another resident (dated 3/4/2023, revised date 3/17/2023). The goal: will have no emotional distress from the incident. Interventions included: monitor every day for 72 hours whereabouts/activities of involved residents, educate to call for assistance with the staff to help her redirect the other resident. 3. a problem to address her vascular dementia with behavioral disturbances (initiated 9/15/2022, revised 2/7/2023). The goal: will be able to communicate needs daily. Interventions included: monitor for ability to chew and swallow, monitor communication skills. 4. a problem to address her impaired cognitive function/thought process (initiated 9/15/2022, revised 2/3/2023). The goal: will be able to communicate basic needs daily. 5. a problem to address the potential/actual demonstration of verbally abusive behaviors towards staff (initiated 12/28/2022, revised 1/13/2023). The goal: will have fewer than 3 episodes per shift of verbally abusing staff such as yelling or sudden outbursts of anger. Interventions: assess resident's understanding of the situation and allow time for her to express her feelings. 6. a problem to address her non-compliance/refusal to wear and identification band (initiated 9/15/2022, revised 9/15/2022). Interventions included: explain benefits of wearing the name band and risk and consequences of not wearing it. Review of the facility's Inservice Records showed: 1. On 1/18/2023: Dealing with residents with aggressive or catastrophic reactions and 2. On 3/20-24/2023, Alzheimer/Dementia was given; however, the Lesson Plans were titled Communicating Effectively with Dementia Residents and Recognizing Symptoms of Dementia and Calming Fears. The lesson plans did not address handling of aggressive behaviors after the incident on 3/4/2023. On 6/7/2023 at 1 p.m., an interview was conducted with the Assistant Director of Nurses (ADON). She stated Resident 2's behaviors included angry outbursts, and yelling and screaming at staff. When the ADON was asked was any attempt made to determine possible triggers that may affect Resident 2's outbursts and yelling, she did not know. The ADON confirmed Resident 2 should be monitored for aggressive behavior, but was unable to locate the monitoring or care plan problem. When the ADON was asked about Resident 2's care plan problems and if the goals and/or interventions were compatible with Resident 2's severely impaired cognition, she did not answer. During an interview with the Director of Nurses (DON) on 6/7/2023 at 1:30 p.m., she stated Residents 1 and 2 were being monitored for their whereabouts. She was unable to explain the reason why Resident 2 was being monitored for her whereabouts when the incident on 3/4/2023 happened inside Resident 2's room. The DON confirmed no aggressive behavior monitoring was done for Resident 2 and no care plan to address her aggressive behavior.

Based on observation, interview and record review, the facility failed to ensure a resident with a diagnosis of dementia (a memory disorder with impaired reasoning skills), received the appropriate treatment and services to attain or maintain his or her highest practicable, physical, mental and psychosocial well-being for one of four residents (Resident 2). Resident 2 had an episode of physical aggression with another resident. The facility failed to have a psychiatrist available at the facility to reevaluate and provide proper treatment. This deficient practice has the potential to negatively affect the delivery of services for all residents with a mental disorder. Findings: Clinical record review for Resident 2 was conducted on 6/7/2023. Resident 2 was admitted to the facility with diagnoses including vascular dementia (changes to memory, thinking and behavior, decline in thinking skills), severe with other behavioral disturbances, major depressive disorder, and unspecified mood (affective) disorder. Review of Resident 2 physician's order dated 9/14/2022 showed an order to have Psychiatry and/or Psychology evaluation, treatment and follow up as needed. Review of Resident 2's Psychiatry Diagnostic Interview note dated 11/18/2022 showed Resident 2 was alert, angry and confused. The staff reported the resident displays angry outbursts which are often difficult to redirect. The NP documented the staff continued to monitor and document the resident's episodes of severe agitation, yelling and verbal abuse towards the staff. She documented the resident had aggressive, and verbal behaviors, was irritable, angry, poor impulse control, insight/judgment. The plan and recommendations included monitoring for mood and behavior for verbal aggression and anger. Review of Resident 2's Minimum Data Set (MDS-an assessment tool) dated 2/10/2023, shows a Brief Interview for Mental Status (BIMS) score of 2 (severely impaired cognition) with inattention and disorganized thinking. On 6/7/2023 at 12:15 p.m., an interview was conducted with the Social Service Director (SSD). When the SSD was asked about the facility's Psychiatrist, he stated the facility did not have any psychiatrist since the end of 2022, but a new psychiatrist just started in April 2023. The SSD stated the psychiatrist comes to the facility twice a month; however, she only came twice in April, once in May and currently once in June. When the SSD was asked if a referral for Resident 2 to be reevaluated by the psychiatrist after her physical aggressive behavior on 3/4/2023, he stated he did not get a referral from the staff to order one. An interview was conducted with the Administrator on 6/7/2023 at 12:10 p.m When he was asked about having a psychiatrist evaluation for Resident 2's aggressive behavior, he stated the facility did not have any available Psychiatrist since the end of 2022, but a new Psychiatrist started about 2 months ago. The Administrator stated today, a referral was made for Resident 2 to be evaluated by a psychiatrist. During an interview with the Director of Nurses (DON) on 6/7/2023 at 1:30 p.m., she stated Residents 1 and 2 were being monitored for their whereabouts. She was unable to explain the reason why Resident 2 was being monitored for her whereabouts when the incident on 3/4/2023 happened inside Resident 2's room. The DON confirmed no aggressive behavior monitoring was done for Resident 2 and no care plan to address her aggressive behavior.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections when wash basins and a specimen collection hat were unlabeled in the shared bathrooms of residents' rooms one, two, and three. These failures had the potential for disease transmission among residents if more than one resident were to use any single unlabeled item. Findings: During an observation and interview with certified nursing assistant A (CNA A) on 3/24/23 at 11:15 a.m., two unlabeled wash basins and one specimen collection hat (a wide-brimmed hat shaped basin placed inside a toilet used to collect urine samples) were on a windowsill in the shared bathroom between residents' rooms [ROOM NUMBERS]. The CNA A acknowledged both wash basins and specimen collector were in use; and that, each of these items were not labeled with names of the residents that use them. The CNA A stated the wash basins and specimen collector hat should have been labeled with the residents' names. He stated the bathroom was shared by four residents and, without resident's name labeled on these items, there was the potential that more than one resident would use them, which posed a risk for disease transmission between residents. During an observation with director of nursing (DON) on 3/24/23 at 11:35 a.m., two unlabeled wash basins were on top of a commode in the bathroom of residents' room [ROOM NUMBER]. The DON acknowledged both wash basins were not labeled with residents' names. He stated staff should have labeled each wash basin and urinal and specimen collection hat with a single resident name before use by, and only by, the resident whose name was on the label. Review of the facility's policy and procedure (P&P), Bedpan/Urinal, Offering/Removing, revised February 2018, indicated, Label the resident's bedpan/urinal.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by: 1. The facility failed to use the proper disinfectant to disinfect shared (used for multiple residents) glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions and accepted professional standards for 41 of 41 residents when: 1a. Licensed Vocational Nurse A (LVN A) failed to properly disinfect a shared glucometer during observation for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; 1b. Licensed nurses in three out of three nursing stations: LVN B, LVN C, LVN E, LVN F, LVN G and Registered Nurse D (RN D), did not know the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; and, 1c. The Infection Preventionist/Director of Staff Development (IP/DSD) did not know the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions. Furthermore, concurrent interview and record review with the IP/DSD reflected there had been no staff in-services provided regarding proper disinfection of shared glucometers since 2021. The facility identified 41 residents that had active physician orders for Finger Stick Blood Glucose (FSBG, a procedure where the finger is pricked with a poking device to obtain a blood sample to measure blood glucose level) checks. One out of 41 residents (Resident 90) also had a diagnosis of Chronic Viral Hepatitis B (a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids) at the time of admission on 7/19/21. As of 2/6/23, Resident 90 did not have a designated glucometer and had been given FSBG checks daily with a shared glucometer. The facility's noncompliance with infection control procedures had the potential to cause the development and the widespread transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, is a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C) to 41 of 41 residents. It was unknown when the noncompliance began according to an interview with the DON. Due to the widespread lack of knowledge of proper disinfection procedures demonstrated by eight (8) nursing staff, including IP/DSD, the facility needed to take immediate action to correct the non-compliance. On 2/6/23 at 5:45 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator and Administrator In Training (AIT), due to the facility's failure to ensure that LVN A properly disinfected a shared glucometer for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; failure to ensure LVN B, LVN C, LVN E, LVN F, LVN G and RN D knew the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; failure to ensure the IP/DSD knew the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; and not having staff in-services provided regarding proper disinfection of shared glucometers since 2021. On 2/7/23, at 3:30 p.m., the Administrator submitted an acceptable IJ Removal Plan ([IJRP], a plan with interventions to immediately correct the deficient practices). The acceptable IJRP included the following corrective actions: 1. Identify residents whose blood sugars (BS) need to be monitored. All residents (41 residents) on FSBG checks will be monitored for the following symptoms (ascites [condition in which fluid collects in spaces within your abdomen], tremors, confusion, vomiting of blood, blood in the stool and fatigue) per the Medical Director for 14 days. Resident[s] directly affected will have lab works done on 2/7/2023 for hepatitis B and C. 2. IP/DSD/Designee in-service and educated facility and/or registry licensed nursing staff (nurses employed through a contracted agency) on the glucometer manufacturer's guidelines for proper cleaning and disinfecting and return demonstration done to ensure it is done correctly. a. Glucometer to be cleaned and disinfected immediately after resident use (Sani-Cloth or equivalent) with 2 minutes wet time. b. Check if glucometer is in proper working condition prior to use. c. Daily QA (quality assurance) maintenance of each glucometer and to ensure glucometer is in proper working condition and if Licensed Nurses are cleaning/disinfecting it according to manufacturer's guidelines and proper use of recommended wipes. 3. IP/DSD/Designee will randomly perform spot check on all shifts daily x 2 weeks then monthly, and findings will be reported to QAPI (Quality Assurance and Performance Improvement) Committee. 4. IP/DSD/Designee in-service and education will be completed with the licensed nursing staff prior to the start of their shift and by 02/07/2023. 5. Corrective Action Plan reviewed at QAPI Committee Meeting on 02/07/2023. 6. A separate glucometer machine was provided for the resident identified with hepatitis, cleaned after each use and routine QA started. (forms/Sig [signature] attached) 7. Skills competency glucometer cleaning/disinfectant in serviced to Licensed nurse by IP/DSD/Designee. 8. P and P [Policy and Procedure] on bloodborne pathogens updated according to updated systemic changes and discussed and approved by QAPI Committee. On 2/8/23, at 9:48 a.m., the Department of Public Health removed the IJ while onsite after the surveyors verified the facility implemented the facility's IJRP by observations, interviews, and record reviews. The DON, Administrator, AIT and DSD/IP were informed. 2. The Director of Nursing (DON) and IP/DSD did not know the disinfectant wipe manufacturer's instructions for wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect); and LVN B and RN H did not allow enough wet time, according to the manufacturer's instructions, during the disinfection of a shared glucometer for three of 41 residents (Residents 25, 39, and 97). 3. A nurse (LVN I) failed to perform hand hygiene between tasks during medication administration for one of 6 residents (Resident 72). 4. Four nursing staff (Certified Nursing Assistants R, S, U and LVN X) failed to wear proper PPE (Personal Protective Equipment - protective equipment used when caring for patients to prevent the spread of diseases) when working in facility areas that required them. 5. A nurse (LVN X) failed to take her temperature with a thermometer and screen for COVID-19 upon entering the facility to start work. 6. Nursing and maintenance staff failed to maintain oxygen concentrators in good working condition for two of two residents (Residents 15 and 24) with oxygen concentrators when the filters of their oxygen concentrators had a layer of grayish matter buildup on them. These failures placed residents at increased risk of healthcare-associated infections. Findings: 1a. During a medication administration observation on 2/6/23, at 8:36 a.m., with Licensed Vocational Nurse A (LVN A), a registry nurse, at Station 2, LVN A completed a blood check on Resident 25 with a glucometer. She placed the glucometer on the top of the medication cart without cleaning or disinfecting it. At 8:40 a.m., LVN A moved down the hall to Resident 9's room and prepared medications for Resident 9. She brought the prepared medications along with the same glucometer used for Resident 25, without wiping it down first, to Resident 9's bedside. At 8:49 a.m., LVN A administered the medications. After medications were given to Resident 9, LVN A was asked to exit Resident 9's room before completion of the BS check. During a concurrent observation and interview on 2/6/23, at 8:53 a.m., with LVN A, when asked how the shared glucometer was disinfected between Resident 25 and Resident 9, LVN A stated she used alcohol wipes. LVN A stated she did not know the facility's procedure for glucometer disinfection. LVN A reached for the Lysol wipes (a common household disinfecting wipe typically found at grocery stores) in the medication cart and wiped the glucometer with a Lysol wipe. LVN A stated she needed to ask a supervisor about the glucometer disinfection procedure because she did not know it. After a few minutes, LVN A returned to the medication cart and stated, They [supervisor] said Lysol wipe is ok. At 9:08 a.m., LVN A completed the BS check for Resident 9 with the shared glucometer. 1b. During an interview on 2/6/23, at 9:45 a.m., with LVN B, at Station 3, when asked about the glucometer disinfection method, LVN B stated she used alcohol wipes to clean and disinfect it, and the wet time should be three minutes. She stated the glucometers were shared among residents. During an interview on 2/6/23, at 10:35 a.m., with LVN C (a registry nurse), at Station 1, LVN C was asked about the glucometer disinfection method, LVN C stated she used Lysol wipes to clean and disinfect it. During an interview on 2/6/23, at 4:05 p.m., with LVN E, at Station 2, LVN E stated the glucometer was used for all residents at the nursing station and alcohol wipes were used to clean the glucometer between residents. LVN E stated she did not know the wet time. During an interview on 2/6/23, at 5:01 p.m., with RN D, at Station 1, when asked about the facility's glucometer disinfection method, RN D stated, he used Lysol wipes with a two-minute wet time. RN D stated he did not remember when an in-service about glucometer disinfection was provided, but he remembered there was one. During a concurrent observation and interview on 2/6/23, at 5:05 p.m., with LVN E, at Station 1, LVN E used alcohol wipes to clean a glucometer after a BS check was completed. LVN E then placed the glucometer inside the medication cart. When asked how to disinfect shared glucometers, LVN E stated she used alcohol, Lysol, or whatever was available in the cart. When asked about the wet time, LVN E stated, It dries by itself. During an interview on 2/6/23, at 5:11 p.m., with LVN F, at Station 2, when asked about the facility's glucometer disinfection method, LVN F stated she wiped the glucometer with alcohol wipes and dried it with the tissue. LVN F stated it could take 5 to 10 minutes to dry. LVN F stated an in-service on glucometer cleaning was provided in 2022. During an interview on 2/6/23, at 5:14 p.m. with LVN G (a registry nurse), at Station 3, LVN G stated it was her first day of work at the facility. LVN G stated she had not completed a BS test yet, but had to do one later. When asked how to clean and disinfect the glucometer, LVN G stated she would use alcohol swabs to clean the glucometer. LVN G showed a small basket that contained a glucometer and alcohol swabs. LVN G stated no in-service was given regarding glucometer disinfection upon orientation. 1c. During a concurrent interview and record review on 2/6/23, at 4:09 p.m., with the IP/DSD, the IP/DSD reviewed the facility's binder that contained documentation of nursing staff in-services/training completed between January 2021 to February 2023. The IP/DSD confirmed there were no in-services/training or competencies completed by licensed nurses regarding the facility's procedure for cleaning and disinfecting shared glucometers. During an interview on 2/6/23, at 5:22 p.m., with the IP/DSD, the IP/DSD stated, there were no in-services since 2021. When asked how staff cleaned and disinfected glucometers, the IP/DSD stated, with the Lysol yellow [package] or purple [top] disinfectant wipes. The IP/DSD stated, We tell the staff to use Lysol disinfectant. The IP/DSD stated alcohol is not an antiviral (A drug used to treat infections caused by viruses) or disinfectant and should not be used. The IP/DSD was asked by a surveyor if Lysol kills hepatitis or HIV, the IP/DSD reviewed the Lysol package instructions and stated, No, it doesn't. The IP/DSD stated she did not know what the glucometer manufacturer recommended to use for disinfection of the glucometer. The IP/DSD stated she was not aware that the nursing staff used alcohol to disinfect the glucometers. She said glucometer disinfection instructions were not part of the orientation for registry nursing staff. During a review the product labeling for the Lysol disinfectant wipes provided by the facility, it indicated, Kills Salmonella [a bacteria that can cause an infection in the intestinal tract through contaminated water or food], Influenza A Virus (H1N1) [a virus that causes an infection of the nose, throat and lungs], Herpes Simplex Virus Type 1 [a virus that causes herpes infection], Staphylococcus aureus [a bacteria found on human skin], Escherichia coli [E.Coli, a bacteria that is commonly found in the lower intestine] and Respiratory Syncytial Virus [RSV, a common respiratory virus that causes cold-like symptoms] on hard, non-porous surfaces in 4 minutes .To Disinfect: Allow [surface] to remain wet for 4 minutes. Allow surface to air dry . The Lysol disinfectant wipes did not contain a disinfectant that would protect against bloodborne infectious diseases such as Hepatitis B, Hepatitis C, or HIV. On 2/6/23, the facility provided a list of residents with physician's orders for FSBG in the facility. The list identified 41 residents. During a review of Resident 90's Admission Record, dated 7/19/21, it indicated, Resident 90 was admitted to the facility with diagnoses including Chronic Viral Hepatitis B and Diabetes. Resident 90 had a BIMS of 15 (Brief Interview for Mental Status, is an assessment tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment), which indicated he was cognitively intact. During an interview with Resident 90 on 2/6/23, at 4:40 p.m., he stated his BS was checked daily. When asked whether he had his own glucometer, Resident 90 stated, No, the girls [nurses] use the machine they have here. I don't have my own machine. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, the P&P indicated, Reusable items are cleaned and disinfected or sterilized between residents . Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. During a review of the Food and Drug Administration's (FDA) Letter to Manufacturers of Blood Glucose Monitoring Systems Listed With the FDA, dated 12/27/17, it indicated, The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol (alcohol) solutions are not effective against viral bloodborne pathogens. (https://www.fda.gov/medical-devices/in-vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda) According to the online publication titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration by the Centers for Disease Control and Prevention (CDC), dated 3/2/2011, it indicated, An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV [hepatitis B virus], hepatitis C virus, and HIV) through contaminated equipment and supplies if devices used for testing and/or insulin (medication to lower blood glucose) administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of hepatitis B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings . Blood glucose meters are devices that measure blood glucose levels. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html) During a review of the manufacturer's instructions for cleaning and disinfecting of the glucometer provided by the facility, it indicated, The meter [glucometer] should be cleaned and disinfected after use on each patient . our testing confirmed the wipes listed will not damage the functionality or performance of the meter . [manufacturer] recommends using these wipes to clean and disinfect the [glucometer]: Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels, Super Sani-Cloth Germicidal Disposable Wipes, CaviWipes . please read the manufacturers' instructions before using their wipes on the meter. The manufacturer's instructions indicated, To disinfect nonfood contact surfaces . thoroughly wet surface . allow treated surface to remain wet for a full two (2) minutes . 2. During an interview on 2/7/23, at 9:44 a.m., with the DON and IP/DSD, the DON and IP/DSD were asked to explain the wet time during glucometer disinfection and to describe how nurses would maintain wet time. The IP/DSD stated they will wipe [the glucometer] and let it dry for two minutes. The DON stated, they wipe [the glucometer] with solution, then leave to dry. When asked, How does the glucometer stay wet?, the IP/DSD reviewed and read the manufacturer instructions on the Super Sani-Cloth (disposable disinfection wipes for hard surfaces and medical devices) disinfectant wipe container out loud, allow surface to remain wet for two minutes. The DON stated, We will repeat the in-service [for glucometer disinfection]. When asked how long the nursing staff had been using alcohol swab or Lysol to disinfect the glucometers, the DON stated, I do not know when it started .when I started [employment here], we were supposed to use Sani-Cloth . when I started in December 2022, I did a spot check and we had Sani-Cloth; so in my mind, the nurses were using that . the Lysol is new to me. During an interview on 2/7/23 at 9:55 a.m. with the DON, he stated the manufacturer instructions for the sanitizing wipes indicated the wet time is 2 minutes; so, we wipe the glucometer and let it sit for two minutes to let it dry before it can be used again (instead of properly keeping it wet for the two minutes). During an observation on 2/7/23, at 11:42 a.m., with LVN B, at Station 2, LVN B completed a BS check for Resident 39. LVN B wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds before she proceeded to perform a BS check for Resident 25. After completion of the BS check, LVN B wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds. During an interview on 2/7/23, at 12:00 p.m., LVN B stated she was given an in-service about glucometer disinfection, was instructed to wipe it for two minutes with the Purple wipe [Sani-Cloth] and to let it air dry. LVN B said she did not understand why the glucometer needed to stay wet. LVN B stated she thought that letting the glucometer dry was included in the two minutes, During a concurrent observation and interview on 2/7/23, at 12:09 p.m., with RN H, at Station 2, RN H completed a BS check for Resident 97. RN H wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds. RN H stated, We had an in-service yesterday on how to wipe the glucometer with Sani-Cloth wipes . I knew that already . wipe for two minutes . then let air dry . important to keep it wet to remove microorganisms and sanitize . I did not time it . I let it wet for about 1 minute. During a review of the manufacturer's instructions for cleaning and disinfecting of the glucometer provided by the facility, it indicated, To disinfect nonfood contact surfaces . thoroughly wet surface . allow treated surface to remain wet for a full two (2) minutes . 3. During a medication administration observation on 2/8/23, at 8:19 a.m., with LVN I, at Station 3, LVN I prepared medications for Resident 72. LVN I went into Resident 72's room, put on new gloves at bedside, touched the bed remote to elevate the head of bed and turned off the feeding pump (machine that delivers nutrition into the stomach) with her right gloved hand. LVN I proceeded to administer medications to Resident 72 via the G-tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) without changing gloves. During an interview on 2/8/23 at 8:44 a.m., with LVN I, LVN I acknowledged she should have changed gloves after touching the bed remote and feeding pump. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 5/2020, the P&P indicated, Handwashing: soap .and water for the following situations . Before preparing or handling medications . After contact with objects (e.g. [example] medical equipment) in the immediate vicinity of the resident . 4a. During an observation on 2/6/23 at 5:28 p.m., certified nursing assistant (CNA) R was observed inside an isolation resident room wearing a face mask and gloves. The signs outside of the isolation room indicated anyone entering the room should wear face mask, face shield, gown, and gloves. During an interview on 2/6/23 at 5:28 p.m., with RN D, RN D stated, the room was still in isolation; therefore, CNA R should have had on the required PPE (Personal Protective Equipment - protective equipment used when caring for patients to prevent the spread of diseases) as posted. During an interview on 2/7/23 at 10:56 a.m. with CNA R, CNA R stated, regarding her entrance into an isolation room yesterday evening, in addition to the PPE she had on, she should have had a gown and face shield on. CNA R stated there was an isolation cart outside of the room, and one of the residents in the room was COVID-19 positive. She accidentally went in the room without proper PPE. 4b. During an observation on 2/8/2023 at 1:20 p.m., CNA S went inside the isolation room wearing an N95 (a particulate-filtering facepiece respirator that filters at least 95% of airborne particles) only. CNA S picked up the lunch tray from Bed A, went outside carrying the tray with her bare hands, walked along the hallway and passed the tray to another CNA. There were three postings near the outside the isolation room. The first post indicated, STOP, CHECK WITH CHARGE NURSE BEFORE ENTERING ROOM. VISIT NURSE. It also had pictures of a surgical mask, N95, Gloves, Face shield, and Disposable Gowns. The second post indicated, STOP Transmission Based Precautions STOP. Donning. 1. Hand Hygiene; 2. Gown; 3. Mask; 4. Goggles/Face shield; 5. Gloves. The third posting indicated, STOP Transmission Based Precaution STOP. DOFFING. 1. Gloves; 2. Goggles/Face shield; 3. Gown; 4. Mask; 5. Hand Hygiene. There was an isolation drawer (storage unit containing PPE, such as gowns, gloves, face shields and masks) near the outside the isolation room with a sign that indicated, RED ZONE (a dedicated area for COVID-19 residents). During an interview with CNA S, on 2/8/2023 at 1:25 p.m., she confirmed the isolation room had residents with Coronavirus disease (COVID-19, a disease caused by a contagious virus). CNA S stated, I just picked up the tray . Should I gown up? During a concurrent interview and review of the postings of the isolation room, on 2/9/2023 at 9:28 a.m., LVN T stated the isolation room was their Red Zone. LVN T confirmed there were residents with COVID-19 in the isolation room. LVN T stated any staff who entered the isolation room should wear the proper personal protective equipment (PPE, such as: N95, disposable gown, gloves, face shield or goggles) prior to entry. 4c. During an observation on 2/9/2023 at 12:37 p.m., certified nurse assistant U (CNA U) entered the isolation room wearing N95, disposable gown, and gloves. CNA U did not wear a face shield or goggles inside the isolation room. During an interview with CNA U on 2/9/2023 at 1:30 p.m., CNA U stated she needed to wear N95, gown, gloves and face shield every time she entered the isolation room. The CNA U stated, I'm sorry. I should have worn it (face shield). During an interview with the infection preventionist (IP) on 2/9/2023 at 1:48 p.m., the IP confirmed the isolation room had residents with COVID-19. The IP stated all staff and visitors should wear full PPE prior to entering the isolation room. The IP stated full PPE should be worn when trays are picked up from the isolation room because it was their Red Zone. 4d. During an observation on 2/9/23 at 1:30 p.m., LVN X was observed wearing a mask with ear loops (straps that go around each ear). LVN X was questioned about wearing a mask with ear loops instead of an N95 (which has straps that are placed behind the neck and at the crown of the head). LVN X stated This is my first day here . I am a registry nurse . No one told me I could not wear this mask with ear loops. During an interview with the IP/DSD on 2/13/23 at 8:12 a.m., she stated the facility instituted the wearing of N95s due to an outbreak of Covid-19 and that all staff were required to wear N95s until the positive resident's isolation had been completed on 2/10/23. The IP/DSD stated the facility did not allow staff to wear KN95s (masks with ear loops). She stated LVN X should be wearing an N95. A review of the All Facilities Letter (AFL) 23-12 titled Coronavirus Disease 19 (COVID-19) Recommendations for Personal Protective Equipment (PPE), Resident Placement/Movement, and Staffing in Skilled Nursing Facilities, dated 1/24/2023, referenced a chart of COVID-19 recommendations titled COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category that indicated, COVID Positive Residents . N95 respirator - Yes . Eye Protection - Yes . Gowns - Yes . 5. Review of the facility's COVID-19 Self Screening form for employees, dated 2/9/23, indicated there was no evidence that LVN X completed self-screening on 2/9/23. LVN X was listed on the daily staffing assignment of 2/9/23 as assigned to station 2B for the day shift. During a concurrent interview with the IP/DSD, on 2/13/23 at 8:45 a.m., she stated staff are instructed to take their temperature and to complete the COVID-19 screening questionnaire at the start of their work shift. The IP/DSD confirmed there was no evidence LVN X took her temperature or completed either the screening questionnaires for staff or for visitors on 2/9/23. The IP/DSD stated LVN X should take her temperature and complete the questionnaire. 6a. Review of Resident 24's clinical records indicated, Resident 24 was admitted to the facility with diagnoses including critical illness polyneuropathy (condition involving damage to many nerves in different parts of the body), other pulmonary embolism (occurs when a clump of material, most often a blood clot, gets stuck in an artery (a blood vessel that carries blood from the heart to tissues and organs in the body) in the lungs, blocking the flow of blood) and dependence on supplemental oxygen (a continuous flow of oxygen delivered to people deficient in oxygen). During an initial observation on 2/6/2023 at 9:48 a.m., Resident 24 laid in bed with oxygen delivered to him via (through) nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and with two prongs that are placed in the nostrils for oxygen administration) at 2.5 liters (L- a metric unit of capacity) per minute. The dust filter located at the back of the oxygen concentrator (a machine that concentrates the oxygen from air to supply an oxygen-enriched gas stream) had a buildup of grayish matter. During another observation inside Resident 24's room, on 2/7/2023 at 11:45 a.m., Resident 24's oxygen concentrator's dust filter still had the grayish matter build up. 6b. Review of Resident 15's ADMISSION RECORD, dated February 10, 2023, indicated Resident 15 was admitted to the facility with diagnoses including unspecified atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and chronic obstructive pulmonary disease (COPD - a long lasting lung disease). During an initial observation on 2/6/2023 at 9:55 a.m., Resident 15 laid in bed, with oxygen in placed via NC at 2.5 L per minute. Resident 15's oxygen concentrator's dust filter located at the right side of the machine had some grayish matter build up. During a follow up observation on 2/7/2023 at 11:47 a.m., Resident 15's oxygen filter still had some grayish build up. During an interview with LVN L, on 2/7/2023 at 11:50 a.m., LVN L stated it was the responsibility of both nursing and maintenance staff to keep oxygen concentrators in good working condition. During a concurrent observation and interview with LVN L, on 2/7/2023 at 11:55 a.m., LVN L confirmed the oxygen filters of Resident 24 and Resident 15 were dirty and needed to be cleaned. LVN L further stated the oxygen filters should be cleaned to provide clean air to residents on supplementary oxygen. During an interview with LVN P, on 2/7/2023 at 12:02 p.m., LVN P stated nurses should change the oxygen humidifiers (device used to increase the level of moisture in the oxygen) and maintenance should change or clean the filters. During a concurrent observation of oxygen concentrator filters and interview with assistant director of nursing A (ADON A) on 2/7/2023 at 12:07 p.m., ADON A confirmed the oxygen filters of Resident 24 and Resident 15 needed to be changed. ADON A stated the oxygen filters should be clean. ADON A further stated one staff was assigned to check all oxygen concentrators every two weeks. During a concurrent interview and record review regarding the oxygen log checks, on 2/7/2023 at 12:15 p.m., the central supply staff (CSS) stated he checked the resident's oxygen every other week. The CSS reviewed the log and confirmed he missed checking Resident 24 and Resident 15's oxygen filters for the month of February, 2023. A review of the oxygen log indicated the last time the oxygen filters were cleaned for Resident 24 and Resident 15 was on January 21, 2023. Review of the facility's policy and procedure titled, Oxygen Administration, date revised October 2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. General Guidelines . 3. For concentrators, clean lint and dust filters every 2 weeks and PRN (pro re nata - is a Latin phrase meaning as the circumstances arises) basis. 38087 32398 44583

Based on interview and record review, the facility failed to implement care plan interventions and failed to provide adequate supervision to prevent an accident for one of three sampled residents (Resident 1) when the one-to-one sitter (1:1 sitter, staff designated to be with the resident at all times to ensure safety) went to the bathroom and did not get another staff member to stay with the resident. This resulted in Resident 1's fall, head injuries, and subsequent death. Findings: Resident 1's clinical record documented she was admitted to the facility on [DATE] and had the diagnoses of [CONDITION(S)] (heart muscle does not pump blood as well as it should), dementia (mental disorder caused by brain disease or injury), [CONDITION(S)] (condition that causes loss of vision), abnormalities of gait (manner of walking) and mobility, [CONDITION(S)] (irregular heartbeat), [CONDITION(S)] (a severe mental disorder), [CONDITION(S)] (condition that causes the bones to become brittle and fragile) and history of falling. Resident 1's Minimum Data Set (MDS, an assessment tool), dated [DATE], documented Resident 1 had a brief interview for mental status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment). The MDS documented Resident 1 was totally dependent on staff for transfers and required extensive assistance (staff provide weight-bearing support) with all other activities of daily living (ADLs, basic tasks of everyday life such as bed mobility, walking, eating, dressing, personal hygiene, toileting and bathing). The MDS further documented Resident 1 was not steady and was only able to stabilize herself with staff assistance while moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and transferring from surface to surface. Resident 1's non-compliant care plan, dated [DATE], documented she refused to use her walker at times. Resident 1's elopement risk care plan, dated [DATE], documented she was disoriented to place (did not know where she was), had impaired safety awareness, and had a history of wandering aimlessly. Resident 1's fall risk care plan, dated [DATE], documented she was at risk for falls due to confusion, dementia, gait and balance problems, medications, wandering, and history of falls. Resident 1's fall risk assessment, dated [DATE], documented she had a fall risk score of 65 (a score of 45 or higher indicates high risk for falls). Resident 1's Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) Progress Notes, dated [DATE], documented Resident 1 was involved in an altercation with another resident. The IDT Progress Notes documented Resident 1 had a history of falls and noted multiple behaviors, including angry outbursts, pushing or tapping staff, difficulty sleeping, walking around facility hallways, repetitively touching or tapping facility surfaces (i.e. walls, rails, counters), attempting to go in other resident's room, disrobing, and removing her brief (adult diapers). The IDT Progress Notes also documented that prior to coming to the facility, Resident 1 had an incident where she eloped (left without permission) from home and went missing for some time The IDT Progress Notes further documented the facility would implement 1:1 with [Resident 1] to maintain her safety and the safety of others. Resident 1's clinical record did not record any incident of falls for Resident 1 from the time the facility implemented the 1:1 sitter on [DATE], until [DATE]. Resident 1's Progress Notes, dated [DATE], documented Resident 1 had an unwitnessed fall. The Progress Notes noted that at 3:00 p.m., Resident 1 was on her wheelchair in the hallway with her 1:1 sitter. At 3:20 p.m., Resident 1's nurse and the morning (AM) shift nurse were assisting another resident into bed when they heard a loud slam noise. The Progress Notes further documented the nurses went to assess the situation and noted Resident 1 lying flat on the ground. The Progress Notes documented staff, Applied pressure and a cold compress on the occipital area [back of the head] of head where bleeding was noted. The progress notes documented the AM shift nurse called 911 and Resident 1 was transferred to the acute hospital at 3:45 p.m. During an interview with licensed vocational nurse A (LVN A) on [DATE] at 4:00 p.m., LVN A confirmed she was Resident 1's assigned nurse at the time Resident 1 experienced the fall on [DATE]. LVN A stated at the beginning of her evening (PM) shift, Resident 1 was sitting in the hallway and the 1:1 sitter was sitting next to Resident 1. LVN A explained while she and the AM nurse were doing endorsement (reporting important information to each other) in another resident's room, they heard a loud noise. When they went to check what happened, they saw Resident 1 lying in supine position (flat on her back) on the floor in the hallway. LVN A stated Resident 1 was bleeding from the back of her head. LVN A stated Resident 1 had a 1:1 sitter to help her with ADLs and to prevent her from falling. LVN A stated she did not pay attention to the whereabouts of the 1:1 sitter during Resident 1's fall, as she was just worried about taking care of the resident. LVN A stated if the 1:1 sitter had to leave Resident 1's side for any reason, she needed to inform another staff member so they could watch the resident. During an interview with certified nursing assistant B (CNA B) on [DATE] at 4:45 p.m., she stated she was not the assigned 1:1 sitter for Resident 1 at the time Resident 1 experienced the fall, but was working on Resident 1's station at the time of the fall on [DATE]. CNA B stated she knew Resident 1 fell , but she did not see the fall because she was taking care of another resident. CNA B stated Resident 1 had a 1:1 sitter because she had dementia and she was agitated and combative. CNA B explained the 1:1 sitter had to be with the resident all the time. If she needed to leave the resident, she had to call another staff member to watch the resident and make sure she did not fall. During an interview with the director of nursing (DON) on [DATE] at 5:00 p.m., she stated Resident 1 was confused, agitated and combative with other residents. She stated Resident 1 had a 1:1 sitter to manage behaviors and prevent falls. The DON stated CNA D was the assigned 1:1 sitter when Resident 1 fell on [DATE]. The DON explained that CNA D went to the bathroom and did not ask another staff member to watch Resident 1. The DON stated CNA D should have informed another staff member she needed to use the bathroom so the other staff member could temporarily watch Resident 1 as 1:1 sitter. The DON stated the facility counseled CNA D about what happened and told her she should not have left Resident 1 without informing staff. During an interview with LVN C on [DATE] at 2:45 p.m., she stated she was the nurse on the AM shift when Resident 1 fell on [DATE]. LVN C stated CNA D was Resident 1's assigned 1:1 sitter when the fall occurred. LVN C explained that during shift change, she and LVN A were giving report (endorsement) in another resident's room and heard a smack noise. They ran out of the room and saw Resident 1 lying on the ground. LVN C confirmed CNA D was not present at the scene at the time of the fall. LVN C stated she and other staff asked CNA D what happened and CNA D said she needed to use the bathroom. LVN C stated she did not know if CNA D asked another staff member to take over as 1:1 sitter while she was in the bathroom, but confirmed she did not see any staff members with Resident 1 when she and LVN A saw the resident on the ground. During an interview with CNA D on [DATE] at 10:00 a.m., she confirmed she was the assigned 1:1 sitter when Resident 1 fell on [DATE]. CNA D stated Resident 1 required a 1:1 sitter because at times she would want to keep getting up. CNA D explained that Resident 1 would briefly follow directions when staff asked her to sit down, but would try to get up again shortly after. So staff needed to keep reminding Resident 1 to sit down. CNA D explained that at the time of the fall, she had to use the bathroom, so she put Resident 1 in front of the nurse's station in her wheelchair. CNA D stated there were other staff members in the area at that time. CNA D explained that as she was exiting the bathroom, she heard another resident say that Resident 1 fell . CNA D confirmed she did not get another staff member to take over as 1:1 sitter while she went to the bathroom. Review of the facility's Nursing Staffing Assignment and Sign-In Sheet, dated [DATE], indicated CNA D was the assigned 1:1 sitter during the shift when Resident 1 fell . Review of the facility's Written Warning for CNA D, signed on [DATE], indicated a job performance violation occurred on [DATE]. The Written Warning indicated the nature of CNA D's violation was, not endorsing to another staff person to oversee resident on 1:1. Then patient fell . She was educated to call staff if leaving a patient so that pt [patient] is not alone. During an interview with CNA E on [DATE] at 3:20 p.m., she stated she was not assigned to Resident 1, but worked on the same station when Resident 1 fell on [DATE]. CNA E stated Resident 1 required a 1:1 sitter because she wandered and would get up without asking for assistance. CNA E stated she did not witness Resident 1's fall, as she was doing rounds (checking on and assisting residents) at the time. During an interview with CNA F on [DATE] at 3:30 p.m., she stated she was working on the same station when Resident 1 fell on [DATE]. CNA F stated she did not witness the fall and was not watching Resident 1 at the time of the fall. CNA F stated nobody asked her to watch Resident 1 at that time. CNA F explained that Resident 1 needed a 1:1 sitter because she would get up and walk away. She also stated Resident 1 was getting weaker and did not realize how weak she was. CNA F stated she did not know where the 1:1 sitter was at the time of Resident 1's fall. During an interview with CNA G on [DATE] at 3:40 p.m., she stated she heard about Resident 1's fall, but she did not witness it. CNA G explained she was working on Resident 1's station at the time of the fall, but was working on the other side. CNA G stated Resident 1 required a 1:1 sitter because she was confused and would get up and wander into other residents' rooms. During an interview with LVN H on [DATE] at 4:37 p.m., she stated she was not Resident 1's assigned nurse when she fell on [DATE], but had worked on the other side of the same station that day. LVN H explained that at the time of the fall, she was in the nurse's station doing her charting. LVN H stated she heard a bump noise and when she went out of the nurse's station, she saw Resident 1 on the floor. LVN H stated the 1:1 sitter was not with Resident 1 when she fell . LVN H stated she asked the 1:1 sitter why she was not with Resident 1 and the 1:1 sitter said she had to use the bathroom. LVN H stated the 1:1 sitter did not inform her that she was leaving to use the bathroom. LVN H stated Resident 1 had a 1:1 sitter because she had a history of falls and had behaviors. LVN H stated the 1:1 sitter was supposed to inform another staff member that she was going to the bathroom so the other staff member could cover for her. Resident 1's IDT Fall Review, dated [DATE], indicated she had an unwitnessed fall in the hallway outside her room near the nurse's station on [DATE] at 3:20 p.m. The IDT Fall Review indicated Resident 1 was noted with a laceration (deep cut in the skin or flesh) on the occipital area with bleeding. The IDT Fall Review further indicated that Resident 1 was sent to the acute hospital for further evaluation and treatment. Resident1's ED (emergency department) Provider Notes from the acute hospital, dated [DATE], indicated Resident 1 reportedly fell after coming to stand from her wheelchair striking the back of her head on the hard floor. The ED Provider Notes further indicated, EMS [emergency medical services] reports small laceration and large hematoma [abnormal collection of blood] to posterior [back] scalp. Resident 1's computerized tomography scan (CT scan, procedure used to view internal components of the body) report from the acute hospital, dated [DATE], indicated Resident 1 had acute (sudden onset) traumatic (caused by forces from outside of the body) intraparenchymal and extra-axial hemorrhage (bleeding within the brain and in the area between the brain and the skull), subdural hemorrhage (bleeding into the space directly outside the brain), subdural hematoma (collection of blood in the space directly outside the brain), and subarachnoid hemorrhage (bleeding into the protective lining surrounding the brain). Resident 1's History of Present Illness from the acute hospital, dated [DATE] indicated, Talked RN [registered nurse] PM shift, were endorsed that patient was in a wheelchair, tried to stand up while sitter was in bathroom. She was found laying supine/on her back. Her head fell on a flat metal part on the ground. Resident 1's Assessment & Plan from the acute hospital, dated [DATE] indicated, Appears to be a mechanical fall based on description by SNF [skilled nursing facility], patient tried to get up out of her wheelchair while sitter was gone and fell . Resident 1's Inpatient Medicine Discharge Summary from the acute hospital, dated [DATE] indicated, Patient presented with intraparenchymal and extra axial hemorrhage, subdural hemorrhage, and subarachnoid hemorrhage likely in the setting of her recent fall. Resident 1's IDT Progress Notes, dated [DATE] indicated, Because of [Resident 1's] previous history of combative behaviors, IDT had implemented 1:1 sitter as an intervention with [Resident 1] to keep her and others safe and to help prevent any falls/injuries. Regarding Resident 1's fall on [DATE], the IDT Progress Notes indicated the 1:1 sitter had to use the bathroom and placed Resident 1 in her wheelchair near the station so that staff who were in the station could closely monitor her. The IDT progress notes indicated there were staff members at the station, but did not indicate that the 1:1 sitter informed any of those staff members that she was leaving the resident to use the bathroom. The IDT Progress Notes indicated Resident 1 was in the hospital from [DATE] to [DATE], and she returned to the facility on [DATE]. Resident 1's Certificate of Death indicated she died in the facility on [DATE]. The immediate cause of death listed on the certificate was Complications of Subdural Hemorrhage. The certificate indicated [MEDICATION(S)] Force Injury of the Head was the condition that led to the immediate cause of death. The certificate indicated fell in Skilled Nursing Facility as the description of how Resident 1's injury occurred. The facility's policy titled Falls and Fall Risk, Managing, revised ,d+[DATE], indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes and try to prevent the resident from falling and try to minimize complications from falling. The facility's policy titled Safety and Supervision of Residents, revised ,d+[DATE], 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. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on interview and record review, the facility failed to follow physician's orders for one of three residents (Resident 1) when blood sugar was not checked and medication used to raise blood sugar was not administered to Resident 1 according to a physician ordered [DIAGNOSES REDACTED] (low blood sugar state) order set, and when insulin was administered to Resident 1 after a meal instead of prior to a meal as ordered by the physician. This resulted in Resident 1's blood sugar dropping and transfer to an acute care hospital. Findings: Review of Resident 1's Order Summary Report dated (MONTH) 7, (YEAR) indicated she was diagnosed with [REDACTED]. A physician's order, dated 5/20/18, indicated, [MEDICATION NAME] Mix 70/30 (a mixture of insulins) 100 UNIT/ML (units/milliliter, units of measure) . Inject 40 units subcutaneously (beneath the skin) two times a day related to TYPE 2 DIABETES MELLITUS . Inject 40 units subcutaneously before breakfast and 40 units before dinner. Inject 15 minutes before meal. Another physician's order dated 5/19/18 indicated [DIAGNOSES REDACTED] STEP 1 . For Blood Glucose (a form of sugar) <70mg/dl (mg, milligrams a unit of measure for glucose (a type of sugar) per dl, deciliter a unit of measure for blood) - Give 15mg of fast acting carbohydrates (food substance that is composed of starch and/or sugar) . OR Give glucogel (oral gel composed of sugar used to raise blood sugar) . 1 tube. Recheck FSBG (fasting blood sugar - test done in the morning for blood sugar levels before the person has eaten) after 15 min (minutes) and if BS (blood sugar) is still 70 (mg/dl) and below, give [MEDICATION NAME] (medication used to raise blood glucose) IM/SQ (intramuscularly/subcutaneously - into the muscle/beneath the skin) . Review of Nursing Progress Notes for Resident 1, dated 5/28/18, indicated, . checked Pt (patient) blood sugar at 6:28 am, FSBS was 65 (mg/dl). Initiated [DIAGNOSES REDACTED] protocol. Gave glucogel . no confusion (of Resident 1) noted. There was no documentation to indicate Resident 1's BS was rechecked 15 minutes later. Review of Nursing Progress Notes for Resident 1, dated 5/28/18, indicated, At 7am, relieved endorsement from N[NAME] (night) shift . Went to check patient . When blood sugar check it increased to 70, . resident was alert . At 8am . she (Resident 1) ate breakfast, which was fed to her by the CNA (certified nursing assistant) . rechecked BS (blood sugar) . Then gave resident . 70/30 (70/30 referred to the insulin mixture) . Review of Resident 1's Medication Administration Record [REDACTED]. Review of Nursing Progress Notes for Resident 1, dated 5/28/18, indicated, Around 1pm . patient (Resident 1) was disoriented . BS was checked and was noted to be 30 (mg/dl) . LN (licensed nurse) called 911 (a telephone number used to request public authorities for assistance in an emergency) . At 1:30pm EMS (emergency medical services) had taken resident (Resident 1) to (name of general acute care hospital) . During an interview on 6/8/18 at 2:15 p.m. with CNA C, she stated on 5/28/18 at 8 a.m., she fed Resident 1. During an interview on 6/11/18 at 1 p.m. with the Patient Care Coordinator, she verified that during the morning of 5/28/18, the physician's order for [DIAGNOSES REDACTED] STEP 1 was not followed after the protocol was initiated and Resident 1 received glucogel for a BS of 65 mg/dl. She verified the clinical record lacked documentation that indicated part of the physician's order [REDACTED] STEP 1 to recheck BS after 15 minutes was done. She verified the clinical record lacked documentation that indicated [MEDICATION NAME] was given per the protocol after Resident 1's BS increased to 70 mg/dl. During an interview on 6/11/18 at 2:51 p.m. with RN A, he stated on 5/28/18, at 7:20 a.m., it was his first check of Resident 1's blood sugar and it was 70 (mg/dl). RN A stated he did not administer [MEDICATION NAME] to Resident 1 per physician's order [REDACTED] STEP 1 because breakfast was to be served. During an interview on 6/14/18 at 10:38 a.m. with RN B, she stated on 5/28/18, she checked Resident 1's blood sugar at 6:28 a.m. and that Resident 1's next blood sugar check was done by RN A. Review of the facility's 6/24/08 DIABETIC CARE policy indicated, . Licensed Nurses shall monitor blood glucose per physician's order and administer medication as indicated.

Based on interview and record review, the facility failed to provide supervision for one of 3 sampled residents (1). Resident 1 required supervision due to impaired safety awareness and an unstable psychological condition. This failure resulted in Resident 1 lighting his mattress on fire and endangering the lives of the residents in the facility. Findings: Review of Resident 1's clinical record indicated [DIAGNOSES REDACTED]. Further review of Resident 1's clinical record indicated a physician order dated 9/15/17 for oxygen at two liters per minute via nasal cannula as needed for shortness of breath. Review of Resident 1's care plan initiated on 9/15/17 indicated heightened safety risk due to impaired safety awareness and unstable psychological condition. Among the interventions included staff supervision during smoking times and staff to retain lighters. During an interview with licensed vocational nurse A (LVN A) on 1/11/18 at 10:40 a.m., she stated Resident 1 requested to smoke. LVN A stated she gave certified nursing assistant B (CNA B) Resident 1's cigarette and lighter. She stated the charge nurse has Resident 1's lighter locked in the medication cart. LVN A stated activity staff who supervised Resident 1 in the smoking area should have returned the lighter to the charge nurse after Resident 1 smoked. LVN A stated another resident kept her busy and that she forgot to retrieve the lighter. LVN A stated when the fire alarm sounded, she went to Resident 1's room. She stated the fire was already extinguished. LVN A stated she unplugged the oxygen concentrator and took it out of the room. She stated staff should have immediately removed Resident 1's oxygen concentrator out of his room when the fire was discovered. During an interview with CNA B on 1/11/18 at 11:12 a.m., she stated LVN A gave her Resident 1's cigarette and lighter. CNA B stated she wheeled Resident 1 to the smoking area and gave the cigarette and lighter to the activities assistant (AA). CNA B stated she went back to her work station and resumed care to her other assigned residents. During an interview with Resident 1 on 1/11/18 at 1:00 p.m., he stated he could not recall the fire incident that occurred in his room recently. During an interview with the activities director (AD) on 1/11/18 at 1:45 p.m., she stated the AA made a mistake on 1/2/18 of not getting back Resident 1's lighter after the smoking session. During an interview with the AA on 1/11/18 at 2:15 p.m., he stated Resident 1 had the lighter with him when he wheeled him into the front lobby. The AA stated he thought it was safe for Resident 1 to keep the lighter. The AA stated he was mistaken to allow Resident 1 to keep the lighter. The AA stated he should have returned Resident 1's lighter to the charge nurse after the smoking session. During an interview with CNA C on 1/11/18 at 2:45 p.m., she stated one of the staff in the front lobby asked her to bring Resident 1 back to his room. CNA C stated she was unaware Resident 1 came from the smoking area. CNA C stated she was uninformed that the AA did not get the lighter from Resident 1 after smoking. Review of the Fire Investigation Report dated 1/2/18 indicated at approximately 9:30 a.m., staff noticed fire coming from Resident 1's room. The fire alarm sounded and staff proceeded to the room where they saw Resident 1 next to his bed with the mattress on fire. Resident 1 was removed. The staff put out the fire with a fire extinguisher. The conclusion of the Fire Investigation Report indicated: 1. CNA C when asked to bring Resident 1 him back to his room from the lobby was not informed that Resident 1 was returning from smoking. 2. CNA C wheeled Resident 1 to his room without checking to see if he had any smoking items. 3. Resident 1 had a behavioral episode and lit the mattress on fire out of frustration and feeling of being ignored. Review of the undated policy and procedure titled Safe Smoking Policy indicated Residents that are not deemed safe will have their cigarettes and lighters secured and kept locked. Review of the facility policy and procedure titled Supervision of Resident Care dated 10/13/06 indicated the licensed nurse shall supervise all care and assure that the resident is protected .

Based on interview and record review, the facility failed to ensure the resident's environment remained as free from accident hazards and received adequate supervision and assistance devices to prevent a fall for one of three sampled residents (Resident 1). On 11/17/16, Resident 1 used a walker, which was placed at his bedside, to go to the bathroom. It was uncertain who provided to the walker to the resident. Without assistance, using the walker, Resident 1 walked to the bathroom, had an unwitnessed fall, and sustained an L1 (the first lumbar vertebra (lower back)) fracture (a complete or partial break in a bone). This failure resulted in Resident 1 sustaining a fall and injury. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's Functional Abilities and Goals assessment dated [DATE] through 11/16/16, indicated the resident required partial or moderate assistance with toilet transfer. Review of Resident 1's nurses notes dated 11/15/16, indicated the resident was alert, oriented, and able to make his own decisions. Review of Resident 1's physical therapy (PT) care plan dated 11/15/16 indicated the resident had functional deficits which included a decrease in bed mobility, transfers, gait, sitting balance, standing balance, and lower extremity strength and endurance. Review of Resident 1's occupational therapy (OT) care plan dated 11/15/16 indicated the resident required assistance with activities of daily living (ADLs) and mobility. Review of Resident 1's PT evaluation and plan of treatment dated 11/15/16 indicated the resident was referred to PT for the new onset of the decrease in functional mobility and pain. Resident 1 presented with an impairment of left lower extremity weakness due to pain and spinal stenosis (narrowing of the spinal canal). This impairment limited bed mobility, transfers, gait, and activity tolerance. Review of Resident 1's ADLs Documentation Survey Report dated 11/15/16 through 11/17/16, indicated the resident required limited to total assistance with the support of one person for toilet use. Review of Resident 1's nurse notes dated 11/17/16 at 7:23 a.m., indicated the resident had an unwitnessed fall on 11/17/16 at 2:40 a.m. after using the bathroom. Resident 1 stated when he fell he had a crack on his back. Resident 1 was then transferred to an acute care hospital. Review of Resident 1's computerized tomography (CT, an imaging test of the inside of the body) spine lumbar (lower part of the spine) report dated 11/17/16 at 3:54 a.m., indicated the resident sustained [REDACTED]. Review of Resident 1's Post Fall assessment dated [DATE], indicated the resident had an unsteady gait and used assistive devices (a device which helps people overcome a handicap such as mobility) such as a walker and a cane. He was also compliant with instructions to call for help when necessary. Review of Resident 1's interdisciplinary team (IDT) review dated 11/17/16, indicated the resident stated he went to the bathroom using his forward wheel walker (FWW). After using the toilet, Resident 1 stated he lost his balance and fell when he tried to back out of the bathroom. Resident 1 sustained an L1 fracture as a result of the fall. Review of Resident 1's PT daily treatment note dated 11/17/16, indicated the resident had a fall risk and was ambulating to the bathroom at the time of the fall using his personal walker. It indicated Resident 1 was not cleared for ambulation in the room. During an interview with Resident 1 on 12/1/16 at 11:45 a.m., he stated he went to the bathroom using his walker and when he started to leave, he fell on his back and heard a crack. Resident 1 stated he usually went to the bathroom by himself. He stated the facility did not tell him to ask for assistance when he went to the bathroom. During an interview with the occupational therapist B (OT B) on 12/1/16 at 12:11 p.m., he stated Resident 1 complained of sciatic nerve pain. OT B stated Resident 1's balance was poor and based on the therapy department's evaluation, he could not go to the bathroom by himself. During an interview with physical therapist A (PT A) on 12/13/16 at 9:28 a.m., he stated during the initial evaluation, Resident 1 was in a lot of pain. PT A stated he did not want Resident 1 to walk. During an interview with PT A on 12/13/16 at 1:33 p.m., he stated Resident 1 did not have clearance from the therapy department whether he was able to walk in the room at the time of the fall. PT A stated nursing staff did not ask him whether it was safe for Resident 1 to walk in the room using his walker. During an interview with OT B on 12/13/16 at 1:37 p.m., he stated Resident 1 was at a fall risk. He stated the therapy department provided Resident 1 a wheelchair, but not the walker. OT B stated at the time of the fall Resident 1 was not fit to use a walker, and he was unaware who provided Resident 1 the walker. OT B also stated the nursing staff did not ask him whether Resident 1 was cleared to walk in his room using a walker. During an interview with licensed vocational nurse D (LVN D) on 12/13/16 at 2:23 p.m., she stated at the time of the fall Resident 1 had a walker and a cane in the room. LVN D stated she was unaware where the cane and walker came from. During an interview with LVN C on 12/13/16 at 2:28 p.m., he stated he did not remember if Resident 1 brought a cane or a walker when he was admitted to the facility. During an interview with certified nursing assistant E (CNA E) on 12/14/16 at 8:51 a.m., he stated Resident 1 had a walker in the room. CNA E stated he always made sure the walker was at Resident 1's bedside. During an interview with CNA F on 12/14/16 at 9:20 a.m., she stated Resident 1 had a walker in his room before the fall incident. CNA F stated she had helped Resident 1 to go to the bathroom using a walker. During an interview with PT A on 12/14/16 at 12:58 p.m., he stated on 11/16/16 which was a day before the fall, Resident 1 had pre-gait training which was training to sit and stand to prepare for walking. PT A stated Resident 1's actual gait training occurred after the 11/17/16 fall and the resident started walking on 11/18/16. He stated the therapy department did not provide the walker which Resident 1 used at the time of the fall on 11/17/16. During an interview with CNA E on 12/16/16 at 11:10 a.m., he stated he was not informed Resident 1 was not allowed to use a walker in his room prior to the fall. During an interview with CNA H on 12/16/16 at 11:30 a.m., she stated no one informed her Resident 1 was not supposed to use a walker in his room. During a telephone interview with Resident 1 on 12/16/16 at 11:50 a.m., he stated no one in the facility informed him it was unsafe to use his walker in the room. He also stated he used the walker when he needed to go to the bathroom. Resident 1 stated he would not have used his walker if a staff member told him it was unsafe to do so. Review of the facility 10/13/06 policy SUPERVISION OF RESIDENT CARE indicated to assure that the resident's safety and well-being are maintained, the environment of the resident should be reviewed and checked for safety. All residents shall receive adequate supervision. The licensed nurse shall assure that care is implemented per the resident's individualized care plan.

Based on interview and record review, the facility failed to provide adequate supervision to prevent one of three sampled residents (Resident 1) from falling consistent with the resident's assessed needs and plan of care. This failure resulted in Resident 1 sustaining a subdural hematoma and subsequently passed away. (A subdural hematoma is usually the result of a serious head injury. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death.) Findings: Resident 1's clinical record was reviewed. Resident 1 was a [AGE] year old female, who was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/27/16, indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assistance for toileting. It indicated the resident was unsteady and only able to stabilize with staff assistance when she moved on and off the toilet. Review of Resident 1 ' s MDS, dated [DATE], also indicated functional limitation in range of motion indicated Resident 1 had impairment on one side (which meant that limitation interfered with daily functions or placed resident at risk of injury). Review of Resident 1's Fall Notes (FN), dated 7/4/16, indicated the resident was found face down on the bathroom floor on 7/4/16 at 11:00 a.m. Resident 1 suffered a right upper lip skin tear, swelling of the left cheek and right lip. The FN also indicated Resident 1 attempted to transfer to her wheelchair by herself and fell . Review of another FN, dated 7/4/16, indicated on the same day at 12:20 p.m., Resident 1 had a second fall in her room right next to her bed face down. It also indicated Resident 1 attempted to get her items from her drawer and fell . Resident 1 was found unresponsive 20 minutes after the second fall. Resident 1 vomited and her blood pressure was elevated to 217/117 mm Hg (millimeters of mercury, unit of measurement), and was transferred to an acute care hospital. Resident 1's two fall incidents occurred within 90 minutes and were both unwitnessed. During an interview with licensed vocational nurse A (LVN A), on 7/19/16, at 1:49 p.m., she stated Resident 1 yelled and she found her in the bathroom floor face down on 7/4/16 at 11 a.m. LVN A stated that certified nursing assistant B (CNA B) was not in Resident 1's room to assist her during transfer. LVN A further stated that CNA B should have stayed with Resident 1, and should never have left her unattended alone on the toilet. During a telephone interview with CNA B, on 7/19/16 at 3:51 p.m., she stated she left Resident 1 in the bathroom because she stepped out and assisted another resident. CNA B stated she was not given instructions to supervise Resident 1 more closely after the first fall. During an interview with CNA C, on 7/19/16 at 1:21 p.m., she stated Resident 1 needed extensive assistance with toileting because of her weakness and speech impairment. CNA C stated she would never leave Resident 1 unattended during toileting. During an interview and record review with registered nurse G (RN G), on 7/22/16 at 9:38 a.m., she stated Resident 1 was assessed and was identified as a fall risk. Review of the falls care plan, dated 3/11/13, indicated an intervention to assess and anticipate resident needs in toileting. The fall care plan was revised on 9/11/13, and indicated to assist the resident to the bathroom promptly. During interview with CNA D, who was acting as the team leader and trainer for CNA B, on 7/22/16 at 1:30 p.m., she stated CNAs were all trained to remain with the resident during toileting. CNA D stated CNA B should never have left Resident 1 unattended in the bathroom. During an interview with CNA F, on 7/22/16 at 10:44 a.m., she stated she would stay in Resident 1's room until she finished toileting. CNA F further stated they were all trained not to leave residents alone on the toilet who required transfer assistance. During an interview on 7/22/16 at 1:51 p.m., CNA E acknowledged she was the team leader of the station where Resident 1 resided. CNA E stated CNAs should stay with Resident 1 during toileting and should wait outside the bathroom door until Resident 1 indicated that she was finished. CNA E also stated if another resident needed assistance, she would call for help and would never leave Resident 1 unattended while on the toilet. During an interview with the director of staff development (DSD), on 7/22/16 at 1:36 p.m., he stated all CNAs were given in-service training in assisting residents with their activities of daily living. The DSD also stated floor orientation was given by team leaders who were experienced and highly competent CNAs. A review of Resident 1's Critical Care History and Physical (H&P) from the acute care hospital, dated 7/4/16, indicated she was admitted with an altered mental status following two mechanical falls. A Computerized Tomography (CT, diagnostic procedure that uses special X-ray equipment to help detect a variety of diseases and conditions) scan of the head, dated 7/4/16, revealed a large right hematoma up to 2.2 cm (centimeters, unit of measurement) with midline shift. Further review of Resident 1 ' s Inpatient Medicine Discharge Summary, dated 7/5/16, indicated Resident 1 had a right subdural hematoma with midline shift likely secondary to her two falls at the skilled nursing facility and subsequently passed away on 7/5/16 at 5:25 p.m. A review of the facility's 1/3/10 Fall Prevention Program policy indicated All residents shall remain as free of accident hazard as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents. It further indicated that any residents identified as at risk for falls should have an individual plan of care that includes interventions to prevent falls from occurring.

Based on interview and record review, the facility failed to ensure two of four sampled residents (1 and 2) were free of significant medication errors. Licensed nurse B (LN B) gave Resident 1 [MEDICATION NAME] Insulin (long acting injectable medication to control blood sugar levels) at 9 p.m. on 1/18/13 instead of [MEDICATION NAME] (anti-coagulant to prevent bleeding) resulting in [DIAGNOSES REDACTED] (blood sugar of 70 milligrams per deciliter (mg/dl-unit of measurement) or below. Resident 1 was admitted to the acute hospital emergency department with a significantly low blood sugar level, [DIAGNOSES REDACTED]. Resident 1 returned to the facility the following day with new [DIAGNOSES REDACTED]. Resident 2 did not receive [MEDICATION NAME] for three consecutive days (1/17/13, 1/18/13 and 1/19/13) as ordered by the physician daily at bedtime, and regular insulin was not given to Resident 2 as ordered on [DATE] for [MEDICAL CONDITION] (high blood sugar range from 151 mg/dl and above) resulting in significantly high blood sugar levels of 451 at 4:30 p.m. and 475 at 9 p.m. Findings: 1. Resident 1 was admitted with [DIAGNOSES REDACTED]. During record review on 2/1/13, the physician's orders [REDACTED]. The Medication Administration Record (MAR) on 1/18/13 indicated [MEDICATION NAME] was not administered. Instead Resident 1 received [MEDICATION NAME] 100 units/ml at 9 p.m. without a physician's orders [REDACTED]. During an interview on 2/1/13 at 9:45 a.m. with licensed nurse A (LN A), she stated she worked 11 p.m. to 7:30 a.m. on 1/18/13. LN A stated at 12:10 a.m. on 1/19/13, LN B informed her she gave 1 ml of [MEDICATION NAME]to Resident 1, who was not a diabetic, at 9 p.m. instead of 1 ml of [MEDICATION NAME]. LN A stated she went with LN B to check on Resident 1. LN A said they found Resident 1 "Alert but cold and diaphoretic, in cool, clammy sweat at 12:15 a.m., with a fingerstick blood sugar (FSBS) documented as 53." (Facility's normal blood sugar range is 70-150 mg/dl (milligrams per deciliter). LN A stated a 4 ounces (oz) glass of orange juice with 2 packets of sugar and I tube with Insta-Glucose gel (highly concentrated sugar gel) was given to Resident 1 and 15 minutes later, the FSBS was even lower at 47. The physician was notified and ordered the transfer to acute hospital for treatment and management of [DIAGNOSES REDACTED]. LN A stated when paramedics arrived they checked Resident 1's blood sugar. LN A stated it was 20 and the paramedics gave her [MEDICATION NAME] injection (highly concentrated sugar solution) and took Resident 1 via 911 ambulance to an acute care emergency department for treatment of [REDACTED]. During record review on 2/1/13 with the DON, the interfacility transfer form dated 1/20/13 indicated Resident 1 was treated in the acute hospital for [DIAGNOSES REDACTED] and pneumonia. The readmission orders [REDACTED]. One and a half hours after Resident 1 was readmitted on [DATE], she was found on the floor near her bed "trying to go to the bathroom". Nurses notes indicated there was no injury and Resident 1 was quoted " I forgot to use the call light". On 1/24/13 Resident 1 went to the hospital again. This time the [DIAGNOSES REDACTED]. Resident 1 was intubated and has been in the intensive care unit and still intubated as of 2/7/13. During a telephone interview with LN B on 2/1/13 at 10:55 a.m., she stated she worked 3-11:30 p.m. on 1/18/13. LN B stated she worked past her evening shift and reviewed the MAR (Medication Administration Record). LN B stated she realized she gave [MEDICATION NAME] 1 ml to Resident 1 instead of Resident 2. LN B stated she did not give Resident 2 [MEDICATION NAME] at 9 p.m.. on 1/18/13. LN B stated she immediately informed the night nurse and said, "The bottles of medication on the top drawer of the medication cart looked alike." LN B also stated Resident 1 did not receive the [MEDICATION NAME] 1 ml at 9 p.m. on 1/18/13. 2. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool), dated 1/24/13, indicated Resident 2 was unable to hear and unable to speak (deaf-mute), English was her second language, and communication with Resident 2 was by gesture, facial expression and communication board. During review of Resident 2's clinical record on 2/1/13 at 10:30 a.m. with the director of nurses (DON), a physician's orders [REDACTED]. Give 20 Units at bedtime SQ everyday for diabetes...Regular insulin SQ before meals everyday at 0630, 1130, 1630 and at 2100: Blood Sugar 70-150= 0 units. Less than 70 mg/dl, give snack or 4 oz of juice. Recheck blood sugar in 20 minutes... Greater than 400 mg/dl- give 12 units, recheck blood sugar in 1 hour and notify MD if still greater than 450." Record review with the DON on 2/1/13 indicated licensed nurse C (LN C) made an entry in the MAR on 1/17/13 at 4:30 p.m. indicating Resident 2's blood sugar was 451 and amount of insulin given was documented "N/A" and at 9 p.m., blood sugar was 475 and amount given was left blank. The DON stated if the medication was not given to the resident, the nurse would circle their initials on the MAR and write a narrative on the back of the form stating the reason why medication was not administered. DON stated Resident 1 returned to the facility on [DATE] with [DIAGNOSES REDACTED]. [REDACTED]. During a telephone interview with LN C on 2/4/13 at 3:45 p.m., LN C stated [MEDICATION NAME] was not available on 1/17/13 and she did not administer the 9 p.m. dose. During an interview on 2/1/13 at 10:55 a.m. with LN B, she stated Resident 2 did not receive [MEDICATION NAME] 20 units SQ at 9 p.m. on 1/18/13. LN B stated it was in the top drawer next to the bottle of [MEDICATION NAME]. During an interview with LN D on 2/5/13 at 1:45 p.m., she stated [MEDICATION NAME] was not available and she did not administer the 9 p.m. dose on 1/19/13. During record review on 2/1/13, the MAR indicated there were three evenings [MEDICATION NAME] was not given. At 6:30 a.m. on the morning of 1/18/13, Resident 2's blood sugar was 245 and 4 units of regular insulin were given. On 1/19/13, it was 227 and 4 units were given, and on 1/20/13 it was 265 and 6 units were administered. Resident 2's blood sugar was within normal range. Therefore, beginning on 1/21/13 at 6:30 a.m., through 1/31/13, she did not need regular insulin because her FSBS was within normal range when [MEDICATION NAME] was administered at 9 p.m. in the evening before. During a telephone interview with LN C on 2/4/13 at 3:45 p.m., she stated she worked the 3-11:30 p.m. shift on 1/17/13 when Resident 2 was initially admitted . LN C stated a family member (FM) was at the bedside when she did the FSBS test at 4:30 p.m. and got a reading of 451. LN C stated FM told her it usually ran high. LN C stated she checked the medication cart and the medication room and did not find Regular insulin so she charted "N/A." LN C stated "N/A" stands for not available, and she called the pharmacy for the medication delivery status, but did not inform the attending physician (MD) of the high blood sugar readings at 4:30 p.m. LN C stated she checked the FSBS again at 9 p.m. and the reading was 475, but did not inform the attending physician (MD) of the high blood sugar readings at 4:30 p.m. and 9 p.m. LN C stated she did not give the regular Insulin to Resident 2, she did not inform the MD, the supervisor and/or the DON. LN C stated she did inform the incoming night shift nurse. During an interview with LN E on 2/5/13 at 3:35 p.m., he stated he was the night nurse on 1/17/13. LN E stated he did not recall report of Resident 1's [MEDICAL CONDITION] from the outgoing p.m. nurse. LN E stated he was able to give the 6:30 a.m. regular insulin coverage as ordered. LN E stated the medications ordered on [DATE] including regular insulin and [MEDICATION NAME]for Resident 2 were delivered after midnight. The facility's policy and procedure on Medication Administration, dated 10/13/05, indicated medications shall be administered as ordered by a physician/licensed independent practitioner. "The licensed nurse shall check the resident's identity by: armband with name and date of birth (DOB) or medical record number (MRN), photo ID and DOB or verbal confirmation by name... prior to administering the medication. Medication error is the omission of a dose. The nurse shall notify the physician and observe the resident for any status change." The facility's policy and procedure on Medication Administration General Guidelines dated 09/08 indicates, "Prior to administration, the medication and the dosage schedule on the resident's MAR is compared with the medication label... before the dose is prepared, before the dose is administered and after the dose is given."