Every finding on record at Trinity Hospital Skilled Nursing Facility

Based on interview, record review, and policy review the facility failed to ensure that one of three residents sampled (Resident 1) did not receive unnecessary medications (any drug prescribed or taken that does not provide a clear, valid medical benefit to the person it was given to) when he was given a combination of three medications (Benadryl also known as diphenhydramine [an over-the-counter allergy medication that causes drowsiness], Haldol also known as haloperidol [a strong antipsychotic medication used to treat severe behavioral problems], and Ativan also known as lorazepam [a medication used to treat anxiety disorders and which causes drowsiness]). This failure could have resulted in negative outcomes for Resident 1 such as respiratory depression, falls, fractures, confusion and excessive drowsiness.Findings: Review of the Journal of the American Geriatrics Society (a nationally recognized professional resource for geriatric healthcare [the medical specialty that focuses on the health and care of people over the age of 65]) article titled American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults dated March 29, 2023 indicated a list of medications that are .best avoided by older adults in most circumstances. and The criteria are intended to be applied to adults 65 years or older. Benadryl, Ativan, and Haldol are all listed in the Beers Criteria. Haldol was indicated as a medication that increased the risk of stroke (a medical emergency occurring when blood flow to part of the brain is blocked or a blood vessel in the brain bursts, causing brain cells to die within minutes) in the elderly. Ativan was indicated as a medication that increased the risk of falls and fractures (broken bones) in the elderly. Benadryl was indicated as a medication that increased the risk for confusion and falls in the elderly.Review of Epocrates, a widely used web-based tool for healthcare professionals to check drug interactions (a change in the way a drug acts in the body when taken with certain other drugs) indicated that the use of Ativan, Haldol, and Benadryl together should be avoided due to the risk of respiratory depression (decreased breathing), and psychomotor impairment (slowing of physical movements, speech, and thinking ability which can increase the risk for accidents such as falls.)Review of a facility policy titled, Psychotropic Medication Use, SNF (psychotropic medications are used for mood disorder and mental health) dated March 2017, indicated c. Pertinent non-pharmacological (non-medication) interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation., 16. The staff will observe, document, and report to the Attending Physician (a medical doctor who has primary responsibility for the overall care of a patient in a healthcare facility) information regarding the effectiveness of any interventions, including psychotropic medications. and 18. The Physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.Review of Resident 1's medical record indicated that he was [AGE] years old when he admitted to the facility on [DATE] with diagnoses which included depression.Review of Resident 1's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents), dated 3/18/26 and completed by the Director of Staff Development (DSD) indicated a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 15 out of 15 indicating good decision making ability.Review of Resident 1's record titled, Order Summary Report dated 3/7/26 indicated that Haldol 5 milligrams (mg, a unit of measure) intramuscular (IM - injection into a muscle), Ativan 2 mg intramuscular, and diphenhydramine 50 mg intramuscular was ordered to be given at the same time on 3/7/26.During a concurrent interview and record review on 3/24/26 at 12:50 pm, with the Director of Nursing (DON) of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of March 2026, the DON confirmed that Resident 1's MAR for March 2026 indicated that on 3/7/26, Resident 1 was given an intramuscular injection of diphenhydramine at 1:01 am, an intramuscular injection of Ativan at 1:01 am, and an intramuscular injection of Haldol at 1:02 am. The DON indicated that this is a combination of medications which are frequently used in the emergency room setting for severe agitation (a state of restlessness, tension, or nervous excitement, often resulting in pacing, fidgeting, or hostility) and called a B52. The DON acknowledged that in her 10 years as the DON of the skilled nursing facility (a facility for the elderly [individuals over the age of 65, experiencing decline in health and mobility] which is their home and where they receive medical care) she had never seen it used.Review of Resident 1's record titled Progress Note dated 3/7/26 at 2:01 am and written by Licensed Nurse (LN A), LN A wrote Resident continued screaming and yelling and blocked the entrance of the room by wheeling his wheelchair., Resident wheeled himself to nursing station and glared at nurse and other residents., and Called MD (medical doctor) and he came to facility to talk to resident. Orders provided and administered for agitation and effective. No further monitoring of Resident 1 after the administration of the three medications was recorded in his Progress Notes for the night.During a phone interview on 3/24/26 at 3:44 pm, with the facility's Pharmacist, when asked if Haldol, diphenhydramine, and Ativan should be given together, the Pharmacist indicated, Generally, we would want to avoid that. The Pharmacist indicated that this combination of medications should be avoided in the skilled nursing facility setting. When asked what the potential adverse outcomes of giving the three medications together could be, the Pharmacist indicated .sedation (the medical use of sedation drugs to induce a state of calm, relaxation, or sleepiness, reducing anxiety and discomfort during medical procedures) like side effects (unintended, consequences of a drug or treatment that can be harmful), mainly, over sedation (a state where a person receives a higher level of sedation than intended or required, resulting in excessive depression of the nervous system such as the drive to breathe.)Review of Resident 1's record titled, Progress Note dated 3/11/26, four days after Resident 1 was given the medication combination, and written by the Medical Director (MD) indicated that Resident 1 .was administered IM Benadryl, Haldol, and Ativan x1 that night and he has been fine ever sinceDuring a phone interview with the MD on 3/24/26 at 2:22 pm, the MD indicated that Ativan, Haldol, and diphenhydramine (Benadryl) given together are standard for enforced sedation for people who are out of control. The MD confirmed that Resident 1 received this combination of medications while in the skilled nursing facility, and that it is not given often in skilled nursing. The MD indicated that he felt it was safe to have Resident 1 stay in the skilled nursing facility and have Licensed Nurse (LN) 1 monitor Resident 1, instead of sending Resident 1 to the emergency room in the other part of the facility.Review of a facility policy titled, Behavioral Assessment, Intervention and Monitoring, SNF undated indicated 9. Non-pharmacological approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. And 10. When medications are prescribed for behavioral symptoms, documentation will include: a rationale for use; c. Other approaches and interventions tried prior to the use of antipsychotic medications; h. Monitoring for efficacy and adverse consequences.During a concurrent interview and record review on 3/24/26 at 12:50 pm, with the DON, reviewed Resident 1's care plan and the DON acknowledged that there was no care plan created related to Resident 1's behavior monitoring for the use of Ativan, Haldol, or diphenhydramine.Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, SNF no date, indicated 12. Assessment of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. And 13. The Interdisciplinary Team (IDT is an interdisciplinary team of health care providers who have knowledge of the resident and his or her needs who is involved in making decisions about the resident's care) must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met.During a concurrent interview and record reviews on 3/24/26 at 12:50 pm, the following records were reviewed and interviews conducted with the DON:a.Reviewed Resident 1's progress notes with the DON and the DON acknowledged that there was no documentation of Resident 1 having any behaviors in the days just before or after 3/7/26 and that there was no documentation of any non-pharmaceutical interventions taken before Resident 1 was administered the combination of Ativan, Haldol, and diphenhydramine.b.Reviewed Resident 1's progress notes with the DON and the DON acknowledged that there was no documentation of the IDT team meeting to discuss Resident 1 receiving Ativan, Haldol, and diphenhydramine.c.Reviewed Resident 1's record titled, Informed Consent for Treatment with Anti-Anxiety/Sedative/Hypnotic Medications dated 3/7/26 for Ativan (Lorazepam) with the DON and the DON acknowledged that the record indicated Diagnosis and/or signs and symptoms: Severe Agitation with no specific behaviors to be monitored mentioned in the document.d.Reviewed Resident 1's record titled Informed Consent for Treatment with Anti-Anxiety/Sedative/Hypnotic Medications dated 3/7/26 for Benadryl (Diphenhydramine) with the DON and the DON acknowledged that the record indicated Diagnosis and/or signs and symptoms: Severe Agitation with no specific behaviors to be monitored mentioned in the document.e.Reviewed Resident 1's record titled Informed Consent for Treatment with Anti-Anxiety/Sedative/Hypnotic Medications dated 3/7/26 for Haldol (Haloperidol) with the DON and the DON acknowledged that the record indicated Diagnosis and/or signs and symptoms: Severe Agitation with no specific behaviors to be monitored mentioned in the document.Review of a facility policy titled Informed Consent no date, indicated B. The information material.shall include at least the following: 1. The reason for the treatment.5. The reasonable alternative treatments and risks, and why the health professional is recommending this particular treatment.During an interview on 3/24/26 at 3:55 pm, with the DON, the DON acknowledged that a change in condition assessment (documentation completed in a patient's chart after an unexpected change in the patient's physical or mental state occurs, documentation includes; specific observations, the assessments of the patient performed, and any actions taken, completed to ensure a clear record for communication and follow-up) of Resident 1 was not completed following Resident 1's behaviors and the administration of Ativan, Haldol, and diphenhydramine together on 3/7/26.Review of a facility policy titled, Change in a Resident's Condition or Status, SNF dated March 2017, indicated 7. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental status. And 8. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment (a thorough evaluation that gathers detailed information about a patient's overall status to create a tailored plan of care) of the resident's condition will be conducted.

Based on observation, interview, and record review, the facility failed to maintain professional standards of practice to ensure food service safety for the residents of the facility when: 1. During the initial tour food preparation equipment was not sanitary. 2. Dietary staff failed to maintain clean, sanitary floors. 3. Dietary staff failed to keep foods stored away from unsanitary surfaces in the walk-in refrigerator. These failures had the potential for risk of cross contamination, to cause infection control issues, and lead to food borne illness for residents consuming food in the facility. A review of a facility document titled, Infection Control, Dietary, with an expiration date of 11/07/2025, indicated, .services are provided in a manner that minimizes the risk of hospital acquired infections to patients, staff, and visitors. The document continues, Keep work areas, surfaces.clean and orderly. and Observe safe practices in storing and serving foods. A review of a facility document titled, Cleaning List- AM Cooks, undated, indicated, the cleaning of the steam table (a table with slots to hold food containers which are kept hot by steam or hot water circulating beneath them) and under the steam table is to be done on Tuesdays and Saturdays. A review of a facility document titled, Night Aide: Cleaning Duties, undated, indicated, the kitchen floors were to be swept and mopped daily. 1. During an interview and observation on 9/2/25 at 12:56 pm, the steam table had a build-up of rust and dark burnt food around its body, on 3 sides. The attached stainless steel shelf below had rust, white food particles, dirt, and drops of dried paint . Sitting on the shelf were two shallow serving dishes and one deep serving dish with a lid, all with white food particles on them. The edges of the shelf had dried food drip marks. The legs had dried liquid streak drip marks and mineral streak drip marks. The long plastic cutting board attached to the steam table was stained yellow, with darker yellow/brown spots. Cut marks and cracks were stained a dark color. The Dietary Manger (DM) confirmed that the condition of the steam table and cutting board could cause infection control issues.2. During an interview and observation on 9/2/25 at 12:56 pm, the floor around the steam table had a heavy build-up of hard dirt and grime, dried food particles, and heavy build-up of rust around the legs and underneath the steam table. The DM confirmed that the dirt, grime and rust could cause infection control issues.3. During an interview and observation on 9/2/25 at 1:05 pm, the supporting structure for the condenser (cooling system) in the walk-in refrigerator had a build-up of dirt and grime. The left bracket of the supporting structure of the condenser had an off-white/light yellow, dirt and dark grime coating. There was also small areas with dark centers with a radiating light brown color encompassing the dark centers in an irregular pattern. The right bracket of the supporting structure for the condenser had peeling white paint, along with an off-white, dirt and grime coating. The DM confirmed that the dirt and grime coating and the small areas of varied discoloration could be an infection control issue.During an interview on 9/2/25 at 2:02 pm, the DM confirmed that the steam stable, the floors, and the brackets on the condenser in the walk-in refrigerator were unsanitary and could cause cross-contamination and infection control issues. The DM stated that these conditions could attract pests, rodents, and unknown organisms, which could be harmful to the residents.During an interview on 9/5/25 at 9:01 am, Maintenance (MN) confirmed that the dirt and grime build-up and peeling paint on the brackets of the condenser in the walk-in refrigerator could be a cause for cross contamination and infection control issues. MN stated that the kitchen floors would be back on the schedule for regular maintenance.

Based on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours every day for 7 days a week. This failure had the potential to adversely affect resident's quality of care and quality of life with regards to overall health and well-being.Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information), for Fiscal Year Quarter 2 for 2025, (January 1-March 31), indicated the facility had no RN on duty for;01/04 Saturday (SA); 01/12 (Sunday SU);02/01 (SA); 02/08 (SA); 02/15 (SA); 02/22 (SA);03/01 (SA); 03/08 (SA); 03/22 (SA); and 03/29 (SA).A review of the PBJ for Fiscal Year Quarter 4 for 2024, (July1-September 30), indicated the facility had no RN on duty for;07/01 Monday (MO); 07/03 Wednesday (WE); 07/04 Thursday (TH); 07/05 Friday (FR); 07/06 (SA); 07/07 (SU); 07/08 (MO); 07/09 Tuesday (TU); 07/12(FR); 07/14 (SU); 07/18 (TH); 07/19 (FR); 07/20 (SA); 07/21 (SU); 07/25 (TH); 07/26 (FR); 07/27 (SA); 07/28 (SU); 07/31 (WE); 08/01 (TH); 08/04 (SU); 08/09 (FR); 08/16 (FR); 08/18 (SU); 08/25 (SU); 08/30 (FR); 08/31 (SA); 09/01 (SU); 09/07 (SA); 09/14 (SA); 09/20 (FR); and 09/27 (FR).A review of the PBJ for Fiscal Year Quarter 1 for 2025, (October1 - December 31), indicated the facility had no RN on duty for;10/03 (TH); 10/11 (FR); 10/12 (SA); 10/18 (FR); 10/21 (MO); 11/01 (FR); 11/21 (TH); 11/23 (SA); 11/30 (SA); 12/06 (FR); and 12/08 (SU).During a concurrent interview and record review on 9/5/25 at 11:00 am, with Director of Nursing (DON), the PBJ report was reviewed. DON confirmed that they do not have a full time Registered Nurse (RN) seven days a week eight hours a day.

Based on observation, interview, and record review the facility failed to provide adequate pharmaceutical services, including accurate dispensing, and administering of all drugs, to meet the needs of each resident for two of three Residents (Residents 1 and 8) when Diclofenac Sodium (generic name) External Gel 1% / Voltaren (brand name) External Gel 1% (Topical gel containing an active ingredient of non-steroidal anti-inflammatory drug NSAID for pain relief) was ordered, dispensed, and administered without appropriate order details including the dosage quantity as required by professional standards. This failure had the potential to endanger the health and safety of residents being administered medication without the appropriate order details including dosage amount to be dispensed.During a review of the facility's policy and procedure titled, Medication and Treatment Orders, SNF (Skilled Nursing Facility) Pharmacy, dated 7/3/25, the policy indicated, Orders for medication and treatments will be consistent with principles of safe and effective order writing.All drug orders shall.(include) The name, quantity or specific duration of therapy, dosage, and time or frequency of administration.During a review of the facility's policy and procedure titled, Administering Medications, SNF Pharmacy, undated, the policy indicated, Medication shall be administered in a safe.manner.If a dosage is believed to be inappropriate.the person preparing or administering the medication shall contact the resident's attending provider or the facility's Medical Director.The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication.A review of Resident1's medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included Other Specified Arthritis (a group of conditions that cause inflammation and pain in the joints), Fibromyalgia (condition characterized by muscle pain and other symptoms such as fatigue, sleep disturbance, and cognitive difficulties), and Diabetes Mellitus.A review of Resident 1's medical record indicated that the Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 6/18/25, demonstrated Resident 1 scored 15/15, which equates to being cognitively intact. Resident 1 is their own representative (RP) and makes all their own medical decisions. During a concurrent observation, interview, and record review on 9/4/25 at 8:45 am, with Licensed Nurse (LN) A at the medication cart, Resident 1's medication orders are reviewed during medication pass prior to administration. Resident 1 has a medication order, dated 5/13/25, for Diclofenac Sodium External (topical) Gel 1%, Apply to Left (L) Shoulder, L Hip, topically one time a day for mild pain related to Other Specified Arthritis, Unspecified Site and low back per resident's directions. LN A is observed using the manufacturer's recommended dosing card enclosed in the medication box to measure an amount to administer for Resident 1. LN A states I have never seen an order from the medical provider for Diclofenac Topical Gel/ Voltaren External Gel with the precise dosage provided, so I use the manufacturer's recommended dose guide and make sure there is enough to cover the affected areas since some resident's areas are larger than other resident's areas.A review of Resident 8's medical record indicated that Resident 8 was admitted on [DATE] with diagnoses that included Adult Failure to Thrive (FTT, condition in older adults marked by physical and mental decline), Chronic Lymphocytic Leukemia of B Cell Type (CLL, slow progression type of cancer of the blood and bone marrow), Anemia (Abnormally low number of red blood cells or hemoglobin in the blood). A review of Resident 8's medical record indicated that the MDS BIMS score dated 5/16/25, demonstrated that Resident 8 scored 14/15, which equates to being cognitively intact. Resident 8 is their own RP and makes all their own medical decisions.A review of Resident 8's medical record titled, Order Details, for Voltaren External Gel 1%, Apply to general application topically every 6 hours as needed for mild to severe pain of 1/10 to 10/10 pain. During a concurrent interview and record review on 9/4/25 at 2:00 pm, with the Director of Staff Development (DSD) in the DSD staff office, Resident 1 and 8's medical records titled, Order Details regarding medication orders of Diclofenac Sodium External Gel 1%/ Voltaren External Gel 1% were reviewed. DSD confirms none of the provider's orders have dosages included as is expected per professional standards.During a concurrent interview and record review on 9/4/25 at 2:30 pm, with the Pharmacist (PD) in the conference room, Resident 1and 8's medical records titled, Order Details for Diclofenac Sodium External Gel 1%/ Voltaren External Gel 1% were reviewed. PD confirms the orders have no dosage. PD states this has been an issue since the medication became available over the counter (OTC, not requiring a prescription for at home use). PD confirms the professional standard dictates orders are not complete without a dosage, and there should be at least a maximum dosage in grams (a unit of measure) provided in order to administer the medication at the facility.

Based on interview and nursing schedule review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week. This had the potential to adversely affect all of the residents' quality of life and quality of care. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information) for Fiscal Year Quarter 1, 10/01/24-12/21/24, indicated the facility had no RN on duty for; 10/02/24, 10/03/24, 10/04/24, 10/6/24, 10/07/24, 10/08/24, 10/13/24, 10/14/24, 10/15/24, 10/20/24, 10/21/24, 10/22/24, 10/27/24, 10/28/24, 10/29/24, 11/03/24, 11/4/24, 11/05/24, 11/10/24, 11/11/24, 11/12/24, 11/17/24, 11/18/24, 11/19/24, 11/24/24, 11/25/24, 12/01/24, 12/02/24, 12/03/24, 12/09/24,12/10/24, 12/15/24, 12/16/24, 12/17/24, 12/22/24, 12/23/24, 12/24/24, 12/29/24, 12/30/24, and 12/31/24. A review of the PBJ for Fiscal Year Quarter 2 for 2024, (01/1/24-03/31/24), indicated the facility had no RN on duty for; 01/05/24, 01/06/24, 01/07/24, 01/14/24, 01/20/24, 01/21/24, 01/27/24, 01/28/24, 02/09/24, 02/10/24, 02/18/24, 02/19/24, 02/20/24, 02/21/24, 02/22/24, 02/24/24, 02/29/24, 03/01/24, 03/02/24, 03/03/24, 03/08/24, 03/10/24, 03/15/24, 03/16/24, 03/17/24, 03/19/24, 03/20/24, 03/21/24, 03/22/24, 03/10/24, 03/15/24, 03/16/24, 03/17/24, 03/19/24, 03/20/24, 03/21/24, 03/22/24, 03/24/24, 03/25/24, 03/29/24, 03/30/24, and 03/31/24. A review of the PBJ for Fiscal Year Quarter 4 for 2024, (07/1/23-09/30/23), indicated the facility had no RN on duty for; 07/01/23, 07/08/23, 07/09/23, 07/15/23, 07/16/23, 07/22/23, 07/29/23, 07/30/23, 08/05/23, 08/06/23, 08/13/23, 08/24/23, 08/25/23, 08/26/23, 08/31/23, 09/04/23, 09/08/23, 09/09/23, 09/11/23, and 09/29/23. During an interview on 7/29/24 at 9:30 am, with Chief Executive Officer (CEO) A, CEO A confirmed there was not an RN dedicated to oversee resident care for eight-hours a day, 7 days a week. During an interview on 7/30/24 at 11:52 am, with Chief Nursing Officer (CNO) C, CNO C confirmed there was not an RN dedicated to oversee resident care for eight-hours a day, 7 days a week.

Based on interview and record review, the facility failed to ensure that the attending Physician (AP), took an active role in the supervision of the care for 7 of 9 sampled residents (Resident 1, 3, 6, 7, 8, 9 and 10), when; 1. AP did not acknowledge, sign and date the current Active Orders (the physician's orders give the facility the legal authority to provide specific care and services to residents), for the months of June and July, 2023. 2. AP did not document a Progress Note (a note describing the Resident's current status at the time when the physician visited), in each Resident's medical record after he saw them each month. These failures had the potential for residents to not receive the appropriate level of care and services and negatively impact their ability to attain or maintain their highest practicable level of emotional and physical well-being. Findings: A review of the facility's policy titled, Attending Physician Responsibilities, SNF dated 3/29/22, indicated, The provider will verify the accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident. A review of the facility's policy titled, Medical Staff Delinquent Chart Suspension, Administration dated 1/25/22, indicated, This policy was to ensure timely completion of charts by physicians. Orders for SNF Recap Orders will be completed within five days, after the first of the month. 1. A review of Resident 1's records indicated admission to the facility on [DATE], with the diagnoses of type 2 diabetes mellitus with diabetic nephropathy (diabetes that could include nerve dysfunction) and depressive episodes (depression, a sad mood). A review of Resident 1's, Order Summary Report, dated 6/30/23, indicated AP had not reviewed or signed all Active Orders for Resident 1. A review of Resident 3's record indicated admission was on 11/26/2020, with diagnoses of Dementia, Adult Failure to Thrive (a state of decline), Chronic Obstructive Pulmonary Disease (COPD, chronic inflammatory lung disease), and Diabetes. During a record review of Resident 3's, Active Orders, AP had not signed Resident 3's Active Orders in June and July, 2023. A review of Resident 6's record indicated admission was on 11/08/2022, with diagnoses of Dementia, Hypertension (high blood pressure), Heart Failure, and an unruptured Cerebral Aneurysm (blood clot in the brain. During a record review of Resident 6's, Active Orders, AP had not signed Resident 6's Active Orders in June or July, 2023. Resident 7 was admitted to the facility on [DATE] with diagnoses that included high blood pressure, dementia, anxiety (feelings of fear, dread, and uneasiness), and a left below the knee amputation. During a record review of Resident 7's, Active Orders the AP had not signed Resident 7's Active Orders in June or July, 2023. Resident 8 was admitted to the facility on [DATE] with diagnoses that included heart disease, dementia unspecified severity, without behavioral disturbance, psychotic disturbance (hallucinations, paranoia and delusions), mood disturbance and anxiety, and leukemia (a type of blood cancer). During a record review of Resident 8's, Active Orders the AP had not signed Resident 8's Active Orders for June and July, 2023. A review of Resident 9's record indicated admission was on 12/09/2022, with diagnoses of Dementia, Adult Failure to Thrive, Parkinson's Disease (progressive neurological disorder that affects the nerves and the parts of the body controlled by the nerves), and Atrial Fibrillation (irregular and often very rapid heart rate). During a record review of Resident 9's, Active Orders, AP had not signed Resident 9's Active Orders in June or July, 2023. Resident 10 was admitted to the facility on [DATE] with diagnoses that included cognitive decline, diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's, Active Orders the AP had not signed Resident 10's Active Orders for June and July, 2023. During an interview on 7/21/23 at 11:24 am, Licensed Nurse (LN) A, confirmed that the AP had not signed the Active Orders for June and July, 2023 for Residents 7, 8 and 10. During an interview on 7/21/23 at 11:45 am, the Chief Nursing Officer (CNO), confirmed that the physician had not signed the Active Orders for Resident's 3, 6, 7, 8, 9 and 10, in June and July 2023, and should have within the first 5 days of each month. A review of the facility's policy titled, Attending Physician Responsibilities, SNF dated 3/29/22, indicated, The attending physicians shall be the primary practitioner's responsibility for providing medical services and coordinating the healthcare of each resident. The facility's policy indicated making periodic, pertinent patient visits in the facility and providing appropriate, timely, and pertinent documentation. At each visit, the attending physician will provide a progress note (written, typed, or electronic) in a timely manner for placement in the medical record. 2. A review of Resident 3's record indicated admission was on 11/26/2020, with diagnoses of Dementia, Adult Failure to Thrive, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus. During a record review of Resident 3's, Physician Progress Notes AP had not documented that he visited or evaluated Resident 3's condition in June and July, 2023. Resident 7 was admitted to the facility on [DATE] with diagnoses that included high blood pressure, dementia, anxiety and a left leg below the knee amputation. During a record review of Resident 7's, Physician Progress Notes AP had not documented that he visited or reviewed Resident 7's condition in June or July, 2023. Resident 8 was admitted to the facility on [DATE] with diagnoses that included heart disease, dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and leukemia. During a record review of Resident 8's, Physician Progress Notes AP had not documented that he visited or reviewed Resident 8's condition in July, 2023. A review of Resident 6's record indicated admission was on 11/08/2022, with diagnoses of dementia, Hypertension, Heart Failure, and unruptured Cerebral Aneurysm. During a record review of Resident 6's, Physician Progress Notes AP had not documented that he visited or evaluated Resident 6's condition in June or July, 2023. A review of Resident 9's record indicated admission was on 12/09/2022, with diagnoses of dementia, Adult Failure to Thrive, Parkinson's Disease, and Atrial Fibrillation. Resident 9's MDS dated [DATE], assessed Resident 6's cognition 07/15, (severe impairment). During a record review of Resident 9's, Physician Progress Notes AP had not documented that he visited or evaluated Resident 9's condition in June and July, 2023. Resident 10 was admitted to the facility on [DATE] with diagnoses that included cognitive decline, diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's, Physician Progress Notes AP had not documented that he visited or reviewed Resident 10's condition in June or July, 2023. 45315 During an interview on 7/21/23 at 12:13 pm, with Chief Executive Officer (CEO), he stated that he was not aware that AP was not signing monthly Active Orders or documenting monthy visits and resident conditions in his Progress Notes. The CEO indicated that Active Orders and Physician Progress Notes should be signed and completed by the AP, for each resident at the beginning of every month. During an interview on 7/21/23 at 2:10 pm, with AP, he stated that he was in the facility every other week on the second and fourth Thursday and he signed orders and performed other duties typically on the second Thursday. AP indicated that it was the staff's responsibility to have documentation that required his signature available and ready for him to sign when he comes in. AP stated he was not aware of the time frames for signing Active Orders or making Progress Notes, as specified in the facility's policy. 43031

Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS, a standardized assessment tool that described resident health and functional status) assessments were completed accurately for eight out of nine sampled residents, (Residents 1, 2, 3, 4, 6, 7, 8 and 9) when the MDS's incorrectly indicated that these residents were using restraints (a device that limits a resident's movement). This failure had the potential for an inaccurate picture of the resident's status. Findings: A review of the document titled, Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/1/19, located on the CMS website: MDS 3.0 RAI Manual v1.17.1_October 2019 (cms.gov), page 20 indicated: Medicare and Medicaid participating LTC facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. During a review of Resident 1's Quarterly MDS, (assessment performed every three months), dated 5/18/23, the assessment indicated Resident 1 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 2's Quarterly MDS, dated [DATE], the assessment indicated Resident 2 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 3's Annual MDS Assessment (performed yearly), dated 6/29/23, the assessment indicated Resident 3 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 4's Quarterly MDS, dated [DATE], the assessment indicated Resident 4 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of the Resident 6's Quarterly MDS, dated , 5/17/23, the assessment indicated Resident 6 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 7's Admission MDS Assessment (completed upon admission to the facility), dated 4/24/23, the assessment indicated Resident 7 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During a review of Resident 8's Quarterly MDS, dated [DATE], the assessment indicated Resident 8 was admitted to the facility on [DATE], and bedrails were used as a restraint less than daily. During a review of Resident 9's Quarterly MDS, dated [DATE], the assessment indicated Resident 9 was admitted to the facility on [DATE], and bedrails were used as a restraint daily. During an interview on 7/20/23 at 10:13 am, the MDS nurse (MDS) C confirmed that the MDS assessment, Section P (the portion of the MDS assessment that included use of restraints) had been incorrectly coded for Residents 1, 2, 3, 4, 6, 7, 8 and 9. MDS C stated that bedrails were being used for mobility, not as a restraint. MDS C stated there was fine print at the top of MDS Section P that described what a restraint was and she had not read it, prior to completing the assessment.

Based on interview and nursing schedule review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week, and have a Director of Nursing (DON) on site for 40 hours per week, to supervise the care of all of the residents. This had the potential to adversely affect all of the residents' quality of life and quality of care. Findings: A review of the Payroll Based Journal (PBJ, an electronic system for facilities to submit staffing information) for Fiscal Year Quarter 1 for 2023, (10/1/22-12/31/22), indicated the facility had no RN on duty for; 10/1/22, 10/2/22, 10/08/22, 10/09/22, 10/15/22, 10/16/22, 10/23/22, 11/12/22, 11/13/22, 11/20/22, 11/26/22, 11/27/22, 12/01/22, 12/03/22, 12/04/22, 12/09/22, 12/10/22, 12/11/22, 12/16/22, 12/18/22, 12/22/22, 12/23/22, 12/24/22, 12/25/22, 12/26/22, 12/27/22, 12/28/22, 12/29/22, and 12/31/22. A review of the PBJ for Fiscal Year Quarter 2 for 2023, (1/1/23-3/31/23) indicated the facility had no RN on duty for; 1/6/23, 1/7/23, 1/12/23, 1/14/23, 1/15/23, 1/16/23, 1/22/23, 1/27/23, 1/29/23, 2/3/23, 2/4/23, 2/5/23, 2/10/23, 2/11/23, 2/17/23, 2/18/23, 2/19/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, 3/1/23, 3/2/23, 3/3/23, 3/4/23, 3/10/23 3/17/23, 3/18/23, 3/24/23, 3/26/23, and 3/31/23. During an interview on 7/19/23 at 11:52 am, Chief Nursing Officer (CNO) confirmed there was not an RN dedicated to oversee resident care for eight-hours a day, 7 days a week. The CNO stated that she was providing the duties of the DON temporarily, but only spent about an hour per day overseeing the care of the residents who resided in the skilled nursing facility. The CNO added, We are trying to find and keep more RNs. During an interview on 7/20/23 at 10:01 am, the Director of Staff Development (DSD, an RN), confirmed the facility did not have an RN eight hours a day, 7 days a week. She stated, They do call me in occasionally for RN coverage.

Based on interview and record review, the facility failed to ensure that the Pharmacy Consultant's (PC) Medication Regimen Review (MRR), recommendations were acted upon (responded to), by the attending physician (AP), for eight of nine sampled residents (Resident's 1, 2, 3, 6, 7, 8, 9 and 10), when: 1. AP did not respond to MRR recommendations for Resident 1 in April, 2023. 2. AP did not respond to MRR recommendations for Resident 2 in March and April, 2023. 3. AP did not respond to MRR recommendations for Resident 2 in May, 2023. 4. AP did not respond to MRR recommendations for Resident 6 in June and July, 2023. 5. AP did not respond to MRR recommendation for Resident 7 in July, 2023. 6. AP did not respond to MRR recommendations for Resident 8 in May, 2023. 7. AP did not respond to MRR recommendations for Resident 9 in June, 2023. 8. AP did not respond to MRR recommendations for Resident 10 in June, 2023. These failures had the potential for the residents to have negative clinical outcomes and subject the residents to unwanted and adverse medication side effects and/or harmful interactions. Findings: During a review of a the facility's policy titled, Medication Regimen Reviews, Skilled Nursing Facility (SNF) Pharmacy not dated, indicated, The Consultant Pharmacist shall review the medication regimen of each resident at least monthly. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. The Consultant will provide a written report to the providers for each resident with an identified irregularity. The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed, and dated copy of the report. Copies of drug/medication review reports, including physician responses, will be maintained as part of the permanent medical record. 1. A review of the records indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of depressive episodes (a sad mood), acquired absence of right leg below knee (lower leg amputation), and hypertension (high blood pressure). During a review of Resident 1's MRR, dated 4/1/2023, the PC alerted the AP that three of the medications Resident 1 was taking had possible major medication interactions (an adverse or unwanted reaction between two or more medications), Trazodone (an antidepressant), Cyclobenzaprine (a muscle relaxant), and Duloxetine (an antidepressant). The PC further indicated that Trazodone and Duloxetine were SSRI's (a type of antidepressant that can cause Serotonin Syndrome- muscle rigidity, fever or seizures). The AP had not responded to this recommendation to review Resident 1's medications. 2. A review of Resident 2's record indicated that he was admitted on [DATE], with the diagnoses of multiple sclerosis (a disease that involved damage to the nerves that could result in numbness, difficulty with speech, and inability to walk), paraplegia (inability to voluntarily move the lower parts of the body), and muscle spasms (involuntary muscle contractions). During a review of Resident 2's, MRR, dated 3/1/2023, the PC recommended the AP review Resident 2's medications for possible adverse interactions. The PC indicated that Baclofen (a muscle relaxant), Norco (an opiate pain medication), Diazepam (a muscle relaxant and antianxiety medication), Amitriptyline (an antidepressant), and ondansetron (medication used to prevent nausea or vomiting), when used together increased Resident 2's risk for sedation, falls and injuries. The AP had responded to the recommendation, but according to the PC he could not read the AP's writing, and had not followed up to get clarification. During a review of Resident 2's MRR, dated 4/1/23, the PC alerted the AP once again of potential adverse effects of using the following medications together, Norco, Gabapentin (a medication that was used to treat nerve pain), Diazepam, Baclofen, Amitriptyline, and ondansetron, and added that these medications put Resident 2 at a high risk for Central Nervous System (CNS) which could cause the brain to slow down creating feelings of confusion and sleepiness and serotonin syndrome. The AP had not responded to the PC's recommendations. 3. During a review of Resident 3's record indicated that Resident 3 was admitted on [DATE]. Resident 3's diagnoses included Dementia, Adult Failure to Thrive (not eating, giving up), Chronic Obstructive Pulmonary Disease (lung problems), and Diabetes. During a review of Resident 3's MRR, dated 5/30/23, the PC recommended the AP review Resident 3's high AIC (blood test that monitors blood sugar levels and is used to manage diabetes) level (7.5%, less than 7 is ideal). AP had not responded to this recommendation. 4. A review of Resident 6's record indicated that Resident 6 was admitted on [DATE] with diagnoses that included, Dementia, High blood pressure, Heart Failure, and an Unruptured Cerebral Aneurysm (blood clot in the brain). During a review of Resident 6's MRR, dated 6/2/23, the PC recommended the AP review Resident 6's high blood pressure readings for possible medication adjustments, Resident had 21 Systolic Blood Pressure (SBP) readings greater than 140 mmHg (measurement to record blood pressure). Goal is never to go over 140/90 mmHg, according to American Hospital Association (AHA) guide, given age and comorbidities. The AP did not respond to the PC's recommendation. During a review of Resident 6's MRR, dated 7/7/23, the PC again recommended that AP review Resident 6's continued high blood pressures, Seventeen SBP readings were greater than 140 mmHg. The PC also recommended that AP address a potential medication interaction between Valsartan (a blood pressure medication) and potassium (K+), a supplement. AP did not respond to these recommendations. 5. Resident 7 was admitted to the facility on [DATE] for diagnoses that included high blood pressure, dementia, anxiety (feelings of fear, dread, and uneasiness), and a left leg below the knee amputation. During a record review of Resident 7's, MRR, dated 7/7/23, the PC recommended that the AP review Resident 7's Lisinopril (a blood pressure medication) 15 milligrams (mg, a unit of measure) due to Resident 7's, Majority of blood pressure readings are greater than 140 mmHg (millimeters of mercury), (normal blood pressure systolic readings are 120 mmHg or less), which indicated that the dose may need to be changed. The MRR was not addressed by the AP. 6. Resident 8 was admitted to the facility on [DATE] for diagnoses that included heart disease, dementia, psychotic disturbance (hallucinations, paranoia or delusions), mood disturbance and anxiety, and leukemia, (a type of blood cancer). During a review of Resident 8's MRR, dated 5/12/23, the PC recommended that the AP review her use of Seroquel (an antipsychotic medication) 12.5 mg, for possible discontinuance. The AP did not respond to the recommendation. 7. A review of Resident 9's record indicated that she was admitted on [DATE], with diagnoses that included Dementia, Adult Failure to Thrive, Parkinson's Disease, and Atrial Fibrillation. During a review of Resident 9's MRR, dated 6/2/23, the PC recommended that AP review Resident 9's high blood pressure recordings where 34 Systolic Blood Pressures (SBP) were greater than 140 mmHg and that Resident 9 was taking both Megestrol (an appetite stimulant), and Marinol (an appetite stimulant) which was duplicate therapy and added that, If resident is not increasing weight appropriately, consider discontinuing. A recommendation was also made to review a major medication interaction between Valsartan (a blood pressure medication and Potassium (a supplement). AP did not responded to the PC's recommendations. 8. Resident 10 was admitted to the facility on [DATE] for diagnoses that included cognitive decline, diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's MRR, dated 6/21/23, the PC recommended that the AP include in Resident 10's orders, Recommend orders regarding what to do in the case of hypoglycemia. The AP did not respond to the recommendation. 45315 During in interview on 7/20/23 at 11:30 am, PC stated the AP was required to enter a statement of risk versus benefits when using medications with potential adverse interactions or side effects along with the reason why medication recommendations would not be not followed. The PC added that the AP was required to sign the MRR, and that they were not being addressed or signed by the AP. 43031 During a concurrent interview and record review on 7/20/23 at 11:15 am, Licensed Nurse (LN) A reviewed Resident 3, 6 and 9's MRRs, dated 6/2/23 and 7/7/23 by PC, confirmed that there were no acknowledgements or responses to the PC recommendations by the AP. During a concurrent interview and record review on 7/21/23 at 12:00 pm, Chief Nursing Officer (CNO), reviewed Resident 3, 6 and 9's MRRs, dated 6/2/23 and 7/7/23 by PC, and confirmed that there were no acknowledgements or responses to the PC recommendations by the AP. During an interview on 7/21/23 at 11:00 am, PC indicated that many of the MRR recommendation that were made go unresponded to for long periods of time. PC confirmed that he had not communicated this with the AP, but instead continues to write the recommendations again and waits for the AP to respond. During an interview on 7/21/23 at 12:13 pm, the Administrator (Admin), indicated there was a pharmaceutical meeting every quarter and medications were discussed with AP, and he does not know who follows up. During an interview on 7/21/23 at 2:10 pm, AP indicated that he does follow up on recommendations at the quarterly pharmaceutical meetings. AP confirmed that he has seen the MRRs in the resident's charts, but did not always write a response.

Based on interview and record review, the facility failed to encode a Minimum Data Set (MDS, a standardized assessment tool) and submit assessments as required for one out of two sampled residents (Resident 5), when Resident 5 passed away on 4/22/23, and a discharge MDS was not submitted to CMS (Centers for Medicare and Medicaid). This failure had the potential to result in inaccurate record keeping. Findings: A review of the facility's undated policy and procedure (P&P) titled, Electronic Transmission of the MDS, SNF indicated all MDS assessments would be completed and electronically encoded into the facility's MDS system in accordance with current OBRA (Federal) regulations governing the transmission of MDS data. A review of Resident 5's clinical records indicated Resident 5 was admitted to the facility on [DATE] with the diagnosis of dementia with behavioral disturbances (inability to remember, think, or recall information that included behaviors). Resident 5 passed away on 4/22/23. During a concurrent interview and record review on 7/20/23 at 10:13 am, with MDS Coordinator (MDSC), Resident 5's MDS was reviewed. MDSC confirmed that Resident 5 had passed away and there had not been a discharge MDS completed, which was 82 days overdue. During an interview on 7/20/23 at 12:32 pm, MDSC confirmed the encoded assessment should have been completed within seven days and submitted within 14 days of Resident 5's passing.

Based on observation, interview, and record review, the facility failed to provide one out of nine sampled residents (Resident 4) with treatment and services that were consistent with the facility's policies and procedures (P&P), when Resident 4 developed a stage two pressure ulcer (a shallow open area of the skin with a red or pink woundbed), and a physician ordered treatment was not obtained, his responsible party was not notified, nursing had not documented on his change in condition, and he was not turned and/or repositioned every two hours. This failure had the potential for Resident 4's pressure ulcer (PU) to worsen resulting in a negative health outcome. Findings: A review of the facility's undated P&P titled, Pressure Ulcer Management, SNF indicated when a resident developed a pressure ulcer the physician would be notified no later than 24 hours after discovery of the pressure ulcer and staff would obtain an order for treatment. The P&P indicated nursing interventions that would be included in the resident's Care Plan included hygiene measures, pressure relieving devices, nutrition, and wound healing measures. The P&P indicated the RP would be notified; dietary would be contacted to request a nutritional assessment with recommendations that supported wound healing. The P&P indicated an incident report would be completed and the resident would be placed on alert charting. A review of the facility's undated P&P titled, Change in a Resident's Condition or Status, SNF, defined a significant change of condition as a major decline in resident status that would not resolve itself without staff intervention. The P&P indicated staff would utilize the Interact SBAR Communication Form prior to notifying the provider of the residents change of condition. A review of the facility's undated P&P titled, Care Plans, Comprehensive Person-Centered, SNF, indicated the Care Plan would be person-centered, describe the services that were provided to the resident, and the IDT must review and update the care plan when there has been a significant change in the resident's condition. A review of Resident 4's records indicated admission to the facility on [DATE] with the diagnoses of dementia (memory loss), chronic pain, and polyneuropathy (a condition that affect nerves that could cause symptoms of numbness, difficulty using arms or legs, and changes to the skin). The records indicated Resident 4 was admitted to the facility with no PU's, was incontinent of bowel and bladder, required extensive assistance of two staff members to use the toilet and to move from side-to-side in bed. Resident 4 was totally dependent upon staff for bathing, and was on a turning and repositioning program. Resident 4 had poor cognition (ability to think, reason, or remember), was not his own responsible party (RP), and relied on his RP to make all his decisions. During an interview on at 7/19/23 at 3:07 pm, Resident 4's RP, stated the facility usually called if there was a change of condition with Resident 4 and they had not received any phone calls recently with updates. RP stated the facility had not called to notify that Resident 4 had developed a new PU. During an observation on 07/21/23 at 8:00 am, Resident 4 was observed in bed with eyes closed. The head of the bed (HOB) was raised to approximately 35 degrees and Resident 4 was lying in a supine position (laying on the back). During an observation on 07/21/23, at 10:07 am, Resident 4 was observed in bed with eyes closed. The HOB was raised to approximately 35 degrees and Resident 4 was lying in a supine position. During a concurrent interview and record review on 7/21/23, at 10:23 am, with Licensed Nurse (LN) A, Resident 4's Progress Note, dated 7/18/23, was reviewed. LN A stated the Progress Note indicated Resident 4 had developed a stage 2 PU on the sacrum (lower back area just above the buttocks), A&D ointment (a skin protectant) was placed over the PU, and LN would report the PU to the morning LN. LN A reviewed Progress Notes, dated 7/18/23 through 7/20/23, and stated the Progress Notes did not include expected information such as: notifying or alerting the facility's physician that Resident 4 had a change of condition (development of PU), Resident 4's RP had not been notified, and there did not appear to be any alert charting (a Progress Note that described the wound and was written by the LN during each shift). LN A stated the facility's Registered Dietician (RD) should be notified and confirmed the Progress Notes did not indicate the RD had been alerted that Resident 4 had developed a stage two PU. LN A stated the Interdisciplinary Team (IDT, team members share resident information, updates, and collaborate with each other to develop patient centered care plans) should have met and discussed a plan for the treatment of Resident 4's PU, and confirmed there was no documentation in the Progress Notes that indicated an IDT meeting had been held. During an observation on 7/21/23 at 11:18 am, Resident 4 was observed lying in a supine position with the HOB flat. During a review of Resident 4's record titled, Care Plan (a written plan that provided an individualized plan of care the resident required) Skin Integrity, updated on 1/11/23, the Care Plan indicated the intervention (action to prevent or treat a medical condition) to turn every two hours was to be provided to Resident 4. During a concurrent interview and record review on 7/21/23, at 11:47 am, with Certified Nursing Assistant (CNA) F, Resident 4's POC charting (section of electronic medical records for CNA documentation), was reviewed. CNA F stated Resident 4 was not at high risk for developing PU and that he had, good skin. CNA F stated the turn every two-hour section had not been initiated in the POC section indicating Resident 4 did not require this and he was not repositioned every two hours. CNA F confirmed Resident 4 had developed a new PU and stated Resident 4 was now being repositioned every two hours. During a concurrent observation and interview on 7/21/23, at 12:05 am, with CNA G, Resident 4 was observed laying in a supine position with the HOB flat. CNA G stated Resident 4 had been repositioned about one and a half hours ago (approximately 10:30 am) when CNA G had assisted Resident 4 with getting dressed. Lying underneath Resident 4 was a Hoyer sling (a thick and heavy sling that wrapped around the resident who required use of a Hoyer machine to get out of bed, and would require repositioning the resident to place the sling underneath the resident). CNA G stated the Hoyer sling had been placed underneath Resident 4 at approximately 11:30 am. CNA G was asked to clarify when Resident 4 had last been repositioned due to different times being provided (10:30 am and 11:30 am). CNA G was not able to verbalize an answer. During a concurrent interview and record review on 7/21/23, at 12:21 pm, with Chief Nursing Officer (CNO), Resident 4's medical records were reviewed. CNO reviewed the record titled, Progress Notes, dated 7/18/23 through 7/20/23, and stated when a resident developed a new PU the facility's physician would be notified of the change of condition, new orders to treat the new PU would be obtained, LN would place the resident on alert charting, the care plan would be updated with interventions that were personalized, an incident report would be completed and the RP would be notified. CNO stated an IDT meeting would not be held for the development of a new PU and that the severity of the wound and how the wound was healing would indicate if an IDT meeting would be held. CNO confirmed the Progress Notes did not indicate the physician or resident's RP was notified, an incident report had not been completed, and Resident 4 was not placed on alert charting. CNO reviewed Resident 4's Open Wound Care Plan , dated 7/19/23, and stated the care plan indicated Resident 4 had three interventions that included to monitor the wound, turn every two hours, and provide frequent brief changes. CNO confirmed Resident 4's wound care plan had not included personalized treatment interventions and should have. CNO reviewed Resident 4's Orders, with multiple dates and stated there was an order for A&D ointment to be applied with each brief change and confirmed the order for A&D ointment was written prior to the PU development and there was not a new treatment order that outlined PU treatment that should be provided to Resident 4. During a concurrent observation and interview on 7/21/23, at 4:18 pm, with CNO, CNA F, and CNA G, Resident 4 was observed laying in his bed, supine, with the HOB flat. The Hoyer sling was underneath Resident 4 (four hours after initial observation). CNA F and CNA G stated Resident 4's PU looked better and assisted with rolling over Resident 4 for an observation of the PU. Resident 4 was observed to have a stage 2 PU to the sacrum. The PU wound bed was red in color and the redness extended approximately one and half inches outward, encircling the entire wound bed. When asked if the Hoyer Sling had been left under Resident 4 all day, no answer was provided by CNA F or CNA G.

Based on observation, interview, and record review, the facility failed to ensure that one of one sampled residents (Resident 10) was reassessed for safe smoking, supervised during smoking, and that his plan of care was followed. This had the potential to result in physical and psychosocial harm for Resident 10. Findings: A review of the facility's policy titled, Smoking Policy-Residents, SNF dated 3/29/22, indicated, smoking is not allowed inside the facility, this includes electronic cigarettes. The resident will be evaluated on admission to determine if he or she is a smoker. The evaluation will include the current level of tobacco consumption, method, and the desire to quit smoking. Resident 10 was admitted to the facility on [DATE] with diagnoses that included cognitive decline (difficulty with recall, and thinking), diabetes, high blood pressure, and need for assistance with personal care. During a record review of Resident 10's, Active Orders dated 5/24/23, the orders indicated Resident 10 did not have the capacity to make healthcare decisions and sign consents. During a record review of Resident 10's, Smoking and Safety assessment, dated 5/24/23, Resident 10 used tobacco products and could follow the facility's policy on location and time of smoking. There was no documentation that indicated Resident 10 was being monitored for safety while smoking. During a record review of Resident 10's, Elopement Evaluation dated 5/24/23, Resident 10 was identified to wander throughout the facility. A review of Resident 10's Minimum Data Set, (MDS, a resident assessment tool), dated 6/6/23, indicated for functional ability Resident 10 needed supervision with one person assistance for locomotion off the unit, (how the resident moves to and from off-unit locations) to leave the unit. The designated smoking area was observed to be located outside, off the unit, in the back of the facility. The MDS further indicated that Resident 10 had a severe cognitive impairments (unable to think, reason, and make decisions), with a Brief Interview Mental Status (BIMS) score of 6 out of 15. Section J, health conditions, indicated Resident 10 had one fall within the last month and one fall within the last two to six months. A review of Resident 10's, Tobacco Use care plan, revised 6/12/23, indicated Resident 10's problem was Tobacco Use. The interventions were to conduct smoking safety evaluations on admission and as needed, staff to extinguish cigarettes, and to utilize a cigarette holder. During an observation on 7/18/23 at 12:40 pm, Resident 10 was ambulating with a cane to the dining room from the designated smoking area with no assistance. During an interview on 7/18/23 at 12:42 pm, Resident 10 stated, Yes, I smoke. I just smoked before lunch; they are not always with us. During an interview on 7/18/23 at 1:49 pm, Certified Nursing Assistant, (CNA) D stated, I go with [Resident 10] to smoke, at least to light his cigarette. I think he needs someone all the time because he gets confused. I try to always stay with him. During an observation on 7/19/23 at 9:54 am, the designated smoking area had a table with two chairs and a standing ashtray. There was no call light or alert system to call for staff, no fire extinguisher, and no smoking blanket or smoking aprons were present. During an interview on 7/19/23 at 10:02 am, CNA E stated, [Resident 10] is confused, I always stay with him. I think he needs someone every time he smokes. During an interview on 7/19/23 at 10:47 am, CNA C stated, There was an order for [Resident 10] to have supervision while smoking for the first two weeks after admission, and then it stopped. During a record review of Resident 10's medical chart, the facility had not conducted any reassessments to determine if Resident 10 was safe while smoking. During an interview on 7/19/23 at 11:47 am, Chief Nursing Officer (CNO) confirmed Resident 10 did not have current or ongoing assessments to determine the level of monitoring he should have for safety while smoking.

Based on observation, interview, and record review, the facility failed to provide safe storage and labeling of resident medications and medical supplies when: 1. Over the Counter (OTC) medications were not labeled with an open date in one out of one medication cart (used to store resident medication). 2. Expired wound care supplies were stored in the treatment cart. 3. The treatment cart, located in the hallway across from the nurse's station, was left unlocked and unattended. 4. Expired laboratory supplies were stored in one of two storage rooms. 5. The medication disposal box (where discontinued medication is kept awaiting destruction), located in the nurse's station was not secure and could be easily accessed and the medications removed. These failures had the potential for unsafe medication use, and the use of medical tests and supplies which would no longer be effective, which could lead to negative clinical outcomes for the residents. Findings: 1. During a concurrent observation and interview on [DATE] at 9:07 am, with Licensed Nurse (LN) A, a bottle labeled Diabetic Tussin (an OTC cough syrup), a container labeled Cerovite Senior (an OTC multi-vitamin), and a container labeled Natures Truth D3 (an OTC viatmin supplement), were observed in the medication cart. LN A stated that they were expected to write the date on the containers of OTC medications, when they first opened the bottles and confirmed that the above OTC medications contained no date of when they had been opened. 2. During a concurrent observation of the treatment cart and interview on [DATE] at 9:07 am, with LN A, four packages of Optifoam Gentle wound care dressings had expired on [DATE]. LN A confirmed that the Optifoam Gentle dressings were expired and should have been taken out of the treatment cart. 3. During a concurrent observation and interview on [DATE] at 9:07 am, with LN A, an unattended treatment cart was observed to be unlocked. LN A confirmed the treatment cart was unlocked and should not have been when the cart is unattended by a nurse. 4. During a concurrent observation and interview on [DATE] at 9:07 am, with LN A, expired laboratory supplies were observed in the nurse's station storage area. Six blood specimen collection tubes that included, three yellow topped tubes had an expiration date of [DATE], one red and grey topped tube had an expiration date of [DATE], one lavender topped tube had an expiration date of [DATE], and one blue topped tube had an expiration date of [DATE], were in a drawer and available for use. LN A stated the facility staff did not normally collect blood samples, but if there was an emergency the LN A would utilize the blood specimen collection tubes that were stored in the nurse's station storage area. LN A confirmed the six tubes were expired and should not be available for use. Two Hemoccult tests (a screening test that determined if there was blood in the stool), were observed with an expiration date of [DATE]. LN A confirmed the Hemoccult tests were expired and should not have been available for use. 5. During a concurrent observation and interview on [DATE] at 9:07 am, with LN A, a medication disposal box was observed to be sitting on top of the counter in the nurse's station. On the top left side of the medication disposal box was an opening that could be easily accessed and not prevent the retrieval of the medications. Upon observation, the opening contained more than five loose medications they were easy to remove. LN A confirmed there were more than five loose medications that were not secure in the disposal box and anyone could easily take the medications. LN A stated that nurses were expected to use a white paddle-like device to push the medications into the disposal box, rendering them inaccessible. During an interview on [DATE] at 11:30 am, the Pharmacy Consultant (PC) was asked if LNs were expected to write the opened date onto the bottles of OTC medication. PC was not able to provide an answer. During a review of the facility's undated policy and procedure (P&P) titled, Administering Medications, SNF Pharmacy, the P&P indicated when a multi-dose container was opened, the open date would be recorded on the container. The P&P indicated medication carts were to be locked when out of sight of a LN. During a review of the facility's undated P&P titled, Storage of Medications, SNF Pharmacy, the P&P indicated all nursing staff would be responsible for maintaining medication storage areas in a safe manner. During a review of the facility's undated P&P titled, Discarding and Destroying Medications, SNF Pharmacy, the P&P indicated medication would be destroyed in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances.

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The deep freezer had a collapsed interior lid and ice buildup, where frozen food was stored. 2. Chipped paint with exposed rust or corrosion was on white wire shelves in the three-door reach in refrigerator, where food was stored. 3. The ventilation fans in the walk-in refrigerator, and the fans by the upper windows within the kitchen, had black debris and dust buildup. 4. The pipes under the food preparation sink next to the stove and dishwashing area, were covered with black debris and cumulative dust. 5. An open, unlabed, and undated ice cream cup was in the kitchenette designated for resident snacks. 6. Multiple areas of tile and floor covering was missing from the kitchen floor and there was dirt and debris in the corners of the floor. 7. A large area in the kitchen ceiling had an open hole, exposing the wood rafters near the dishwashing area at the exit door. These failures had the potential for the resident's to consume unsanitary food that had been prepared in a dirty kitchen, exposed to freezer burn, bacteria, mold, dirt and dust and cause them serious food borne illnesses. Findings: During a review of the facility's policy titled, Sanitation dated 2018, the policy indicated that all equipment shall be maintained as necessary and kept in working order.Counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. The kitchen staff is responsible for all the cleaning except for ceiling vents, light fixtures, and the hood over the stove to maintain a clean kitchen. Additionally, the maintenance department will assist kitchen staff as necessary maintaining equipment and performing janitorial duties that the kitchen staff cannot do. 1. During a concurrent observation and interview on 7/18/23 at 10:00 am, the lid on the large deep freezer was collapsed and the inside of the lid was torn away from the outside of the lid and sagging therefore, unable to seal properly. Ice build-up was observed within the collapsed lid and within the body of the freezer. The Dietary Manager (DM) confirmed that the lid was broken, and it was possibly not sealing correctly, noting the ice buildup within. She stated that employees sit on the lid, and a new one needed to be ordered. In an interview on 7/21/23 at 8:45 am, Dietary Cook (DC) 3 confirmed that the freezer lid was broken and that a new one needed to be ordered. According to the USDA Food Code 2022 Section 4-501.11, Equipment shall be maintained in a state of repair and condition that meets requirements specified .equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight and adjusted in accordance with manufacturers' specifications. 2. During a concurrent observation and interview on 7/18/23 at 10:00 am, the three-door reach-in refrigerators had chipped paint with rust or corrosion noted on the white wire shelves where residents' food was stored. The DM confirmed that the shelving was chipped with possible corrosion and agreed that cross contamination could potentially occur and could cause food-borne illness. According to the USDA Food Code 2022 Section 4-202.11 Multiuse food contact- surfaces shall be: Smooth, Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. 3. During a concurrent observation and interview on 7/18/23 at 10:00 am, the ventilation fans within the walk-in refrigerator and the fans in the kitchen near the upper-level windows had black debris and dust accumulation. DC 1 stated that the ventilator fans in the walk-in refrigerator and fans around the kitchen were, definitely dirty and that Maintenance was responsible for the cleaning the fans. The DM confirmed that the dirty vents/fans could cross contaminate food and cause food-borne illness. According to the USDA Food Code 2022 Section 4-601.11 (C) Nonfood- contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of pathogenic organisms, moisture, and debris tht deters the attraction of rodents and insects. 4. During a concurrent observation and interview on 7/18/23 at 10:00 am, the water pipes under the sink areas and overhead along walls within the kitchen had black debris and dust accumulation on them, some had noted corrosion. The DM confirmed the pipes were dirty, some rusty or corroded, all required cleaning, and dirty and corroded pipes in the kitchen could cause cross contamination and food borne illness. 5. During a concurrent observation and interview on 7/18/23 at 1:00 pm, a single, undated, unlabeled open ice cream cup was in the freezer in the kitchenette where resident snack food was kept. Certified Nursing Assistant (CNA) E confirmed the ice cream cup was open, undated, and unlabeled and indicated that it should not have been left that way. CNA E added that the ice cream had been brought in for a special ice cream day, and needed to be thrown away. During an interview on 7/19/23 at 8:30 am, the DM confirmed that an open container of any food item, should either be properly sealed, dated, and labeled, or thrown out. The DM stated that the evening Dietary Aide was responsible for checking the resident food items in the kitchenette. During a record review of the facility's policy titled, Foods brought by family/visitors, Med/Surg, SNF, Swing Bed dated 12/31/2019, indicated that perishable foods (once open), must be stored in resealable containers, labeled and dated, and discarded on the third day. 6. In a concurrent observation and interview on 7/18/23 at 10:00 am, the flooring in the kitchen was observed to be incomplete and unsightly with portions of floor missing, with debris and dirt noted in the corners. DM confirmed that all of the floor tiles had been removed because the floor was in the process of being replaced. DM confirmed that the condition of the flooring made it difficult to clean thoroughly and that there was debris and dirt which could be a source of cross contamination and food borne illness. According to the USDA Food Code 2022 Section 6-201.13 (A) Regarding floor cleaning in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be covered and closed. 7. In a concurrent observation and interview on 7/18/23 at 10:00 am, there was a large gaping open area in the ceiling with exposed wood rafters at the back of the kitchen in the dishwashing area above the exit door. The DM confirmed that the hole was a result of water damage and was scheduled to be fixed by maintenance. DM confirmed that the hole in the kitchen ceiling could be a source of cross contamination and food-borne illness. According to the USDA Food Code 2022 Section 6-201.18 (Ceiling wood) Studs, joists, and rafters may not be exposed in areas subject to moisture.

Based on interview and record review, the facility failed to ensure Resident 1 was free from abuse when Licensed Vocational Nurse (LVN) 1 spoke to Resident 1 in a demeaning and abusive manner on 4/13/2021. The actions of LVN 1 have the potential to decrease Resident 1's self-worth, esteem and lead to adverse clinical outcomes. Findings: A review of the facility's policy titled, Abuse Prevention Program, expiration date 9/28/2021, indicated, Residents have the right to be free from abuse such as verbal, and that administration will protect residents from abuse by anyone including, but not necessarily limitied to facility staff or any other individual. Resident 1 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's mental status was checked on 2/23/2021 with a tool known as the Brief Interview for Mental Status or, BIMS. Resident 1 had a score of 15 indicating full mental function. On 4/14/2021 the Skilled Nursing Facility Director of Nursing (DON) reported an allegation of resident to staff verbal abuse to the California Department of Public Health (CDPH). The DON reported that LVN 1 yelled and treated rudely at Resident 1. LVN 1 appeared flustered and upset and told Resident 1 that she needed to wait. The DON witnessed this behavior and other staff on the unit as well. A review of the document titled, Employee Notice of Termination, dated 4/16/2021 with LVN 1's signature and Director of Human Resources (HR) indicated the following; 1. The misconduct or performance problem was as follows; - Violation of the Abuse Polcy - Resident Abuse-Verbal, Emotional and Psychosocial 2. Where and when did it occur? - 4/5/2021= SNF (Skilled Nursing Facility) - 4/6/2021= SNF - 4/13/2021= SNF 3. We are terminating your employment effective 4/16/2021. During a concurrent interview and record review with the Director of Human Resources (HR) on 4/29/2021 at 8:45 am, HR stated, She was terminated for verbal abuse of the resident. HR confirmed LVN 1 signed the form on 4/16/2021 three days after the incident. The reasons for termination were cited as Resident Abuse- Verbal, Emotional and Psychosocial. During a concurrent interview and record review on 4/29/2021 at 1:15pm, the DON stated, she agreed with statements made in the letter to CDPH regarding the incident with LVN 1. DON stated she witnessed LVN 1 was verbally abusive to Resident 1 and the incident was discussed to the Chef Nursiong Officer (CNO). LVN 1 was terminated. A review of the facility policy titled, Abuse Investigation and Reporting, expiration date 9/28/2021, indicated that if the investigation reveals that the allegation(s) of abuse are founded, the employee will be terminated.

Based on interview and record review, the facility failed to ensure adequate dispensing and administration for a controlled medication (narcotic that could be abused or cause addiction) for one of three sampled residents (Resident 1). Licensed Nurse (LN) A documented she gave a controlled medication ([MEDICATION NAME]) to Resident 1 although he never received it. This had the potential to result in controlled pain for Resident 1. Findings: A review of Resident 1's record indicated he was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. This medication was signed as being given by LN A. A nurse's note written by LN A on 3/25/20 at 8 pm, indicated Resident 1 stated he would like to try some medication to help relax him. LN A called the physician and got a one time order for [MEDICATION NAME] (medication used to treat anxiety). During an interview on 9/14/20 at 11 am, the Chief Nursing Officer (CNO) stated they had suspicions of something going on in 1/28/20 and told LN A they would be monitoring her. On 3/16/20 Registered Nurse (RN) B told CNO that Resident 1 had received [MEDICATION NAME] the night before when LN A worked. Resident 1 reported he had not needed any pain pills. After this incident, CNO stated it was documented by LN A on 3/26/20 that Resident 1 received [MEDICATION NAME]. CNO talked to the Resident who stated he had not needed any pain medication for at least one and a half weeks and felt it was appropriate to discontinue it. Resident 1 stated he had received something for anxiety on night shift but had not received a pain pill. He consented to a urine drug screen which was done that day. CNO stated the urine drug screen was negative for [MEDICATION NAME] and positive for [MEDICATION NAME] even though LN A had signed that she had given both drugs. A review of the urine drug screen, completed on 4/1/20, was negative for [MEDICATION NAME] and had a detection window of one to two days. The drug screen was positive for a metabolite of [MEDICATION NAME]. During an interview on 10/26/20 at 11:50 am, LN A stated she was contacted by Administration about this incident. She stated she gave Resident 1 both [MEDICATION NAME] and [MEDICATION NAME]. When asked why the drug screen did not show [MEDICATION NAME] the only explanation was that she did not watch Resident 1 physically take the [MEDICATION NAME]. During an interview on 9/14/20 at 12:25 pm, the Human Resource Director (HRD) confirmed LN A's termination date was 4/8/20. HRD stated LN A refused, for various reasons, to come in and meet with her and CNO, so LN A was terminated over the phone as a result of the drug diversion investigation for Resident 1. CNO provided a copy of a report she submitted to the California Board of Vocational Nursing which indicated LN A was terminated due to theft from patients and falsification of medical records.

Based on interview and record review, after an allegation of resident to staff abuse was made, the facility failed to suspend the staff member, to prevent further potential abuse, until the investigation was completed. This had the potential to result in further potential abuse and mistreatment to all residents who resided in the facility. Findings: A review of the facility's current policy for Abuse Investigation and Reporting, expiration date 9/28/21, indicated, The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. On 10/12/20 at 2 pm, Certified Nursing Assistant Student (CNAS) A reported an allegation of staff to resident abuse or mistreatment to the California Department of Public Health (CDPH). CNAS A reported Resident 1 urinated in her briefs and Licensed Nurse (LN) B told her to leave the resident in her wet briefs. The investigation report from the facility, dated 10/13/20, indicated Resident 1, CNAS A, and the Director of Staff Development (DSD), who was a witness, had been interviewed and interactions between LN B and Resident 1 had been observed, on 10/12/20. LN B was interviewed the following day, on 10/13/20. The investigation concluded there had been no abuse or mistreatment. There was no indication in the report that LN B had been suspended until the investigation had been completed. During an interview on 10/26/20 at 11:50 am, the Chief Nursing Officer (CNO) stated on 10/12/20, the DSD told her CNAS A might report a possible allegation of abuse involving Resident 1 and LN B. CNO stated she started her investigation immediately and discussed the incident with DSD and Resident 1 before CNAS A reported the allegation to her and to CDPH. As soon as the formal report was made, CNO then interviewed CNAS A. During a subsequent interview on 10/26/20 at 2:50 pm, CNO stated she interviewed LN B, the following day, on 10/13/20. She stated by the time the formal allegation was made by CNAS A, she and others in administration had already determined the abuse was unsubstantiated so she did not suspend LN B.

Based on interview and record review, the facility failed to ensure three of eleven residents (Residents 1, 2, and 3) were treated with dignity and respect when Certified Nursing Assistant (CNA) 1 spoke to them rudely. This had the potential to result in a decline in their emotional and psychosocial well being. Findings: On 7/27/20 at 2:46 pm, the California Department of Public Health (CDPH) received a report of suspected psychological abuse towards Resident 1 by CNA 1. In a follow up report, dated 7/30/20, the facility indicated Residents 1, 2, and 3 had said CNA 1 was rude, mean, or uncaring and they would rather her not care for them. During an interview on 8/3/20 at 1:15 pm, Resident 1 stated CNA 1 has treated him rudely. CNA 1 has told him to go get his own coffee about three different times, while other staff got him coffee every morning, around 6:30 am. Resident 1 explained he uses a wheelchair and needs both hands to move it, so he can't get coffee by himself. Resident 1 stated CNA 1 just acted rude and he didn't want to ask her for anything when she worked and was assigned to care for him. During an interview on 8/3/20 at 1:45 pm, Resident 2 stated CNA 1 was loud, obnoxious. He stated everytime he asked her for something, she would tell him to get it himself, because he needed to walk more. During an interview on 8/3/20 at 2:10 pm, Resident 3 stated CNA 1 was harsh, uncaring, and rude. Resident 3 stated CNA 1 did not want to help like the other staff, so she was hesitant to ask for help, when CNA 1 worked. During an interview on 8/3/20 at 2:25 pm, License Nurse (LN) 1 stated she heard CNA 1 cursing and saying the F word loudly at the nurses station on 7/27/20. LN 1 stated she asked CNA 1 not to say those words. LN 1 also stated CNA 1 got Resident 4 up in a wheelchair pushed her outside her room, slammed the door, and yelled for another staff member. She stated Resident 4 had cognitive impairment, but looked startled. During an interview on 8/18/20 at 10:50 am, CNA 1 she has asked residents to walk with her to get coffee if that resident was supposed to walk. She also stated she has offered to help another resident to put on his prosthetic (artificial) leg and walk to get coffee. CNA 1 denied telling any resident to go get your own coffee but stated she wanted her residents to remain as mobile as possible. CNA 1 stated she said, Freakin and FreakIt and that may sounded like cursing. She stated she may have cursed once but immediately said oops I'm sorry. A review of the facility's current Resident Rights policy, dated 5/22/19, indicated, all employees shall treat all residents with kindness, respect, and dignity. In a final report, dated 8/3/20, the facility indicated, The final determination is that the emotional and psychosocial well-being of the residents is at risk, and that the best course of action is to terminate employment due to the probability of the incident occurring again, and the affect that the presence of the employee would have on residents and patients. During an interview on 8/3/20 at 12:45 pm, the Chief Nursing Officer (CNO) stated this was the first time (7/27/20) a resident had complained to staff about CNA 1. She stated they interviewed residents who were alert about CNA 1 and because of the effects of her actions on the residents' well being, CNA 1 was terminated effective 7/27/20.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) were free from abuse when a Registered Nurse (RN) B, slapped and forced Resident 1 into a shower chair against her will. This failure resulted in the physical abuse and mental anguish to Resident 1. Findings: A review of Resident 1's record indicated she was admitted to the facility on dated 5/28/19 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS-resident assessment) dated 6/9/19, indicated Resident 1 was alert, oriented and had intact cognition (able to think and reason). Resident 1 was her own responsible party (RP). On 8/5/19 at 4:34 am, [STATE] Department of Public Health (CDPH) received a report from the facility that Resident 1 refused shower, and Certified Nursing Assistant (CNA) A requested help from Registered Nurse (RN) B to get Resident 1 into the shower chair. RN B proceeded to squeeze Resident 1's hands hard, crossing her arms and restraining her. Resident 1 stated RN B hit her face, CNA A did not see this but heard a slap sound when she turned around to grab the shower blanket. During an interview on 8/14/19 at 8 am, Resident 1 stated CNA A came into her room to give her a shower and she refused. Resident 1 stated CNA A left the room and came back with RN B. She stated RN B yelled and glared at her and stated, Yes, you are taking a shower. Resident 1 stated RN B was vicious pulling off her clothes. RN B grabbed and squeezed her hands, twisted her arms across her chest as she put her in shower chair. Resident 1 stated, I did not want a shower and asked RN B to stop. During an interview on 8/14/2019 at 9:48 am with the Chief Nursing Officer (CNO), stated RN B abused Resident 1 when she restrained her arms leaving bruises on both hands. CNO stated the expectation was if residents refused showers, to try and come back and offer at a later time. CNO stated all residents have the right to refuse shower and those rights need to be honored. CNO confirmed that RN B did not follow their process and she was shocked when RN B acted like this. During an interview on 8/14/19 at 11:46 am, CNA A stated she requested RN B to come to Resident 1's room. CNA A stated RN B insisted on speaking with Resident 1's shower refusals herself. RN B told Resident 1 she was taking a shower in a mean voice. CNA A stated RN B turned Resident 1 around on bed towards shower chair, firmly held Resident 1's wrists, hands and crossed arms over chest then placed in shower chair. She stated Resident 1 cried and was agitated after the incident. CNA A stated she heard a slap sound, turned around and Resident 1 was holding her face. CNA A stated she noticed both hands starting to bruise. CNA A stated Resident 1 was afraid to leave her room. A review of the facility policy and procedure titled, Abuse Prevention Program, expiration date 5/22/20, indicated that their residents have the right to be free from abuse which includes verbal or physical abuse and physical restraint not required to treat resident's symptoms.

Based on observation, interview, record review, the facility failed to maintain a clean and orderly environment in the dietary department when there was visible dust accumulated on the wall vents, lighting fixtures, exposed ceiling pipes, and ceiling vent. This failure could lead to the spread of infections, communicable diseases, and food born illness to all residents (12) who are served out of this kitchen. Findings: During observations in the dietary department from 8/26/19 through 8/28/19, the following were observed: * Ceiling vent located directly above the tray line area (where food is prepared), had a thick dark fuzzy dust-like material built up on its surface, and this material could be seen extending up the pipe. * Wall vents located on entrance side of the kitchen, which blow directly towards the tray line area, had a thick dark fuzzy dust-like material built up on there exterior surfaces. * The light fixtures above the tray line area, had a thick dark fuzzy dust-like material built up on there surfaces. * All the exposed water pipes (fire sprinkler system) throughout the kitchen had a thick dark fuzzy dust-like material built up on there exterior surfaces. The above findings were verified during a concurrent interview and observation, with the Dietary Services Manager (DSM) on 8/28/19 at 6:45 am. The DSM acknowledged the items that needed to be cleaned, and reported that it had recently been identified by their facility's registered dietitian, and that maintenance had been notified, as they are responsible for cleaning this area of the kitchen. The facility's undated policy titled, Infection Control, Environmental Services, was reviewed and indicated that nosocomial (facility-based) infections may occur as a result of exposure to contaminated surfaces, equipment, air dust, and hands of personnel. According to the (YEAR) Food Code recommendations published by the United States Public Health Services, Food and Drug Administration, prepared and stored food should be protected from all potential contaminations, which includes dust. All non-food surfaces shall be kept free of an accumulation of dust, dirt, food residue, and other debris.