Every finding on record at The Rehabilitation Center of Bakersfield

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when:1. One can of roasted diced tomatoes was dented.2. Multiple food items were expired in dry storage room.3. Cauliflower and cabbage were expired in the walk-in refrigerator.4. Multiple food items were uncovered and undated in the walk-in freezer.5. One freezer containing partially melted ice cream was not maintained at the required temperature for frozen food storage.6. One cook did not wear a hair restraint while in the kitchen.7. C-wing's ice machine chute (the passage where ice travels down into a storage bin) was visibly dirty.These failures posed the risk of food borne illness in a medically fragile resident population of 146 facility residents who received food prepared in the kitchen and ice after the closing of the kitchen.Findings:1.During a concurrent observation and interview on 1/12/2026 at 1:13 p.m. with the Dietary Manager (DM) in the dry storage room, one can of roasted diced tomatoes was dented. The DM stated the can needed to be put in the disposal pile due to the risk of botulism (severe illness caused by a toxin that causes muscle weakness).During a review of the facility's policy and procedures (P&P) titled, Food Storage, dated 11/1/2014, the P&P indicated, Dented of bulging cans should be placed in separate area and returned for credit.2. During a concurrent observation and interview on 1/12/2026 at 1:17 p.m. with the Dietary Manager (DM) in the dry storage room, an opened gallon bottle of apple cider vinegar had a use by date of 8/6/2025. The DM stated it needed to be thrown away immediately.During a concurrent observation and interview on 1/12/2026 at 1:21 p.m. with the DM in the dry storage room, a clear plastic container labeled Classic Noodles with a use by date of 5/20/2025. The DM stated the noodles needed to be thrown away.During a concurrent observation and interview on 1/12/2026 at 1:24 p.m. with the DM in the dry storage room, a container of Mayo packets with a use by date of 11/16/2025 and a bottle of thickened orange juice with a use by date of 1/6/2026. The DM stated they needed to be thrown away.During a concurrent observation and interview on 1/12/2026 at 1:28 p.m. with the DM in the dry storage room, there was a container labeled Red onions with a use by date of 3/8/2025. Four of the six red onions had very dark decaying spots. The DM stated the red onions were unusable and needed to be thrown away.During a concurrent observation and interview on 1/12/2026 at 1:29 p.m. with the DM in the dry storage room, a bin labeled Red Potatoes were wilted and had many spuds growing with a use by date of 12/24/2025. The DM stated the potatoes needed to be thrown away.During a concurrent observation and interview on 1/12/2026 at 1:30 p.m. with the DM in the dry storage room, a container labeled Potatoes with a use by date of 12/24/2025 were wilted and had many spuds growing. The DM stated the potatoes needed to be thrown away.3. During a concurrent observation and interview on 1/12/2026 at 1:35 p.m. with the Dietary Manager (DM) in the walk-in refrigerator, two bags of cauliflower had a use by date of 1/10/2026. DM stated the cauliflower was expired and needed to be thrown away.During a concurrent observation and interview on 1/12/2026 at 1:36 p.m. with the DM in the walk-in refrigerator, two bags of cabbage had a use by date of 1/7/2026. DM stated the cabbage was expired and needed to be thrown away.4. During a concurrent observation and interview on 1/12/2026 at 1:37 p.m. with the Dietary Supervisor (DS) in the walk-in freezer, an opened, unlabeled and undated plastic bag contained an unknown pink meat with ice crystals. DS stated the meat was pork, and it should have been ensured it was closed with a label and date.During a concurrent observation and interview on 1/12/2026 at 1:39 p.m. with the DS in the walk-in freezer, a box of dinner rolls was uncovered and undated. The DS stated the dinner rolls should have been covered and dated.During a concurrent observation and interview on 1/12/2026 at 1:41 p.m. with the DS in the walk-in freezer, a box of chicken patties and a box of chicken and vegetable protein enchiladas were opened, uncovered and undated. The DS stated all foods needed to be covered, labeled and dated.5. During a concurrent observation and interview on 1/12/2026 at 1:44 p.m. with the Dietary Manager (DM) in the kitchen, a small white freezer had numerous vanilla ice cream cups that were not frozen, with no thermometer in the freezer. DM retrieved a thermometer and placed it in the freezer. At 1:55 p.m. (11 minutes later) DM checked the thermometer, and it read 11 degrees Fahrenheit. DM stated the freezer temperature should have been 0 degrees Fahrenheit or below and should not be used.During a review of the facility's policy and procedures (P&P) titled, Refrigerator/Freezer Temperature Records, dated 11/1/2014, the P&P indicated, The freezer temperature must be 0 F [Fahrenheit] or below. Corrective action should be taken to correct the temperature or the items should be moved to another storage area to maintain acceptable temperature.6. During a concurrent observation and interview on 1/12/2026 at 1:49 p.m. with the Dietary Manager (DM) in the kitchen, [NAME] 1 cleaned a stove top while not wearing a hair restraint. DM stated all personnel in the kitchen needed to wear hair restraints.During a review of the facility's policy and procedures (P&P) titled, Dietary Department- Infection Control for Dietary Employees, undated, the P&P indicated, Personal cleanliness is required in sanitary food preparation. Clean hair- covered with an effective hair restraint while in all kitchen and food storage areas.7. During a concurrent observation and interview on 1/14/2026 at 2:40 p.m. with Maintenance in the C-Wing hydration room, Maintenance opened the lid to ice machine to visualize cleanliness. Observed ice chute with thick white build up and when the inside of the ice chute was wiped with a paper towel there was an unknown slimy brown residue. Maintenance confirmed the ice machine was dirty and needed to be cleaned.During an interview on 1/14/2026 at 2:53 p.m. with Maintenance Director (Main D), Main D stated the ice machine chute is cleaned once a month and should not have been dirty.During a review of the facility's policy and procedure (P&P) titled, Ice Machine- Operation and Cleaning, dated 10/1/2014, the P&P indicated, On no less than a monthly basis, remove the ice to wash the inside of the machine. wash the inside of the machine. sanitize the inside of the machine

The facility failed to implement and maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of disease and infections when: 1. Resident 40 was not properly assessed for susceptibility or risk factors prior to being cohorted (group of people who share a room) with Resident 152 who was confirmed to have herpes zoster (shingles- contagious painful, blistering rash). This failure had the potential to result in an avoidable transmission of a communicable disease and potential health complications to Resident 40. 2. a. There was no signage posted outside the room to indicate which resident required transmission-based precaution (TBP-either as standard precaution, contact precautions, droplet and airborne) in Rooms 316. b. There was no signage posted outside the room to indicate the type of precautions Enhanced Based Precautions (EBP-precautions used for residents with wounds, indwelling medical devices or those infected with multidrug resistant organisms (MDRO) requiring gowns and gloves) in Rooms 311, 314, 315, 318, and 321. These failures had the potential to result in the spread of infectious diseases among staff and residents. 3. Two staff members, Certified Nursing Assistant (CNA) 3 and Licensed Vocational Nurse (LVN) 3, did not wear proper personal protective equipment (PPE) while providing care to Resident 15 who was on Enhanced Barrier Precautions (EBP). 4. Two of Two staff (Certified Nurse Assistant [CNA] 5 and Housekeeper [HK] 2) did not follow the facility's policy and procedures for hand hygiene. This failure had the potential to spread germs and cause illnesses. 5. One ice scoop was stored inside the ice bucket during dining service. This failure had the potential to contaminate the ice served to residents. 6. Trash was not properly discarded in the 'C-Wing' Biohazard room. This failure had the potential to spread germs and cause illnesses. Findings:1.During a review of Resident 40's Face Sheet (demographics), Resident 40 was admitted to the facility on [DATE] with diagnosis of type 2 diabetes mellitus (chronic condition when the body doesn't produce or use sugar effectively). During a concurrent observation and interview on 1/13/2026 at 8:50 a.m. with Resident 40 in his room, there was a PPE cart by the front door, Resident 40 stated his roommate, Resident 152, was on quarantine (staying away from others to minimize contagious spread of a disease) due to having shingles. Resident 40 confirmed he did not have shingles. During a concurrent interview and record review on 1/16/2026 at 9:27 a.m. with Infection Preventionist (IP) 2, Resident 40's full medical record was reviewed. Resident 40's full medical record did not show a history of varicella-zoster virus (chicken pox), a varicella vaccination (shot used to weaken the virus), or an assessment of various risks associated to resident placement with shingles. IP 2 stated Resident 40 should have had a documented assessment for cohorting with a resident who was confirmed to have shingles. IP 2 further stated the assessment should have included a history of chicken pox and vaccination of varicella. During an interview on 1/16/2026 at 9:42 a.m. with the Director of Nursing (DON), the DON stated the IPs should have documented a risk assessment for Resident 40 contracting shingles due to being cohorted with Resident 152. During a review of Resident 152's Physician Orders (PO), dated 1/7/2026, the PO indicated Resident 152 was on Contact Isolation for Shingles. During a review of the CDC's Varicella-Zoster Virus (VZV), Guidelines dated 2/6/2025, the VZV indicated, .Prevention of transmission of VZV in healthcare settings involves ensuring individuals have evidence of immunity to varicella. CDC recommends that susceptible individuals should not enter the room of a patient with. localized herpes zoster. During a review of the facility's policy and procedures (P&P) titled, Resident Isolation- Categories of Transmission-Based Precautions, dated 1/1/2012, the P&P indicated, Contact precautions are implemented for residents known or suspected to be infected or colonized with. Cutaneous Zoster [painful skin rash caused by virus- varicella zoster]. Resident Placement. The resident is placed in a private room. when a private room is not available, the Infection Control Coordinator assesses various risks associated with other resident placement options (e.g., cohorting). 2. During an initial observation on 1/12/2026 at 1:13 p.m. to 3:09 p.m. in Station D, there was an isolation cart set up observed outside the following residents' room (Rooms 311, 314, 315, 316, 318, and 321) which housed two residents per room. The set-up cart included PPE (personal protective equipment-masks, gowns, and gloves). There were no isolation precaution signage outside the rooms. During an interview on 1/13/2026 at 8:19 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she could not tell what type of isolation precaution was needed for room [ROOM NUMBER], and 318. During a concurrent interview and observation on 1/13/2026 at 9:20 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she could not tell what type of isolation precaution was needed for room [ROOM NUMBER]. There was an isolation cart observed outside the door. with no signage. During an interview on 1/13/2026 at 9:41 a.m. with Infection Preventionist (IP) 1, IP 1 stated PPE isolation carts should include a clear identification of the type of infection or precaution as well as an indication of which resident is affected. IP 1 could not state what type of isolation precaution was needed for room [ROOM NUMBER] and room [ROOM NUMBER]. During a concurrent interview and record review on 1/15/2026 at 9:14 a.m. with Registered Nurse (RN), 2, RN 2 verified physician's order dated 1/2026 for the residents in the following rooms: room [ROOM NUMBER] A had an order for EBP and Contact Precaution due to infection in the blood room [ROOM NUMBER] B had an order of EBP due to presence of urinary catheter. room [ROOM NUMBER] B had an order of EBP due to intravenous (IV) antibiotic therapy for bone infection. room [ROOM NUMBER] B had an order for EBP precaution due to her infection in the urine and sepsis (blood infection). room [ROOM NUMBER] B had an order for TBP for eye infection. room [ROOM NUMBER] B had an order for EBP due to IV antibiotic therapy for post-surgery. room [ROOM NUMBER] B had an order for EBP for IV antibiotic therapy for infection of the lower extremities. RN 2 also stated residents who have an order for TBP should have the appropriate PPE in isolation cart outside their room with appropriate signage. The California Department of Public Health (CDPH)'s All Facilities Letter (AFL) 24-15, dated 6/13/2024, the document indicated, California SNFs [Skilled Nursing Facilities] should refer to the CDC website on Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) . for guidance and tools for implementing EBP. CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/2024, the document indicated, When implementing. Enhanced Barrier Precautions, it is critical to ensure staff have. access to appropriate supplies. To accomplish this. Make PPE, including gowns and gloves, available immediately outside of the resident room. During a review of the facility's policy and procedure (P&P) titled `Resident Isolation-Categories of Transmission- Bases Precautions dated 1/1/2012 indicated I. Transmission-based precautions are used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infections. During a review of facility's P&P titled IPC303 Enhanced Barrier Precautions with a revised date of 10/15/2024, indicated When transmission-based precautions are not appropriate and in addition to Standard precautions, Enhanced Barrier Precautions will be used . Process .2. For residents for whom EBP are indicated, EBP is employed when performing the following high -contact resident care activities .a. dressing .5. Post the appropriate Enhanced barrier Precautions sign on the resident's room door to inform caregivers of the appropriate task requiring the use of PPE . 9. To facilitate compliance with EBP: .v. Provide education to residents, legal representatives and visitors as appropriate. 3. During a review of Resident 15's History and Physical (H&P), dated 2/26/2025 by Medical Doctor (MD)1,H&P indicated that Resident 15's present illnesses were dysphagia (difficulty swallowing), a feeding tube, and dementia (decline in thinking). During a concurrent observation and interview on 1/14/2026 at 3:30 p.m. in resident 15's room, observed LVN3 and CNA3 entering room [ROOM NUMBER] wearing gloves and masks. LVN3 was observed turning off and disconnecting Resident 15's feeding tube. LVN3 left the room and CNA3 proceeded to change Resident 15's soiled brief and provide personal hygiene. During an interview, LVN3 indicated the PPE that should have been worn for EBP was mask, gloves, and gown due to Resident 15's feeding tube and doctor's order for EBP. During a review of Resident 15's Physician Order (PO), dated 7/8/2025, the PO indicated Resident 15 was to be on EBP to reduce the spread of infections due to Resident 15's history of multi drug resistant organism and tube feeding. During a review of Resident 15's Care Plan Report (CP), dated 1/15/2026, the CP stated, Utilize PPE during high contact resident care. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 10/15/2024, the P&P indicated, EBP is to be used during high-contact resident care activities . changing briefs. During a review of the All Facilities Letter (AFL- memo issued by the California Department of Public Health) dated 6/13/2024, the AFL indicated skilled nursing facilities should implement Personal Protective Equipment (PPE) to prevent the spread of Multidrug-resistant Organisms (MDRO). Specifically, Enhanced Barrier Precautions (EBP), which involve the use of gloves and a gown during high-contact care activities (person hygiene and linen changes) for residents who have indwelling devices (such as feeding tube), chronic wounds, or MDROs. During a review of CDC recommendations dated 4/2/24, indicated Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities (personal hygiene, linen change, providing medications and treatments such as wound dressing change) for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 4. On 1/12/2026 at 4:58 PM, during dining service, CNA 5 failed to perform hand hygiene after donning a hair net and proceeded to serve meals to multiple residents without washing or sanitizing hands. During an interview on 1/12/2026 at 5:07 p.m., with CNA 5, CNA 5 acknowledged they did not perform hand hygiene in between resident contacts. CNA 5 confirmed they completed hand hygiene training but did not perform hand hygiene as required to prevent the spread of illness. During a concurrent observation and interview on 1/13/2026 at 11:10 a.m., with HK 2, in the 'C-Wing' Hallway, HK 2 handled soiled trash from the housekeeping cart with ungloved hands and disposed of it in the biohazard room. HK 2 then exited the room without performing hand hygiene and placed hands into their uniform pocket. HK 2 stated their usual practice was to perform hand hygiene after discarding trash, however failed to do so at the time of the observation. During an interview on 1/15/2026 at 4:10 p.m., with Infection Preventionist (IP) 2, IP 2 stated CNA 5 and HK 2 did not follow facility policy for hand hygiene. IP 2 stated it was the expectation that staff performed hand hygiene in between tasks, when leaving resident rooms, and when visibly soiled to prevent cross contamination and the spread of diseases within the facility. During a review of the facility's P&P titled Hand Hygiene dated 9/01/2020, the P&P indicated, .The Facility Considers hand hygiene as the primary means to prevent the spread of infections .Facility , healthcare personnel (HCP), Residents, visitors, and volunteers must perform hand hygiene to prevent the transmission of HAIs [healthcare-associated infections] .The following situations require appropriate hand hygiene . before and after assisting a resident with dining .when hands are visibly soiled . 5. During an observation on 1/12/2026 at 4:30 p.m., in the dining room, staff served resident meal trays. One blue ice scoop (a small shovel used to serve ice cubes) was stored in a bucket filled with ice on the 'Drink service cart'. Staff served residents ice in their cups then returned the scoop to the ice bucket. Staff repeated this process throughout the dining service. During an interview on 1/12/2026 at 4:52 p.m., with CNA 4, CNA 4 stated they were not aware of the facility's policy that addressed whether ice scoops may be stored inside ice buckets but reported the ice scoops on the units were stored separately. CNA 4 stated the 'Drink service cart' was prepped for service by kitchen staff with the ice scoop already stored in the ice bucket. During an interview on 1/12/2026 at 5:16 p.m., with the Certified Dietary Manager (DM), the DM stated ice scoops should be stored separately from the ice. The DM stated repeatedly touching the ice scoop and putting it back into the ice bucket should not be done to avoid contamination of the ice. The DM stated staff required reeducation on the proper handling of the ice. During an interview on 1/15/2026 at 4:10 p.m., with IP 2, IP 2 stated the facility followed the Centers for Disease Control and Prevention (CDC- the national public health agency of the United States) guidelines for infection prevention and control practices utilized in the facility. A review of the CDC's document titled Part II. Recommendations for Environmental Infection Control in Health-Care Facilities dated 1/11/2024, indicated, .Do not handle ice directly by hand, and wash hands before obtaining ice .Do not store the ice scoop in the ice bin. 6. During a concurrent observation and interview on 1/12/2026 at 2:27 p.m., with HK 1, in the 'C-Wing' Biohazard room, there was a cluttered area that contained nine bags of trash, one plastic container with yellow fluid, and cardboard boxes that were stacked on the biohazard receptacle (bin) and room counter. Trash bags were also stuffed underneath the counter. The large black trash bin used to store and transport trash was empty. During an interview on 1/13/2026 at 10:10 a.m., with the Environmental Services Manager (ESM), the ESM stated facility trash was not collected at the regular scheduled time, therefore the trash was left on the floor. The ESM stated the trash was removed from the bin to make room for the excess and that this practice occurred on occasion when the trash not picked up by the vendor. The ESM stated there was no process in place to address the excess trash when not collected as scheduled. During an interview on 1/15/2026 at 4:10 p.m., with IP 2, IP 2 stated discarded trash left on the floor was unsanitary. The IP 2 stated trash should be stored in the appropriate containers to prevent contamination and transmission of germs. The IP 2 stated she was aware that trash service was delayed, however staff should have promptly removed the trash from the floor and stored the trash in the assigned trash bin. During a review of the facility's P&P titled Medical Waste- Containers and Storage dated 1/01/2012, the P&P indicated, .waste is stored so that it is protected from animals and does not provide a breeding place or a food source for insects and rodents .The infection control coordinator or designee monitors the medical waste storage areas to assure that medical waste is treated, disposed of, or picked up by the authorized vendor on a timely basis .

Based on interview and record review, the facility failed to ensure one of 29 sampled residents (Resident 9) was treated with dignity and respect, when Resident 9 used her call light to request assistance and did not receive staff assistance for approximately 45 minutes. This delay in response demonstrated a lack of respectful and dignified care and had the potential to negatively impact the resident's self-esteem. Resident 9 stated the delay in assistance was disrespectful.During a review of Resident 9's face sheet (a document containing demographic and admission information), it was noted that the resident was admitted to the facility on [DATE]. The documented diagnoses upon admission included Parkinsonism (a slowly progressive neurological disorder characterized by the gradual loss of dopamine-producing nerve cells in the brain) urinary tract infection, and a history of falls.During a review of Resident 9's Minimum Data Set (MDS-a resident assessment tool used to identify cognitive and physical functional status) assessment dated [DATE] it was noted that Resident 9's Brief Interview for Mental Status (BIMS) score was 11 out of 15. According to the BIMS scoring scale (0-6 severe cognitive impairment, 7-12 moderate cognitive impairment, 13-15 cognitively intact), this score indicates that Resident 9 had a moderate cognitive deficit.During an interview on 1/12/2026 at 3:07 p.m. with Resident 9, Resident 9 stated an incident that occurred on 1/11/2026 at approximately 7:10 p.m. Resident 9 further stated her urine leaked through her brief and clothing. She activated her call light to request staff assistance. According to the resident, she waited approximately 30 minutes with no response. Due to the lack of assistance, she independently propelled herself in her wheelchair to the nursing station to request help. Resident 9 stated after an additional 40 minutes, a staff member arrived and assisted her with changing her brief.During an interview on 1/14/2026 at 9:28 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 9 was frequently incontinent with bowel and bladder and staff should assist Resident 9 immediately upon request. During an interview on 1/14/2026 at 2:04 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 9 was incontinent of bowel and bladder. The CNA 2 stated that all call lights should be answered in a timely manner, generally within five minutes. CNA 2 further stated that it was unacceptable for a soiled brief to remain on a resident for approximately 45 minutes.During an interview on 1/14/2026 at 3:50 p.m. with License Vocational Nurse (LVN) 1, LVN 1 confirmed she worked the PM shift on 1/11/2026. LVN 1 stated while she was administering medications, Resident 9 approached her in the hallway in her wheelchair and requested assistance with changing her soiled brief. LVN 1 stated that she informed Resident 9 that CNA 1 was on a scheduled break and Resident 9 needed to continue to wait. During an interview on 1/14/2026 at 4 p.m. with CNA 1, CNA 1 confirmed she worked the PM shift on 1/11/2026 and was assigned to provide care to Resident 9. CNA 1 stated that at approximately 8:35 p.m., LVN 1 approached her and requested that she assist Resident 9. CNA 1 stated that LVN 1 reported Resident 9 was seated in her wheelchair, appeared upset, and stated that her call light had been activated for approximately 30 to 35 minutes. CNA 1 further stated that upon entering Resident 9's room, the resident was yelling at her and stated her call light had been on for an extended period. During an interview on 1/15/2026 at 8:44 a.m. with Resident 9, Resident 9 stated the delay in assistance was disrespectful.During a review of the facility policy and procedure (P&P) titled, Call System, date 8/24/2024, the P&P indicated, . Facility Staff will answer call alerts promptly and in a courteous manner.During a review of the facility's P&P titled, Resident Rights-Quality of Life, date January 2017, the P&P indicated, To ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being .

Based on observation and interview the facility failed to ensure the residents' disposable care equipment (emesis basin, urinal, and urine collection containers) was maintained in a clean, sanitary and safe manner. The disposable care equipment's were found unlabeled, undated and uncovered in multiple residents' bathroom and at bedside. This deficient practice had the potential to expose residents to cross contamination and risk for infection.Findings:During initial rounds on 1/12/2026 at 2:50 p.m. to 2:54 pm, the following were observed:Bathroom in room [ROOM NUMBER]- there was an unlabeled urinal hanging on the safety rail and one unlabeled plastic bottle of body wash. There were two female residents housed in the room [ROOM NUMBER]. Bathroom in room [ROOM NUMBER]- there was an uncovered, unlabeled urine collection container found on the floor. There were two female residents housed in room [ROOM NUMBER]. Bathroom in room [ROOM NUMBER]- there was one unlabeled and undated emesis basin containing one toothbrush with a dried whitish substance covering the bristles and one unlabeled half-filled bottle of body wash.room [ROOM NUMBER] A- there was one unlabeled urinal hanging on the bedrail. Bathroom in 314- there was two unlabeled emesis basins containing one toothbrush each basin with a dried whitish substance covering the bristlesBathroom in 316 B- there was one unlabeled emesis basin containing one toothbrush with a dried whitish substance covering the bristles.During an interview 1/13/2026 8:53 a.m. with Certified Nursing Assistant 6 (CNA), CNA 6, stated that all disposable care equipment (emesis basin, urinals, and urine collection containers) should not be stored on the floor and they should be covered with clear plastic bag, labeled and dated. During an interview on 1/13/2026 at 8:57 a.m. with CNA 7, CNA 7 stated that the disposable care equipment such as basins, urinals and emesis basin are to be changed on a weekly basis. During an interview on 1/14/2026 9:24 a.m. with Infection Preventionist 1 (IP), IP 1 stated that these disposable items should be stored in a plastic bag labeled with their name and room number when not in use and it should be disposed of when soiled. During an interview on 1/14/2026 at 9:31 a.m. with IP 2, IP 2 stated that her function was to oversee infection control and CNAs were expected to change the disposable equipment when it is soiled, and if the urinal lid was missing. IP 2 confirmed that all disposable equipment should be labeled with their name before use, it should be stored in a clean plastic bag and stored at their bedside. The urinals should have a lid and it could be hung in their rails for use. During an interview on 1/14/2026 at 9 a.m. with the Director of Nursing (DON), DON stated the facility had no policy on the care and disposal of residents' bedside care equipment.

Based on an interview and record review, the facility failed to inform the Office of the State Long-Term Ombudsman (SLTO - independent advocate for residents in nursing homes) when one of three sampled residents (Resident 159) was transferred urgently to the general acute care hospital (GACH) and subsequently discharged from the GACH to an assisted living. This failure had the potential for Resident 159 to not receive the proper oversite, protection, and advocacy of the Office of the State Long-Term Ombudsman regarding continuity of care for future medical needs.During a review of Resident 159's admission Record (AR), dated 1/15/2026, the AR indicated that Resident 159 was admitted on [DATE] for management of an infection requiring intravenous (IV - medication administered directly into a vein) infusion of an antibiotic (medication used to treat infection).During a review of Resident 159's Order Summary Report (OSR), dated 10/19/2025, the OSR indicated that Resident 159 started IV antibiotic infusion on 10/20/2025 and was to continue until 11/2/2025.During a review of Resident 159's Physician Order, (PO) dated 10/26/2025, the PO indicated for Resident 159 to be sent urgently to a higher level of care for further evaluation of AMS (altered mental status) with a 7-day bed hold.During a review of Resident 159's eINTERACT Transfer Form V5, dated 10/25/2025, the transfer form had no indication of ombudsman notification.During an interview on 1/15/2026 at 11:59 a.m. with the case manager (CM) 1, the CM1 indicated that it was her responsibility to notify the ombudsman of Resident 159's transfer to the hospital as soon as possible when urgently transferred. CM1 verified this was not done.During an interview on 1/15/2026 at 11:59 a.m. with the Social Services Director (SSD), the SSD indicated that it was her responsibility to track transfers and that Resident 159's transfer was not on her internal tracking list. The SSD verified that Resident 159 did get admitted to the acute care hospital and did not return to the facility. The SSD verified the ombudsman was not notified.During a review of the facility's policy and procedure titled, Notice of Transfer / Discharge (NTD), dated 10/2017, the NTD indicated that, the State Long Term Ombudsman . when a resident's urgent medical needs require immediate transfer . be provided notice as soon as practicable.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) for one resident (Resident 13) accurately reflected her clinical status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) for Resident 13. During a review of Resident 13's undated admission Record , it indicated Resident 13 was admitted to the facility on [DATE] with a diagnosis that included: Hypertensive and chronic kidney disease with heart failure and stage 5 chronic disease, or end stage renal disease (high blood pressure has significantly damaged the kidneys and heart, leading to kidney failure (Stage 5/ESRD), requiring dialysis or transplant, and often accompanied by heart failure), and dependence on renal dialysis.During a concurrent interview and record review on 1/14/2026 at 10:10 a.m. with MDS Coordinator (MDSC), Resident 13's MDS Section O: J1- Special treatments, dated 3/19/2025 was reviewed. The MDS Section O: J1 indicated Resident 13 was not on dialysis. MDSC stated Resident 13 was admitted on [DATE], was already on dialysis, and there was a discrepancy on the MDS entry, the data was not accurately entered for the annual MDS dated [DATE]. During a review of Resident 13's Order Summary Report dated 3/5/2025, it indicated, Resident has dialysis M, W, F {Monday, Wednesday, Friday} for end stage renal disease at {Name of dialysis Center}. Chair time is at 4:30 a.m.p/u {pick up} time at 4 a.m. During a follow up interview on 1/15/2026 at 4 p.m. with MDSC stated, We don't have a policy and procedure on data entry, per our DON (Director of Nursing) and consultant, we follow RAI (Resident Assessment Instrument).

Based on observation, interview, and record review, the facility failed to ensure baseline comprehensive, person-centered care plans were developed and implemented for one of 29 sampled residents (Resident 44) when:1. Resident 44 did not have a care plan to address an identified need for oral care.2. Resident 44 did not have a care plan to address enteral feeding (getting nutrition through the stomach) need within 48 hours of admission.These failures resulted in a lack of guidance for staff for the provision of necessary care and placed Resident 44 at risk of inadequate nutrition, infection, decline, and comfort.Findings:1.During a review of Resident 44's Face Sheet (demographics), Resident 44 was readmitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing), gastrostomy status (surgical opening in the stomach to receive nutrients and fluids via a tube), and type 2 diabetes mellitus (chronic condition when the body doesn't produce or use sugar effectively).During a concurrent observation and interview on 1/12/2026 at 3:03 p.m. with Resident 44 in his room, Resident 44's lips were severely cracked with flaking skin, and his tongue was red, cracked and covered with thick yellow scales. Resident 44 stated his lips and tongue were hurting and described the pain as a burning feeling. Resident 44 further stated staff were not consistent with providing daily oral care and he was unable to do it by himself.During a concurrent interview and record review on 1/15/2026 at 1:40 p.m. with the Director of Nursing (DON), Resident 44's Physician Orders (PO) dated 1/8/2026, and Care Plans were reviewed. The PO indicated oral care was to be completed every shift (three times a day) and there was no care plan for oral care. The DON stated Resident 44 should have a care plan for oral care.During a review of the facility's policy and procedures (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The baseline care plan will be developed and implemented, using the necessary combination of problem specific care plans to promote continuity of care and communication among facility staff. within 48 hours of the resident's admission. It will include, at minimum, the following information necessary on each care plan to properly care for a resident: initial goals based on the admission orders, physician orders.2. During a concurrent observation and interview on 1/12/2026 at 3:03 p.m. with Resident 44 in his room, there was a kangaroo pump (machine to deliver enteral feedings) next to Resident 44's bed, actively infusing [brand of nutrients] 1.5 calories at 50 mL an hour. Resident 44 stated he was previously hospitalized and lost the ability to swallow so he elected for a tube to be inserted in his stomach to receive nutrition.During a review of Resident 44's Physician Orders (PO), dated 1/8/2026, the PO indicated to administer [brand of nutrients] 1.5 calories at 50 mL an hour for 20 hours a day.During a concurrent interview and record review on 1/15/2026 at 1:45 p.m. with the DON, Resident 44's care plans were reviewed. The DON stated Resident 44 should have had a care plan completed within 48 hours of admission (by 1/10/2026) to include enteral feeding. The care plan for enteral feeding was not completed until 1/13/2026, five days after admission.During a review of the facility's policy and procedures (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The baseline care plan will be developed and implemented, using the necessary combination of problem specific care plans to promote continuity of care and communication among facility staff. within 48 hours of the resident's admission. It will include, at minimum, the following information necessary on each care plan to properly care for a resident: initial goals based on the admission orders, physician orders, dietary orders.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services for two of 29 sampled residents (Resident 44 and Resident 152), when:1. Resident 44 did not receive the necessary assistance with oral hygiene in accordance with the residents' assessed needs for seven days. This failure resulted in Resident 44 suffering unnecessary oral discomfort.2. Resident 152 did not receive physical therapy services necessary to maintain or improve functional abilities for two weeks. This failure had the potential to result in decline in mobility.Findings:1. During a review of Resident 44's Face Sheet (demographics), Resident 44 was readmitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing), gastrostomy status (surgical opening in the stomach to receive nutrients and fluids via a tube), and type 2 diabetes mellitus (chronic condition when the body doesn't produce or use sugar effectively).During a concurrent observation and interview on 1/12/2026 at 3:03 p.m. with Resident 44 in his room, Resident 44's lips were severely cracked with flaking skin, and his tongue was red, cracked and covered with thick yellow scales. Resident 44 stated his lips and tongue were hurting and described the pain as a burning feeling. Resident 44 further stated staff were not consistent with providing daily oral care and he was unable to do it by himself.During an interview on 1/12/2026 at 3:27 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 confirmed Resident 44 needed maximum assistance with oral care, and stated oral care was completed once a day. CNA 8 further stated oral care was completed on whichever shift was able to complete the task.During a concurrent interview and record review on 1/15/2026 at 1:40 p.m. with the Director of Nursing, the following documents were reviewed:-Resident 44's Physician Orders (PO), dated 1/8/2026, the PO indicated oral care was to be provided three times a day (every shift).-Resident 44's Oral Hygiene, dated 1/8/2026 through 1/15/2026, the Oral Hygiene indicated Resident 44 received oral care once a day on 1/8/2026 and 1/10/2026, and twice a day on 1/9/2026 and 1/11/2026 through 1/15/2026.The DON stated Resident 44 should have received oral care three times a day in accordance with the physician order.During a review of Resident 44's admission Minimum Data Set (MDS-federally required clinical assessment tool) Section GG, dated 10/29/2025, the MDS indicated Resident 44 required moderate assistance for oral hygiene.During a review of facility's policy and procedures (P&P) titled, Oral Care, dated 1/1/2012, the P&P indicated, All residents receive appropriate oral care . It is the responsibility of each staff member within the nursing department is to ensure good oral care for each resident. Document oral care on any pertinent observations in the resident's medical record.2.During a review of Resident 152's Face Sheet, Resident 152 was admitted to the facility on [DATE], with diagnoses to include hemiplegia following cerebral infarction affecting left side (inability to move one side after stroke- loss of oxygen to the brain), muscle weakness, abnormalities of gait and mobility (unsteady, difficulty walking), muscle atrophy (shrinking/getting weaker).During a concurrent observation and interview on 1/13/2026 at 8:49 a.m. with Resident 152 in his room, Resident 152 was sitting in a wheelchair next to his bed. Resident 152 stated he was supposed to receive physical therapy 5 times a week but last week he only received physical therapy twice. Resident 152 further stated he wanted more physical therapy, so he could get strong enough to go home.During a concurrent interview and record review on 1/14/2026 at 9:42 a.m. with the Director of Rehabilitation (DOR), the following documents were reviewed:-Resident 152's Physician Order (PO), dated 12/29/2025, the PO indicated Resident 152 was to receive physical therapy five times a week for four weeks with a goal to ambulate 150 feet with a walker.-Resident 152's Physical Therapy Treatment Encounter Notes (PTTEN), dated 1/4/2026 through 1/14/2026, the PTTEN indicated Resident 152 only received physical therapy two times (1/4/2026 and 1/10/2026) in ten days.The DOR confirmed Resident 152 did not receive physical therapy in accordance with the physician order for the week of 1/4/2026 to 1/10/2026. The DOR stated there was not enough days left in the week of 1/11/2026 to 1/17/2026 to receive physical therapy five times a week. The DOR further stated he was not aware of Resident 152 not receiving physical therapy in accordance with the physician order and the assistant director of rehabilitation (ADOR) was responsible for scheduling.During an interview on 1/14/2026 at 2:54 p.m. with the ADOR, the ADOR stated she scheduled Resident 152 for physical therapy five times a week and was unaware he did not receive therapy.During a review of Resident 152's admission MDS Section GG, dated 11/17/2025, the MDS indicated Resident 152 needed maximum assistance to stand from a sitting position and Resident 152 was unable to ambulate 10 feet due to safety concerns.During a review of Resident 152's Care Plan Report, dated 11/17/2025, the report indicated, at risk for further function decline due to muscle weakness and reduced mobility. pt [patient] will ambulate 150 ' [feet] FWW [front wheel walker]. PT [physical therapy] 5W4W [five times a week for four weeks].

Based on observation, interview, and record review, the facility failed to ensure safe administration of enteral nutrition (method of delivering liquid nutrition directly into the stomach or small intestine via a tube) for one of 29 sampled residents (Resident 44), when Resident 44 was observed lying flat while receiving nutrition via gastrostomy tube (surgical opening in the stomach to receive nutrients and fluids via a tube). This failure had the potential to result in aspiration (when food, liquid or saliva accidentally go down the airway) and pneumonia (lung infection).Findings:During a review of Resident 44's Face Sheet (demographics), Resident 44 was readmitted to the facility on [DATE] with diagnoses to include dysphagia (difficulty swallowing), gastrostomy status (surgical opening in the stomach to receive nutrients and fluids via a tube), and type 2 diabetes mellitus (chronic condition when the body doesn't produce or use sugar effectively).During a concurrent observation and interview on 1/12/2026 at 4:05 p.m. with Infection Preventionist (IP) 2, in Resident 44's room, Resident 44 was observed lying flat while receiving enteral feeding. IP 2 stated Resident 44 needed to be sitting up while receiving enteral feeding to prevent aspiration and infection.During an interview on 1/15/2026 at 1:45 p.m. with the Director of Nursing (DON), the DON stated no resident should ever lay flat while receiving enteral feeding for risk of aspiration.During a review of Resident 44's Physician Order (PO), dated 1/8/2026, the PO indicated to elevate the head of the bed 30-45 degrees while receiving enteral feedings.

Based on observation, interview and record review, the facility failed to ensure safe handling of oxygen treatment was followed according to facility's policy and procedure to one resident (Resident 61). This failure had the potential to adversely affect Resident 61's respiratory health when her nasal cannula oxygen tubing was not replaced after 7 days of use. During a review of undated admission Record, it indicated Resident 61 was admitted to the facility on [DATE] with diagnosis that included COPD {Chronic Obstructive Pulmonary disease, asthma {a chronic lung condition where airways become inflamed, swollen, and narrow, producing excess mucus, making breathing difficult, dependence on supplemental oxygen. During a concurrent observation and interview on 1/12/2026 at 1:55 p.m. in room [ROOM NUMBER] Bed B, Resident 61 was observed receiving Oxygen treatment via a nasal cannula {NC} at 3 liters per minute. Resident 61 stated, They change the tubing but not sure how often. During a review of Order Summary Report for Resident 61, dated 5/29/26, it indicated Check O2 tubing date to ensure current for the week every night shift every Sunday. During a concurrent observation and interview on 1/12/26 at 2:28 p.m. with the Licensed Vocational Nurse (LVN 4), LVN 4 stated, the NC tubing was changed, weekly, dated and timed. LVN 4 also stated that Resident 61 was receiving O2 treatment for COPD, a progressive lung condition causing airflow obstruction, making breathing difficult. During an observation of the NC tubing for Resident 61 with LVN 4, the date on tubing indicated ;1/3/2026. LVN 4 stated, It should have been changed on 1/10/2026. During a review of Order Summary Report for Resident 61, dated 12/12/2024, it indicated Oxygen @ 3 LPM via nasal Cannula continuously for COPD. During a review of facility's policy and procedure (P&P) titled, P- N P94 Oxygen Therapy, dated October 30, 2025, the P&P indicated. a. Oxygen equipment shall be maintained as follows: i. The tubing and mask should be changed at least every 7 days and labeled with the date of change.

Based on observation, interview, and record review, the facility failed to provide food at a palatable and safe temperature to one of 29 sampled residents (Resident 102), when Resident 102 was served cold soup during the meal. This failure had the potential to result in decreased meal satisfaction, inadequate nutritional intake, and increased risk of health complications such as unintended weight loss or dehydration. Findings:During an observation on 1/12/2026 at 5:02 p.m. in the dining hall, Certified Nursing Assistant (CNA) 5 served Resident 102 a cup of French onion soup. Resident 102 took a sip of the soup and shouted the soup was cold and she did not want the soup anymore.During an observation on 1/12/2026 at 5:05 p.m. in the dining hall, CNA 5 got a replacement cup of French onion soup and served again to Resident 102. Resident 102 took a sip of the soup and shouted, that is cold, I don't want it. Resident 102 pushed the cup of soup towards the other end of the dining table.During a concurrent observation and interview on 1/12/2026 at 5:07 p.m. with the Dietary Manager (DM) in the dining hall, the DM took Resident 102's second soup and checked the temperature, it read 116 degrees Fahrenheit. The DM stated the soup should have been hotter.During a concurrent observation and interview on 1/12/2026 at 5:27 p.m. with the DM in the kitchen, the DM went to the warmer and removed one of the cups of soup and checked the temperature. The temperature read 145 degrees Fahrenheit. The DM stated soups should be served at 170 degrees Fahrenheit.During a review of Recipe: French Onion Soup, dated 2025, the Recipe: French Onion Soup indicated, Serve on trayline at the recommended temperature of 170 F - 190 F .During a review of the facility's policy and procedures (P&P) titled, Food Temperatures, dated 10/10/2023, the P&P indicated, Acceptable serving temperatures. Soup. Preferable temperature 160 F - 175 F.

Based on observation, interview, and record review, the facility failed to ensure four of four outside dumpsters' lids were closed. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 146 residents.Findings:During a concurrent observation and interview on 1/12/2026 at 1:57 p.m. with the Dietary Manager (DM) outside in the trash area, four of four dumpsters had overflowing trash with lids being unable to close, and multiple items of trash scattered around the dumpsters on the ground that contained food items. The DM confirmed that trash should not be laying on the ground and the lids should be covering all trash in the dumpsters.During an interview on 1/14/2026 at 2:03 p.m. with the Registered Dietician (RD), the RD stated she oversees the kitchen and lids to the dumpsters should be fully closed, to keep rodents out.During a review of the U.S [United States] Food and Drug Administration's (FDA) Food Code, dated 2022, the FDA Food Code indicated in Section 5-501.15 Outside Receptacles, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers .

Based on interview and record review, the facility failed to ensure oversight and monitoring of antibiotic use for one of 29 sampled residents (Resident 44) when Resident 44 was administered two separate antibiotics without documented indication and appropriate physician review. This failure resulted in Resident 44 receiving two unnecessary medications with the possibility of adverse drug reactions and antibiotic resistance.Cross reference to F757Findings:During a review of Resident 44's Face Sheet, Resident 44 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease stage 3, and type 2 diabetes mellitus (chronic condition when the body doesn't produce or use sugar effectively).During a concurrent interview and record review on 1/16/2026 at 9:18 a.m. with Infection Preventionist (IP) 2, the following documents were reviewed:-Resident 44's Physician Orders (PO), dated 12/16/2025, the PO indicated to administer azithromycin 500 mg (milligram-unit of measurement) for three days for ppx (prophylactic-used for preventive measures).-Resident 44's PO, revised on 12/16/2025, the PO indicated to administer cefdinir 300 mg twice a day for 10 days for UTI (urinary tract infection- infection in the bladder, kidney or tube the urine travels through to exit the body).-Resident 44's Lab Results Report, dated 12/15/2025, the report indicated Resident 44 had a urine sample tested and the urine culture does not meet the UTI criteria. According to recent guidelines by multiple clinical societies, antibiotic therapy is not recommended . -Resident 44's Medication Administration Record (MAR), dated December 2025, the MAR confirmed Resident 44 received 13 doses of Cefdinir from 12/12/2025 to 12/18/2025 and three doses of Azithromycin from 12/16/2025 to 12/18/2025.-Facility Antibiotic tracking log, undated, the Antibiotic tracking log indicated Resident 44 was not being monitored for antibiotic use of azithromycin and cefdinir.The IP 2 confirmed there was no tracking or monitoring for Resident 44 while receiving two different antibiotics and stated Resident 44 should have been monitored by the IPs for antibiotic usage.During a review of the facility's policy and procedures (P&P) titled, Antibiotic Stewardship, dated 5/20/2021, the P&P indicated, The IP is responsible for tracking the following antibiotic stewardship processes. The antibiotic ordered, dose, route, and ordering physician as well as the cost of the drug. Whether or not the resident's condition met McGeer's Criteria [standardized set of rules used in nursing homes to consistently identify when a resident has an infection such as a UTI] when the antibiotic was ordered. if cultures were ordered. any changes in antibiotic orders during therapy. Outcomes of antibiotic therapy. The IP will provide results of tracking antibiotic use.

Based on interview and record review, the facility failed to ensure documentation was maintained to verify that influenza (a highly contagious viral infection of the respiratory tract) and pneumococcal (a bacterial infection that may cause pneumonia and other serious illnesses) immunizations were offered in accordance with facility policy to one of five residents (Resident 2) reviewed for immunizations. This failure placed Resident 2 at risk for acquiring influenza and/or pneumococcal disease.During a review of Resident 2's face sheet (a document containing demographic information), it was noted that the resident was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy (brain dysfunction caused by a chemical imbalance related to an underlying illness) and Pneumonitis (inflammation of lung tissue) due to aspiration of food and vomit.During a concurrent interview and record review on 1/15/2026 at 9:24 a.m. with the Infection Preventionist (IP) 2, IP 2 stated she was unable to locate documentation in the Resident 2's electronic medical record indicating that influenza and pneumococcal vaccines were offered or administered. IP 2 stated these immunizations should have been offered; however, the documentation was missing. Resident 2 was admitted to the facility on [DATE].During a review of the facility P&P titled, Pneumococcal Vaccination, dated 4/27/2023, the P&P indicated, .The facility will provide all residents the opportunity to receive the pneumococcal vaccine, unless it is medically contraindicated, or the Resident is already immunized according to the Centers for Disease Prevention and Control recommendations or state/local public health guidelines. To prevent pneumococcal disease and its complications to residents. To properly administer pneumococcal vaccination and monitor for complications .During a review of the facility policy and procedure (P&P) titled, Influenza Prevention and Control, dated October 2020, P&P indicated, .The facility will follow infection prevention and control policies and procedures to minimize the risk of Residents acquiring, transmitting or experiencing complications from influenza. Before offering the influenza vaccine, each Resident or the Resident's representative will be given education regarding the risk and benefits and potential side effects of the immunization. The CDC Vaccination Information Statement (VIS) will be used as part of the Resident's (representative's) education. B. Residents are offered an influenza immunization every year during flu season, unless the immunization is medically contraindicated, or the Resident has already been immunized during the current flu season. C. The Resident or representative must give consent prior to receiving the vaccine. They can refuse the immunization-with such refusal being noted in the Resident's medical record. 4. The Resident's medical record will include documentation that indicates, at a minimum, the following: i. The Resident or the Resident's representative was provided education regarding the risk and benefits and potential side effects of the influenza vaccination.

Based on interview and record review, the facility failed to follow infection prevention and control procedures for COVID-19 (a highly contagious respiratory infection) in accordance with the facility's vaccination policy, when:1. Resident 124 declined the COVID-19 vaccination; however, there was no documentation that the facility provided education regarding the risks and benefits of the vaccine. This failure posed the potential risk of COVID-19 transmission and compromised Resident 124's ability to make an informed decision regarding vaccination. 2. There was no documentation verifying Certified Nursing Assistant (CNA 1) was vaccinated for influenza and COVID-19. This failure risked 146 residents at risk of exposure of influenza and COVID-19.1. During a review of Resident 124's face sheet (a document containing demographic information), it was noted that the resident was admitted to the facility on [DATE] with a diagnosis that included Diabetes Mellitus (a chronic disease associated with abnormally high levels of the sugar glucose in the blood). During a concurrent interview and record review on 1/15/2026 at 9:39 a.m. with the Infection Preventionist (IP) 2, IP 2 stated that Resident 124 declined the COVID-19 vaccination. IP 2 further stated that she was unable to locate documentation indicating that the facility had provided education regarding the risks and benefits of the vaccine to Resident 124 or the resident's responsible party.During a review of the facility P&P titled, COVID-19 Vaccination Program, date 4/27/2023, the P&P indicated, . The Facility will offer SARS-CoV-2 vaccinations (including additional and booster doses) to all Residents. They will be encouraged but are not required to be vaccinated or boosted. In this case, all requirements of education, consent, administration, reporting and documentation will be the responsibility of the Facility.2. During a concurrent interview and record review on 1/15/2026 at 10:05 a.m. with the IP 2, IP 2 stated CNA 1 had consented to the influenza and COVID-19 vaccines; however, there was no documentation provided, confirming that the vaccines were administered.During a review of the facility P&P titled, COVID-19 Vaccination Program, date 4/27/2023, the P&P indicated, . All Health Care Personnel (HCP) are required to be fully vaccinated.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 obtained complete vital signs (heart rate, temperature, respiration [breathing] rate, and blood pressure [force of blood on the walls of the blood vessels as the heart pumps blood around the body] that indicate a person's essential body functions) for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 was unable to obtain viable vital signs after four attempts. This failure resulted in delay in care and resulted in Resident 1 being found unresponsive (medical emergency in which a patient does not respond to activity, touch, sound, other stimulation).Findings:During a review of Resident 1's admission Record (AR), dated 11/6/25, the AR indicated Resident 1 had diagnoses of Essential (Primary) Hypertension (elevated blood pressure, normal blood pressure is less than 120/80 mmHg [millimeters of mercury - measures the force of blood against the blood vessel]), and Atherosclerotic Heart Disease of Native Coronary Artery (build-up of fat inside the native coronary artery [original, natural blood vessel that supplies oxygen-rich blood to the heart muscle]) without Angina Pectoris (chest pain). The AR indicated, Resident 1 was DNR [Do not Resuscitate - healthcare providers will not perform Cardiopulmonary Resuscitation (chest compressions) or other life-saving measures if a patient's breathing or hear stops].During a review of Resident 1's Care Plan (CP), dated 7/20/24, the CP indicated, Focus. The resident has coronary artery disease [a condition where plaque buildup narrows or blocks blood vessels supplying oxygen-rich blood to the heart] . Interventions. Monitor blood pressure. Notify physician of any abnormal readings.During a review of the facility's Vital Sign Tower Preventative Maintenance (VSTPM - quarterly [every three months] inspection log), dated 10/17/25, the VSTPM indicated, the facility's vitals machine towers were last inspected on 10/17/25.During a review of Resident 1's Alert Note (AN), dated 10/17/25, the AN indicated, 7:15 [10/17/25] pm resident [1] was found unresponsive [not responding to verbal, touch, or pain] in bed. DON [Director of Nursing] and MD [Medical Doctor] notified. Family notified [LVN 1 notified the DON, MD, and Resident 1's family].During a review of Resident 1's Weights and Vitals Summary (WVS), (This document is used by CNAs to document the vital signs of the residents) dated 1/23/26, the WVS indicated, Resident 1's last vital signs were taken on 10/10/25.During an interview on 11/4/25 at 2:47 p.m. with CNA 1, CNA 1 stated on 10/17/25 at 3 p.m. she attempted to check Resident 1's blood pressure four times using the vitals machine tower, but there was no reading. CNA 1 stated the vital machines tower was showing three horizontal lines on her first two attempts, and then ERR (error) on her third and fourth attempt. CNA 1 stated at 5:30 p.m., she notified Licensed Vocational Nurse (LVN) 1, CNA 1 was unable to get Resident 1's blood pressure using the vital sign machine. CNA 1 stated she did not attempt to use a manual blood pressure monitor. CNA 1 stated at around 6:30 p.m. on 10/17/25, she went into Resident 1's room and saw Resident 1 unresponsive. CNA 1 notified LVN 1 Resident 1 was unresponsive.During an interview on 11/4/25 at 3:04 p.m. with LVN 1, LVN 1 stated CNA 1 told her CNA 1 was unable to obtain a blood pressure reading on Resident 1 on 10/17/25. LVN 1 stated she was going to use the manual blood pressure monitor to check Resident 1's blood pressure because sometimes the vital sign machine's blood pressure cuff would not work. LVN 1 stated she did not notify anyone when the vitals sign machine was not working. LVN 1 stated she did not get the chance to check Resident 1's blood pressure during her shift because Resident 1 became unresponsive when LVN 1 came back from her lunch. LVN 1 stated when she came back from lunch at around 7 p.m. on 10/17/25, she was notified Resident 1 was already unresponsive. LVN 1 stated Resident 1 was pale, cold, and without signs of life. LVN 1 stated Resident 1 was DNR (Do not Resuscitate [if the heart stops beating or if a resident stops breathing, it is the resident's choice to allow a natural death]).During an interview on 12/30/25 at 3:40 p.m. with DON, DON stated if CNA 1 was unable to take Resident 1's vital signs, the nurse should have checked Resident 1's vital signs. DON stated CNA 1 should have also attempted to use the manual blood pressure monitor if CNA 1 was unable to obtain a blood pressure reading using the vital sign machine. DON stated the facility did not get a report of a broken vitals machine tower on 10/17/25 (the day when CNA 1 was unable to obtain Resident 1's blood pressure using the vitals sign machine).During an interview on 1/8/25 at 12:33 p.m. with Maintenance Supervisor (MS), MS stated the facility had eight vitals machine towers. MS stated around the end of December 2025, before he checked the eight vitals machine tower for maintenance, he did not identify any of the towers as broken.During an interview on 2/2/26 at 3:13 p.m. with DON, DON stated if the vitals machine tower showed three horizontal lines, it meant the machine was trying to obtain a blood pressure reading. DON stated if the vitals machine tower showed ERR, it meant error, the blood pressure cuff was not properly attached, and the vitals machine tower was not pumping air into the blood pressure cuff.During a review of the facility's Owner's Manual Touchscreen Vital Signs Monitor (OMTVS), dated February 2024, the OMTVS indicated, EEE905: PRINTER ERROR TROUBLESHOOTING TIPS: DO NOT USE THE MONITOR. CONTACT DIRECT SUPPLY FOR SERVICES. IF THIS ERROR CONTINUES TO APPEAR, PLEASE CONTACT DIRECT SUPPLY WITH THE ERROR YOU ARE SEEING.During a review of the facility's policy and procedure (P&P) titled, Change in Condition, dated 8/25/22, the P&P indicated, 1. It is the responsibility of the person who observes the change to report the change to the Licensed Nurse. 2. The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate.During a review of the facility's P&P titled, Obtaining Vital Signs, dated 8/22/19, the P&P indicated, Purpose To take clinical measurements that indicated the state of a resident's basic body functions. Policy Vital signs are obtained as appropriate. Vital signs will include temperature, blood pressure, pulse and respiration rate. Procedure I. Vital signs will be taken with the following frequency but not limited to. When there is a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was served food at a palatable temperature. This failure had the potential for Resident 1 to not eat, lose weight, and not meet his nutritional needs.Findings:During a concurrent observation and interview on 8/1/25 at 1:24 p.m. with the Dietary Supervisor (DS), in Resident 1's room, Resident 1 was about to eat his lunch. DS checked the meat's temperature in Resident 1's the meal tray. DS stated the temperature was 100 (Fahrenheit-temperature measurement). During a concurrent observation and interview on 8/1/25 at 1:30 p.m. with DS, at the nurses' station, DS checked the temperature of the green beans and the salad in the test tray (a sample meal tray used to assess the quality and accuracy of food service, ensuring it aligns with dietary requirements and standards). DT stated the green beans were at 100 and the salad was at 50.During a concurrent observation and interview on 8/1/25 at 1:38 p.m. with Resident 1 in his room, Resident 1 had his meal tray on the tray table, Resident 1 stated his food was not hot enough to his liking.During a review of Resident 1's Outcomes Summary Report (OSR), dated 5/2/25, the OSR indicated, Resident 1's BIMS (Brief Interview for Mental Status - cognition assessment tool, 15-point scale: 0-7 severe impairment, 8-12 moderate impairment, 13-15 cognitively intact) score was 12.During a review of the facility's policy and procedure (P&P) titled, Food Temperatures, dated 10/10/23, the P&P indicated, 4. Acceptable Serving Temperature:.Meat, entrees > [greater than] 140.Hazardous salads, desserts < [less than] 41.

Based on observation, interview, and record review, the facility failed to: 1. Serve residents food timely and at a palatable (pleasant to taste) temperature for two of three sampled residents (Resident 1, Resident 2). 2. Document food temperatures prior to distributing the residents meals for two of three sampled residents (Resident 1, Resident 2). These failures had the potential for reduced resident meal intake and the potential for the residents to contract food borne illness. Findings: 1. During a review of Resident 1's Minimum Data Set (MDS -a standardized assessment to evaluate a resident ' s functional abilities and healthcare needs), dated 1/30/25, under the section Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns], the BIMS score was 15 (cognition intact). During an interview on 6/16/25 at 12:30 p.m. with Resident 1, Resident 1 stated at times (not specific) his meals come in very late, and the food can be cold when it is delivered. Resident 1 stated he loves to have coffee and when it is brought to him the coffee can be cold. Resident 1 stated he had not received his lunch meal yet. During a review of Resident 2's MDS dated [DATE], under the section BIMS, the BIMS score was 12. During an interview on 6/16/25 at 12:49 p.m. with Resident 2, Resident 2 stated meals were being served late. Resident 2 stated it is now 1:12 p.m. and lunch has not been provided. Resident 2 stated yesterday (6/15/25) she did not receive her dinner until 9 p.m. Resident 2 stated the food that is supposed to be hot is cold, and the food that is supposed to be cold is warm or hot. Resident 2 stated for example, when she is served milk it is warm. During an interview on 6/16/25 at 1:37 p.m. with Dietary Supervisor Assistant (DSA), DSA stated she has been aware of resident complaints (not specific who) regarding meals being served late. DSA stated the last complaints she heard about late meals were over the weekend. DSA stated breakfast should start to be served at 6:30 a.m. and all residents should have their meals by 7:30 a.m., Lunch should start to be served at 11:30 a.m. and all residents should be served by 12:45 p.m., Dinner should start to be served at 4:30 p.m. and all residents should be served by 5:45 p.m. During a concurrent observation and interview on 6/16/25 at 1:59 9.m. with DSA, the last lunch meal tray was served, and food temperatures were taken. DSA observed and confirmed the following food temperatures: a. Sweet potato fries were 101.5 degrees Fahrenheit (°F). DSA stated the temperature should have been 145 °F. b. Roast beef sandwich was 100 °F. DSA stated the temperature should have been 165 °F. c. Chocolate pudding was 66.6 °F. DSA stated the temperature should have been 41 °F or lower. d. Coleslaw was 70.9 °F. DSA stated the temperature should have been 41 °F or lower. e. Milk was 64.6 °F. DSA stated the temperature should have been 41 °F or lower. f. Chocolate milk was 60 °F. DSA stated the temperature should have been 41 °F or lower. g. Coffee was 159°F. DSA stated she was not sure what the temperature of coffee for residents should be. DSA stated the temperatures of food and drinks should be per the policy and procedure to prevent residents from getting sick. 2. During a concurrent interview and record review on 6/16/25 at 1:24 p.m. with DSA, the facility Food Temperature Log (FTL), dated June 2025 was reviewed. The FTL indicated the following missing temperature entries missing: a. On 6/1/25 - There were no temperature entries for facility residents dinner dessert, milk, juice, starch substitute (range of plant foods including grains like wheat, rice, barley, oats, rye, corn, and breads and potatoes) and meat substitute. b. On 6/2/25 - There was no temperature entry for facility resident lunch meat substitute. c. On 6/3/25 - There were no entries for facility resident lunch and dinner meat and starch substitute. d. On 6/4/25 - There were no entries for facility resident dinner meat and starch substitutes. e. On 6/5/25 - There were no entries for facility resident lunch meat substitute. There were no entries for facility resident dinner meat and starch substitutes. f. On 6/6/25 - There were no entries for facility resident dinner meat and starch substitutes. g. On 6/7/25 - There were no entries for facility resident dinner meat and starch substitutes. h. On 6/8/25 - There were no entries for facility resident lunch and dinner meat and starch substitutes. i. On 6/9/25 - There were no entries for facility resident lunch and dinner meat and starch substitutes. j. On 6/10/25 - There were no entries for facility resident dinner meat and starch substitutes. k. On 6/11/25 - There were no entries for facility resident dinner milk, meat, and starch substitutes. l. On 6/12/25 - There were no entries for facility resident dinner meat and starch substitutes. m. On 6/13/25 - There were no entries for facility resident dinner soup, entrée (main portion of the meal), mechanical soft (a type of diet texture) entrée, gravy, vegetable, starch, puree (a type of diet texture) meat, puree vegetable, puree starch, dessert, milk, juice, meat substitute, and starch substitute. n. On 6/14/25 - There were no entries for the facility residents breakfast juice, and milk. No entries for the facility resident lunch milk, juice, meat substitute, and starch substitute. No entries for facility resident dinner soup, entrée, mechanical soft entrée, gravy, vegetable, starch, puree meat, puree vegetable, puree starch, dessert, milk, juice, meat substitute, and starch substitute. o. On 6/15/24 - There were no entries for the facility resident dinner milk, juice, meat substitute, and starch substitute. p. On 6/16/25 - No entries for the facility resident lunch milk, juice, meat substitute, and starch substitute. No entries for facility resident dinner soup, entrée, mechanical soft entrée, gravy, vegetable, starch, puree meat, puree vegetable, puree starch, dessert, milk, juice, meat substitute, and starch substitute. DSA stated the temperature entries should have been placed into the log prior to the residents meal being served. DSA stated the FTL should be reviewed daily to ensure staff were placing the temperatures of the meals provided to residents. During a review of the facility ' s policy and procedure (P&P) titled, Food Temperatures, dated 9/28/23, the P&P indicated, Where to Record Temperature . Record the reading on DS16 -Form A - Temperature Log at the beginning of tray line making sure to take the temperature of each pan of product before serving. Acceptable Serving Temperatures . Cereal, gravy . > (greater than) 140 (degrees Fahrenheit) . Casseroles . >140 (degrees Fahrenheit) . Meat, entrees . >140 (degrees Fahrenheit) . Potatoes, pasta . >140 (degrees Fahrenheit) . Soup . >140 (degrees Fahrenheit) . Pureed food . >140 (degrees Fahrenheit) . Vegetable . >140 (degrees Fahrenheit) . Coffee . >140 (degrees Fahrenheit) . Hazardous salads, dessert . < (less than) 41 (degrees Fahrenheit) . Pastries, cakes . < 60 (degrees Fahrenheit) . Milk, Juice . <41 (degrees Fahrenheit) . Eggs . >140 (degrees Fahrenheit). If the temperature does not meet applicable serving temperatures, reheat the product or chill the product to the proper temperature . During a review of the facility ' s policy and procedure (P&P) titled, Meal Service Times, dated 7/1/14, the P&P indicated, Purpose . To provide the dietary department with guidelines for meal service. Meals are served at regularly scheduled hours . There is no more than 14 hours between dinner and breakfast the following morning . The Dietary Manager is responsible for monitoring meal service time daily to ensure the facility meets posted meal times. Meal times are typically at 7:00am (a.m.), 12pm (p.m.), 5:00pm.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was provided a meal tray for lunch. This failure had the potential for Resident 1 to experience unmet nutritional needs. Findings: During an observation on 1/30/25 at 1 p.m., with Resident 1, in Resident 1's room, Resident 1's roommate (Resident 3) was provided his meal tray by Certified Nursing Assistant (CNA) 1. When this surveyor exited Resident 1's room approximately 34 minutes later, Resident 1 had not received a meal tray. During a concurrent observation and interview on 1/30/25 at 1:34 p.m., with Licensed Vocational Nurse (LVN) 1, in the hallway, there were no meal carts left in the hallway. LVN 1 stated all lunch trays were passed to the residents and then picked up and returned to the kitchen. LVN 1 stated after speaking with several staff, none of the CNAs had passed Resident 1 a meal tray. During an interview on 1/30/25 at 1:36 p.m., with CNA 2, CNA 2 stated she was assigned to Resident 1. CNA 2 stated she did not provide Resident 1 a meal tray. During an interview on 1/30/25 at 2:20 p.m. with CNA 1, CNA 1 stated she did not deliver Resident 1's meal tray. During an interview on 1/30/25 at 3:28 p.m. with Director of Nursing (DON), DON stated Resident 1 should have been provided a meal tray. During a review of the facility's policy and procedure (P&P) titled, Menus dated 4/1/14, the P&P indicated, Purpose.To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.Daily menus will include planning for three meals and an evening snack.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent (%) when five medication errors occurred within 39 opportunities resulting in a 12.82% error rate for three of six sampled residents (Resident 45, Resident 74, and Resident 107). This failure had the potential for Resident 45, Resident 74, and Resident 107 not receiving the full therapeutic effects of the medications and potential for adverse health outcomes. Findings: During an observation on 1/7/25 at 8:59 a.m. with Licensed Vocation Nurse (LVN) 2 in Resident 45's room, LVN 2 administered Mucus Relief (medication to help relieve congestion) 400 mg (milligrams) to Resident 45. During a concurrent interview and record review on 1/7/25 at 2:22 p.m. with LVN 2, Resident 45's Medication Administration Record (MAR), dated January 2025 was reviewed. The MAR indicated the following medications: Mucinex Allergy Tablet (Fexofenadine HCl - medication to treat allergies) Give 1 tablet by mouth two times a day for coughing/allergies and Fluticasone Propionate (medication to treat allergies) Suspension 50 MCG/ACT (micrograms/actuation) 1 spray in each nostril one time a day for allergies 2 stated she administered Mucus Relief instead of Mucinex Allergy, as that was the only medication in stock. LVN 2 stated she charted Fluticasone as administered at 9 a.m. but she did not actually administer it to the Resident 45. During an observation on 1/7/25 at 10:51 a.m. with LVN 3 in Resident 74's room, LVN 3 administered Naproxen (medication to treat fever and pain) 220 mg and Simethicone (medication to treat bloating and gas) 80 mg. During a concurrent interview and record review on 1/7/25 at 2:45 p.m. with LVN 3, Resident 74's MAR, dated January 2025 was reviewed. The MAR indicated, Naprosyn Oral Tablet (Naproxen) Give 220 mg by mouth three times a day for PAIN MANAGEMENT TAKE WITH FOOD, administration time 8 a.m. The MAR indicated, Simethicone Oral Tablet 80 MG (Simethicone) Give 1 tablet by mouth after meals and at bedtime for gas/bloating, administration time of 9 a.m. LVN 3 stated both medications were given past the allowed time. During a review of Resident 107's MAR, dated January 2025, the MAR indicated the following: Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet via G-Tube one time a day.Docusate Sodium Liquid 50 MG/5ML Give 10 ml via G-Tube one time a day. Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet via G-Tube one time a day. Pepcid Oral Tablet 20 MG (Famotidine) Give 1 tablet via G-Tube one time a day. Magnesium Oxide Oral Tablet 400 MG (Magnesium Oxide) Give 1 tablet via G-Tube Two times a day. During a concurrent observation and interview on 1/8/25 at 10:17 a.m. in Resident 107's room, LVN 4 began to administer the following medications via Resident 107's gastrostomy tube (G-tube - a small flexible tube in the stomach to provide medications): Aspirin 81 (prevent blood clots) Oral Tablet Chewable, Docusate Sodium (to treat constipation) Liquid 50 MG/5ML (milliliters), Lisinopril (to treat high blood pressure) Oral Tablet 10 MG, Famotidine (to treat excessive stomach acid) 20 MG, Magnesium Oxide (to treat low magnesium levels) 400 MG. LVN 4 stated she had completed the medication administration at 10:18 a.m. and was going to dispose of the plastic medication cups from each medication. LVN 4 was asked by surveyor to recount the medications she had administered to Resident 107 and LVN 4 stated she had missed one crushed medication (unidentifiable) which remained in a medication cup. During a review of the facility's policy and procedures (P&P) titled, Medication - Administration, dated 1/1/12, the P&P indicated, Policy I. Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. Procedure I. Administration of Medications. B. The Licensed Nurse will prepare medications within one hour of administration. i. Medications may be administered one hour before or after the scheduled medication administered time. VI. Medication Rights A. Nursing Staff will keep in mind the seven rights of medication when administering medication. B. The seven rights of medication are: i. The right medication. iv. The right time.Documentation A. The time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administered the drug or treatment.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Fall Management Program, for one of three sampled resident (Resident 2) when the facility failed to: 1. Complete the Post Fall Evaluation (PEE- document to help identify possible causes of a fall and prevent future falls). 2. Develop a care plan (personalized plan of care outlining a person ' s needs and how they will be addressed) to prevent future falls for Resident 2. These failures resulted in Resident 2 falling multiple times in five months and sustaining left intertrochanteric (are bony protrusions on the thighbone) femoral (thigh bone) fracture (broken bone) requiring surgical operation. Findings: 1. During a review of Resident 2 ' s Admission Record, (AR) the AR indicated, Resident 2 was admitted on [DATE], diagnoses included Dementia (a decline in mental ability that affects a person's daily life; characterized by a loss of cognitive functioning such as thinking, remembering, and reasoning, that worsens over time), Bipolar disorder (a serious mental illness that causes extreme shifts in mood, energy, thinking, behavior, and sleep). During a review of Resident 2's annual Minimum Data Set, (MDS - an assessment tool) dated 7/30/24, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status) score was 3 (a score of 0-7 suggests the resident has severely impaired cognition). The MDS indicated Resident 2 need supervision or touch assistance (helper provides verbal cues and/or touching/steading and/or contact guard (staff provides a light touch to help a resident with balance while resident perform a task) assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) chair/bed-to-chair transfer (the ability to get to and from a bed to a chair (or wheelchair), and walk 50 feet (once standing the ability to walk at least 50 feet and make two turns). During a review of Resident 2 ' s Change of Condition, (COC) dated 6/20/24, the COC indicated Resident 2 had an unwitnessed fall (fall not observed by staff) in his room. Resident 2 ' s Post Fall Evaluation, (PEE) dated 6/20/24, was reviewed. The PEE under the Care Planning and Clinical Suggestions section were not completed (blank). During a review of Resident 2 ' s COC, dated 7/25/24, the COC indicated Resident 2 had an unwitnessed fall. The COC indicated, Received report from PM staff (Resident 2) sustained a fall. Upon walking into room resident lying in bed resting. Upon assessing (Resident 2), noticed small amount of blood to back of the head. Small laceration (cut or tear in the skin) noted.Recommendation of Primary Clinicians . Send to ER (emergency room ) for further Eval (evaluation). Resident 2 ' s PEE dated 7/25/24, was reviewed. The PEE under Fall Details, Contributing Factors, Medication Changes, Physical Findings, MDS, Care Planning, and Clinical Suggestions sections were not completed (blank). During a review of Resident 2 ' s COC, dated 9/1/24, the COC indicated Resident 2 had an unwitnessed fall exiting the restroom. The COC indicated, (Resident 2) was observed with blood on face and floor, . Ambulance called and sent to (acute hospital) for further evaluation. Resident 2 ' s PEE dated 9/1/24, was reviewed. The PEE under Fall Details was noted as incomplete. The PEE under Contributing Factors, Medication Changes, Physical Findings, MDS, Care Planning, and Clinical Suggestions sections were not completed (blank). During a review of Resident 2 ' s COC, dated 9/16/24, the COC indicated Resident 2 had an unwitnessed fall on the right side of Resident 2 ' s bed. Resident 2 ' s PEE dated 9/16/24, was reviewed. The PEE under Fall Details, Contributing Factors, Medication Changes, and Physical Findings were noted as incomplete. The PEE under Care Planning, and Clinical Suggestions sections were not completed (blank). During a review of Resident 2 ' s COC, dated 10/13/24, the COC indicated Resident 2 had an unwitnessed fall in the facility hallway. Resident 2 ' s Change of Condition Follow-Up Note, (COCFUN) dated 10/13/24, indicated, (Resident 2) had complaints of pain (pain scale not indicated) to left leg. (Resident 2) was transferred to (acute hospital) for further evaluation and treatment. Resident 2 ' s PEE dated 10/13/24, was reviewed. The PEE under Fall Details were noted as incomplete. The PEE under Contributing Factors, Medication Changes, Physical Findings, MDS, Care Planning, and Clinical Suggestions sections were not completed (blank). During a review of Resident 2 ' s hospital record, dated 10/13/24, the record indicated Resident 2 sustained an acute (sudden in onset) mildly displaced (out of alignment) left intertrochanteric femoral fracture. The record indicated Resident 2 had surgical repair of left intertrochanteric femoral fracture on 10/14/24. During an interview on 10/22/24 at 1:44 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Post evaluations (PEE) are completed to find the reason for fall, so the resident ' s care plan can be updated to prevent future falls. During a concurrent interview and record review on 11/19/24 at 12:19 p.m. with Director of Nursing (DON), Resident 2 ' s PEE dated 6/20/24, 7/25/24, 9/1/24, 9/16/24, and 10/13/24, were reviewed. DON confirmed the post falls evaluations (PEE) were not completed for the above fall incidents. DON stated, Post fall evaluations (PEE) information was used to develop care plans to prevent future falls. 2. During a concurrent interview and record review on 11/19/24 at 12:19 p.m. with DON, Resident 2 ' s COC, dated 6/20/24, 7/25/24, 9/1/24, 9/16/24, and 10/13/24 were reviewed. DON stated Resident 2 had multiple falls. Resident 2 ' s care plan with the focus on (Resident 2) is at high risk for falls related to Dementia, Gait instability (an abnormal, uncoordinated, or unsteady walking pattern) and history of recurrent falls, date initiated 10/31/23 was reviewed. There were no care plans developed for the fall incidents on 6/20/24, 7/25/24 and 9/1/24. DON confirmed care plans were not developed after Resident 2 ' s fall incidents on 6/20/24, 7/25/24, and 9/1/24. During a review of the facility ' s P&P titled, Fall Management Program, revised 3/13/21, the P&P indicated, To provide residents a safe environment that minimizes complications associated with falls .Post-Fall Response A. following every resident fall, the licensed nurse will perform a post fall evaluation and update, initiate, or revise the Resident ' s care plan as necessary .D. Once the Post-Fall Huddle is completed the licensed nurse will immediately update the care plan with recommendations E. The Post-Fall Huddle form and documentation of the post-fall investigation will go to the IDT (Interdisciplinary Team - group of professionals who assess, coordinate, and manage each resident ' s comprehensive needs) meeting for review Fall investigation, Reporting and Documentation A. Following a resident fall, the licensed nurse with the most knowledge of the incident will complete an incident and Accident Report . C. The IDT will investigate the fall including a review of the Resident ' s medical record, post-fall huddle and review of the incident and Accident Reports D. The IDT will review the circumstances surrounding the fall them summarize their conclusions on an IDT note . prevent more falls, the IDT will review and revised the care plan as necessary.

Based on observation, interview, and record review, the facility failed develop and implement a care plan (CP- provides direction on the type of nursing care the individual may need) for one of three sampled residents (Resident 1) identified as high risk for developing pressure injuries (PI- is localized damage to the skin and underlying soft tissue usually over a bony prominence). This failure resulted in Resident 1 developing a DTI (deep tissue injury- intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]) in left foot, a blister to right heel (back part of the foot below the ankle), and unstageable PI (obscured full- thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the PI cannot be confirmed because it is obscured by slough [yellow or white material consisting of dead cells which attaches to the wound bed] or eschar [dead tissue that forms over healthy skin]. If slough or eschar is removed, a Stage 3 [Full-thickness loss of skin, in which adipose (fat) is visible] or Stage 4 [Full-thickness skin and tissue loss with exposed muscle, tendon [flexible tissue, similar to a rope], ligament [a band of tissue that connects bones, joints or organs], cartilage [a strong, flexible connective tissue that protects joints and bones] or bone are visible in the pressure injury] are revealed) to the coccyx (tailbone). Findings: During an observation on 5/16/24 at 10:30 a.m. outside of Resident 1's room, Resident 1 was observed lying on his bed. Resident 1 was on his right side facing the wall with a lightweight blanket draped across his body. Resident 1 had pillows elevating his legs with his heels floating above the bed. During a concurrent observation and interview on 5/16/24 at 1:03 p.m. with Certified Nursing Assistant (CNA 3), outside Resident 1's room, Resident 1 was noted on his right side facing the wall with a lightweight blanket draped across his body. Resident 1 had pillows elevating his legs with his heels floating above the bed. CNA 3 stated was assigned to Resident 1. CNA 3 stated Resident 1 was dependent with activities of daily living (ADL). CNA 3 stated Resident 1 had multiple sores (PI). There was no meal tray noted in Resident 1's room. CNA 3 confirmed Resident 1 did not have a meal tray in his room and Resident 1 was not fed lunch. CNA 3 stated the last time she checked Resident 1 was at 10 a.m. today. CNA 3 stated she was assigned to the dining room for meal service. CNA 3 stated No one covers (provides care or services: feeding, changing, or turning for Resident 1) while I'm on break or when I'm assigned in the dining room. CNA 3 confirmed Resident 1 was in the same position she left him in at 10 a.m. (3 hours) today. During a review of Resident 1's Admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses including hemiplegia (muscle weakness or partial paralysis [unable to move body] on one side of the body that can affect the arms, legs, and facial muscles]) and hemiparesis (one-sided muscle weakness) following cerebral infraction (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles) affecting right dominant (ruling or governing) side, other symptoms and signs involving cognitive functions (such as attention, memory, and executive functions [reasoning, planning, problem solving, and multitasking]), following unspecified cerebrovascular disease (a variety of medical conditions that affect the blood vessels of the brain and the circulation [movement of blood] in the brain), unspecified severe protein calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), nutritional deficiency (occurs when the body is not getting enough nutrients such as vitamins and minerals) and need for assistance with personal care. During a review of Resident 1' s quarterly Minimum Data Set, (MDS- an assessment tool) dated 2/13/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- an assessment of cognition [mental processes including perception, memory, and thought]) score was 4 (a score of 0-7 indicates resident has severely impaired cognition). The MDS indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) for eating, toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on bed), lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support), and chair/bed-to chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, (Braden) dated 2/27/24, the Braden Scale indicated, Resident 1 scored 12 (score of 10-12 indicate high risk for developing a pressure injury). During a review of Resident 1's Nutrition/Dietary Note, (NDN) dated 4/12/24, the NDN indicated Resident 1's current weight was a 125 pounds on 4/5/24 in comparison to 141 pounds on 3/3/24 (16 pounds and 11.3% weight loss in approximately one month). The NDN indicated, Significant weight loss at 1 mo (month) and 6 mo is unplanned and undesired.Diet: regular diet (general or normal diet), regular texture (all food textures and covers [NAME] that people with no chewing or swallowing issues eat), thin liquids (are most often used if you do not have a swallowing problem with liquids. Examples are water, milk, tea, coffee, and juice) . (Resident 1) continues with GT (gastrostomy tube (also called a G-tube) is a tube inserted through the belly that brings nutrition directly to the stomach) in place . This writer visited (Resident 1) this morning. (Resident 1) has a thin appearance and muscle wasting (loss of muscle mass) to bilateral calf muscles. (Resident 1) eats better at lunch and dinner, (sic) and is assisted with meals but eats slowly.Due to significant weight losses; (sic) recommended restart enteral feedings (tube feeding delivers liquid nutrition through a flexible tube that goes directly into the stomach) for nocturnal feedings (when the tube feeding is done overnight). Recommended Jevity 1.5 (is calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) @ (at) 65 cc (cubic centimeters- unit of measure)/hr. (hour) x.(times) 12 hours. Goal: Enteral feeding/PO (by mouth) intakes to meet estimated nutritional needs; maintain adequate hydration status; improve skin integrity; no significant weight variance (changes in weight). During a review of Resident 1's SBAR (situation, background, appearance, and review) Communication Form, (SBAR) dated 4/20/24, the SBAR indicated, Wound Nurse notified me Resident has a new DTI in left foot (4/20/24). During a review of Resident 1's SBAR, dated 4/25/24, the SBAR indicated Resident 1 had a blister to right heel (4/25/24). During a review of Resident 1's SBAR, dated 4/26/24, the SBAR indicated, (Resident 1) noted to have a 4.2x3utd [sic] (unable to determine) pressure injury to coccyx today (4/26/24). During a review of Resident 1's SBAR, dated 4/28/24, the SBAR indicated, (Resident1) continues to be on monitoring for unstageable pressure injury to the coccyx, and blister to left heel, (Resident 1) turned and repositioned every 2 hours as tolerated. During a review of Resident 1's SBAR, dated 5/3/24, the SBAR indicated, Assessed by Wound Specialist with MD orders: left posterior (back) heel unstageable (4/28/24), left lateral (to the side of, or away from, the middle of the body) planter (the thick tissue on the bottom of the foot) foot DTI larger (4/20/24), Coccyx clarified to sacrococcyx (the fused sacrum [a triangular bone in the lower back] and coccyx)unstageable and larger (4/26/24), right heel clear fluid bister now DTI and larger (4/25/24) . During a review of Resident 1's NDN, dated 5/12/24, the NDN indicated, (Resident 1's) WTS (weights): 116.5# (pounds) (5/3/24) 127.8#(4/5/24) (sic), 141.4#(2/3/24) (sic), 144.6#(11/1/23) (sic) WT changes: 11.3#(8.9%)loss (sic) x1 week, 8.5#(6.8%) (sic) loss x1 month, 25.1#(17.8%)lossx3 (sic) months, 28.1#(19.4%)loss (sic) x6 months . Skin: US (unstageable) to left posterior heel, Sacrococcyx. (Resident 1) was placed on nocturnal feedings & (and) has snacks bw (between) meals. During a concurrent interview and record review on 5/30/24 at 12:44 p.m. with Director of Nursing (DON), The SBAR dated 4/20/24, 4/25/24, and 4/26/24, were reviewed. DON confirmed Resident 1 developed three PIs while in the facility's care. DON stated Resident 1 also had a significant weight loss. Resident 1's active care plans (care plans CNAs were able to view in point of care (POC= electronic charting system), was reviewed. There was no care plan developed and implemented for PI prevention. DON confirmed the findings and stated Resident 1 was sent out to the acute hospital (2/5/24) and when Resident 1 was sent out, the nurses deactivated Resident 1 ' s care plans. DON was informed Resident 1 had no lunch meal tray on 5/16/24. DON reviewed Resident 1's NDN dated 4/12/24 and 5/12/24, DON confirmed Resident 1 had orders to receive PO diet, snacks, and G-tube feedings. Resident 1's Documentation Survey Report, DSR dated 4/2024 and 5/2024, was reviewed and there was no documentation Resident 1 was provided 65 out 177 meals. DON confirmed the findings and stated Resident 1 should get a regular diet and should get three meals a day. During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention, revised September 1, 2020, the P&P indicated, To provide interventions for Residents identified as high risk for developing pressure injuries Policy The licensed Nurse will develop a care plan that contains interventions for Residents who have risk factors for developing pressure injuries or for those Resident who have pressure injuries and at risk of developing additional pressure injuries.II. Regardless of the score, the Licensed Nurse will develop and individualized care plan for the Resident's risk factors in consultation with the following: .C. Registered Dietician .III. The nursing staff will implement interventions identified in the care plan which may include,(sic) but are not limited to the following: . B. Repositioning and turning C. Heel and elbow protectors . E. Off-loading pressure from heels . K. Monitoring food and fluid intake .VII. Licensed Nurses will document the effectiveness of the pressure injury prevention techniques in the Resident's medical record on a weekly basis A. Interventions that are not effective or that the resident refuses . C. The care plan will be initiated on admission and updated as necessary .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the prescribed nutrition (three meals a day: breakfast, lunch, and dinner) to meet nutritional needs and maintain desirable weight. This failure resulted in a 24.5- pound weight loss and 17.3 percent (%) of body weight in two months for Resident 1. Findings: During a concurrent observation and interview on 5/16/24 at 1:03 p.m. with Certified Nursing Assistant (CNA) 3 outside Resident 1's room. CNA 3 stated she was assigned to Resident 1. There was no lunch meal tray noted in Resident 1's room. CNA 3 confirmed Resident 1 did not have a lunch meal tray in his room. CNA 3 confirmed Resident 1 did not have a meal tray in his room and Resident 1 was not fed lunch. CNA 3 stated she last checked Resident 1 at 10 a.m. today. CNA 3 stated she was assigned to the dining room for meal service and no one covers (provides care or services: feeding, changing, or turning for Resident 1) while I'm on break or when I'm assigned in the dining room. During a review of Resident 1's Admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses including hemiplegia (muscle weakness or partial paralysis [unable to move body] on one side of the body that can affect the arms, legs, and facial muscles]) and hemiparesis (one-sided muscle weakness) following cerebral infraction (occurs as a result of disrupted blood flow to the brain and you may become paralyzed on one side of the body, or lose control of certain muscles) affecting right dominant (ruling or governing) side, other symptoms and signs involving cognitive functions (such as attention, memory, and executive functions [reasoning, planning, problem solving, and multitasking]), following unspecified cerebrovascular disease (a variety of medical conditions that affect the blood vessels of the brain and the circulation [movement of blood] in the brain), unspecified severe protein calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), nutritional deficiency (occurs when the body is not getting enough nutrients such as vitamins and minerals) and need for assistance with personal care. During a review of Resident 1' s quarterly Minimum Data Set, (MDS - an assessment tool) dated 2/13/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- an assessment of cognition [mental processes including perception, memory, and thought]) score was 4 (a score of 0-7 indicates resident has severely impaired cognition). The MDS indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) for eating, toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), roll left and right (the ability to roll from lying on back to left and right side, and return to lying on back on bed), lying to sitting on side of bed (the ability to move from lying on the back to sitting on the side of the bed and with no back support), and chair/bed-to chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). During a review of Resident 1's care plan (CP- provides direction on the type of nursing care the individual may need) with the focus on nutritional problem or potential nutritional problem r/t [related to] low fluid/food intake, initiated 2/6/24, with the goal The (Resident 1) will maintain adequate nutritional status as evidenced by maintaining weight . no s/sx (signs and symptoms) of malnutrition (lack of proper nutrition), and [sic] consuming at least (70) % of all meals daily through review date. The CP indicated, Monitor/document/report PRN [as needed] any.Refusing to eat, . and Provide and serve diet as ordered. Monitor intake and record q [every] meals. During a review of Resident 1's Long Term Care Evaluation, (LTCE) dated 3/31/24, the LTCE indicated, Resident 1 was taking nutrition and hydration orally (by mouth) and had no signs or symptoms of swallowing disorder. During a review of Resident 1's CP with the focus on Consuming less food and fluids. Pushes staff away when assisted with meals. Gets agitated when directed against his will. , initiated 4/4/24, with the goal (Resident 1) will consume 50% of meals , initiated 4/14/24. The CP indicated, Do not rush the patient to eat. Take your time to assist patient to eat. , initiated 4/14/24, Encourage patient to eat at least 75% of meal served. , initiated 4/14/24, and monitor percentage of meals consumed , initiated 4/14/24. During a review of Resident 1's Nutrition/Dietary Note, (NDN) dated 4/12/24, the NDN indicated, Resident 1's current weight was a 125 pounds on 4/5/24 in comparison to 141 pounds on 3/3/24 (16 pounds and 11.3% weight loss in approximately one month). The NDN indicated, Significant weight loss at 1 mo (month) and 6 mo is unplanned and undesired.Diet: regular diet (general or normal diet), regular texture (all food textures and covers food that people with no chewing or swallowing issues eat), thin liquids (are most often used if you do not have a swallowing problem with liquids. Examples are water, milk, tea, coffee, and juice) diet.pro (protein) + (plus) snacks TID (three times a day) Rt (Resident 1) continues with GT (gastrostomy tube [also called a G-tube] is a tube inserted through the belly that brings nutrition directly to the stomach) in place.This writer visited (Resident 1) this morning.(Resident 1) has a thin appearance and muscle wasting to bilateral calf muscles. (Resident 1) eats better at lunch and dinner, [sic] and is assisted with meals but eats slowly.Due to significant weight losses; [sic] recommended restart enteral feedings (tube feeding delivers liquid nutrition through a flexible tube that goes directly into the stomach) for nocturnal feedings (when the tube feeding is done overnight). Recommended Jevity 1.5 (is calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short- term tube feeding) @ (at) 65 cc (cubic centimeters- unit of measure)/hr. (hour) x.(times) 12 hours.Goal: Enteral feeding/PO (by mouth) intakes to meet estimated nutritional needs; maintain adequate hydration status; improve skin integrity. During a review of Resident 1's NDN, dated 5/12/24, the NDN indicated, (Resident 1's) WTS (weights): 116.5# (pounds) (5/3/24) .Jevity 1.5 @ 65 cc/hr x 12 hours. Diet: Regular- standard portion diet, Regular texture, Regular/Thin consistency (includes all liquids and is considered non-restrictive) . (Resident 1) Noted w/ (with) continued sig. (significant) weight loss. (Resident 1) has a variable PO intake. (Resident 1) was placed on nocturnal feedings & (and) has snacks bw (between) meals. During a concurrent interview and record review on 5/30/24 at 12:44 p.m. with Director of Nursing (DON), Resident 1's Order Details, (OD) dated 4/9/24, the OD indicated, Order Summary . diet Regular . DON reviewed Resident 1's OD dated 5/12/24, the OD indicated, Order Summary Fortified Diet (adding everyday foods which are high in calories and protein. This does not increase the volume but can significantly increase the calories, protein, and other nutrients) diet [sic] Regular texture, Regular/Thin consistency. DON stated Resident 1 should be provided three meals a day (PO- by mouth), snacks and nocturnal GT feedings (Jevity). Resident 1's Documentation Survey Report, DSR dated 4/24 and 5/24 indicated: Resident 1's Task Nutrition- Amount Eaten for 4/24 4/10/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/16/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/17/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/17/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/17/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/18/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/18/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/18/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/19/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/20/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/21/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/21/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/21/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/22/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/22/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/23/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/23/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/24/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/24/24 at lunch, the DSR indicated there was no documentation a meal was provided. 4/24/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/25/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/25/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/25/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/26/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/26/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/26/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/27/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/27/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/27/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 4/28/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/28/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/29/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/29/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/30/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 4/30/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 4/30/24 at dinner, the DSR indicated, there was no documentation a meal was provided. Resident 1's Task Nutrition- Amount Eaten for 5/24 5/1/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 5/1/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 5/1/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/2/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 5/2/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/3/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 5/3/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 5/3/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/4/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 5/5/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 5/5/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 5/5/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/6/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 5/6/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/7/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 5/7/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/8/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/13/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/14/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/15/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/18/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/19/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/20/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 5/20/24 at lunch, the DSR indicated, there was no documentation a meal was provided. 5/20/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/21/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/24/24 at dinner, the DSR indicated, there was no documentation a meal was provided. 5/25/24 at breakfast, the DSR indicated, there was no documentation a meal was provided. 5/26/24 at dinner, the DSR indicated, there was no documentation a meal was provided. During a concurrent interview and record review on 5/30/24 at 12:44 p.m. with DON, DON confirmed the above findings and stated there was no documentation Resident 1 was provided 65 out 177 meals. Resident 1's Weights and Vital Summary for 3/24 thru 5/24, was reviewed and DON confirmed Resident 1's weight on 3/3/24 was 141 pounds. On 4/5/23, 125 pounds (16-pound weight loss and 11.3 percent of body weight in approximately one month). On 4/26/24, 127.8 pounds and on 5/3/24, 116.5 pounds (11.3- pound weight loss and 8.8 percent of body weight in one week). DON stated Resident 1 had a weight loss of 24.5 pounds (17.3 percent of body weight in two months) in two months. During a review of the facility's policy and procedure (P&P) titled, Evaluation of Weight & Nutritional Status, revised April 21, 2022, the P&P indicated, To ensure that residents maintain acceptable parameters of nutritional status through evaluation of weight and diet. Policy I. The Facility will work to maintain an acceptable nutritional status for residents by: .B. Analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs. C. Defining and implementing interventions for maintaining, or [sic] improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice.II. Definitions.B. Weight Loss -5 % &/or 5lb [pounds] in one month, 7.5 in three months, or 10% in six months, as well as unplanned weight.C. Avoidable - The resident did not maintain acceptable parameters of nutritional status and that the Facility did not do one or more of the following: .(2) Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; (3) Monitor and evaluate the impact of interventions; .

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards when one of 22 sampled residents of (Resident 1) was allowed to smoke unsupervised with oxygen applied. This resulted in Resident 1 sustaining second degree burns (partial thickness burns involving the top two layers of the skin) to the right and left cheeks. Findings: During a review of Resident 1's Admission Record, (AR) the AR indicated, Resident 1 is an [AGE] year-old male, admitted on [DATE], with the following diagnoses: Dementia (is not a single disease, but a term for range of conditions that affect the brain's ability to think, remember, and function normally) with psychotic disturbances (refers to the mental state where person has trouble figuring out what is real, may have auditory, visual, hallucinations), bipolar disorder (mental illness characterized by extreme mood swings), schizophrenia (a serious mental disorder in which people interpret reality abnormally) and tobacco use. The AR indicated Resident 1 is his own responsible party. During a review of Resident 1 ' s care plan with the focus on [Resident 1] is a smoker, High risk for injury r/t [related to] smoking., initiated 2/23/22, the care plan included the following interventions: instruct resident about the facility policy on smoking: locations, times, safety concerns initiated 2/23/22, monitor oral hygiene initiated 2/23/22, and the [Resident 1] requires SUPERVISION while smoking initiated 5/22/23. During a review of Resident 1 ' s care plan with the focus on, [Resident 1] Safety Regarding Lighter Use, the resident is non-complainant [resistant] with the facility ' s policy and wants to keep a lighter and cigarette on him initiated 11/11/23, the care plan included the following interventions: discuss the consequences of fire hazards, including personal injury and community safety Initiated 11/11/23, document any incidents or near misses related to lighter use and adjust the care plan accordingly initiated 11/11/23, educate the resident on fire safety and the specific risks of carrying a lighter initiated 11/11/23, and provide alternative coping strategies if the lighter is used for non-smoking purposes . initiated 11/11/23. During a review of Resident 1 ' s Order Details (OD) dated 3/23/24, the OD indicated, Oxygen @ [at] 3L [liters-unit of measure]/ [per] min[minute ]Via Nasal Cannula [thin plastic tube used to deliver oxygen to the nostrils] to keep O2 [oxygen] Sat [saturations- how well the lungs are working] at/[or]above 93% [normal range 95%-100%] DX [diagnosis] SOB [shortness of breath] every shift. During a review of Resident 1 ' s Smoking Safety, (SS) evaluation dated 3/25/24, the SS indicated, Balance problems while sitting or standing. Follows the facility ' s policy on location and time of smoking . [Resident 1] has history of smoking (no documentation regarding Resident 1 ' s ability to hold, light, and extinguish cigarette or the type of supervision Resident 1 needed). During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 3/30/24, the MDS indicated, Resident 1' s Brief Interview for Mental Status score (BIMS score - an assessment to determine a resident ' s cognitive [term for mental processes] ability) score of 11 (a score of 8 to 12 indicates moderately impaired cognition). During a review of Resident 1 ' s Medication Administration Record, (MAR) dated 4/1/24 to 4/30/24, the MAR indicated Resident 1 received Oxygen @ 3L/min Via Nasal Cannula to keep O2 Sat at/above 93% DX SOB every shift -Start Date- 3/23/24 2300 . [required to check each shift, not documented each time oxygen is applied] During a review of Resident 1 ' s Progress Notes, (PN) dated 4/24/24 at 11:15 a.m., the PN indicated, [Resident 1] was found [sic] burns to the face while outside in the smoking area. During a review of the SBAR Communication Form [Method of documenting the condition of a patient to include Situation, Background, Assessment, Recommendation] dated 4/24/24 the SBAR Communication Form indicated, on 4/24/24 the resident sustained a skin wound or ulcer (open sore). The SBAR Communication Form indicated the resident sustained burns to the face and under the section titled Pain Evaluation, the documentation indicated the resident is experiencing pain due to Burns to face. During a review of Resident 1 ' s Weekly Skin/Wound Assessment, (WSWA) dated 4/24/24 at 12:25 p.m., the WSWA indicated Resident 1 sustained burns to the following areas: right cheek had popped blisters measuring 3.5 centimeters (cm - unit of measurement) in length and 2 cm in width; left cheek had a popped blister measuring 1.5 cm in length and 1.5 cm in width. The WSWA indicated, [Resident 1] has dark colored facial hair from soot/smoke to mustache, beard, right eyebrow, and eyelashes. During a concurrent observation and interview on 4/26/24 at 10:26 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was lying in bed. Resident 1 ' s face had circular redness with white colored substance noted on the right cheek approximately the size of a soda can, the skin under Resident 1 ' s nose was black (possible facial hair) with the white substance over the top of the skin, the left cheek had a quarter sized patch of red skin with white substance noted on top. Resident 1 stated, I started to light my cigarette and I just caught on fire [referring to the day of the incident on 4/24/24]. Resident 1 stated no one from the facility has talked to him about oxygen use on the smoking patio. Resident 1 stated I don ' t usually wear oxygen. Resident 1 stated he had a Certified Occupational Therapy Assistant (COTA 1) take him out to the smoking patio [on the day of the incident]. He stated, I told him [COTA 1] I want to go outside so I could smoke. Resident 1 stated when he went to the smoking patio there were no staff members present only other residents. Resident 1 stated occasionally there was a staff member on the smoking patio but usually it is only residents. During an interview on 4/26/24 at 10:48 a.m. with Certified Nursing Assistant (CNA 1), CNA I stated she has been assigned to care for Resident 1 and is familiar with his care needs. CNA 1 stated Resident 1 smokes independently and does not require assistance with holding or lighting his cigarette, she stated Resident 1 keeps his cigarettes and lighter in his room. CNA 1 stated he stores his cigarettes and lighter in his nightstand, and has found lighters in his closet. CNA 1 stated she has taken the resident out to the smoking patio area in the past. CNA 1 stated, when she takes the resident out to the smoking patio to smoke, If I don ' t see anyone [staff member on the smoking patio] I will just wait there with him. During an interview on 4/26/24 at 1:37 p.m. with Director of Nursing (DON), DON stated Central Supply (CS) was supposed to go to the smoking patio at 10 a.m. DON confirmed CS did not go to the smoking patio on 4/24/24. DON stated there was no staff on the smoking patio when Resident 1 sustained burns to the face. During a review of Resident 2' s MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 15 (13 to 15 points indicates cognitive intactness). During an interview on 4/29/24 at 2:07 p.m. with Resident 2, Resident 2 stated she was out on the smoking patio on 4/24/24. Resident 2 stated when she went outside to the smoking patio Resident 1 was already in the middle of the courtyard. Resident 2 stated Resident 1 had his oxygen on. Resident 2 stated, I told him [Resident 1] you cannot be smoking with oxygen on [and] he said, ' No no [COTA 1] turned it off. ' Resident 2 stated she was going to check to make sure his oxygen tank was off and just as she was next to Resident 1, she saw Resident 1 ' s face go up in flames. Resident 2 stated she grabbed the nasal cannula and threw it on the ground and then patted Resident 1 ' s face to put the fire out. Resident 2 then stomped on the nasal canula because it was still on fire. During an interview on 4/29/24 at 3 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated she responded when COTA 2 came running in on the date of the incident. LVN 1 stated COTA 2 informed her residents need a nurse outside on the smoking patio. LVN 1 stated, I went running and looked around, I noticed [Resident 1 ' s] face was black, and [Resident 2] was calling me over, the nasal cannula was black, and on the ground, it was not on fire. During an interview on 4/29/24 at 3:08 p.m. with COTA 2, COTA 2 stated she was crossing through the outside courtyard going to activities department, when she heard Help Help. COTA 2 stated she only saw two residents on the smoking patio. COTA 2 stated she turned around and ran to get a nurse. COTA 2 stated she took LVN 1 to where the two residents were outside on the smoking patio. During a concurrent interview and record review on 4/29/24 at 3:23 p.m. with Director of Nursing (DON), DON reviewed Resident 1 ' s OD, dated 3/23/24. DON stated Resident 1 did have an order for oxygen dated 3/23/24. DON reviewed Resident 1 ' s care plan initiated on 2/23/23 with the focus on, [Resident 1] is a smoker. High risk for injury r/t smoking. DON confirmed no interventions for oxygen were developed prior to the Resident 1 smoking with oxygen on and sustaining burns to his face. DON confirmed one of Resident 1 ' s care plan interventions initiated on 5/22/23 indicated Resident 1 needed supervision while smoking. DON confirmed Resident 1 was smoking unsupervised with oxygen on when his face caught on fire resulting in burns to Resident 1 ' s face. DON stated Resident 1 ' s face was observed to be black in color but then the face developed blisters, DON described Resident 1 ' s burns as second-degree burn. During a concurrent interview and record review on 5/30/24 12:18 p.m. with DON reviewed Resident 1 ' s care plan with the focus on, [Resident 1] Safety Regarding Lighter Use, the resident is non-complainant with the facility ' s policy and wants to keep a lighter and cigarette on him., initiated 11/11/23, the care plan included the following interventions: discuss the consequences of fire hazards, including personal injury and community safety initiated 11/11/23, document any incidents or near misses related to lighter use and adjust the care plan accordingly initiated 11/11/23, educate the resident on fire safety and the specific risks of carrying a lighter initiated 11/11/23, and provide alternative coping strategies if the lighter is used for non-smoking purposes . initiated 11/11/23. Requested the policy and procedure (P&P) regarding lighter use. DON stated the facility does not have a P&P for safe lighter storage. DON stated safe lighter storage now is a lock box, but prior to the incident the alert and oriented residents were allowed to keep their lighter and cigarettes. DON reviewed Resident 1's medical record and was unable to provide evidence the interdisciplinary team (IDT) developed an individualized plan of care for safe storage and use of smoking materials for Resident 1. DON was unable to provide evidence Resident 1 was educated regarding the risk of smoking and smoking safety measures. During a review of facility policy and procedure (P&P) titled, Resident Safety, revised 4/15/21, the P&P indicated, Purpose To provide a safe and hazard free environment Policy Resident will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstance that pose a risk for the safety and wellbeing of the Resident. Procedure I. During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident ' s safety (e.g., fall, smoking, . ) as well as any other Resident specific safety risks II. During the quarterly care plan review, when there is a change in condition or if an accident or incident occurs that involves the Resident ' s safety, the Resident ' s risk will be reevaluated III. After a risk evaluation is completed, a Resident -centered care plan will be developed to mitigate safety risk factors IV. The IDT will establish a person -centered observation or monitoring system for the resident to address the identified risk factors identified. During a review of facility P&P titled, Smoking Residents, effective date 8/18/23, the P&P indicated, 2. Smoking by residents is allowed outside the facility in designated, marked smoking areas with the following safety measures readily available: . 4. Oxygen use is prohibited in smoking areas.6. Using the Resident Smoking Assessment, the Licensed Nurse will assess residents who express a desire to smoke, upon admission, quarterly, annually and upon significant change of condition, and present it to the Interdisciplinary Team (IDT)for review. 8. The IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke. 9. The resident and/or Responsible Party will be educated regarding the risk of smoking and smoking safety measures recommended by the IDT. This document will be in the resident ' s clinical record.

Based on interview and record review, the facility failed to re-assess the pain and utilize pain medication according to physician's orders to treat breakthrough pain (a sudden increase in or exacerbation of pain that may occur in residents despite having a stable and well controlled chronic pain regimen) for one of four sampled residents (Resident 1). This failure resulted in unmanaged moderate to severe pain for a terminally ill (illness that cannot be cured and is expected to end in death) resident (Resident 1). Findings: During an interview on 2/26/24 at 10:18 a.m. with Resident 1, Resident 1 stated he had a lot of issues with pain, especially at night. Resident 1 stated he did not feel like his pain was being managed. During a review of Resident 1's Minimum data Set (MDS- comprehensive assessment tool) under Brief Interview for Mental Status (BIMS- an assessment used to determine the ability to think and remember), dated 12/18/23, the BIMS indicated, Resident 1 had a BIMS Summary Score of 10. BIMS of 8-12 indicates some cognitive impairment but still able to make needs known. During a review of Resident 1's Order Summary Report (OSR), dated 2/26/24, the OSR indicated, Diagnoses. IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY (damage of the peripheral [close to the edge or boundary] nerves where cause cannot be determined). PRIMARY OSTEOARTHRITIS [breakdown of the joints causing pain], LEFT ANKLE AND FOOT. UNILATERAL [on one side] OSTEOARTHRITIS, LEFT KNEE. DISPLACED FRACTURE [broken bone]. LEFT FEMUR [leg bone]. During a review of Resident 1's OSR, dated 2/26/24, the OSR indicated, Acetaminophen [medication also known as Tylenol, used to relieve mild to moderate pain] Extra Strength Oral Capsule 500 MG [milligrams] (Acetaminophen) Give 1 capsule by mouth three times a day for pain management. Acetaminophen. Give 2 tablet by mouth every 8 hours as needed for PAIN SCALE 1-4 [pain screening tool used to assess pain severity at that moment in time using a 0-10 scale, with zero meaning no pain and 10 meaning worst imaginable pain and where 1-3 indicates mild pain, 4-6 indicates moderate pain, and 7-10 indicates severe pain]. Morphine Sulfate [medication used to treat moderate to severe pain]. Give 0.25 ml [milliliters] by mouth every 1 hours as needed for pain or breathlessness. Morphine Sulfate Oral Tablet 15 MG. Give 1 tablet by mouth every 8 hours for pain. During a concurrent interview and record review on 2/26/24 at 1:24 p.m. with Director of Nursing (DON), Resident 1's Weights and Vitals Summary (WVS), dated December 2023, January 2024 and February 2024 were reviewed. The WVS indicated, Resident 1 complained of pain using a pain scale on the following dates and times: December 2023 12/24/23 at 8:25 a.m. 5/10 12/24/23 at 1:23 p.m. 4/10 12/24/23 at 5:07 p.m. 8/10. Resident did not have pain re-assessed again until 12/25/23 at 9:35 a.m. 5/10. 12/26/23 at 9:02 a.m. 5/10 12/27/23 at 5:02 p.m. 7/10. Resident 1's pain did not get re-assessed until 12/28/23 at 8:42 a.m. January 2024 1/31/24 at 8:52 a.m. 6/10 1/30/24 at 9:13 a.m. 6/10 1/25/24 at 4:14 p.m. 4/10 1/24/24 at 5:48 p.m. 5/10 1/24/24 at 8:44 a.m. 6/10 1/19/24 at 7:56 a.m. 6/10 1/18/24 at 9:36 a.m. 6/10 1/13/24 at 8:53 a.m. 6/10 1/12/24 at 12:42 p.m. 5/10 1/12/24 at 8:36 a.m. 6/10 1/7/24 at 8:30 a.m. 6/10 1/7/24 at 12:49 p.m. 4/10 1/6/24 at 9:39 a.m. 5/10 1/1/24 at 4:43 p.m. 6/10 February 2024 2/23/24 at 8:40 a.m. 6/10 2/18/24 at 8:45 a.m. 6/10 2/17/24 at 4:19 p.m. 6/10 2/17/24 at 8:24 a.m. 6/10 2/14/24 at 9:08 a.m. 7/10 2/12/24 at 5:02 p.m. 4/10 2/11/24 at 12:35 p.m. 4/10 2/11/24 at 9:14 a.m. 6/10 2/6/24 at 9:02 a.m. 6/10 2/5/24 at 4:20 p.m. 4/10 2/5/24 at 8:46 a.m. 8/10 During a concurrent interview and record review on 2/26/24 at 1:41 p.m. with DON, Resident 1's Medication Administration Record (MAR), dated December 2023, January 2024 and February 2024 were reviewed. The MAR indicated, Acetaminophen (medication also known as Tylenol, used to relieve mild to moderate pain) . Give 2 tablet by mouth every 8 hours as needed for PAIN SCALE 1-4. Morphine Sulfate (medication used to treat moderate to severe pain) . Give 0.25 ml by mouth every 1 hours as needed for pain or breathlessness. DON stated Resident 1 should have been given something for breakthrough pain if routine pain medications were not effective. DON stated morphine or Tylenol was not administered anytime in December 2023, January 2024, or February 2024 when Resident 1 complained of pain. During a concurrent interview and record review on 2/26/24 at 1:58 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's MAR, dated December 2023, January 2024 and February 2024 were reviewed. The MAR indicated, Resident 1 had complained of moderate to severe pain on multiple occasions. LVN 2 stated Resident 1 has Tylenol and liquid morphine for breakthrough pain. LVN 2 stated Resident 1 should have gotten the liquid morphine if he was complaining of pain 6, 7, or 8 out of 10. During a concurrent interview and record review on 2/26/24 at 2:02 p.m. with LVN 2, Resident 1's clinical record (CR) was reviewed. LVN 2 was unable to locate any documentation or progress note indicating Resident 1's pain was addressed. LVN 2 stated there was no documentation in the clinical record that hospice [program that provides pain and symptom relief to people who are near the end of life] was notified, or a non-pharmacological [intervention that does not involve the use of medicine] was used to alleviate pain on the days Resident 1 complained of moderate to severe pain in December 2023, January 2024, or February 2024. During an interview on 2/26/24 at 2:07 p.m. with LVN 1, LVN 1 stated when she gives Resident 1 his routine Tylenol, the system triggers her to document the residents pain level. LVN 1 stated she is not required to re-assess pain level after administration of routine pain medication. LVN 1 stated she only goes back to re-assess pain level if the medication is given as needed (PRN) because only PRN orders trigger her to re-assess the pain level. During an interview on 2/28/24 at 2:08 p.m. with Registered Nurse Case Manager (RNCM), RNCM stated she works for the hospice company, she goes out to see Resident 1 about twice a week. RNCM stated Resident 1 was complaining of pain a lot more at night last September, so the physician increased his morphine from 2 times a day to 3 times a day. RNCM stated Resident 1 will sometimes complain of pain in his left arm even with the routine pain medications. RNCM stated Resident 1 would benefit from the PRN pain medications and she and the other hospice nurses had previously educated the facility licensed nurses about utilizing the morphine PRN. RNCM stated Resident 1 likes to take the liquid morphine with Pepsi because he does not like the taste. RNCM stated Resident 1 is alert and able to verbalize his needs. During a review of Resident 1's Nursing Summary Notes (Hospice NSN), dated 12/11/23, the NSN indicated, Education provided to Staff on giving the Morphine Sulfate PRN in between the routine one. Advice to mix it with soda, juice, or ice cream because the patient is complaining that the taste is so bad and that is the reasons why he doesn't want to take it. Staff verbalizes understanding. During a review of Resident 1's Notes on Pain (NOP), dated 12/20/23, the NOP indicated, Patient reporting pain to back, states it is all the time. [LVN 2] located and reports patient receives MSER [Morphine Sulfate Extended Release-medication designed to release an active ingredient over a period of time] TID [three times a day] and has not been using MSIR [Morphine Sulfate Instant Release-medication designed to release active ingredient instantly providing relief for a shorter period of time]. Advised to offer to patient. During a review of Resident 1's care plan (CP), dated 8/7/23, the CP indicated, Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. During a review of Resident 1's care plan (CP), dated 10/25/23, the CP indicated, Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. During a review of the facility's policy and procedure (P&P) titled, P-PA01 Pain Management, dated 05/25/23, the P&P indicated, 1. Pain Assessment a. A pain assessment will be completed for each resident upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is a significant change in status. b. The Licensed Nurse will complete a Pain Assessment for residents identified as having pain. 2. Pain Management a. The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR) b. After medications/interventions are implemented, the licensed nurse will re-evaluate theresident's [sic] level of pain within one hour. c. The Licensed Nurse will assess the resident for pain and document results on the MAR each shift d. If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician. 4. Documentation a. Pain Assessments will be maintained in the resident's medical record. b. The Licensed Nurse will document resident's pain level and response to interventions in the medical record. c. The Licensed Nurse will update the Care Plan for pain management with any change in treatment and/or medication.

Based on observation, interview and record review, the facility failed to ensure 1. Two staff (Certified Nursing Assistant [CNA] 1, and Licensed Vocational Nurse [LVN] 1) followed the facility policy and procedure (P&P) on transferring residents with a mechanical lift for one of one sampled resident (Resident 1). 2. Implement Resident 1's care plan for safe transfer when two staff members did not assist Resident 1 with a mechanical lift transfer. These failures resulted in Resident 1's unexpected fall to the floor, fractured (broken) left leg and emotional distress from feeling trapped by the cast. Findings: 1. During a review of Resident 1's Admission Record, dated 12/22/21, Resident 1's Admission Record indicated, the facility admitted Resident 1a [AGE] year-old male, on 5/19/22. Resident 1 ' s diagnoses included: generalized muscle weakness, chronic (permanent) kidney disease, respiratory (insufficient oxygen or excess carbon dioxide [waste product of breathing] in the blood) failure, type 2 diabetes mellitus (body unable to regulate and use sugar as fuel) with nerve damage, chronic obstructive pulmonary disease (COPD, a lung disease), morbid obesity (severely overweight, leading to health related conditions), heart disease with an irregular heart rhythm. Resident 1's Admission Record indicated, Resident 1 was legally blind. During a concurrent observation and interview on 1/24/23, at 11:08 AM, in Resident 1's room, with Resident 1, Resident 1 was lying in bed, his left leg in a fiberglass cast, resting on a pillow. Resident 1 stated on Sunday, 1/15/23, staff were transferring him in the lift when he fell hard to the ground and felt a lot of pain in his left leg. Resident 1 stated, I'm blind, I didn't see what exactly happened. Resident 1 stated, It kills me to lay here like this, I feel so trapped because of this cast. During an interview on 1/25/23, at 6:45 AM, with CNA 1, CNA 1 stated, on 1/15/23, he operated the mechanical lift controls and guided the sling with Resident 1 in it. CNA 1 stated, LVN 1 was standing behind Resident 1's wheelchair. CNA 1 stated, he thought the control button was accidentally pushed as the sling was pulled to position Resident 1, then Resident 1 suddenly dropped to the floor. CNA 1 stated, Resident 1's leg was underneath him on the left side. CNA 1 stated he checked the lift earlier that day, that it was running a little slow because the battery was going dead. CNA 1 stated, usually they (staff) just use the lift even when the battery is going dead. During an interview on 1/25/23, at 6:55 AM, with LVN 1, LVN 1 stated, she was standing behind the wheelchair, when she saw Resident 1 suddenly go down. LVN 1 stated, she thought CNA1 had already checked the lift before using it. LVN 1 stated, We don't help prepare the resident, we (nurses) just go in as the second person when they (CNAs) are ready. LVN 1 stated that it was only CNA 1 that guided the sling while also operating the controls for the mechanical lift. LVN 1 stated that she just went to the room to be there. LVN 1 stated that she does not feel comfortable operating the mechanical lift. LVN 1 was unable to verbalize the procedure for use of the mechanical lift in the transfer of a resident. During a review of Resident 1's Minimum Data Set (MDS-a standardized assessment tool) section G, dated 1/2/23, the MDS indicated that Resident 1 requires the physical assist of 2 or more staff during transfers between surfaces. During a review of the [Hospital] Emergency Documentation Computerized Tomography (CT, a serial X-Ray) Impression for Resident 1, dated 1/16/23, the Emergency Documentation CT Impression indicated, Resident 1 had a fracture to the left leg after falling from the mechanical lift. During a review of the [Hospital] History and Physical Reports for Resident 1, dated 1/16/23, the History and Physical Reports indicated, Resident 1 has a Fracture of femoral condyle (portion of the leg bone that sticks out by the knee), left, closed-s/p (after) fall from [hoyer, type of mechanical lift] lift . Patient likely poor candidate for surgery given already poor functional status, physical handicap and medical comorbidities (the presence of two or more diseases or medical conditions in a patient). During a review of the User Manual for the Invacare Reliant 450 (type of mechanical lift), dated 2018, the User Manual for the Invacare Reliant 450 indicated, With one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle (on select models) or sides of the sling to seat the patient well into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. During a review of the Total Mechanical Lift Competency Validation for LVN 1, dated 8/16/22, the Total Mechanical Lift Competency Validation indicated, two staff members must check that the battery is fully charged, two staff must ensure that the lift moves up and down, two staff must check the sling for damage, two staff must check the position of the sling is placed correctly, two staff should check that the sling being used is the correct sling for the lift, and two staff should verify the position of the sling prior to operation. During a review of the facility's policy and procedure (P&P) titled, Total Mechanical Lift, dated 9/29/16, the P&P indicated, Nursing Staff will be trained to use the mechanical lift . Two staff must check the lift battery is fully charged, there are no loose parts and it operates up and down. Two staff must check the sling, bindings, and loops for fraying, wear and tear, and damage. Two staff to check the sling being used was made for the use with the lift being used and the sling is the correct size. 2. During an interview on 1/26/23, at 2:53 PM, with the Director of Staff Development (DSD), DSD stated, the facility in-services for staff does not incorporate the mechanical lift user's manual, as part of the transfer of residents using the mechanical lift. DSD stated, the facility training does not include the role of each staff member during the transfer process while using the mechanical lift. DSD stated, both staff members should have checked the lift to ensure the mechanical lift was in working condition, both staff should help position the resident on the sling, and both staff members should be hands on during the transfer of the resident. DSD stated, while one staff member is operating the controls to raise the resident up, the other staff member should be guiding the resident and positioning the resident into the wheelchair. DSD stated, if both staff members are not actively assisting with the transfer, it is not an appropriate transfer. DSD stated, Both staff have to be hands-on, they can't just be in the room. DSD stated, all nursing staff in the facility should be competent in the use of the mechanical lift. During a review of Resident 1's Care Plan for Risk for Falls, initiated 7/11/22, the Care Plan indicated the following: Assist Resident with ambulation and transfers, utilizing therapy recommendations, assist resident with safe transfer utilizing the lift .Determine Residents ability to transfer resident required Hoyer lift with 2 persons assist . Evaluate fall risk on admission and PRN [as needed]. During a review of Resident 1's Care Plan for Activities of Daily Living (ADL) Self Performance, initiated 11/18/22, the Care Plan indicated, Resident 1 was totally dependent on 2 staff for transferring, and Resident 1 required mechanical lift with 2 staff assistance for transfers.

Based on observation, interview, and record review, the facility failed to maintain the nutritional status for one of 23 sampled residents (Resident 2) when: 1. Staff did not administer Resident 2's [MEDICATION(S)] (appetite stimulant) as ordered. 2. Staff did not provide Resident 2's eight ounces (oz - a unit of measurement) of whole milk and 120 milliliters (ml - a unit of measurement) and thickened cranberry juice at lunch time. 3. Interdisciplinary Team (IDT - group of medical professionals working together to provide best care for resident) members did not address consistently in their weekly meeting Resident 2's continued weight loss. 4. Staff did not consistently document Resident 2's food intake (meal percentage). 5. Staff did not consistently document Resident 2's weekly weight per facility's policy and as recommended by the Registered Dietitian (RD). These failures resulted in Resident 2's significant weight loss of 52.2 pounds (lbs - a unit of measurement) (31.4%) from 12/27/21 to 4/12/22 (three months and 16 days) and had the potential for dehydration. Findings: 1. During a review of Resident 2's Weights and Vitals Summary, dated 3/1/22 through 4/30/22, the Weights and Vitals Summary indicated, Resident 2 was 66 inches tall. The Weights and Vitals Summary indicated, Resident 2's weight, [on] 4/12/22, 114.2 lbs. Weight [on] 12/27/21, 166.4 lbs, [weight loss of] -31.4%, 52.2 lbs [total weight loss] . During a review of the Registered Dietitian (RD) Progress Notes, dated 4/7/22, the Progress Notes indicated, Suggest appetite stimulant. During a review of the RD's Progress Notes dated 4/22/22, the Progress Notes indicated, Res [resident] previously [with] order for appetite stimulant, though no [current] order found in med list. Res would benefit from stimulant greatly . Suggest appetite stimulant . During an interview on 4/25/22, at 11:55 AM, with Family Member (FM) 1, FM 1 stated, Since he [Resident 2] came here on 12/26/21, he has not been eating good. He [Resident 2] has been losing weight for some time. During a concurrent interview and record review, on 4/26/22, at 12:15 AM, with Quality Coordinator (QC), Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The PO indicated, [MEDICATION(S)] 400 mg [milligram - a unit of measure] po [by mouth] QD [once a day] . The PO indicated, [MEDICATION(S)] was discontinued (stopped) on 3/28/22. QC stated, [MEDICATION(S)] was not available and was not administered to Resident 2 since it was ordered by the physician on 3/22/22. During a concurrent interview and record review, on 4/26/22, at 12:30 PM, with Licensed Vocational Nurse (LVN) 1, Resident 2's Progress Notes, dated 3/29/22 was reviewed. The Progress Notes indicated, Was notified by pharmacy that [MEDICATION(S)] was on back order until further notice and they don't know when it will be in stock. LVN 1 stated, As far as I know there was no follow up [for another substitute medication for [MEDICATION(S)]] until 4/22/22 [24 days after the pharmacy had notified the facility about the [MEDICATION(S)] was on back order] and [30 days after the [MEDICATION(S)] was first ordered by the physician on 3/22/22]. During an interview on 4/29/22, at 2:50 PM, with Interim Director of Nursing (IDON), IDON stated, The licensed nurse should have called and informed the physician [on 3/22/22] that the medication [[MEDICATION(S)]] was not available and [the physician] could have changed the [[MEDICATION(S)]] order for another substitute. IDON stated, The nurse failed to inform him [physician] as soon as possible. IDON stated, the licensed nurse should always contact the doctor as soon as possible after being informed the medication was not available. During an interview on 4/26/22, at 12:40 PM, with RD, RD stated, she recommended [MEDICATION(S)] for Resident 2 and noted the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RD stated, she was not informed Resident 2's [MEDICATION(S)] was unavailable. During a review of the Progress Note, dated 4/29/22, at 8:13 PM, the Progress Note indicated, The order you have entered [MEDICATION(S)] Tablet 30 mg ([MEDICATION(S)]) [antidepressant, may cause weight gain in some people] Give 1 tablet by mouth at bedtime for M/B [manifested by] for poor appetite related to depression, unspecified. During a review of the Progress Note, dated 4/29/22, at 8:16 PM, the Progress Note indicated, Received new order to start Resident [2] on [MEDICATION(S)] for poor appetite. [Family] made aware. 2. During a concurrent observation and interview on 4/25/22, at 11:40 AM, with Restorative Nursing Assistant (RNA), in the dining area, Resident 2 was eating his lunch with other residents. Staff did not serve Resident 2 the eight oz of whole milk and the 120 cc of thickened cranberry juice as indicated on Resident 2's meal card. RNA stated, Resident 2 should have been served eight oz of whole milk (thickened) and the thickened cranberry juice for lunch. RNA stated, Resident 2 had been losing weight. During a review of the IDT Note, dated 4/11/22, the IDT Note indicated, Resident [2] is on fortified [extra calories/nutrients] puree texture diet with nectar thick liquids .RD saw resident on 4/7/22 and recommended appetite stimulant, start resident to RNA [assisted] dining .Goal is to halt weight loss. During a review of Resident 2's PO, dated 3/14/22, the PO indicated, 8 oz of whole milk TID [three times a day] with meals. During a review of Resident 2's PO, dated 3/22/22, the PO indicated, Diet Clarification: Fortified puree [blenderized] texture diet with nectar thick liquids as per RD recomm [recommendations]. During a review of the facility's policy and procedure (P&P) titled Physician Orders, dated 8/21/20, the P&P indicated, VIII. Whenever possible, the licensed nurse receiving the order will be responsible for documenting and carrying out the order . XI. Supplies and medications required to carry out the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. During a concurrent interview and record review, on 4/26/22, at 12:15 PM, with QC, the weekly IDT Notes, dated 3/22 and 4/22 were reviewed. QC stated, the IDT meeting for weight variance [change] occurred weekly every Thursday. QC was unable to provide written documentation of IDT meetings for weight variance for the weeks of 3/24/22, 3/31/22 and 4/7/22. QC stated, the IDT meeting for weight variance should have addressed Resident 2's continued weight loss weekly. During a review of the facility provided policy and procedure (P&P), titled, Nutritional Status Evaluation Committee, dated 6/2018, the P&P indicated, The weight of residents will be monitored for variance and the Nutritional Status Evaluation Committee will intervene when appropriate. II. Prior to each meeting, the Director of Nursing Services or designee will compile a list of residents who are at risk for, or in need of weight change. Residents that meet the following criteria may be included on the list for discussion: A. Insidious [gradual, unintended, progressive] weight change over a three (3) to twelve (12) month period B. 2% weight change in 1 week C. 5% and/or 5 pound weight change in 1 month D. 7.5% weight change in 3 months E. 10% weight change in 6 months. 4. During a concurrent interview and record review, on 4/29/22, at 4:05 PM, with Medical Record Director, Resident 2's Documentation Survey Report, dated 4/2022 was reviewed. The Documentation Survey Report indicated, on 4/13/22 and 4/14/22 during dinner time, the meal percentage were blank. Medical Record Director stated, staff should document Resident 2's food intake after each meal. During a review of the the facility provided P&P, titled, Food Intake - Recording Percentage & Nutritional Assessment, dated 1/1/12, the P&P indicated, After a resident has completed the meal, the CNA [Certified Nursing Assistant] will record the amount eaten on the resident's food intake record after the completion of each meal. 5. During a review of Resident 2's Monthly Nutrition Note, dated 4/7/22, the Monthly Nutrition Note indicated, Weight Changes: 25.6# [pounds] loss past mo [month] (18%), 43.4# loss past 3 mo (27.2%). Res [resident] [with] significant wt [weight] loss. Goal is to halt losses at this time. Suggest. weekly wts x 4 wks [weeks]. During a concurrent interview and record review, on 5/2/22, at 3:37 PM, with RD, Resident 2's Weekly Weights, dated 4/22 were reviewed. RD stated, she recommended weekly weights on 4/7/22, but there were no weekly weights documented for Resident 2, for the week of 4/18/22 to 4/22/22. During a review of the the facility provided P&P, titled, Evaluation of Weight & Nutrition Status, dated 1/2019, the P&P indicated, The Nutritional Status Evaluation Committee may include, but is not limited to: A. Director of Nursing Services and/or designee B. Dietician/Food and Nutrition Manager .E. Any resident meeting the criteria for physician prescribed weight loss and any resident at risk for weight loss .will be weighed weekly, with the weight entered the weekly weight progress notes. Weekly weights will be reviewed during the meeting of the Nutrition & Weight Variance Committee. i. Residents at risk include . the following: a. Significant weight loss or gain identified in a 30, 90, and 190 day period; b. Residents demonstrating insidious weight loss .

Based on observation, interview, and record review, the facility failed to ensure the Treatment Nurse (TN) 1 performed a pain assessment, and administered pain medication before changing the wound dressing of the pressure injuries for one of one resident (Resident 1). This failure resulted in Resident 1 requesting the treatment to stop and screaming in pain during wound dressing. Findings: During an observation on 4/26/22, at 9:02 AM, in Resident 1's room, Resident 1 was positioned to his left side, in bed for dressing change of his wounds. Certified Nursing Assistant (CNA) 1 was in the room to interpret for Resident 1. CNA 1 explained to Resident 1, the Treatment Nurse (TN) 1 will be changing the dressings to his wounds. It was noted TN 1 did not assess Resident 1 for pain prior to dressing change, nor anticipated pain. During an interview on 4/26/22, at 9:05 AM, with TN 1, TN 1 stated, Resident 1 was first admitted on [DATE] with multiple wounds. [Resident 1] had a Braden Score (evaluates patient's risk of developing a pressure ulcer; Very High Risk: Total Score 9 or less. High Risk: Total Score 10-12. Moderate Risk: Total Score 13-14) of 11 obtained on 9/16/21. TN 1 stated, on 4/11/22, [Resident 1] acquired the following pressure injuries: 1) A Stage 2 (a shallow open ulcer with a red/pink wound bed, without slough [soft dead tissue]) pressure injury to the right hip, unstageable (an ulcer difficult to categorize due to being covered by slough and/or eschar [hard dead tissue] in the wound bed), 2) Unstageable pressure injury to the right trochanter (upper end of the thigh bone). 3) Unstageable pressure injury to the side of the right foot, and 4) A deep tissue injury (purplish discoloration of intact skin or blood-filled blister) to the right heel. TN 1 stated, Resident 1 had an existing Stage 3 (full thickness skin loss) pressure injury to the coccyx (tailbone). During a concurrent observation and interview on 4/26/22, at 9:10 AM, with CNA 1, in Resident 1's room, TN 1 removed the old dressing from Resident 1's right thigh wound. Resident 1 (interpreted by CNA 1) stated, Stop Touching! Behave! CNA1 tried to calm the resident, especially during the cleansing of the wound with normal saline (solution used to clean wounds) solution. CNA 1 stated, [Resident 1] felt the cleaning solution was too cold. During a concurrent observation and interview on 4/26/22, at 9:15 AM, with CNA 1, in Resident 1's room, TN 1 removed the old dressing from Resident 1's coccyx and cleansed the wound. Resident 1 screamed in pain. Resident 1 (interpreted by CNA 1) stated, It hurts when you touch it. Stop messing with it so much. Stop! TN 1 did not stop and continued to dress Resident 1's wound. During a concurrent observation and interview on 4/26/22, at 9:18 AM, CNA 1 raised Resident 1's right foot to prepare for the wound dressing change on the side of the right foot and the right heel. Resident 1 screamed in pain. Resident 1 (interpreted by CNA 1) stated, It hurts really bad! My foot is no good no more. Stop messing with it. TN 1 continued to cleanse the wound with normal saline, applied [MEDICATION(S)] (an antiseptic to treat skin infection), alginate (highly absorbent dressing that reduces bacterial infection), and a thick dressing over the wound. TN 1 did not stop and continued to dress the wounds on the right foot, as Resident 1 screamed in pain. During an interview on 4/26/22, at 9:30 AM, with TN 1, TN 1 stated, I should have made sure he was given pain medication before I did the dressing. I did not give him pain medication. At 9:39 AM, TN 1 stated,Resident 1 gets daily wound dressing change. I should have given him the pain medication before treatment, waited for 30 minutes, and then started the dressing change. TN 1 stated, after the treatment, [Resident 1] was in severe pain and I told LVN 1 to give [Resident 1] pain medication. During a review of Resident 1's Treatment Administration Record (TAR), dated 4/2022, the TAR indicated, Cleanse unstageable pressure injury to the right thigh with normal saline, pat dry, apply [MEDICATION(S)], and a dry dressing daily times 21 days, then re-evaluate. Cleanse Stage 2 to right hip with normal saline, pat dry, apply [MEDICATION(S)] (topical cream to treat skin irritation), and cover with a dry dressing daily times 21 days, then re-evaluate. Cleanse Stage 3 to sacrococcyx [tailbone] with normal saline, pat dry, apply [MEDICATION(S)] [antibacterial cream], and cover with dry dressing daily times 21 days, then re-evaluate. During a concurrent interview and record review on 4/26/22, at 10 AM, with Medical Records Director (MRD), Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] was not administered for 29 days out of 30, except once on 4/26/22, with the time of administration not documented. MRD verified the findings and stated there were no pain medication administered for Resident 1 except on 4/26/22. During a review of Resident 1's MAR, dated 4/2022, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The licensed nurses documented zero pain for all the days in April, when wound dressing was done daily, except on 4/26/22. The MAR, dated 4/26/22, was reviewed. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (moderate pain). During a review of the facility's policy and procedure (P&P) titled Pain Management, dated 11/2016, the P&P indicated, Pain Assessment: A licensed nurse will assess each resident for pain. Facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible.ll. Pain Management: A. The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff will implement timely interventions to reduce an increase in severity of pain. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 1/1/12, the P&P indicated, IX. Documentation: A. The time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug or treatment.

Based on interview and record review, the facility failed to ensure one of one resident (Resident 1) was transferred from wheelchair to bed using a Hoyer Lift (a mechanical device used for transferring patients) with two-person assist. This failure resulted in Resident 1 sustaining severe pain (pain scale from 8-10) and fracture of the left distal femur (a break of the thigh bone just above the knee). Findings: During an interview on 4/27/22, at 1:56 PM, with Interim Director of Nursing (IDON), IDON stated, on 4/25/22, she reported to the Department [California Department of Public Health], [Resident 1] sustained a distal fracture to the left femur on 4/22/22 while being transferred from wheelchair to bed. IDON stated, she called the [CONDITION(S)] (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) center, spoke with the nurse and interviewed the driver of the transportation, who took [Resident 1] to and from the [CONDITION(S)] center. Neither the nurse and the driver reported [Resident 1] injured himself at the [CONDITION(S)] center nor during transport. IDON stated, she interviewed the two Certified Nursing Assistants (CNA 6 and CNA 7), who both claimed [Resident 1] buckled his knees while being transferred from wheelchair to bed, and then later complained of pain to the left knee. Initially, the nurse gave him Tylenol (mild pain [pain scale from 2-4] medication) for pain but was not relieved. He continued to call and complained of severe pain (pain scale from 8-10) to the left knee. [Resident 1] was given [MEDICATION(S)], (stronger narcotic pain medication) but pain was not relieved. IDON stated, she was notified around 8 PM. The nurse notified the doctor of {Resident 1 ' s] continued pain and was advised to send [Resident 1] to the hospital. IDON stated, she interviewed [Resident 1] and Resident 1 informed her (CNA) 6 and (CNA) 7 transferred him from wheelchair to bed, his legs bent, and then he felt pain on his left knee. During an interview on 4/27/22, at 2:16 PM, with CNA 6, CNA 6 stated, [Resident 1] came back from [CONDITION(S)] on 4/22/22, between 12 PM and 1 PM. [Resident 1] was in his room seated in his wheelchair and wanted to return to bed. We were passing and picking up trays when [Resident 1] pressed his call light and requested to go back to bed. CNA 6 stated, CNA 7 helped in getting [Resident 1] up from the wheelchair to the bed. We both held him under each arm, got him up, pivoted his body, moved him to the edge of the bed, and sat him down. We lifted his legs to the bed and made him comfortable in bed. Later, he complained of pain on the left knee. We notified Licensed Vocational Nurse (LVN) 7. LVN 7 gave him Tylenol for pain. CNA 6 stated, I know him from another long term care facility. We always do a two-person transfer, without the use of the Hoyer lift. Now, they tell us to transfer him using a Hoyer lift. During an interview on 4/27/22, at 2:40 PM, with CNA 7, CNA 7 stated, she was in the small dining room assisting another patient when CNA 6 called for help. CNA 7 stated, We held him [Resident 1] by his pants and stood him up to transfer from the wheelchair to the bed. CNA 7 stated, Usually, he helps to stand, but this time he did not. He must be tired from [CONDITION(S)]. We put him in bed and then later, he complained of pain to the left knee. The therapist who was working with him told us [Resident 1] required Hoyer lift on transfer. During an interview on 4/27/22, at 2:57 PM, with CNA 8, CNA 8 stated, she stayed with her patient [Resident 1] until 6 PM. At 5 PM, he was in a lot of pain on his knees. [Resident 1] explained how the girls (CNA 6 and CNA 7) transferred him to his bed, each holding him under his arm, his legs bent back, and his knees started hurting. CNA 8 stated, [Resident 1] was usually Hoyer. CNA 8 stated, the two girls who transferred him said they knew him from another long term care facility and over there, they transferred him with two-person assist without a Hoyer lift, and they were used to that. CNA 8 stated, We transfer him using a Hoyer Lift with two-person assist here since he is heavy. During an interview on 5/3/22, at 10:46 AM, with Resident 1, through a Spanish interpreter CNA 1, Resident 1 stated, he was in his wheelchair, and he wanted to go back to bed. Two girls helped him transfer to bed. The two girls were holding him under each arm. He did not fall. His knees buckled up and his knees started to hurt. His knees touched the floor, he was kneeling on the floor. Resident 1 stated, I did not have pain before I went to [CONDITION(S)]. I did not hurt myself at the [CONDITION(S)] center. I did not fall or hurt myself during transport from the [CONDITION(S)] to the facility. The pain started when I was being transferred from my wheelchair to bed. I do not remember them holding me by my pants. The girls were holding me under my arms. Resident 1 stated, I was being transferred using the 'machine' (referring to the Hoyer Lift) before the incident, but the two girls (CNA 6 and CNA 7) held me under my arms to transfer me from wheelchair to bed. I did not say anything. I thought they would use the machine. During a concurrent interview and record review, on 6/3/22, at 10:45 AM, with Medical Records Director (MRD), Resident 1's Minimum Data Set (MDS- an assessment tool), Section G of the MDS -Functional Status, Transfer, dated 4/27/22 was reviewed. The MDS-Functional Status on Transfer indicated, Self-performance: 4 [total dependence - full staff performance every time during entire stay 7-day period) and Support: 3 (two-person physical assist). MRD verified the findings. During a concurrent interview and record review on, 6/3/22, at 10:46 AM, with MRD, Resident 1's Physical Therapy Treatment Encounter Notes, dated 4/12/22 was reviewed. The Physical Therapy Treatment Encounter Notes indicated, Transfers: Chair/bed-to-chair transfer= Dependent (Hoyer lift). MRD stated, the therapist notes indicated [Resident 1] had to be transferred using a Hoyer Lift. During a concurrent interview and record review, on 6/13/22, at 12:10 PM, with Quality Coordinator (QC), the Interdisciplinary Team Notes (IDT- a team of health professionals with varying expertise working together collaboratively towards a common goal), dated 4/25/22 was reviewed. The IDT Notes indicated, [Resident 1] had an acute fracture of the distal femur and he required extensive two-person assist with bed mobility and transfer. It also indicated education had been started for safe transfer, and competency/skills check for all certified nursing assistants. QC stated, on stand-up meeting, they discussed safe resident transfer using the Hoyer Lift, which was recommended by the physical therapist. QC stated, she did not document in the IDT Notes the need for Resident 1 to use a Hoyer Lift on transfer. QC stated, on the day of the incident, the two CNAs [CNA 6 and CNA 7] did not transfer [Resident 1] using the Hoyer Lift. During an interview on 6/13/22, at 12:20 PM, with Director of Staff Development (DSD), DSD stated, she provided in-service education on safe transfer and the use of a Hoyer Lift to the certified nursing assistants [CNA 6 and CNA 7]. DSD stated, she did a focus training for CNA 6 and CNA 7. DSD was unable to provide documentation of the in-service training because her education binder was missing. During a concurrent interview and record review, on 6/14/22, at 12:15 PM, with Medical Records Director (MRD), Resident 1's ADL [Activity of Daily Living] Care Plan dated 5/2/22 was reviewed. The ADL Care Plan indicated, Use Hoyer Lift with two-person for transfer. During a review of the facility's policy and procedure (P&P) titled, Transfer, dated 1/1/12, the P&P indicated, Safe and efficient transfers are combination of the resident ' s physical ability and perceptual capacity, proper equipment, appropriate techniques, and good planning. ll. General Transferring Principles: . k. Do not pull on the arms of the residents. Use the least dependent transfer method possible. Vll. Mechanical Lift Transfer: A. Mechanical lift transfers are usually used for residents who are very large or extremely dependent.

Based on observation, interview, and record review, the facility failed to follow CDC (Centers for Disease and Control Prevention) recommended practices (Preparing for COVID-19 (a mild to severe illness that is caused by a coronavirus, is transmitted chiefly by contact with infectious material (such as respiratory droplet) and is characterized especially by fever, cough, and shortness of breath and may progress to pneumonia and [MEDICAL CONDITION]) in Nursing Homes.Cloth face coverings (cloth mask) are not considered PPE and should only be worn by HCP for source control, not when PPE is indicated) in the use of PPE when: a. One Occupational Therapist Assistant (OTA- works with residents to improve their self care skills) was wearing a cloth mask (textile (cloth) covers are intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing or coughing) inside the facility's Occupational Therapy room with residents' present. b. One Certified Nursing Assistant (CNA) 1 wore a cloth mask while performing resident care. c. Restorative Nursing Assistant (RNA) 1 wore a cloth mask while performing resident care. d. One Registered Dietitian (RD) was wearing a cloth mask at the nurse's station. e. One Admission Coordinator (AC) was not wearing a mask in the facility hallway. f. One Quality Assurance (QA) staff member was wearing a cloth mask while talking with residents' in facility hallway. g. One Social Services Worker (SS) 1 was wearing a cloth mask in the facility hallway. h. One Vocational Nurse Supervisor (LVNS) was wearing a cloth mask in the facility hallway. i. RNA 2 wore a cloth mask while performing resident care. These failures have the potential to result in continued spread of COVID-19 infection to 111 residents, staff, and visitors. Findings: a. During a concurrent observation and interview on 6/25/20, at 11:20 AM, with OTA, in the OT room with residents' present. OTA was observed wearing a cloth mask. OTA stated he worked directly with residents today wearing the cloth mask. b. During a concurrent observation and interview on 6/25/20, at 11:27 AM, with CNA 1, in the facility hallway. CNA 1 was observed wearing a white mask. CNA 1 stated the facility provided the cloth masks and she was unaware cloth masks were not to be worn at work. CNA 1 stated she helped residents' get dressed and changed their briefs wearing the cloth mask. c. During a concurrent observation and interview on 6/25/20, at 11:30 AM, with RNA 1, in the facility hallway. RNA 1 was observed wearing a white cloth mask. RNA 1 stated she was not told to wear a surgical mask. RNA 1 stated she wore the cloth mask while getting residents' up into the wheelchair. d. During a concurrent observation and interview on 6/25/20, at 11:35 AM, with RD, at the nurse's station. RD was observed wearing a cloth mask. RD stated they could wear either cloth or surgical masks. RD stated she wore a cloth mask, while talking with the residents' in their room regarding their diets. During an interview on 6/25/20, at 11:55 AM, with the Infection Preventionist (IP), IP stated CNA 2 was tested for COVID-19 and received a positive test result on 6/4/20. IP stated Resident 1, was admitted to the hospital on [DATE]. Resident 1 was tested for COVID-19 on 6/24/20, and received a positive COVID-19 test result on 6/25/20. IP stated the HCP should not wear cloth masks in the facility. IP stated HCP should be wearing surgical masks only. During a review of the Microbiology Immunology report, dated 6/25/20, the Microbiology(Study of simple organisms including viruses) Immunology (Study of immune system), the Microbiology Immunology report indicated Resident 1's COVID-19 nasopharyngeal test (sample was taken from back nose throat) was obtained on 6/24/20. Resident 1's COVID-19 test result on 6/25/20, indicated COVID-19 was detected (positive). e. During a concurrent observation and interview on 6/25/20, at 3:29 PM, AC was observed exiting the Administrative Coordinator's office without a mask. AC stated she should wear a mask while in the facility. f. During a concurrent observation and interview on 6/25/20, at 11:15 AM, in the facility hallway, QA was observed wearing a white cloth mask while talking to two residents' in wheelchairs. QA stated the facility provided the cloth mask. g. During a concurrent observation and interview on 6/25/20, at 11:25 AM, with SS 1, in the facility hallway. SS 1 was observed wearing a white cloth mask. SS 1 stated, They (cloth facial covering) are given by the facility. SS 1 stated he wears a cloth mask, while talking and interacting with the residents' in their room. h. During a concurrent observation and interview on 6/25/20, at 11:35 AM, with LVNS, in the facility hallway, LVNS was observed wearing a white cloth mask. LVNS stated, They gave each staff about five cloth masks. LVNS stated she wears a cloth mask while she performs medication administration and other direct patient care with the residents'. i. During a concurrent observation and interview on 6/25/20, at 11:45 AM, with RNA 2, in the facility hallway. RNA 2 was observed wearing a cloth mask. RNA 2 states she wears a cloth mask when she is assisting the residents' with changing their clothes or changing their briefs. During a review of the facility's policy and procedure titled, Cleaning Cloth Face Coverings (Masks) dated 6/2/20, indicated 1. Cloth face coverings (masks) may be worn by facility staff in non-direct care roles. During a review of CDC guidelines titled [MEDICAL CONDITION] 2019 (COVID-19) Interim Infection Prevention and Control Recommendations for Health Care Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 6/19/20, indicated HCP should wear a facemask at all times while they are in healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. When available, facemasks are preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth face coverings should NOT be worn instead of a respirator or facemasks if more than source control is needed. During a review of the Centers For Medicare & Medicaid Services (CMS) guidelines titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 6/19/20, indicated, HCP (Healthcare Personnel) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth face covering.

Based on observation, interview, and record review, the facility failed to provide adequate behavioral health services to meet the needs of one of four sampled residents (Resident 1) when the facility failed to: 1. Ensure individualized care plans were developed, revised and/or followed and failed to ensure the Interdisciplinary Team (IDT is a multidisciplinary group of professionals working collaboratively with a common purpose to set goals and make decisions for resident care) collaborated when Resident 1 had behavioral changes. This resulted in ongoing behavioral issues. 2. Ensure the licensed nurses conducted ongoing assessments and documentation of Resident 1's behavioral status every shift for 72 hours according to the Alert Charting Documentation policy and procedure. This had the potential for a decline in Resident 1's psychological well-being to go unnoted. 3. Ensure behavior monitoring was initiated when Resident 1 was started on an antipsychotic medication (a class of medication primarily used to manage [MEDICAL CONDITION]) for behavioral problems. This had the potential for ineffective medication management of behaviors to go unnoted and acted upon by staff. The above failures resulted in Resident 1 striking Resident 2 in the face causing a skin tear to Resident 2's mouth and Resident 2's right arm on 9/4/19 and had the potential for other residents to be harmed. Findings: 1. During a review of the facility report dated 9/4/19, the report indicated, 9/4/19 @ (at) 6:15 AM (Resident 1) approached (Resident 2) in the main dinning (sic) area and proceeded to punch (Resident 2) in the face and chest area. (Resident 2) fell to the ground after standing up and staff separated them and called the police department. During a review of a follow up report from the facility dated 9/4/19, the report indicated, . Body check was done to both residents (Resident 2) sustained a skin tear to the side of his mouth and to his right arm. No injuries noted on (Resident 1). Both residents were sent out to the acute hospitals. (Resident 1) for altered mental status and (Resident 2) for complaints of pain to his knees . During an observation and interview with Resident 1 on 9/10/19, at 10 AM, in the resident's room, he was noted sitting in a wheelchair. He asked, What the hell do you want? Resident 1 stated his left and right brain fight with each other. Resident 1 refused to answer any questions asked and stated he did not know where he was, what city he was in, and repeated that his brain was fighting with itself since 1938. During an interview with Licensed Vocational Nurse (LVN) 1 on 9/10/19, at 10:15 AM, she stated Resident 1 has a history of threatening staff and other residents. When she was asked if she could recall specific incidents, she was unable to state any specific incidents. During an interview with LVN 2, on 9/10/19, at 10:19 AM, she stated Resident 1 has a history of being aggressive. She stated the resident has physically threatened other residents with butter knives and has attempted to physically harm residents and staff by swinging his arms with closed fists in an attempt to hit them. During an observation and interview with Resident 2 on 9/10/19, in Resident 2's room, at 10:30 AM he stated, I got assaulted (by Resident 2). He stated on 9/4/19, Resident 1 entered the dining room around six in the morning and told him to Shut the (expletive) up. Resident 1 then approached him and punched him in the jaw causing Resident 2 to fall out of his wheelchair onto the floor. Resident 2 was observed with scratches to both his arms. Resident 2 stated the scratches were from the incident with Resident 1 which occurred on 9/4/19. Resident 2 stated he felt the facility was negligent by allowing Resident 1 get into altercations with everyone (referring to staff and residents). During an interview with Certified Nursing Assistant (CNA) 1, on 9/10/19, at 10:45 AM, she stated Resident 1 was known to get upset. During an interview with Registered Nurse (RN) 1, on 9/10/19, at 10:58 AM, he stated Resident 1 is known to be resistant to staff during personal care. During an interview with Resident 3, on 9/10/19, at 12:17 PM, he stated he was present when Resident 1 punched Resident 2 in the face causing him to fall. He stated Resident 1 told Resident 2 to 'shut the (expletive) up' and then punched him in the face. He stated a week before the 9/4/19 incident, Resident 1 entered the dining room and yelled at the residents in there. Resident 3 stated approximately two months prior, Resident 1 approached him and yelled at him. During a review of the clinical record of Resident 1 and interview with the Director of Nursing (DON), on 10/16/19, at 2:37 PM, the following nursing notes and Change of Condition documents were reviewed: a. On 3/15/19, at 2:15 AM, the nursing note indicated, Resident (1) refused to go to his room stating he didn't have to go to this room. Resident was yelling and throwing things at staff. Resident took pitcher off cart urinated in it and threw it at nurse. Police was called out. Resident is now in room [ROOM NUMBER]A temporary. On 3/15/19, untimed, a nursing note indicated, Resident refused V/S (vital signs which typically include blood pressure, pulse, respiratory rate and temperature). Resident is out of bed without any gown or clothes on. Resident refused to let CNA (Certified Nursing Assistant) put gown on. On 3/15/19, at 5:30 AM, the nursing note indicated, Resident is up still combative swinging at staff. Refusing to let CNAs take him back to his room. A short term care plan dated 3/15/19 at 2:15 AM, was written for the problem of Combative to staff. The one approach included to monitor closely. The DON could find no documented evidence the resident was monitored closely. The DON also stated a comprehensive long term care plan (a plan developed to meet the resident's long term care needs) should have been written but was not. b. On 5/27/19, at 6:35 PM, the Change of Condition document indicated, At around 6:35 PM, resident (1) came up to me @ the nurse's station asking if dinner was served. I told him that it was served 30 min (minutes) (ago) and complaining that he never had his dinner . they (CNAs) gave him a sandwich (and a) banana, but then all of sudden he threw it to the staff with no reason, then he grabbed the water container, water jug (and) threw it . The DON stated a comprehensive care plan was imitated for Resident 1 on this date 5/27/19. During a review of the problem RESIDENT CARE PLAN . BEHAVIOR PROBLEM dated 5/27/19, the problem indicated Resident 1 was verbally abusive and had socially inappropriate behavior with potential for harming others. The interventions listed included to monitor and document behaviors in the MAR (medication administration record) and to refer Resident 1 to the behavior management committee. After reviewing the clinical record for Resident 1, the DON could find no documented evidence behavior monitoring was initiated or that the resident was referred to the behavior management committee. c. On 6/5/19, at 12:30 PM, the Change of Condition document indicated Resident 1 threatened residents and family members in the dining area with butter knives. The documentation indicated Resident 1, was . showing knives (butter) from the kitchen to family members of other residents. Resident was in the hallway with three butter knives in his hand . Very combative (and) aggressive, thinks people are trying to kill/hurt him. After reviewing the clinical record of Resident 1 the DON was unable to find any new approaches to the care plan although she stated there should have been new approaches to address the resident's behavior. She also stated an Interdisciplinary Team meeting should have been conducted and there was no documented evidence an IDT meeting was held to address the resident's behavior. d. On 6/26/19, at 12 AM, the nursing notes indicate Resident 1 became combative with staff and was resistive with care. The DON stated there were no new approaches or revisions to the care plan. The DON stated there should have been new approaches and revisions to the care plan. e. On 6/30/19, at 7 AM, the nursing notes indicate Resident 1 threw a vase at the wall in the dining room because he was cold. The DON stated there was no IDT, no revision to the care plan. She stated there should have been an IDT meeting conducted and the care plan should have been revised to include new approaches. During a review of Resident 1's Minimum Data Set (MDS assessment which measures the health status of residents) dated 7/24/19, the MDS indicated the resident's cognition was moderately impaired. During a review of the facility policy and procedure titled, Behavior Management last revised 3/2018, the policy indicated, Purpose . To ensure the facility provides the necessary behavioral health care and services to residents in accordance with their comprehensive assessment and person-centered plan of care . Procedure . II When a resident exhibits mood/behavioral symptoms, the IDT will assess the resident's mood and behavior status and document in the medical record . III Implementation of interventions to alleviate possible causal factors . When a behavioral problem is recognized through the nursing assessment utilizing the change of condition process . Nursing Staff will share the assessment results with the Interdisciplinary Team (IDT) . The IDT will attempt to identify the root cause of the behavior . The IDT will convene to discuss care plan interventions and document the IDT recommendations and interventions in the medical record . the Behavior Management/Psychoactive Review Committee will . Review care plan(s) to determine if care plan(s) need to be up-dated; Utilize the IDT assessment process to identify additional resources if the resident does not respond to standard interventions and/or medications. During a review of the facility policy and procedure titled, Comprehensive Person-Centered Care Planning last revised 11/2018, the policy indicated, . It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents . updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident . The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment . In addition, the comprehensive care plan will also be reviewed and revised at the following times . Onset of new problems . Change of condition . To address changes in behavior and care . During a review of the policies and procedures and interview with the Director of Nursing (DON), on 10/16/19, at 2:37 PM, after reviewing the policy and procedure for Comprehensive Person-Centered Care Planning she stated, Obviously we (facility) didn't follow this policy and procedure. DON stated the comprehensive care plan was not updated and implementation of interventions listed were not done as indicated. 2. During a review of the clinical record for Resident 1 and interview with the DON, on 10/16/19, at 2:37 PM, she stated Alert Charting is documentation done by the licensed nurses whereby the licensed nurse documents every shift (the facility has three shifts AM - 6:30 AM to 3 PM, PM - 3 PM to 11 PM, and Night - 11 PM to 6:30 PM) for 72 hours after a change of condition is identified with a resident. The DON reviewed the clinical record for Resident 1 and noted the following: a. On 3/15/19 at 2:15 AM, Resident 1 had verbal and physical outbursts. There was no alert charting by the licensed nurses after 2 PM on 3/15/19. No alert charting for 3/15/19 N[NAME] shift, 3/16/19 AM shift, 3/16/19 PM shift, 3/16/19 N[NAME] shift, 3/17/19 AM shift, 3/17/19 PM shift, or 3/17/19 N[NAME] shift. b. On 5/27/19 at 6:35 PM, Resident 1 had verbal and physical outbursts. There was no alert charting by the licensed nurses on 5/29/19 PM shift. c. On 6/5/19 at 12:30 PM, Resident 1 was threatening residents and resident family members. There was no alert charting by the licensed nurses on the 6/5/19 PM shift, 6/6/19 PM shift, and 6/8/19 AM shift. d. On 6/26/19 at 12 AM, Resident 1 was combative with staff and resistive to care. There was no alert charting by the licensed nurses documented other than the initial note at 12 AM. No alert charting on 6/26/19 AM shift, 6/26/19 PM shift, 6/26/19 N[NAME] shift, 6/27/19 AM shift, 6/27/19 PM shift, 6/27/19 N[NAME] shift, 6/28/19 AM shift, 6/28/19 PM shift, or 6/28/19 N[NAME] shift. e. On 6/30/19 at 7 AM, Resident 1 had a physical outburst and there was no alert charting for 6/30/19 PM shift, 6/30/19 N[NAME] shift, 7/1/19 AM shift, 7/1/19 PM shift, 7/1/19 N[NAME] shift, 7/2/19 AM shift, 7/2/19 PM shift, 7/2/19 N[NAME] shift, or 7/3/19 AM shift. During an interview with the DON on 10/16/19, at 2:37 PM, after reviewing Resident 1's clinical record, the DON stated documentation for alert charting was not done per the facility policy and procedure for Resident 1. The DON reviewed the policy and procedure for alert charting and stated she was not aware the DON or designee was responsible for reviewing the progress of the resident's condition on a daily basis. The DON stated a daily review for residents on alert charting was not being done. The facility policy and procedure titled Alert Charting Documentation dated 1/1/12, indicated Purpose . To ensure the timely, ongoing assessments and documentation of residents who have had a change in condition while at the facility . Alert charting is required but not limited to the following . Changes in mental/behavioral condition . Licensed Nurses on each shift are responsible for assessing residents, including vital signs and documenting the resident's status related to the change of condition . The Licensed Nurse will update Care Plans to reflect any change in condition . The Director of Nursing (or designee) will follow up daily on the progress of the resident's condition . The Licensed Nurses will be responsible for removing the resident from the alert charting list after the 72 hours or when he (sic) resident's condition is stable. Documentation should reflect the resident's improved or stable condition . Notes pertaining to the change of condition will be maintained in the resident's medical record as narrative notes. 3. During a review of the clinical record of Resident 1, the physician's orders were reviewed. A 3/16/19 physician's order was noted for [MEDICATION NAME] (antipsychotic medication) 50 milligrams (mg - a unit of measurement) every hour of sleep for a [DIAGNOSES REDACTED]. On 7/30/19, the [MEDICATION NAME] was increased to 50 mg twice a day for sudden mood changes and outburst. There was no documented evidence behaviors were monitored in (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, or (MONTH) 2019. During a review of the clinical record for Resident 1 and interview with the Social Services Designee (SSD), on 10/2/19, at 11:33 AM, she reviewed the clinical record of Resident 1 and could not find any documented evidence the resident's maladaptive behavior of sudden mood changes and angry outbursts were monitored every shift for (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, or (MONTH) 2019. She stated the resident's behaviors should have been monitored. During a review of the facility policy and procedure titled, Behavior/Psychoactive Drug Management last revised 11/2018, the policy indicated, To provide a therapeutic environment that supports residents to obtain or maintain the highest physical, mental, and psychosocial well-being . Antipsychotic medications . These are the most powerful and dangerous of the [MEDICAL CONDITION] medication. Because of this, they are the most highly regulated drugs used in Skilled Nursing Facilities . Occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the Medication Administration Record [REDACTED]

From the National Center for Biotechnology Information, U.S. National Library of Medicine, National Institute of Health, at www.ncbi.nlm.nih.gov: (C)ellulitis can develop if bacteria enter the skin through cuts or sores (and can) make your skin swell and become red, warm and tender. Left untreated, ([MEDICAL CONDITION]) sometimes can have serious complications. It is important to keep your skin protected while it heals. It often arises in wounds or sores. [MEDICAL CONDITION] affects the deeper layers of skin . Severe [MEDICAL CONDITION] is a deeper pus-producing infection. Diabetes is a disease in which the body does not control the amount of glucose (a type of sugar) in the blood . This disease occurs when the body does not make enough insulin or does not use it the way it should (also known as diabetes mellitus). Based on interview and record review, the facility failed to permit one of three sampled residents (1) to remain in the facility after Resident 1 took some controlled medications from an unattended medication cart. Such failure resulted in Resident 1 being involuntarily discharged from the facility without medications to control his blood sugar or wound care supplies for his leg infection. Resident 1 paid for a two-day motel stay, then went to a homeless shelter, and then was admitted to a general acute care hospital for high blood sugar and worsening of his leg wounds. Findings: During an interview with a staff person at the Kern County Public Guardian (KCPG), on 6/12/17, at 1:10 PM, he stated Resident 1 told him he had been kicked out of of the facility and insulted by the facility Administrator on 6/3/17. The KCPG staff stated Resident 1 had to pay for a taxi cab to a low-cost motel. During a concurrent record review and interview with the Director of Nursing (DON), on 6/12/17, at 3:39 PM, the document titled Face Sheet, indicated Resident 1 was admitted to the facility on [DATE], and then discharged on [DATE]. The DON was unable to find any documentation in Resident 1's clinical records related to his discharge. The DON stated Resident 1 was discharged because he had a disagreement with the Administrator. He stated He left in a cab, I don't know where. The clinical record for Resident 1 was reviewed. The document titled history and physical examination [REDACTED]. Resident 1's [DIAGNOSES REDACTED]. A physician order, dated 6/2/17, indicated Resident 1 was to have a blood sugar test three times a day, and to receive insulin (a medication that lowers blood glucose levels) injections if the blood sugar was too high. Another physician order, dated 5/16/17, indicated Resident 1 had daily treatment orders for a licensed nurse to cleanse the wounds on both his lower legs with a salt solution, and apply an ointment called Santyl (a prescription strength ointment that removes dead tissue from wounds so they can start to heal, and must be applied at least daily to be effective), then cover the wounds with a medicated dressing, and then wrap each lower leg with a gauze bandage and a compression wrap. During an interview with the Licensed Vocational Nurse (LVN) 1, on 7/6/17, at 3:17 PM, she stated the Administrator and DON spoke with Resident 1 on 6/3/17, and the Administrator told her (Resident 1) has to go. LVN 1 stated Resident 1 was then asked to leave the facility because Resident 1 was responsible for missing pain medications - [MEDICATION NAME](a strong prescription pain medicine that contains [MEDICATION NAME], an opioid or narcotic). During an interview with LVN 2, on 7/6/17, at 8:50 PM, she stated the Administrator had asked Resident 1 to leave the facility because the Administrator believed the resident stole his prescribed [MEDICATION NAME] her medication cart. LVN 2 stated, that on 6/3/17, she hid the narcotic keys inside the Medication Administration Record [REDACTED]. LVN 2 stated I guess the residents were watching me. That happened around 2-3 AM. A resident told me that some residents were around my medication cart. LVN 2 continued I discovered (Resident 1's) [MEDICATION NAME] bubble pack was missing at around 4 AM. It had 8-9 blue pills. (Resident 2) is alert and very aware of his medications. I went to speak with him about the missing medications and he just said okay. Around 5 AM or 5:30, another resident came and told me that (Resident 2) was out in the patio and he removed his cigarettes from his shirt pocked and some blue pills fell out of his pocket. I went to ask the resident but he denied it. LVN 2 stated, the Administrator and the DON came in to talk to the resident and a few hours later the DON told her that Resident 2 was leaving the facility. LVN 2 stated, The DON and the Administrator helped him pack and I saw them escort him in his wheelchair out of the facility. LVN 2 was asked where the [MEDICATION NAME] (MS Contin) bubble pack was located, she stated, It was in the locked narcotic box. I guess they were watching me and knew what keys I used. I know it was wrong. I left the keys in my MAR (Medication Administration Record) on top of the cart. LVN 2 stated the facility did not discipline her because she left the medication keys unattended on top of the medication cart, and instead the facility took action against Resident 1 for taking the narcotic medications and asked him to leave. During an interview with the Administrator, on 7/6/17, at 3:37 PM, he stated Resident 1 was being accused of taking [MEDICATION NAME] pain pills out of a facility medication cart without authorization. The Administrator stated Resident 1 became upset and left the facility. The Administrator stated He left AMA (also know as a discharge Against Medical Advice). During a review of the clinical record with the Administrator and medical records personnel, they were unable to find documentation of Resident 1 leaving the facility AMA. During an interview with Resident 1, on 8/3/17, at 2:46 PM, he stated that on the morning of 6/3/17, (The Administrator) came out yelling: You're out of here. Resident 1 stated the Administrator became angry and had an argument with him and pushed him in his wheelchair to his room to gather his belongings. Resident 1 stated the Administrator asked a nurse to remove his PICC line (Peripherally Inserted Central Catheter - a flexible tube inserted into the vein, used to administer the antibiotics for his leg wound [MEDICAL CONDITION]), and pushed him in his wheelchair out the front door of the facility with no treatment supplies for his leg wounds, no supplies to check his blood sugar levels, and no insulin to treat his diabetes. Resident 1 stated, My leg ulcers (open wounds) were getting better when I was in the facility. I didn't want to leave, but the Administrator said that he would call the police if I didn't leave. Resident 1 stated he was on the side of the street and had to call and pay for a taxi cab to take him to a low cost motel, because he had no where else to go. Resident 1 stated he did not have food to eat. He spent two days in the motel, and then to a homeless shelter. Resident 1 stated within days after he left the facility, his wounds became painful, red, and were draining large amount of fluids with a bad odor. Resident 1 stated he was readmitted to a hospital on [DATE] for worsening condition of the wounds to both legs and high blood sugar levels. The admission agreement for Resident 1, dated 5/11/17, indicated Transfer and Discharges . If you are transferred or discharged against your wishes, we will provide transfer and discharge planning as required by law. During a review of the clinical record for Resident 1 from his stay at a General Acute Care Hospital, the Physician Assessment, dated 6/10/17, indicated he was admitted with Admission Diagnosis 1) Bilat (bilateral, or both) LE (lower extremities) [MEDICAL CONDITION] and 2) abscesses (area full of pus, indicating infection), Bilat Ulcers with exudate (drainage) and pus. Pain management. The document titled Progressive Patient Interdisciplinary Care Plan/Communication, dated 6/10/17, at 6 PM, indicated Resident 1's blood glucose level was 424 (normal glucose range is between 70 - 110. Blood glucose levels over 400 can lead to many serious health problems, including coma and death). The document titled History and Physical, dated 6/10/17, indicated (H)e has been having persistent pain, swelling, redness . and foul smelling discharge coming out of the ulcers in the bilateral legs. The document further indicated, The patient will be admitted (the the hospital). At this time he will be started on (two different IV) antibiotics .

Based on interview and record review, the facility to treat one of 24 sampled residents (21), one of seven random residents (27) and one of seven confidential residents (30) with respect and dignity. This resulted in residents having low self esteem and embarrassment. Findings: 1. During an interview with Resident 27, on 10/28/15, at 10:28 AM, she stated, I call the staff when I need water or to use the bathroom. I would do it myself but I can't get out of bed on my own. I have had to pee in bed about ten times in the last few weeks because they (staff) took so long to come help me. I felt so sad, like a baby wetting her clothes, humiliating it's horrible. The staff tell me that they couldn't help me because they are working short staff. During a review of the Grievance/Complaint log with the Social Service Director (SSD) on 10/29/15, at 10:54 AM, she was asked about the multiple grievances and complaints of CNAs' (Certified Nursing Assistants) turning call light off without completing the task. She stated, The CNA's are talked to. 2. During an interview with Resident 30, on 10/28/15, at 10:30 AM, Resident 30 stated it does take on average 30 to 45 minutes for her needs to be taken care of. She stated she calls for such things as water and assistance to the bathroom and assistance with cleaning herself up after she has used the bathroom. She stated, without the staff assistance she cannot get to the bathroom on time. When the staff have taken too long to answer the call light, she stated she has had accidents (incontinent (lack of urinary control) episodes). She stated, It makes me feel bad .you're grown and someone has to change you. The facility policy and procedure titled, Call System, dated 6/15/11, read in part, To provide a mechanism for residents to promptly communicate with staff The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities . Nursing staff will answer call bells promptly . Upon responding to request, if item is requested that is not available . assistance will be obtained from the Charge Nurse . In answering to request, staff will return to resident with the item or reply promptly . Assistance will be offered before leaving . Call bells located within resident bathrooms are considered emergency calls due to the potential for falls and injury . These lights have a more frequent audio sound and the call light above the room door may be red. 3. During a concurrent interview with Resident 21 and Family 2, on 10/26/15, at 9 AM, on' The Initial Tour' Resident 21 indicated she remembered going to a doctor's appointment with no shoes on Family 2 stated, The staff gave a reason for that particular incident, but there had been several incidents regarding dressing and preparing her for activities in a dignified manner. Family 2 stated she feels like staff treats her like that because Oh its just her . As if she won't remember. During an interview with License Nursed (LN) 3, on 10/29/15, at 10:50 AM, she stated she knew about the incident when she was sent to Physical Therapy wearing just a gown and other times when she was not dressed appropriately for therapy and doctors appointments. During an interview with CNA 1, on 10/29/15, at 11 AM, she stated, I was here when she went to the doctors with no shoes. Night shift dressed her so I did not check her before leaving . She also needs to have a prosthetic bra (a contoured device which simulates breast tissue, usually worn inside a brassiere which is composed of foam or gel) and a neck collar (type of brace worn around the neck for support or stabilization). I told my supervisor and she told the night shift staff . I don't know why it's still happening. During an interview with LN 1, on 10/29/15, at 2 PM, she stated, I heard the complaints to my staff regarding different incidents of not putting Resident 21's neck brace back after showers, not having shoes at doctors appointments and wearing night gowns to Physical Therapy. During a review of the clinical record for Resident 21, the Care Plan Activities Of Daily Living (ADL) Functional, dated 9/2013, indicated Resident 21 needs extensive assist with dressing and that Resident 21 would be dressed appropriately. The facility policy and procedures titled Residents Rights- Quality of Life revision date 1/2012, indicated under Procedure .X. Facility Staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care during treatment procedures. XI. Demeaning practices and standards of care that compromise dignity are prohibited. Facility Staff will promote dignity and assists residents as needed .

Based on observation, interview, and record review, the facility failed to: 1. Appropriately address/respond to one of 24 sampled resident's (1) significant weight loss in a timely manner. This resulted in the resident losing additional weight which had the potential for a decline in the health and wellness of the resident. 2. Accurately record the meal intake percentage for one (11) of 24 sampled resident's two observed meals, a resident with identified significant weight loss. This had the actual result of inaccurate assessment data. 3. Conduct weights as per facility policy for one (11) of 24 sampled residents for her first month in the facility. This had the potential for delayed identification of a significant weight loss. Findings: 1. During an initial tour observation with the Director of Staff Development (DSD), on 10/26/15, at 9:30 AM, Resident 1 was observed lying in bed. When the clothes closet was opened there were several opened and unopened food items noted including bags of potato chips, cheese puffs, cereal (fruit loops), and drinks. During an observation on 10/26/15, at 11:38 AM, Resident 1 was observed lying in bed with the head of the bed up and a friend at his bedside. Resident 1 was eating a burrito and drinking a Starbuck's coffee. Resident 1 stated his friend purchased the burrito for him because he did not like anything coming out of the (facility) kitchen. Resident 1 acknowledged he turned the facility lunch tray away. During an observation and concurrent interview on 10/27/15, at 8:40 AM, Resident 1 was observed eating a bowl of fruit loops. He acknowledged the fruit loops were from his personal inventory and they were a bit stale since he purchased them prior to his most recent discharge from the hospital (sometime in 9/2015). He stated, he did not like the food provided by the facility; therefore, chose to eat his own food items. During a subsequent interview with Resident 1, on 10/27/15, at 1:02 PM, he stated, I can't stand the food. Resident 1 stated, I've told everyone. During a review of the clinical record for Resident 1, the physician's orders [REDACTED]. The resident was receiving a no added salt, no concentrated sweets diet. The documented weight trend was as follows: 10/10/15 - 224.0 pounds (lbs) 10/17/15 - 207.5 lbs (weight loss of 16.5 lbs in one week, 7.3 % weight loss in one week) 10/19/15 - 204.0 lbs (weight loss of 3.5 lbs in two days) 10/24/15 - 182.0 lbs (weight loss of 25.5 lbs in one week, 12.2 % weight loss in one week). During a concurrent interview and record review with Licensed Nurse (LN) 1, on 10/29/15, at 1:50 PM, she was asked if significant weight changes were reported to the physician. She acknowledged, the physician should be notified of significant weight changes. She was asked if the weight loss of 16.5 lbs in one week that occurred between 10/10/15 and 10/17/15, with Resident 1, was reported to the physician timely to be acted upon. She stated, if the physician was notified, a change of condition report would be placed in the resident's clinical record and the nurse would document the physician notification in the nurse's notes. After reviewing Resident 1's clinical record, she was unable to find documented evidence the physician was notified timely of the significant weight change that occurred between 10/10/15 and 10/17/15. The change of condition report and the evidence the physician was made aware of the change in weight, was documented in Resident 1's clinical record on 10/28/15 (11 days later), when the resident lost an additional 25.5 lbs, for a total weight loss of 42 lbs in a two week span. LN 1 stated, it was the restorative nursing assistants (RNAs) who were responsible for weighing the residents and notifying the nursing staff of the weight changes. During a concurrent interview and record review with RNA 1, on 10/29/15, at 2 PM, she stated the restorative department weighs the residents on Saturday and Sunday, and LN 4 reviews those weights on the following Monday. During an interview with LN 4, on 10/29/15, at 2:05 PM, she was asked the process when a significant weight change occurs with a resident. She stated, the licensed nurses should create a change of condition report and notify the physician and both the change of condition report and the notification to the physician should be documented in the nurse's notes. After reviewing Resident 1's clinical record, she was unable to find evidence a change of condition document was created or that the resident's physician was notified of the significant weight loss of 16.5 lbs in one week, which occurred with Resident 1 between 10/10/15 and 10/17/15. It was not until 10/28/15, when a change of condition report was noted and the physician was made aware of a significant weight change. She stated, the interdisciplinary team (IDT) should have met the following week with recommendations. During a review of the 10/21/15 IDT note, it was noted the IDT recommended a sugar free house nourishment three times a day during medication pass. After a subsequent interview with LN 4, she stated the resident was already receiving a house nourishment and could not state the reason the IDT recommended something the resident was already receiving. During a concurrent interview and clinical record review, with the Dietary Services Supervisor (DSS), on 10/29/15, at 2:40 PM, the document titled, DIET HISTORY/FOOD PREFERENCES, dated 10/12/15, was reviewed. Under the dislikes section, Eggs were marked as the only disliked item. The DSS, was informed, the resident stated he did not like any of the food served in the facility. She acknowledged, she was aware of this and stated prior to his latest discharge, the facility staff would purchase the resident outside food because he was picky. She acknowledged the DIET HISTORY/FOOD PREFERENCES, should have been updated with his dislikes. The facility policy and procedure titled, Evaluation of Weight & Nutritional Status, date revised 8/1/14, defines significant weight loss as 5% in one (1) month, 7.5% in three (3) months, or 10% in six (6) months . It further indicates, III .Clinical Evaluation . B. Any resident weight that varies from the reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days, will be evaluated by the IDT (Interdisciplinary Team) .i. Once weight gain or loss .is identified, the IDT .Committee will .Notify the Attending Physician . The facility policy and procedure titled, RDs FOR HEALTHCARE, INC. WEIGHT CHANGE PROTOCOL, undated, indicated, Early identification of a weight problem and possible cause(s) can minimize complications . Residents will be weighed on a monthly basis and weekly for those newly admitted and those deemed to be at high risk for weight changes . The following criteria define significant or insidious weight changes .3# (pounds) weight loss or gain in 1 week or as facility policy states .5# weight loss or gain in 1 month . 5% weight loss or gain in 1 month 7.5% weight loss or gain in 3 months . Under the ASSESSMENT subheading it indicates, Determine if the .weight change is felt to be temporary or permanent .weight change is an expected or desired outcome .diet order is appropriate to meet the goal .meals sent to resident meet their needs and goals .intake of the resident will be sufficient to meet needs or goals . 2. During a review of the clinical record for Resident 11, the document titled Vital Signs and Weight Record indicated Resident 11 weighed 191.6 pounds on 9/6/15, but weighed 179.4 pounds on 10/5/15, showing a loss of 12.2 pounds in one month. This calculates to over a 6% weight loss in one month. The document titled MDS (Minimum Data Set, a comprehensive standardized assessment tool), dated 10/10/15, indicated the 179 pound weight was significant, since it was over a 5% loss in one month. The MDS also indicated this was a weight loss not prescribed by her physician. The document titled IDT Assessment of Significant Weight Change/Hydration/Skin status, dated 10/16/15, read Weight loss may be due to decreased PO (by mouth) intake . The document titled Nutritional Progress Notes, dated 10/21/15, and written by a Registered Dietician, indicated Resident 11 lost additional weight, now calculated to be a 15.6 pound weight loss, or a 8.1% loss over one month. The document titled Nutritional Status - Interdisciplinary Care Plan dated 10/21/15, indicated under Goal, for Resident 11 to consume 75-100% of meals. The Care Plan indicated under Approach / Interventions to Monitor for acceptance & tolerance of diet, Monitor meal intake, and Encourage to eat 75% of meals. The document containing the meal percentages for 10/2015 was reviewed, and contained many illegible entries, making it impossible to determine how much food Resident 11 consumed for many meals. During an observation on 10/26/15 and 10/27/15, of Resident 11's lunches those days, she was noted to eat only a bite or two of each meal. During a concurrent record review and interview with the DSS on 10/29/15, at 2:45 PM, she was asked what was the meal percentage consumed by Resident 11 for her noon time meal on 10/26/15, and on 10/27/15, according to the documentation. The DSS looked at the documentation, and stated It's hard to tell and stated 70% for the lunch on 10/26/15, and 70% for the lunch on 10/27/15. During a concurrent record review and interview with the Medical Records Director (MRD) on 10/29/15, at 10:45 AM, she was asked the same questions, and the MRD answered 60% for 10/26/15, and 100% for 10/27/15. During a concurrent record review and interview with LN 7, on 10/29/15, at 12:35 PM, she was asked the same questions, and LN 7 answered 75% for 10/26/15, and 65% for 10/27/15. 3. The facility policy and procedure titled Evaluation of Weight & Nutritional Status, dated 8/1/14, read Each resident will be weighed within twenty-four (24) hours of admission, weighed weekly for four (4) weeks, and weighed monthly or as needed thereafter. The weight will be documented in the resident chart and accompanying forms. During a review of the clinical record for Resident 11, the document titled Face Sheet indicated she was admitted to the facility on [DATE]. During a review of the clinical record for Resident 11, the document titled Vital Signs and Weight Record indicated Resident 11 weights were as follows: 8/15/15 - 196.4 pounds (admission weight) 9/6/15 - 191.6 pounds 10/5/15 - 179.4 pounds The weights, which according to the facility's policy and procedure, that were to have been done on 8/22/15 and 8/29/15, could not be found in the clinical record. During a concurrent record review and interview with the Registered Dietician, on 10/28/15, at 8:40 AM, she indicated the new admission weekly weights had not been conducted for Resident 11.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (5) received [MEDICATION NAME] (antidepressant medication commonly used for neuropathic pain-nerve pain) medication as ordered by the physician which resulted in the resident having unrelieved pain. This had the potential to compromise Resident 5's ability to maintain her well-being. Findings: During a review of the clinical record for Resident 5, the physician's orders [REDACTED]. The following physician's orders [REDACTED]. [REDACTED]. On 10/8/13, a physician's orders [REDACTED]. On 10/15/13, a physician's orders [REDACTED]. intensity). On 11/23/13, a physician's orders [REDACTED]. On 12/9/13, a physician's orders [REDACTED]. During a concurrent interview with Licensed Nurse (LN) 3 and review of the clinical record for Resident 5 on 12/18/13, at 8:35 AM, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. He stated the [MEDICATION NAME] medication was not recopied in the new MAR from the physician's orders [REDACTED]. A review with LN 3 of the 12/2013 MAR indicated [REDACTED]. The document titled "Pain Assessment Flow Sheet" (used to evaluate the effectiveness of the PRN (as needed) medication regimen) for 12/2013, indicated there were 10 days the licensed nurse did not document the pre (before)-[MEDICATION NAME] (drug that relieves pain) pain intensity, the non-pharmacological intervention (referring to therapy that does not involve drugs), [MEDICATION NAME] dose and post (after) [MEDICATION NAME] pain intensity in the Pain Assessment Flow Sheet for the [MEDICATION NAME] that was administered. This was validated by LN 3. During an interview with Resident 5 on 12/18/13, at 12:35 PM, she stated she had pain all the time and her pain medications were not working and the facility had called her physician. She added she wanted an ultrasound due to the worsening pain on her back, shoulder and neck. During a concurrent observation and interview with Resident 5, on 12/19/13, at 10:05 AM, she was sitting up in her wheelchair next to her bed. She stated she had pain on her lower back, left leg, neck, right shoulder, and she had a stiff neck. She added she had pain on the left side of her body all the way down to her left hip, the intensity of the pain she had on a pain scale of 0-10 was a 7 (0-no pain, 10-worst pain). According to the facility pain intensity scale, a pain scale of 7 signifies severe/very severe pain. Resident 5 stated the pain was always there and she had difficulty sleeping at night. She stated the pain was getting worst and she wanted to see a physician regarding the pain. During an interview with the Assistant Director of Nursing, on 12/19/13, at 11:15 AM, she verified the medication [MEDICATION NAME] which was indicated for chronic pain had not been administered to Resident 5 from 12/1/13/ to 12/17/13. The facility policy and procedure titled "Pain Management" undated, read "Procedure...Pain Management...A. The Licensed Nurse will administer pain medication as ordered and document all medication administered on the MAR...B. Nurses will complete the Pain Flow Sheet for residents receiving PRN pain to evaluate the effectiveness of the medication regimen...C. The Licensed Nurse will assess the resident for pain and document results on the MAR indicated

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (5) was free of significant medication error when Resident 5 did not receive [MEDICATION NAME] (antidepressant medication commonly used for neuropathic pain-nerve pain) medication as ordered by the physician. This resulted in the resident having unrelieved pain and the potential to compromise Resident 5's ability to maintain her well-being. Findings: During a review of the clinical record for Resident 5, the physician's orders [REDACTED]. Dx (diagnosis) chronic pain..." During a concurrent interview Licensed Nurse (LN) 3 and review of Resident 5's clinical record on 12/18/13, at 8:35 AM, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. He stated the [MEDICATION NAME] medication was not recopied in the MAR from the physician's orders [REDACTED]. During an interview with Resident 5 on 12/18/13, at 12:35 PM, she stated she had pain all the time and her pain medications were not working and the facility had called her physician. She added she wanted an ultrasound due to the worsening pain on her back, shoulder and neck. During a concurrent observation and interview with Resident 5, on 12/19/13, at 10:05 AM, Resident 5 was sitting up in her wheelchair next to her bed. Resident 5 stated she had pain on her lower back, left leg, neck, right shoulder, and she had a stiff neck. She added she had pain on the left side of her body all the way down to her left hip, the intensity of the pain she had on a pain scale of 0-10 was a 7 (0-no pain, 10-worst pain). According to the facility pain intensity scale, a pain scale of 7 signifies severe/very severe pain. Resident 5 stated the pain was always there and she had difficulty sleeping at night. She stated the pain was getting worst and she wanted to see a physician regarding the pain. During an interview with the Assistant Director of Nursing, on 12/19/13, at 11:15 AM, she verified the medication [MEDICATION NAME] which was indicated for chronic pain was not administered to Resident 5 from 12/1/13/ to 12/17/13. The facility policy and procedure titled "Pain Management" undated, read "The Licensed Nurse will administer pain medication as ordered and document all medication administered on the MAR..."

Based on interview and record review, the facility failed to protect Resident A from verbal abuse from staff, resulting in the resident feeling unsafe. Findings: During an interview with the Assistant Director of Nurses (ADON) on 6/21/12 at 3:35 PM, she described Resident A as alert with occasional confusion. The ADON stated, "When I conducted the investigation Resident A was able to recount the event clearly." The clinical record for Resident A was reviewed on 6/21/12. The face sheet dated 2/28/12 indicated Resident A was her own responsible party. The Care Plan titled "Needs Assist with ADLs" (activities of daily living such as dressing, toileting, hygiene, walking, and transferring) indicated resident required extensive assistance with one to two staff assist for toilet use and transfers. The approach plan included "have call light within reach and answer promptly." The nurse's notes dated 6/3/12 at 6 AM, read "Resident had altercation with the CNA (certified nursing assistant)....put on call light....CNA told me the morning shift will take me to the bathroom and she left....Called a second time and CNA returned....she was yelling at me...." During an interview with Resident A on 6/21/12 at 4:40 PM, she described "I put on the call light to go to bathroom and CNA 1 told me she would be with me in a little while and walked out of the room. I spilled water on me and I put on my call light again. CNA 1 returned and appeared disgusted with me for putting on my call light again. I told her I spilled water on my bed and clothing and would like it changed and I still had to go to the bathroom. She stormed out of the room and returned with the bedding and began throwing things around the room. I told her I still had to go to the bathroom, she stopped and looked at me asked me what I wanted 'the bed changed or the bathroom'? I told her the bathroom and she stopped making the bed and helped me to the bathroom." Resident A stated CNA 1 finished making her bed and then returned to the bathroom and was yelling at her. Resident A stated, "She yelled at me for being on the call light all the time to go the bathroom. She told me 'you go 20 times a night, you go too much.' She kept yelling at me while I was in the bathroom, I told her to stop yelling at me or I would report her and she said she didn't care." Resident A stated she does not want CNA 1 to provide care for her again and she was afraid of her. During an interview with Resident B on 6/21/12 at 5 PM, she stated, "Yes, I heard yelling early in the morning but did not know at the time who or what was going on for sure. I learned what happened later in the day." The facility policy and procedure titled "Abuse-Prevention Program" revised 1/1/12, read "The Facility does not condone any form of resident abuse, neglect and/or mistreatment, and continually monitors facility policies, procedures, training programs, and systems in order to maintain an environment free from abuse and mistreatment."