Every finding on record at The Springs at Pacific Regent

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when:1. On the clean dish rack there was a cracked 7.5 quart plastic cambro container, two serving dishes that had food particles stuck on them and four wet mixing bowls stacked on a shelf.2. Refrigerated food items had a white, fuzzy substance growing on them and were stored alongside unspoiled food products. Two refrigerated peeled and cut cucumbers were wrapped in plastic and not labeled or dated.3. A large cambro container in the warming oven had a yellow, clear, liquid substance in it that was labeled as olives. Food particles and crumbs were in the drawers and on the shelves of the prep cart. A spatula was covered with a slimy, greasy coating. There were grease smudges on the back of the plate dispenser. 4. The cook (CK) took temperatures of the food on the steam table without visualizing where the temperature probe was placed. 5. The temperature of soup was not taken prior to placing the soup on the meal tray for service.These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses.Findings:1.On 8/3/25 at 7:30 A.M., an observation and interview was conducted with the Dietary Supervisor (DS) of the clean dish storage rack. The DS stated these dishes were clean and ready for service. Four mixing bowls were stacked on top of each other, and water was in the bottom of each bowl. Two serving dishes had food particles on them. A 7.5-quart plastic cambro container was cracked. The DS removed the four wet mixing bowls, the serving dishes with food particles on them and the cracked cambro container from the clean storage rack. 2. On 8/3/25 at 7:43 A.M., an observation of the produce walk-in refrigerator and an interview was conducted with the DS. There was spoiled produce stored with non-spoiled produce: Two cantaloupes in a box that were brown, soft and indentable to touch. The DS stated the cantaloupes should be thrown away. One plastic container of blueberries had a fuzzy white substance growing on multiple blueberries. The DS removed the container immediately and stated he would throw it away. Multiple soft apples, brown in color and indentable to touch were found in a box. The DS removed the apples immediately and stated he would throw them away. Half of a box of yellow squash were brownish in color, had slimy soft spots and were squishy to touch. Approximately 30 yellow squashes had visible fuzzy, white substance growing on them. The DS stated he would throw the entire box away. Two refrigerated, peeled, and cut cucumbers were wrapped in plastic and not labeled or dated.3. On 8/3/25 at 8:05 A.M., an observation and interview of the food prep area was conducted with the DS. There was a plastic container in the warming oven that had a clear, yellow liquid substance in it that was labeled as olives. The DS stated it was melted margarine. The utensil prep cart had food particles and crumbs in the drawers and on the shelves. A spatula was covered with a slimy, greasy coating. There were grease smudges on the back of the plate dispenser. 4. On 8/4/25 at 11:53 A.M., an observation of the tray line was conducted. CK placed foil covered containers onto the steam table. CK put the thermometer probe through the top of multiple foil covered containers to take to the temperature reading of the food. The thermometer probe was not visualized to be touching the food, and the probe could be heard hitting the bottom of the metal food container. On 8/4/25 at 12:04 P.M., an interview was conducted with the DS. The DS stated the thermometer probe should have been visualized touching the food when taking the temperature. The DS stated this would ensure the temperature of the food was taken appropriately. 5. On 8/4/25 at 12:27 P.M., an observation and interview was conducted with the DS. The DS handed a bowl of soup to the dietary aide. The dietary aide placed the soup on a meal tray in the food cart for service. The food temperature log was requested for review. The log entry for the soup was blank. The DS stated the temperature of the soup was not taken before being served and it should have been. On 8/5/25 at 8:51 A.M., an interview was conducted with the DS. The DS stated cracked cambro containers should have been thrown away due to the potential for contamination. The DS stated spoiled food should not have been stored with non-spoiled food. The DS stated the refrigerated food should have been checked daily to ensure the quality of the food product. The DS stated that all food products that had been used should have been wrapped in plastic, labeled and dated. The DS stated that prep carts should have been clean with no food particles in the drawers and the cart should have been free from grease smudges. On 8/5/25 at 9 A.M., an interview was conducted with the Registered Dietician (RD). The RD stated she was informed that there was spoiled cantaloupes, white fuzzy growth on the blueberries, brown apples and yellow squash with fuzzy, white growth on them and these items were mixed with unspoiled produce. The RD stated the food should have been checked and there should not have been spoiled products mixed with unspoiled products. The RD stated spoiled food could have affected the rest of the food products. The RD acknowledged there were unlabeled, undated ready to use cucumbers wrapped in plastic in the refrigerator and there was a container that had clear, yellow liquid in the warming oven that was labeled ''olives. The RD stated all food needed to be wrapped, labeled and dated when stored. The RD stated wet mixing bowls and dirty serving dishes should not have been put on the clean utility shelves. The RD stated a cracked cambro storage container should have been thrown away because it could have been an infection control issue and contaminate other food items.On 8/6/25 at 1:54 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated his expectation was that a cracked cambro container should have been thrown away immediately due to potential for contamination and all items on the clean utility rack should have been free of food particles and water accumulation. The DON stated his expectation was that all drawers and prep carts should have been inspected and cleaned from food particles, crumbs and grease. The DON stated that his expectation was that there should not have been any spoiled food in the refrigerator and that it should have been thrown away immediately. The DON stated he expected food should have been inspected daily for spoilage. The DON stated that all food items should have been correctly labeled and dated. The DON stated his expectation was that the food temperatures should have been taken with the thermometer probe inserted into the food in order to get an accurate reading. The DON stated his expectation was that the soup temperature was taken prior to being placed on a meal tray for service. A review of the facility's policy titled Storage of Food and Supplies dated 2023, indicated, .5. Routine cleaning. should be developed and followed.; . 7. Remove foods from the packing boxes upon delivery 11. Liquid foods.which have been opened will be tightly closed, labeled, and dated. A review of the facility's policy titled Labeling and Dating of Foods dated 2022, indicated, All food items in the refrigerator need to be labeled and dated. The individual preparing/handling a food shall be responsible for date marking at the time of processing and/or storage. For foods that are prepared by the facility.and stored cold shall be clearly marked to indicate the date by which the food shall be consumed or discarded. Once daily, the PM [NAME] and/or PM Diet Aide will be responsible to inspect the refrigerators and discard perishable foods.in order to ensure food safety.

Based on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices related to hand hygiene (washing hands with soap and water or using alcohol-based hand sanitizer) during wound care for one resident (Resident 51). As a result of this deficient practice, Resident 51 was at an increased risk of infection. Findings: A review of Resident 51's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain) and hemiplegia (paralysis or severe weakness on one side of the body).A review of Resident 51's physician order for wound treatment dated 7/29/25, indicated Resident 51 had an unstageable pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the coccyx (tailbone) area. On 8/6/25 at 10:24 A.M., an observation of wound treatment for Resident 51 was conducted with Licensed Nurse (LN) 2 and Certified Nursing Assistant (CNA) 2. LN 2 and CNA 2 were observed wearing Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) including gloves. LN 2 and CNA 2 stated they were cleaning and changing the resident's soiled brief before starting Resident 51's wound care. Some stool was observed on Resident 51's bilateral buttock. After cleaning Resident 51, CNA 2 stepped out to grab some supplies. When CNA 2 came back with the supplies, LN 2 stepped out to wash her hands. LN 2 then came back, donned new gloves, and proceeded with wound treatment while CNA 2 supported the resident who was turned to her left side. After informing Resident 51 that LN 2 was starting the wound care, LN 2 removed the foam dressing that covered Resident 51's pressure ulcer. The wound was open, clean, and located slightly below the coccyx and slightly right to the midline. The wound was approximately 2.5 cm (centimeters) by 4 cm in measurement. LN 2 used dressings soaked with wound cleanser to gently pat on the wound. LN 2 removed her gloves and put on a new pair without performing hand hygiene.LN 2 stated the wound was a pressure ulcer with hypergranulation (healthy tissue that normally forms during wound healing grows too much and rises above the level of the surrounding skin), with slough (a type of dead tissue that can prevent healing) about 5 to 10% at 3 o'clock to 5 o'clock, and with possible undermining (the destruction of tissue extending under the skin) to 12 o'clock. LN 2 pat-dried the wound with dry dressings. LN 2 removed her gloves and put on a new pair without performing hand hygiene.LN 2 applied a medicated ointment to the wound bed.LN 2 removed her gloves and put on a new pair without performing hand hygiene.LN 2 applied a medicated power to the wound bed.LN 2 removed her gloves and put on a new pair without performing hand hygiene.LN 2 applied a special dressing that promoted wound healing.LN 2 removed her gloves and put on a new pair without performing hand hygiene.LN 2 covered the wound with a foam dressing.On 8/6/25 at 10:43 A.M., an interview with LN 2 was conducted. The wound treatment observation for Resident 51 was discussed with LN 2. LN 2 stated she should have done hand hygiene between glove changes.On 8/6/25 at 1:55 P.M., an interview was conducted with the Infection Preventionist (IP). The IP was asked about the facility's hand hygiene policy. The IP stated the staff were expected to perform hand hygiene when donning a new gloves. On 8/6/25 at 2:29 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that performing hand hygiene during wound care was expected and necessary before putting on a new pair of gloves to decrease the risk of infections. A review of the facility's undated policy and procedure titled Hand Hygiene, indicated, .2. Use an alcohol-based hand rub.for the following situations: .b. Before and after direct contact with residents; c. Before preparing or handling medications; .g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; .j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; .m. After removing gloves; .r. After removing and disposing of personal protective equipment.

Based on interview and record review the facility failed to ensure the baseline care plan included person-centered care during mealtimes for one of fourteen residents (Resident 86) within 48 hours of the resident's admission. This failure to develop the baseline care plan within 48 hours of admission for mealtime assistance resulted in the resident calling to request mealtime set ups multiple times a day continuously since admission. Findings:A review of the facility's admission Record indicated Resident 86 was readmitted to the facility on [DATE] with diagnosis including Pigmentary Retinal Dystrophy (an inherited eye disorder that causes loss of sight). On 8/3/25 at 9:10 A.M., an interview was conducted with Resident 86. Resident 86 stated that she was legally blind and needed help with meal tray set up. Resident 86 stated she needed staff to identify the food items and the location of the food on her plate. Resident 86 then stated that she would have to wait to eat and then call to remind the staff that she needed help with her tray set up almost every meal. Resident 86 stated she should not have to remind the staff of her needs every day. On 8/6/25 at 11:20 A.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated she was not aware that Resident 86 was legally blind. CNA 1 stated it was her first time to take care of Resident 86, and she was not informed of Resident 86's blindness. On 8/6/25 at 11:31A.M., an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated he knew Resident 86 was blind and that she needed help with mealtime set up. LN1 stated mealtime set up should have been included in Resident 86's care plan and help should have been provided. On 8/6/25 at 1:55 P.M., a concurrent interview and record review with LN3 was conducted. LN 3 reviewed Resident 86's written care plans and stated there was no intervention to provide set up assistance during mealtimes. LN 3 stated mealtime assistance should have been a part of Resident 86's baseline care plan. On 8/6/25 at 2:29 P.M., a concurrent interview and record review with the Director of Nursing (DON) was conducted. The DON acknowledged that there was no care plan developed for Resident 86's mealtime assistance. The DON stated the purpose of baseline care plan was to identify basic needs of a resident at the time of admission to the facility. The DON stated that a care plan for meal tray set up should have been developed. A review of the facility's undated policy titled Comprehensive Person-Centered Care Planning, indicated, .1. Within 72 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care.On 8/14/25 at 12:29 P.M., a telephone interview was conducted with the Assistant Director of Nursing (ADON). The ADON was informed that the facility's policy titled Comprehensive Person-Centered Care Planning did not follow the Federal Regulation for Baseline Care Plan development within 48 hours. The ADON stated the facility's policy should have been in alignment with Federal regulations.

Based on interview and record review, the facility failed to provide proper pharmaceutical services when the Medication Administration Record (MAR) and Controlled Medication Count Sheet (CMCS) did not reconcile for two randomly selected residents (Resident 91 and 61). This failure had the potential to place Resident 91 and Resident 61 at risk for inaccurate pain medication administration and/or diversion (illegal distribution or abuse of prescription drugs) of controlled medications (medications that the use and possession of are controlled by the federal government). Findings:1. A review of Resident 91's admission record indicated the resident was admitted to the facility on [DATE] for the diagnosis including post-surgery care for joint replacement surgery and osteoarthritis (a condition where the cartilage in the joints wears down over time and causes pain). A review of Resident 91's physician order dated 7/21/25 indicated: Oxycodone HCL oral tablet (a type of controlled medication) 5 MG (milligrams). Give one tablet by mouth every 4 hours as needed for moderate pain level 4-6 (pain scale that utilizes numbers used to evaluate a person's perceived pain level) and give 2 tablets by mouth every 4 hours as needed for severe pain level 7-10. A review of Resident 91's MAR and CMCS indicated: A dose of the resident's Oxycodone HCL 5 MG had been removed from the locked supply on 7/31/25. Resident 91's MAR for Oxycodone HCL 5 MG had blank entry on 7/31/25 and it could not be determined if the medication had been given to the resident.2. A review of Resident 61's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including post-surgery care.A review of Resident 61's physician order dated 5/28/25, indicated: Hydrocodone-Acetaminophen Oral Tablet (a controlled medication) 10-325 MG. Give 1 tablet by mouth every 4 hours as needed for severe pain (level 7-10). On 8/5/25 at 10:50 A.M., an interview was conducted with Licensed Nurse (LN) 4. LN 4 stated the process of controlled medication administration was to verify resident's pain level, remove the medication from its locked storage, compare the physician's order to the MAR and CMCS, administer the medication, and document on the MAR and CMCS. LN 4 stated it was important that the MAR and CMCS reconciled to prevent diversion of the medications. On 8/6/25 at 9:32 A.M., a concurrent interview and record review was conducted with the Director of Nursing (DON) for Resident 61's MAR and CMCS for Hydrocodone-Acetaminophen oral tablet.The DON reviewed Resident 61's MAR and CMCS for Hydrocodone-Acetaminophen 10-325 MG on the following dates:- 8/5/25 at 1:23 A.M. - 8/1/25 at 1:59 A.M.- 7/27/25 at 9:42 P.M.- 7/24/25 at 6:20 P.M.- 7/23/25 at 12:30 P.M.- 7/18/25 at 5:17 A.M.- 7/15/25 at 11:29 A.M.- 7/15/25 at 12:03 A.M.- 7/11/25 at 4:45 A.M.- 7/10/25 at 5:26 P.M.- 7/9/25 at 10:30 P.M.- 7/23/25 at 9:41 A.M. The DON stated the MAR and CMCS did not reconcile. The DON then reviewed Resident 91's MAR and CMCS for oxycodone 5 MG and stated that they did not reconcile on 7/31/25.The DON stated the MAR and CMCS should reconcile because they were documentation of controlled medications, nursing communication, and accountability of the staff giving controlled medications. A review of the facility's undated policy titled Controlled Medications - Storage and Reconciliation indicated, .6. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration. Amount administered. Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for one resident (1) reviewed for wound care and treatment. This deficient practice placed Resident 1 at risk for harm related to poor wound healing and infection. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of type two diabetes mellitus (health condition in which the body is unable to regulate blood sugar levels; can lead to complications of poor circulation and multi-system problems with the eyes, heart, kidneys, and limbs [arms, legs]), per Resident 1's Admission Record. A record review of Resident 1's Minimum Data Set (MDS- nursing assessment tool that is used to develop a plan of care) dated 6/21/24 , indicated a Brief Interview for Mental Status (BIM- developed by reviewing the resident's status during the prior seven day period) score of 15 points out of 15 possible points which indicated Resident 1 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/4/24 at 11:25 A.M., an interview, and record review was conducted with the infection prevention (IP) nurse. The IP nurse stated that Resident 1 tested positive for COVID-19 (a highly contagious respiratory disease casued by the SARS virus) on 6/21/24. The IP nurse stated that Resident 1 had a surgical wound appointment on 6/21/24 for her recent right below-the-knee amputation (RBKA; surgery- removal of a limb/body part because of injury or disease, such as diabetes), but missed the appointment due to a positive COVID-19 test. The IP stated that once Resident 1 was cleared from COVID-19 precautions, she had an appointment scheduled on 7/2/24 for vascular surgery and dialysis. On 9/4/24 at 2:13 P.M., an interview and record review was conducted with licensed nurse (LN) 1. LN 1 stated that Resident 1 had daily wound treatments for her RBKA site. LN 1 acknowledged that the treatment administration record (TAR) dated 6/21/24 with the order that indicated Treatment: Surgical Incision site: RBKA-Cleanse area with WD (wound) cleanser, pat dry, apply xeroform, gauze, wrap it with kerlix and ACE (elasticized bandage) wrap with Amusheild [sic], daily dressing change; f/u with [MD NAME] 6/21/24 . was blank. LN 1 stated that Resident 1's wound treatment was not done because it was not checked off. LN 1 stated that on 6/27/24, she documented 8 (eight) meaning absent from facility and stated that Resident 1 was still on isolation precautions due to COVID-19, so she (Resident 1) should had been in the facility. However, LN 1 futher stated that she thought Resident 1 had dialysis that day, and was out of the facility. LN 1 stated this was the reason why she did not do (provide) Resident 1's wound treatment. LN 1 stated it was important to do daily dressing changes per Medical Doctor's (MD) orders for Resident 1's RBKA surgical wound because Resident 1's has a history that compromised circulation to her limb, due to type two diabetes mellitus, which can affect wound healing and cause infection complications. On 9/4/24 at 12:28 P.M., an interview was conducted with the assistant director of nursing (ADON). The ADON stated she would have to re-educate the licensed nurses to help with wound treatments if the wound nurse is unable to complete a treatment and/or assist if needed. The ADON stated it was important to do daily wound treatments for Resident 1 because complications such as growth of bacteria to surgical site, cellulitis (skin infection), worsening of wounds, and prolonged wound healing that can send Resident 1 back to the hospital. On 9/5/24 at 3:15 P.M., an interview was conducted with LN 2. LN 2 stated she was the wound nurse on 6/22/24 and 6/23/24 for Resident 1. LN 2 stated that on 6/22/24 with Resident 1's RBKA surgical wound treatment, she was unsure why she had charted eight that indicated absent from facility. LN 2 acknowledged that Resident 1 had tested positive for COVID-19 on 6/21/24 that indicated that Resident 1 was still in the facility due to isolation precautions. LN 2 stated that on 6/23/24 she had charted seven to indicate see nurses notes and stated she would usually put a nursing note, but acknowledged there were no nurses' notes written by her, regarding Resident 1's RBKA surgical wound treatment. LN 2 stated I can't re-call her [Resident 1] specifically an amputee if I did any treatments on her because of the COVID-19 outbreak at the facility. On 9/6/24 at 12:28 P.M., an interview was conducted with the ADON. The ADON stated Resident 1 had diabetes and was at risk for complications of infection and poor wound healing due to poor circulation and slower healing with wounds especially with someone with diabetes and further amputation of the limbs to potentially lose more of her [Resident 1]'s extremity. The ADON stated it was important for Resident 1's RBKA surgical wound treatments to be done daily, per MD orders. In addition, the ADON stated her expectations was for [the wound nurse/nurses] to include progress notes about Resident 1's RBKA surgical wound care but with no progress notes I don't know what happened that day. A review of the facility's undated policy and procedure titled, CARE AND TREATMENT WOUND MANAGEMENT, indicated It is the policy of this facility to identify, assess and treat wounds on admission or throughout our residents stay .

Based on interview and record review, the facility failed to maintain an effective infection control program when the facility did not: 1. Report coronavirus (COVID-19: A highly contagious respiratory disease caused by the SARS-CoV-2 virus) outbreaks to the local/state public health officials in a timely manner. 2. Review the facility infection control policies and procedures on an annual basis during a COVID-19 outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) at the facility. These failures had the potential to increase the risk of healthcare-associated infections for staff, residents, and visitors in the facility. Findings: 1. A joint interview and record review of the facility's infection control log was conducted on 6/27/24 at 12 P.M., with the infection preventionist (IP) nurse. The IP stated that two nursing staff (licensed nurse [LN] 1 and 2) had COVID-19 symptoms that started on 6/16/24. The IP nurse stated that COVID-19 testing was conducted when LN 1 tested positive on 6/18/24 and LN 2 tested positive on 6/19/24. The facility's infection control line log titled OUTBREAK COVID-19 CASE LOG JUNE 2024 was reviewed. This record indicated that LN 3 was symptomatic along with a positive COVID-19 test result on 6/20/24 with six more symptomatic residents who tested positive on 6/21/24. The IP stated that the outbreak should have been reported on 6/21/24 when more residents tested positive, however, he did not report the outbreak immediately because he was off duty (not working) that day. The IP stated he was the only one responsible to report the outbreak during the time more residents started testing positive on 6/21/24. The IP stated that currently, the facility had 15 residents and 11 staff members who also tested positive for COVID-19. The IP stated that the outbreak should been reported immediately but was not reported until 6/25/24. An interview with the Director of Nursing (DON) was conducted on 7/9/24 at 3:39 P.M. The DON stated that the IP had support from other nursing staff who were trained in infection control and were available to report the COVID-19 outbreak. The DON acknowledged that the infection control outbreak was not reported in a timely manner. A review of the facility's policy and procedure dated 10/2022, INFECTION SURVEILLANCE OUTCOME AND REPORTING indicated . 8. Should any resident(s) or staff be suspected or diagnosed as having a reportable communicable/infectious disease according to state-specific criteria, such information shall be promptly reported to appropriate local and/or state health department officials . 2. An interview and policy review was conducted on 7/8/24 at 11 A.M., with the infection preventionist (IP) nurse. The IP confirmed that the facility's policies and procedures for infection control were not reviewed annually. The IP nurse stated that he did not know if he was responsible to review and/or revise the infection control policies on an annual basis.The IP nurse stated it is important to keep everyone safe and reduce outbreaks to keep the residents safe since most residents are a high-risk population. I think we should look at the policies and procedures and make sure it is new and keeping current [sic] with any policy and regulation changes. The IP acknowledged that an outbreak could have been minimized or prevented if the facility's infection control policies and procedures were current. A review of the following facility's policies and procedures was conducted: Infection Surveillance (Outcome) and Reporting; revision/reviewed date(s) 10/2022. Resident Visitation During a Pandemic or Outbreak; revision/reviewed date(s) 10/2022. Staffing During Emergency and Staff Recall; revision/reviewed date(s) 10/2022. COVID-19 Testing; revision/reviewed date(s) 10/2022. Emerging Infectious Disease (EID): Coronavirus Disease 2019 (COVID-19); revision/reviewed date(s) 11/8/22 An interview with the Director of Nursing (DON) was conducted on 7/9/24 at 3:39 P.M. The DON stated that his expectations was for the IP to review the facility's infection control policies and procedures on an annual basis. A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) April 12, 2024 https://www.cdc.gov/infection-control/hcp/core-practices/ .Provide written prevention policies and procedures that are available, current and based on evidenced-based guidelines (e.g. CDC/HICPAC, etc.).

Based on interview and record review, the facility failed to ensure one medication (med) was administered per physician ' s order for one resident (2). Resident 2 ' s Insulin Lispro (med to control high blood sugar) was administered via injection, and not via insulin pump (medical device that supplies a continuous flow of insulin subcutaneously [beneath the skin]), as ordered. As a result, Resident 2 ' s blood sugar level dropped below a normal range. This failure had the potential to affect Resident 2 ' s health, comfort, and well-being. FINDINGS: Resident 2 was admitted to the facility on [DATE] with diagnoses which included diabetes type 1 (DM 1 - high blood sugar; body produces very little insulin - hormone that lowers the level of sugar in the blood), end stage renal disease (permanent kidney failure) and cirrhosis of the liver (severe scarring of the liver). A review of Resident 2 ' s medical records were conducted. The Order Summary Report, dated 4/1/2024, indicated Resident 2 had an order for Insulin Lispro Injection 100 UNIT/ML (unit per milliliters) - Inject 40 unit [sic] subcutaneously one time a day for DM1 via insulin pump. The Medication Administration Record (MAR), dated 4/2/2024, included documentation that licensed nurse (LN) 1 administered 40 units of Insulin Lispro at 9 a.m. A progress note dated 4/2/2024, included documentation that Resident 2 ' s blood sugar was 26, and upon being rechecked, the blood sugar was 24 (DM 1 normal blood sugar range is between 80 and 130). Per this record, the LN referenced the MAR and documented that Resident 2 had been administered an incorrect insulin dosage at breakfast time . On 4/16/2024, at 12 p.m., an interview was conducted with LN 3. LN 3 stated that Resident 2 ' s insulin was administered incorrectly on 4/2/2024. LN 3 stated that LN 1 administered 40 units of Insulin Lispro via injection with a syringe, but should have administered (the Insulin Lispro) via Resident 2 ' s insulin pump. On 4/16/2024, at 12:20 p.m., an interview was conducted with LN 1. LN 1 stated she was the nurse who administered medications to Resident 2 on 4/2/2024. LN 1 stated she did not know what an insulin pump was. LN 1 stated she should have double checked and asked another nurse instead of administering the insulin incorrectly. On 4/16/2024, at 1 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that all medications must be administered as ordered by the physician, to ensure resident safety. The DON acknowledged that LN 1 administered the insulin incorrectly and that the physician ' s order was not followed. A review of the facility undated policy titled, Medication Administration, indicated that Medications must be administered in accordance with the written orders of the attending physician.

Based on interview and record review, the facility failed to develop and implement person-centered care plans related to the monitoring and inspection of bed alarms (auditorial alarms that alerts caregivers when patients leave or attempt to leave their beds), for three of three residents (Resident 1, 2, and 3), reviewed for accidental falls. As a result, there was the potential for Resident 1, 2, and 3 ' s bed alarms to not be monitored for functionality and staff were unaware of the bed alarms were in use. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral autosomal dominant arteriopathy (an inherited disease that causes strokes and other neurological impairments), per the facility ' s Admission Record. On 3/1/24 Resident 1 ' s clinical record was reviewed. According to the facility ' s Admission Minimum Data Set (MDS-a clinical assessment tool), dated 2/14/24, Resident 1 was alert, but aphasic (inability to form words), and required staff assistance for transferring, (lying to standing, and to sitting) eating, and toileting. The resident had a history of falls, prior to admission. According to the nurses note, dated 2/12/24, a bed alarm was implemented for safety reasons, to alert staff when resident attempted to get out of bed. According to the care plan, titled Actual Falls, dated 2/11/24, Resident 1 had unwitnessed falls in his room on 2/11/24, 2/12/24, and 2/15/24. The bed alarm was not listed as an intervention for prevention of falls. There was no documented evidence a care plan related to the monitoring of the bed alarm was developed or implemented. 2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included wedge compression fracture of second lumbar vertebra (lower spine) and history of falling, per the facility ' s Admission Record. On 3/1/24, Resident 2 ' s clinical record was reviewed. According to the facility ' s Admission MDS, dated [DATE], a cognitive score of 10 was listed, which indicated, moderately impaired cognition. The functional status indicated staff assistance was required for transferring, eating, and toileting. The resident had a history of falls prior to admission. According to the nurses note, dated 12/5/23, a bed alarm was implemented for safety reasons, to alert staff when resident attempted to get out of bed. According to the Facility ' s Change of Condition Evaluations, dated 12/5/23, 12/6/23, 12/7/23, 12/10/23, 12/16/23, 12/23/23, 2/5/24, 2/19/24, and 2/22/24, Resident 2 had unwitnessed falls in her room. A care plan, titled Actual Fall, dated 2/6/24, listed fall prevention interventions, which did not include the use of a bed alarm. There was no documented evidence a care plan related to the use of bed alarms was developed or implemented. 3. Resident 3 was admitted to the facility on [DATE], with diagnoses which included nontraumatic subdural hemorrhage (bleeding in the brain), and difficulty walking, per the facility ' s Admission Record. On 3/1/24, Resident 3 ' s clinical record was reviewed. According to the facility ' s Admission MDS, dated [DATE], a cognitive score of 14 was listed, indicating cognition was intact. The functional status indicated staff assistance was required for transferring, eating, and toileting. The resident had a history of falls, prior to admission. According to the nurses note, dated 12/5/23, a bed alarm was implemented for safety reasons, to alert staff when resident attempted to get out of bed. According to the Facility ' s Change of Condition Evaluations, dated 1/27/24, 1/30/24, and 2/6/24, Resident 3 had unwitnessed falls in his room. A care plan, titled Actual Fall, dated 1/30,24, listed fall prevention interventions, which did not include the use of a bed alarm. There was no documented evidence a care plan related to the bed alarms were developed or implemented. On 3/1/24 at 12:15 P.M., an interview was conducted with LN 1. LN 1 stated bed alarms were considered a restraint and before they could be utilized, they required a physician ' s order for use, a signed consent from the resident or their responsible party (a person assigned to represent the resident for medical and financial decisions), and a care plan needed to be developed. On 3/1/24 at 12:45 P.M., an interview was conducted with LN 2. LN 2 stated care plans were required for all bed alarms, so staff were aware they were being use and someone was monitoring them to ensure they were working. LN 2 stated by not having a care plan, staff were unaware the bed alarm existed, and no interventions were in placed to monitor the alarms necessity or effectiveness. On 3/4/24 at 3:20 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated bed alarms should be care planned to ensure someone was checking their functionality and placement. The DON stated the harm of not having a care plan for bed alarms was, no plans were in place for staff monitoring. The DON reviewed the records for Resident 1, Resident 2, and Resident 3 and stated there were no care plans in place and there should have been. According to the facility ' s policy, titled Bed Alarm, undated, .6. The Clinical Team/Designee will develop a care plan that addresses: Restraint usage, Interventions to promote restrain reduction or elimination, Interventions which minimize potential functional decline associated with restraint . According to the facility ' s policy, titled Care Planning, undated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident .

Based on interview and record review, the facility failed to accurately assess post Fall Risk Evaluations to ensure a higher score was in place after an actual fall, in order to prevent future falls from occurring for one of three residents, (Resident 2) reviewed for Accidents related to falls. As a result, post Fall Risk Evaluation scores decreased after each fall, putting Resident 2 at risk for additional falls. Findings: Resident 2 was admitted to the facility on [DATE], with diagnoses which included wedge compression fracture of second lumbar vertebra (lower spine) and history of falling, per the facility ' s Admission Record. On 3/1/24, Resident 2 ' s clinical record was reviewed. According to the facility ' s Admission MDS, dated [DATE], a cognitive score of 10 was listed, which indicated moderately impaired cognition. The functional status indicated staff assistance was required to transfer (moving from lying, to standing and to sitting), eating and toilet use. The resident had a history of falls, prior to admission. According to the physician orders, dated 12/5/23, Safety-Monitor episodes of attempting to transfer (out of bed/wheelchair) unassisted every shift. Safety-sensor alarm pad to bed-alert staff of unassisted transfers. The Admission Fall Risk Evaluation, dated 12/4/23, listed a fall risk score of 21, (score of 10 and higher indicates high risk for falls, 9 and below indicates moderate to low risk). According to the Facility ' s Change of Condition Evaluations, dated 12/5/23, 12/6/23, 12/7/23, 12/10/23, 12/16/23, 12/23/23, 2/5/24, 2/19/24, and 2/22/24, Resident 2 had (nine) unwitnessed falls in her room. The post Fall Risk Evaluation for the 12/6/23 fall was decreased from 21 to 15. The post Fall Risk Evaluation for the 12/16/23 fall was decreased from 15 to 13. The post Fall Risk Evaluation for the 2/5/24 was increased by one to 14. The post Fall Risk Evaluation for the 2/19/224 fall was decreased from 14 to 13. There were no post Fall Risk Evaluations conducted for the falls that occurred on 12/5/23, 12/7/23, 12/10/23, 12/23/24, and 2/22/24. A care plan, titled Actual Fall, dated 2/6/24, had falls listed with dates, but did not include the falls that occurred on 12/5/23, 12/23/23 and 2/19/24. On 3/1/24 at 12:15 P.M., an interview was conducted with Licensed Nurse 1 (LN 1). LN 1 stated if a fall occurred, the LNs were expected to complete a change of condition, notify the physician and family, and conduct a post Fall Risk Evaluation. LN 1 stated with each fall, the post Fall Risk Evaluation score should increase, because the risk of future falls increased. LN 1 stated the scores were important to inform staff of the risk and with higher scores, the more fall prevention interventions were put into place. On 3/1/24 at 12:45 P.M., an interview was conducted with LN 2. LN 2 stated Fall Risk Evaluation scores should increase after each fall and not go lower. LN 2 stated if the score decreased, then LNs were not accurately completing the evaluations. LN 2 stated the purpose of scoring residents ' Fall Risk was to alert staff and to ensure after each fall, more fall precautions and interventions were being put into place. On 3/1/24 at 1:24 P.M. an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated she provides in-services to the certified nursing assistants on a monthly basis for fall preventions. The DSD stated she had not recently provided fall prevention in-services to the LNs. The DSD reviewed her training calendar and stated her last fall in-service to LNs was in February 2023. On 3/4/24 at 3:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated post Fall Risk Evaluations should increase after each fall and should never go down. The DON stated the purpose of post Fall Risk Evaluations was to prevent future falls, by putting more fall prevention interventions in place. The DON stated when post Fall Risk Evaluations were not accurately conducted, residents were at risk for additional falls. According to the facility ' s policy, titled Fall Management System, revised June 2018, .1. On admission, the Fall Risk Evaluation will be completed to determine his/her risk for sustaining a fall . 3. When a resident sustains a fall, .A Fall Risk Evaluation will be completed post fall; incident .4. Review of the fall will include investigation to determine probable causal factors .

Based on record review the facility failed to ensure 2 of 13 sampled resident's (24 and 107) Physician Orders for Life Sustaining Treatment (POLST) document was acknowledged and signed by the resident's physician. As a result, the residents' end of life wishes may not have been followed. Findings: 1. Resident 24 was admitted to the facility on [DATE], with diagnosis that included spinal stenosis, per the facility's Face Sheet. Resident 24 was cognitively intact according to the history and physical dated 7/24/23. On 8/24/23 Resident 24's Electronic Medical Record (EMR) was reviewed. The POLST in the EMR chart was signed by Resident 24 and dated 7/23/23. A copy of the POLST was requested on 8/23/23 and was received 8/24/23. The POLST was not signed by Resident 24's physician until 8/23/23. 2. Resident 107 was admitted to the facility on [DATE], with diagnosis that included a stroke, per the facility's Face Sheet. On 8/24/23, Resident 107's Electronic Medical Record (EMR) was reviewed. The POLST was not found in the EMR chart. A copy of the POLST was requested on 8/23/23 and was received 8/24/23. The POLST was signed by Resident 107 on 8/7/23, but was not signed by Resident 107's physician until 8/23/23.

Based on interview and record review the facility failed to ensure 1 of 13 sampled residents (36) was properly assessed for a psychiatric diagnosis when he was prescribed, and administered antipsychotic and anti-seizure medications. As a result, Resident 36 received medications for a condition he did not have. Findings: Resident 36 was admitted to the facility on [DATE], with diagnosis that included encephalopathy (disease of the brain), and dementia (decline in cognition, memory loss) per the facility's Face Sheet. On 8/25/23 Resident 36's Electronic Medical Record (EMR) was reviewed. Resident 36 had a physician's order dated 7/6/23, for Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 100 mg, give 300mg every night for behavioral and physical symptoms. Resident 36 also had an order dated 7/10/23, for Depakote sprinkles (used to treat seizure disorders, mental/mood conditions (such as manic phase of bipolar disorder), and to prevent migraine headaches) oral cap delayed release, 125 mg 1 capsule every day for behavioral and physical symptoms of dementia, and give 1 capsule at bedtime for same. The facility developed a Care Plan for dementia with the use of psychoactive medications (meds) prior to this admission, and there were no indication why the medications would be administered when Resident 36 had no diagnosis for these meds. There was an initial Medication Regime Review (MRR), by the consultant pharmacist dated 7/6/23. The MRR indicated the consultant pharmacist had, No issues found during the drug regime review. The DON was interviewed on 8/25/23 at 10:43 A.M. The DON stated Resident 36 had multiple admissions and had issues while at the facility. The DON stated they reduced Resident 36's medications , but unsure why he was on them on admission.

Based on observation, interview and record review, the facility failed to develop a care plan for 1 of 13 sampled residents (125). This failure had the potential risk of not providing appropriate and individualized care for Resident 125. Findings: Resident 125 was admitted to the facility on [DATE] with diagnoses that included Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, and retention of urine (the bladder does not empty completely) according to the facility's Admission Record. An observation of Resident 125 was conducted on 8/23/23 at 9:15 A.M. Resident 125 was reclining in bed and had an indwelling urinary catheter draining amber-colored urine. A review of Resident 125's medical record was conducted on 8/23/23 at 9:30 A.M. A physician's order, dated 8/17/23, indicated, Indwelling urinary catheter: change urinary drainage bag as needed; Indwelling urinary catheter: secure with catheter strap; Indwelling urinary catheter: cleanse site with soap and water. In addition, no care plan for the urinary catheter was located. A concurrent record review and interview was conducted with the Director of Nursing (DON) on 8/24/23 at 10:40 A.M. The DON stated, There is no care plan and there should be, so there is a plan to protect the resident and a pathway for consistent care is laid out. A review of the facility's policy, undated, titled Care Planning/Care Conferences indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident .Procedures: 1. A comprehensive care plan is developed withing fourteen (14) days of resident admission .

Based on interview and record review the facility failed to ensure the Medication Regime Review (MRR) identified 1 of 13 sampled residents (36) who was on multiple psychoactive medications without a psychiatric diagnosis. As a result, Resident 36 received inappropriate medications. Findings: Resident 36 was admitted to the facility on [DATE], with diagnosis that included encephalopathy, and dementia per the facility's Face Sheet. On 8/25/23 Resident 36's Electronic Medical Record (EMR) was reviewed. Resident 36 had a physician's order dated 7/6/23, for Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder) 100 mg, give 300mg every night for behavioral and physical symptoms. Resident 36 also had an order dated 7/10/23, for Depakote sprinkles (used to treat seizure disorders, mental/mood conditions (such as manic phase of bipolar disorder), and to prevent migraine headaches) oral cap delayed release, 125 mg 1 capsule every day for behavioral and physical symptoms of dementia, and give 1 capsule at bedtime for same. There was only an initial Medication Regime Review (MRR), by the consultant pharmacist dated 7/6/23, the MRR indicated the consultant pharmacist had, No issues found during the drug regime review. The DON was interviewed on 8/25/23 at 10:43 A.M. The DON stated Resident 36 had multiple admissions and had issues while at the facility. The DON stated they reduced Resident 36's medications , but unsure why he was on them on admission.

Based on interview and record review the facility failed to ensure 1 of 13 sampled residents (53) had not been put on Trazodone for a non-FDA approved indication, which resulted in this medication becoming an unnecessary drug for Resident 53, as this medication had been prescribed without an adequate (FDA approved) indication. This deficient practice resulted in this resident receiving Trazodone for a clinical indication, which had not been FDA approved, which could have caused this resident harm. Findings: Resident 53 was admitted to the facility on [DATE], with diagnosis that included encephalopathy, per the facility's Face Sheet. On 8/25/23 Resident 53's Electronic Medical Record (EMR) was reviewed. Resident 53 had a physician's order dated 7/18/23, for Trazodone (DESYREL) [a medication used to treat depression] 50 mg 1 tablet by mouth at bedtime for insomnia. This medication had been prescribed to treat Resident 53's inability to sleep, not depressive disorder for which this medication has been FDA approved. Depression is disease which can occur 24 hours a day, and not just in the evenings, (at the time of sleep). There was no evidence in the resident's medical record to indicate that the facility had ruled out any other causes for this resident's inability to sleep. Pragma Pharmaceuticals, LLC, the manufacturer of Trazodone states the following in their product package information dated 6/2017: (Trazodone) DESYREL is indicated for the treatment of major depressive disorder (MDD) (1). DOSAGE AND ADMINISTRATION, Starting dose: 150 mg IN Divided DOSES DAILY. May be increased by 50 mg per day every three to four days. Maximum dose: 400 mg per day in divided doses (2.1). As indicated in the manufacturer's product information, this medication should be administered in Divided daily dosages, not just once a day at BEDTIME. A review of Resident 53's clinical record revealed that the facility had not attempted to use any non-drug therapy to assist with Resident 53's inability to sleep, despite the fact that Trazodone's (use in the treatment of insomnia), has never been FDA approved.

Based on observation, interview and record review, the facility failed to ensure that medications were administered safely for 1 of 13 sampled residents (155). This failure had the potential to cause a medication error for Resident 155. Findings: Resident 155 was admitted to the facility on [DATE], with diagnoses that included a fracture of the left femur (thigh bone) and a history of falling, according to the facility's Admission Record. An observation was conducted of Resident 155 on 8/22/23 at 11:35 A.M. Resident 155 was relaxing in bed and a medicine cup with 3 medications was set on the overbed table. A concurrent observation and interview was conducted with licensed nurse (LN) 11 on 8/22/23 at 11:36 A.M. LN 11 stated the medicine cup on the overbed table contained two doses of Colace (stool softener) and one dose of Senna (laxative). LN 11 stated, It is not acceptable to leave unattended meds (medications) at the resident's bedside. A review of Resident 155's medical record was conducted on 8/23/23 at 11 A.M. No Interdisciplinary Team (IDT) assessment for safe self-administration of medications was located. An interview was conducted with the Director of Nursing (DON) on 8/24/23 at 9:30 A.M. The DON stated, It is not acceptable to leave meds, unless the resident has been assessed. It could mean that residents don't get their meds, or they get duplicate doses or another resident could take it. A review of the facility's policy, undated, titled, Self-Administration of Medications, indicated, Purpose . to maintain the safety and accuracy of medication administration .Procedures: 2. If a resident desires to participate in self-administration, the IDT will assess and periodically re-evaluate the resident .

Based on observation, interview, and record review the facility failed to offer bed hold upon transfer to the hospital for one of 4 residents reviewed for bed hold. This failure had the potential for the resident or the resident representative to be uninformed of bed hold rights. Findings: Resident 1 was admitted on [DATE] with diagnosis of Sepsis (a serious in which the body responds improperly to an infection) according to Resident 1 ' s Admission Record. An interview with LN 2 was conducted on 5/23/23 at11:50 A.M. LN 2 stated she assisted with Resident 1 ' s transfer to the hospital. LN stated the Director of Nursing (DON) informed her that Resident 1 was screaming and had put her hand in her mouth. LN 2 stated Resident 1 ' s behavior was unmanageable, and the Nurse Practitioner had ordered to send Resident 1 to the emergency room for further evaluation. LN 2 stated bed hold was offered only upon admission. The Social Service Director (SSD) was interviewed on 5/23/23 at 1:35 P.M. The SSD stated the Admissions staff were responsible for bed hold notifications. During an interview on 5/23/23 at 2:19 P.M. with the Admissions/Marketing (AM) staff, the AM stated her assistant completed bed hold notifications when a resident was transferred to the hospital. The AM stated a 7-day bed hold was automatic for residents with Medical insurance, and bed hold was offered if a resident had private insurance. The AM stated Resident 1 ' s daughter was not called for bed hold due to having Medical insurance. During an interview on 6/2/23 at 10:47 A.M. with the Director of Nursing (DON), the DON stated there should have been a follow up with Resident 1 ' s family member in case they had further questions regarding bed hold. During a review of the facility ' s undated Policy and Procedure titled Admission/Discharge/Transfer indicated, It is the policy of this facility to inform the resident, or the resident ' s representative, in writing, of the right to exercise the bed hold provision of seven (7) days, upon admission and before transfer to a general acute care hospital .2. This information shall be provided to the resident and/or his/her representative in a language they can understand at the time of: Admission, Transfer to the general acute hospital .

Based on observation, interview, and record review, the facility failed to develop and implement a care plan regarding a resident ' s behavior for one of one resident reviewed for care planning (Resident 1). This failure had the potential to affect the delivery of care to the residents. Findings Resident 1 was admitted on [DATE] with diagnosis of Sepsis (a serious in which the body responds improperly to an infection) according to Resident 1 ' s Admission Record. During a review of Resident 1 ' s facility progress note dated 5/11/23, the note indicated Resident 1 was transferred to the emergency room for evaluation and treatment of poor oral intake and hitting staff. During an interview with LN 1 on 5/23/23 at 11:45 A.M., LN 1 stated Resident 1 was legally blind, hard of hearing and only understood Chinese language. LN 1 stated Resident 1 had episodes of agitation by screaming and shouting in Chinese language. LN 1 stated Resident 1's behavior included spitting out food, yelling and screaming. An interview with LN 2 was conducted on 5/23/23 at11:50 A.M. LN 2 stated she assisted with Resident 1 ' s transfer to the hospital. LN 2 stated the Director of Nursing (DON) informed her that Resident 1 was screaming and had put her hand in her mouth. LN 2 stated Resident 1 ' s behavior was unmanageable, and the Nurse Practitioner had ordered to send Resident 1 to the emergency room for further evaluation. The Social Service Director (SSD) was interviewed on 5/23/23 at 1:35 P.M. The SSD stated she was aware of Resident 1 ' s behavior since admission. SSD stated she witnessed Resident 1 being agitated slapping herself and yelling. SSD stated Resident 1 was transferred to a private room due to the agitation and screaming. During an interview and concurrent record review with the DON on 5/23/23, at 2:37 P.M., the DON stated Resident 1 was biting and hitting her hand on the day Resident 1 was transferred to the emergency room . The DON stated Resident 1 has had these behaviors since admission. During a review of Resident 1 ' s record, the DON stated the SSD documented Resident 1 ' s behavior on 5/9/23 in the progress notes. The DON reviewed Resident 1 ' s care plans and did not find a care plan regarding Resident 1 ' s behaviors. The DON stated there should be a care plan to address Resident 1 ' s behaviors because Resident 1 may hurt herself. A review of the facility ' s undated Policy and Procedure titled Care Planning / Care conference indicated, .It is the policy of this facility that the interdisciplinary team (IDT-group of people with different expertise) shall develop a comprehensive care plan for each resident .4. Revision and update of care plan should transpire to accommodate resident needs .

Based on observation, interview, and record review, the facility failed to develop and implement a care plan regarding an allegation of inappropriate handling during bedside care for one of one resident (Resident 1). This failure had the potential for Resident 1 to continue to not receive appropriate care and interventions. Findings: Resident 1 was admitted to the facility on [DATE] with the diagnosis of Fracture of Left Tibia (shinbone of lower leg) according to Resident 1's face sheet. During an interview on 5/3/23 at 9:40 A.M., with the ADON, the ADON stated Resident 1 has been discharged from the facility. During an interview on 5/3/23 at 10:10 A.M., with the Administrator (ADMIN), the ADMIN stated Resident 1 complained about being uncomfortable with the care of Certified Nurse Assistant (CNA) 1. ADMIN stated Resident 1 was anxious and often needed Valium (a medication that treats anxiety) to calm her nerves. The ADMIN interviewed Resident 1 and stated Resident 1 stated CNA 1 did not clean her the same way as when Resident 1 was at the hospital. ADMIN stated Resident 1 complained that CNA 1 did not know what he was doing. The Manager of the Day (MOD) was interviewed on 5/5/23 at 10:45 A.M. The MOD stated Resident 1 informed her that Resident 1 felt uncomfortable with CNA 1. The MOD stated Resident 1 complained that CNA 1 used a washcloth that was not warm enough and swiped the wrong way during peri care (cleaning private areas of a patient). According to the MOD, Resident 1 further stated Resident 1 was not sure if it was a dream or not. An interview and concurrent record review was conducted on 5/3/23 at 2:39 P.M. with the Assistant Director of Nursing (ADON). The ADON stated she could not find a care plan addressing Resident 1's allegation with CNA 1's inappropriate way of providing bedside care. During an interview on 5/22/23 at 10:12 A.M. with the Director of Nurses (DON), the DON stated care plans were needed to cover the basis of all the resident's needs pertaining to the situation. A review of the facility's undated Policy and Procedure (P&P) titled, Care Planning / Care conference, the P&P indicated, .It is the policy of this facility that the interdisciplinary team (IDT-group of people with different expertise) shall develop a comprehensive care plan for each resident .4. Revision and update of care plan should transpire to accommodate resident needs .

Based on interview and record review, the facility failed to ensure a safe, orderly discharge, when the receiving facility was unaware the resident was coming and a bed was not available when he arrived for one of four residents, (Resident 1), reviewed for discharges. As a result, there was no continuum of care and Resident 1 did not to have a place to sleep for the night. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included sepsis (a serious medical condition resulting from harmful bacteria in the blood, or other bodily tissues) per the facility's Admission Record. On 3/8/23 Resident 1's clinical record was reviewed: According to then physician's order, dated 12/23/22, Resident 1 was capable of understanding rights, responsibilities, and informed consent. According to the facility's Progress Notes, the Social Services Director (SSD), dated 2/21/23 at 2:15 P.M., documented, Met with patient in person to confirm discharge. SSD once again asked patient regarding discharge and patient confirmed he only wishes to return to his previous living and have confirmed I have a place and will be let in once transportation drops me off .SSD reviewed other placement options as well and patient firmly stated he will only return to prior address. The next Progress Note, dated 2/22/23 at 2:20 P.M., the SSD documented SSD received a call from (name of person) at Veterans Village regarding Resident 1 .patient does not have a room there any longer .SSD promptly notified physician as well as APS {adult protective services} . According to the Discharge Summary and Post-Discharge Note, dated 2/22/23, Licensed Nurse 1 (LN 1) documented Resident 1 was being discharged home and discharge instructions were given to the resident and his representative. According to the discharge note, dated 2/22/23 at 12:30 P.M., LN 1 documented Resident 1 left ambulating with a walker and was being discharged to an assisted living. LN 1 did not document who Resident 1 left with or how the resident was being transported. According to the care plan, titled Discharge Care Plan, undated, listed an intervention of .Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan as needed. On 3/8/23 at 11:19 A.M., an interview and record review was conducted with LN 1. LN 1 stated she escorted Resident 1 to the lobby downstairs once he was discharged . LN 1 stated Resident 1 told her he was going to have a friend pick him up. LN 1 stated Resident 1 told her he was going to a Veteran's Assisted Living Facility. LN 1 stated she never called the assisted living facility to give report. LN 1 reviewed her Discharge Summary and Discharge note. LN 1 stated she check the box for instructions were given to representative, and it was premature, because she was just trying to get all the paperwork ready. LN 1 stated she does not know exactly when Resident 1 left, who he left with, or how he was transported, because she left him alone in the lobby. LN 1 stated she should have called the receiving facility, documented when he left and with who, and how he got there. LN 1 stated she now realizes it was not a safe discharge, because no one was there to welcome him. On 3/8/23 at 11:36 A.M., an interview was conducted with the SSD. The SSD stated Resident 1 listed the Veteran village as his home address and permanent living place. The SSD stated she had no idea the Veteran's Village was a place that temporarily housed the homeless. The SSD stated Resident 1 told her he had called the Veterans Village and ensured her that they knew he would be coming, and he had a room. The SSD stated she should have called to verify his placement, but at the time, she believed Resident 1. The SSD stated the facility paid for transportation for the resident and provided proof, the transportation service was provided. The SSD stated once she learned Resident 1 was not accepted into the Veteran's Village, she assisted him with getting a hotel and then she immediately notified the physician and APS. The SSD stated Resident 1 was still residing at the hotel. On 3/8/23 at 11:23 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated when residents were discharged , he expected the LNs to document when the resident left, with who, and how they were transported. The DON stated staff should have verified where the resident was going and confirmed there would be someone there to receive him. The DON stated Resident 1's discharge was not organized or safe, because he did not have a bed available, and he had no safe place to go after arriving. According to the facility's policy, titled Discharge or Transfer, undated, It is the policy of this facility to provide the Resident with a safe organized structured transfer and/or discharge from the Facility .

Based on interview, and record review, the facility failed to ensure Licensed Nurses performed ongoing skin assessments to mitigate the development of a pressure ulcer for one of three sampled residents (Resident 1). This failure had the potential to contribute to delayed care and treatment of Resident 1's unstageable pressure ulcer. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis that included joint replacement surgery post left femur fracture, per the facility's admission record. On 1/18/23, a review of Resident 1's MDS (health status screening and assessment tool), section C dated 8/17/21, indicated Resident 280's BIMS Summary Score (test for cognitive function) was 11 (moderately impaired). On 1/28/23 a review of Resident 1's medical records was conducted from 8/10/21 to 8/30/21 indicated the following: Resident 1 had blanchable redness on the sacrum area (tailbone) and was identified as high risk to develop skin breakdown as indicated on the initial admission assessment dated : 8/10/2021. Braden Scale Assessment (a measurement tool for skin breakdown risks) dated: 8/10/21, indicated a score of 14 (high risk for skin breakdown), confined to bed and required some assistance with change in positioning. 8/17/21, indicated a score of 17 (high risk for skin breakdown), walks occasionally and required some assistance with change in positioning. 8/25/21, indicated a score of 17 (high risk for skin breakdown), walks occasionally and required some assistance with change in positioning. Skin Assessment / Shower Sheet: The licensed nurses missed three out of six opportunities for Resident 1 to have a skin assessment: 8/13/21 No shower sheet 8/17/21 Resident 280 refused a shower - No skin assessment 8/20/21 Resident 280 refused a shower - No skin assessment 8/23/21 No shower sheet 8/27/21 Bed bath and a dressing to sacrum area - no skin assessment 8/30/23 No shower sheet Care Plan, dated 8/10/21 indicated potential impairment of skin integrity r/t fragile skin. Interventions: Monitor and document location, size, and treatment of skin injury. Weekly Summary dated 8/18/21 indicated no skin issues. Interdisciplinary (IDT) Note dated 8/25/21 indicated no skin issues for Resident 1. A Physician Note, dated 8/25/21 indicated, new wound unstageable pressure injury located coccyx measuring: Area: 69.7 cm Volume: 7.0 cm Length: 9.3 cm Width: 8.4 cm Depth: 0.1 cm On 1/18/21 at 10:43 A.M., an interview and concurrent review of Resident 1's record was conducted. The TN (Treatment Nurse) reviewed the [NAME] Scale Assessments, Skin Assessments, shower sheets, weekly licensed nurse summaries, the IDT note and the physican note dated 8/25/21. The TN stated, an initial skin assessment is done by the admission nurse and LN's should have conducted weekly skin assessments. The Treatment Nurse was unable to find documentation of weekly skin assessments within Resident 1's record. On 1/18/23 at 3:18 P.M., an interview and concurrent medical record review was conducted with the DON. The DON stated, initial skin assessments should be documented on admission and weekly, including deep tissue injuries, pressure sores and surgery sites. The DON verified an initial skin assessment was completed on admission but was unable to locate any weekly skin assessments for Resident 1 after the initial assessment. The DON stated, it is the expectation for the licensed nurse to complete a weekly skin assessment on residents as per the facility policy and procedure. The DON stated, it is important for the licensed nurse to perform weekly skin assessments to identify any skin issues and implement timely treatment(s). The DON stated, the assessments should have been completed by the licensed nurse for Resident 1. The licensed nurses are not following the facility policy and procedure for weekly skin assessments, and they should have for Resident 1. The facility's policy entitled, Skin Management, no date, indicated, . residents do not develop pressure ulcers, or that residents admitted with wounds will not develop signs and symptoms of infection . 4 .skin weekly will be done by licensed staff . 6. A report of all wound progress will be updated by the licensed staff weekly and as needed . The facility's policy entitled, Skin Management, no date, indicated, .have weekly skin / wound assessment completed by a nurse. A skin alteration is identified as an Arterial Ulcer, Diabetic Neuropathic Ulcer, Pressure Ulcer, Venous Insufficiency Ulcer, Surgical Wound, Lacerations, Bruises and Redness . 2. Wound status and treatment will be re-evaluated weekly and as needed . The facility's policy entitled, Skin Management, revised 5/2007, indicated, A weekly summary of resident status will be completed on all residents .