Every finding on record at University Post Acute

Based on observations, interviews and record reviews the facility failed to ensure the Speech Therapist's ST - a speech language pathologist who assess and treat people who have speech, language, voice and swallowing disorders) recommendation was followed for 1 (one) of 9 (nine) residents (Resident 22), since June 27, 2025.This failure had the potential to place Resident 22's health at risk and to miss identifying any undetected disease.During a review of Resident 22's admission Record (contains demographic and medical information), it indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), moderate protein calorie malnutrition (poor intake leading to weight loss or weakness) and dementia (a group of diseases and illnesses that affect thinking, memory, reasoning, personality, mood and behavior). During a concurrent observation and interview on November 17, 2025, at 9:42 AM, with Resident 22, inside her room, Resident 22 was awake. Resident 22 reported she had difficulty swallowing her food and required hot drinks to soften foods. Resident 22 further stated she had to constantly remind the staff to provide hot drinks. Resident 22 stated her mouth feels extremely dry and she struggles to produce moisture. Resident 22 reported she kept telling the staff, when they pick up her meal tray, that she cannot swallow her food, but stated, they (staff) don't do anything about it.During an interview on November 19, 2025, at 9:18 AM, with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 22 usually request hot water and sugar for tea with meals. During an interview on November 19, 2025, at 10:05 AM, with the Director of Nursing (DON), the DON reported that Resident 22 eat poorly, sometimes due to not liking the food and preferring only tea. The DON stated on June 27, 2025, Resident 22 was evaluated by the speech therapist and was placed on an IDDSI (International Dysphagia Diet Standardization Initiative - a global standard to describe texture modified foods and thickened liquids used for individuals with dysphagia) diet level; however, the resident had not reported swallowing issues until yesterday [November 18, 2025]. The DON stated her expectation is for the CNAs to notify the nurses if they observed anything concerning, such as poor intake when they pick up meal trays. The DON acknowledged Resident 22's meal percentages are sometimes as low as 10% but could not identify any specific interventions implemented in response to poor intake. The DON further stated snacks are provided by dietary department. During an interview on November 19, 2025, with the License Clinical Psychologist (LCP), the LCP stated Resident 22 had longstanding complaints of difficulty swallowing and dry mouth for as long as I have known her. The LCP reported Resident 22 continues to voice swallowing concerns to nursing staff and that the nurses are aware of these ongoing complaints. During a review of Resident 22's Physician Orders, it indicated Fortified Diet IDDSI 7: Easy to chew texture (soft, tender food texture), IDDSI 0: Thin (liquid) consistency, **extra gravy on all meat, Extra 8 oz (ounce- unit of measurement) fluids on all trays. dated August 25, 2025. During a review of Resident 22's SLP Evaluation and Plan of Treatment, dated June 27, 2025, it indicated, Patient Referral and History.Current Referral: Reason for Referral/ Current Illness. Pt [patient] referred to skilled ST (Speech Therapy) due to difficulty with swallowing and aspiration precautions.Previous tests: Prior MBS (Modified Barium Swallow- a test used to check a person's ability to swallow)/FEES (Fiberoptic Endoscopic Evaluation of Swallowing - a procedure used to assess swallowing)/GI (Gastrointestinal)/ENT (Ears, Nose and Throat)= No. Assessment Summary. Clinical Impressions.Pt reports concern about xerostomia (dryness of her mouth) and food getting stuck. Pt independently uses liquids mixed with textures to help soften food prior to swallowing. Pt has hx [history] of GERD which seems to impact her efficiency in swallowing . Recommendations. Further testing: MBS/FEES/ENT/GI indicated=Yes. During a review of Resident 22's ENT consult, dated June 27, 2025, it indicated, PHYSICAL EXAM. THROAT/MOUTH: very dry mouth, difficulty swallowing and eating and decrease appetite possible due to dryness. During a telephone interview on November 19, 2025, at 6:00 PM, with the Speech Therapist (ST), the ST stated she evaluated Resident 22 on June 27, 2025, and again on November 18, 2025, due to the resident's ongoing complaints of difficulty swallowing. The ST reported she documented recommendations in the electronic record and will usually communicates referral needs to the Rehab Manager for physician follow up. When asked about Resident 22's MBS (Modified Barium Swallow) test listed in her June 27, 2025, evaluation, the ST stated she could not recall whether the facility followed up or if a physician was notified. During an interview on November 20, 2025, at 4:58 PM, with the Director of Nurses (DON), the DON stated referrals such as Modified Barium Swallow (MBS) requires a physician order and are scheduled by social services department, who tracks appointments and follows up on any missed or rescheduled evaluations. The DON further stated her and the social services department maintained a monthly tracking list of all pending and completed referrals to ensure they are not missed. During an interview on November 20, 2025, at 5:06 PM, with the ADON, the ADON confirmed the ST completed an evaluation on June 27, 2025, and recommended a Modified Barium Swallow (MBS) study for Resident 22. When surveyor asked about the follow up, the ADON stated she did not see any documentation indicating whether the physician was notified, whether the recommendation was accepted or declined, or why the MBS study was not completed. ADON acknowledged that there was no documentation in Resident 22's clinical records explaining why the MBS recommendation was not followed through. During a review of the facility's policy and procedure (P&P) titled, Physicians, Consulting, dated January 25, 2025, was reviewed. The P&P indicated, To promote continuity of care. Procedures. 4. If treatment or medication are ordered by the consulting physician, it will communicate to a licensed staff to carry out the new treatment order.

Based on observation, interview, and record review the facility failed to ensure a physician's order for RNA (Restorative Nursing Assistant, staff trained to help residents maintain or improve function) to perform AAROM ( active - assisted range of motion) was implemented for one (1) of nine (9) sampled residents (Resident 4) when there was no documented evidence that the AAROM was provided to Resident 4, since October 17, 2025.This failure placed Resident 4 at risk for functional decline due to the inability to verify that restorative nursing services were implemented as ordered.During a review of Resident 4's admission Record (contains demographic and medical information), it indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses of dementia (a group of diseases and illnesses that affect thinking, memory, reasoning, personality, mood and behavior), fracture of the lower end right radius (broken wrist bone that is healing but still requires exercises to restore movement and prevent stiffness), muscle weakness (a condition in which muscles are weak, making harder for the resident to perform movements or regain strength after an injury).During a record review of the Resident 4's SBAR-Change of Condition Report (Situation-Background-Assessment-Recommendation- a structured communication tool that helps to share information about the condition of a patient or issue that needs to be address), dated June 11, 2025, the SBAR indicated, A. Situation. 2. Witnessed fall in hallway., C. Assessment. 1. Assess Resident's signs/symptoms. she (Resident 4) was seen catch her foot on from of wc (wheelchair), causing her to fall on R (right) side landing on R wrist and then bumping forehead on w/c (wheelchair)., c/o (complain of) pain 7/10 to R wrist.During a review of Resident 4's Care Plan (a plan that serves as a guide, outlining the patient's health needs, the desired outcomes, and the necessary actions to achieve those outcomes), dated October 16, 2025, the care plan indicated, Resident is on restorative nursing program to maintain current functional status. Goal. will maintain current level of functioning through next review date. Interventions/Tasks. RNA for AAROM (active - assisted range of motion) exercises to bilateral UE/LE (upper and lower extremities) QD (daily) 3 x (three- times) week as tolerated.During a review of Resident 4's physicians order, dated October 16, 2025, it indicated, RNA(Restorative Nursing Assistant, staff trained to help residents maintain or improve function) for AAROM (Active - Assisted Range of Motion, exercises where staff help the resident move their joints) exercises to bilateral UE(upper extremities)/LE (lower extremities) QD (daily) 3 x(three times)/week as tolerated. every Mon, (Monday), Wed (Wednesday) and Fri (Friday).During an observation on November 18, 2025, at 1:55 PM, Resident 4 was seated in a wheelchair near the nurse's station. Resident 4 was awake and made brief verbal responses; however, she was unable to sustain conversation or describe whether she was receiving any restorative exercises.During a concurrent interview and record review on November 19, 2025, at 2:52 PM, with the Assistant Director of Nurses (ADON), the ADON reviewed Resident 4's RV - Restorative Nursing Summary, in the Electronic Medical Record System (EMR). The ADON could not find documented evidence that RNA provided AAROM treatment to Resident 4. The ADON further stated that the physician's order was not transcribed on the RNA MAR (MAR - Medication Administration Record, a document used to keep an accurate record of the type of medication or treatment and the time it is administered).During a review of the facility's policy and procedure titled, Restorative Nursing Services, dated January 25, 2025, it indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation. 2. Resident may be started on restorative nursing program upon admission, during the course of stay or when discharge from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered and are outlined in the residents' plan of care. The ADON was unable to demonstrate that the facility followed the policy, as no documentation existed in the EMR showing that restorative services were provided in accordance with the resident's care plan or physician orders.

Based on observation, and interview, the facility failed to ensure resident bedrooms meet the required minimum 80 square feet (sq. Ft) per resident for 19 of 21 rooms measured in the facility (room [ROOM NUMBER]-8 and 11-21). This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms.During an environmental tour with the Maintenance Supervisor (MS), on November 18, 2025, at 4:16 PM, nineteen of the 21 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows:1. room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident.2. room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident.3. room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident.4. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.5. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.6. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.7. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.8. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.9. room [ROOM NUMBER], the total floor area measured 150 sq ft and two beds occupied the room, which yielded 75 sq ft for each resident.10. room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.11. room [ROOM NUMBER], the total floor area measured 150 sq ft and two beds occupied the room, which yielded 75 sq ft for each resident.12. room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.13. room [ROOM NUMBER], the total floor area measured 151.28 sq ft and two beds occupied the room, which yielded 75.64 sq ft for each resident.14. room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.15. room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.16. room [ROOM NUMBER], the total floor area measured 152.4 sq ft and two beds occupied the room, which yielded 76.2 sq ft for each resident.17 room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.18. room [ROOM NUMBER], the total floor area measured 152.4 sq ft and two beds occupied the room, which yielded 76.2 sq ft for each resident.19. room [ROOM NUMBER], the total floor area measured 139.7 sq ft and two beds occupied the room, which yielded 69.85 sq ft for each resident.During an interview on November 19, 2025, at 4:50 PM with the Administrator, the administrator confirmed that 19 rooms out of 21 did not meet the required minimum 80 square feet (sq. ft) per resident. The administrator reported there had not been no resident complaints regarding the room size and that the facility did not have a policy addressing room - size requirements. During an interview on November 19, 0225, at 4:54 PM with the Maintenance Supervisor, the maintenance supervisor confirmed the measurements taken were accurate. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of the three sampled residents (Resident 1) left the facility without the staff ' s knowledge. This failure resulted in Resident 1 eloping for a duration of approximately 6 hours and traveling a distance of about 17 miles away from the facility, posing a potential safety risk to the clinically compromised resident (Resident 1). Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE] with a diagnosis that included unspecified dementia (a general term for a group of symptoms that affect a person ' s ability to think, remember, and reason, and can interfere with their daily life), Alzheimer ' s disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated 7/05/2024, indicated, Resident 1 ' s score was a 4 which indicated Resident 1 had severe cognitive impairment. During an interview on 9/25/2024, at 11:00 a.m. with Assistant Director of Nursing (ADON) 1, ADON 1 mentioned that Resident 1 left the facility unnoticed by the staff around lunchtime and was located approximately 17 miles away at 4:30 PM on the same day. During a review of the facility documented titled 5 Day Look Back/Follow-up, dated 9/16/2024, the document indicated Resident 1 was reported missing from the facility around lunchtime and was later found at an acute general hospital at 4:30 PM. Upon further review, it was revealed that Resident 1 was interviewed regarding the incident. According to Resident 1, she travelled to her previous residence by taking the bus. During a telephone interview on 10/03/2024, at 9:59 a.m. with the Director of Nursing (DON) 1, DON 1 indicated Resident 1 went missing on 9/16/2024, approximately around lunch time, without any of the staff noticing. Upon expressing concern that the facility ' s safety and supervision policy for residents was not followed, DON 1 did not provide a specific response. During a review of the undated facility provided policy and procedure (P&P) titled, Safety and Supervision of Residents, the P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed when a resident received a new mental diagnosis for 1 (Resident #18) of 3 sampled residents reviewed for PASARRs. Findings included: A typed document from the California Department of Health Care Services, dated 09/09/2023, specified Per Title 42 of the Code of Federal Regulations sections 483.100 through 483.138, individuals identified with a SMI [serious mental illness] and/or ID/DD/RD [intellectual disability/developmentally disability/related condition] must be screened and evaluated to determine whether SNF [skilled nursing facility] level of care and specialized services in the least restrictive setting that best meets their needs are required. An Admission Record revealed the facility admitted Resident #18 on 03/18/2022. According to the Admission Record, on 04/06/2022, the resident received diagnoses of anxiety disorder, depression, and schizoaffective disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #18 had active diagnoses to include anxiety disorder, depression, and schizophrenia. Resident #18's care plan included a focus area updated 02/08/2024, that indicated the resident took psychotropic medications due to schizoaffective disorder manifested by auditory hallucinations secondary to hearing non-existent voices. Resident #18's care plan included a focus area updated 02/08/2024, that indicated the resident used valproic acid for mood disorder manifested by mood swings which caused angry outbursts. Resident #18's medical record revealed no evidence to indicate a PASARR evaluation was completed after the resident was diagnosed with anxiety disorder, depression, and schizophrenia. During an interview on 07/26/2024 at 8:50 AM, the Assistant Director of Nursing stated she submitted Resident #18's Level I PASARR; however, the resident received new diagnoses after they were assessed by physician and she did not know a new one PASARR needed to be completed. During an interview on 07/26/2024 at 8:55 AM, the Director of Nursing stated Resident #18's PASARR should have been resubmitted with the resident's new serious mental illness diagnoses.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for 1 (Resident #6) of 3 sampled residents reviewed for PASARRs. Findings included: A typed document from the California Department of Health Care Services, dated 09/09/2023, specified Per Title 42 of the Code of Federal Regulations sections 483.100 through 483.138, individuals identified with a SMI [serious mental illness] and/or ID/DD/RD [intellectual disability/developmentally disability/related condition] must be screened and evaluated to determine whether SNF [skilled nursing facility] level of care and specialized services in the least restrictive setting that best meets their needs are required. An Admission Record revealed the facility admitted Resident #6 on 10/18/2023. According to the Admission Record, the resident had a medical history that included diagnoses of anxiety disorder, schizoaffective disorder, unspecified psychosis, and suicidal ideation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #6 had active diagnoses to include anxiety disorder, psychotic disorder, and schizophrenia. Resident #6's care plan included a focus area initiated 10/18/2023, that revealed Resident #6 was at risk for being resistive to care related to anxiety, dementia, schizoaffective disorder, psychosis and suicidal ideation. A care plan, initiated 10/19/2023, revealed Resident #6 used antipsychotic medication for schizoaffective disorder manifested by delusions that led to aggressive behaviors. A care plan, updated 02/08/2024, revealed Resident #6 used antidepressant medication for depression manifested by an inability to sleep and diagnoses of depression, anxiety disorder, schizoaffective disorder and psychosis. Resident #6's Preadmission Screening and Resident Review Level I Screening, dated 10/18/2023, revealed a negative Level I outcome due to a 30-day Exempted Hospital Discharge. Resident #6's medical record revealed no evidence to indicate a PASARR evaluation was completed after the resident remained in the facility 30 days after admission. During an interview on 07/26/2024 at 8:50 AM, the Assistant Director of Nursing (ADON) stated she was the one that reviewed the PASARRs. The ADON stated Resident #6's PASARR was missed because she was not familiar with the 30-day exemption/resubmission. During an interview on 07/26/2024 at 8:55 AM, the Director of Nursing stated Resident #6's PASARR should have been resubmitted when the 30 day period was completed.

Based on interview, record review, and facility policy review, the facility failed ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 (Resident 41 and Resident #45) of 13 sampled residents. Specifically, the facility failed to code Resident #41 received hospice care and Resident #45 received an antidepressant medication. Findings included: An undated facility policy titled, Certifying Accuracy of the Resident Assessment, indicated, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. 1. An Admission Record indicated the facility admitted Resident #41 on 12/10/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of senile degeneration of the brain. Resident #41's Order Summary Report, for active orders as of 07/01/2024, indicated an order dated 05/23/2024, to admit the resident to hospice services. A significant change in status assessment Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #41 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS did not indicate the resident received hospice care. Resident #41's care plan, included a focus area initiated 05/24/2024, that indicated the resident was on hospice care for the diagnosis of senile degeneration of the brain. During an interview on 07/26/2024 at 8:28 AM, the MDS Coordinator stated the MDS reflected a resident's baseline status, their function and mobility to track if the resident improved and/or declined. The MDS Coordinator stated the information came from the nurse's documentation, certified nursing assistant charting for activities of daily living function, physician notes during the look-back period, physician orders and medications including psychotropic medications. The MDS Coordinator stated the significant change in status assessment MDS was completed for Resident #41 because the resident was not at their baseline and was placed on hospice services. The MDS Coordinator stated she coded that the resident's life expectancy was less than six months; however, she confirmed that hospice was not coded, but it should have been. During an interview on 07/26/2024 at 8:54 AM, the Director of Nursing (DON) stated the MDS was a resident assessment that was developed for the improvement of residents and should be coded correctly to accurately reflect the resident. The DON stated the information for the MDS came from interviews, observations, and chart review. The DON stated Resident #41 was placed on hospice and when the significant change in status assessment was completed, hospice care should have been coded. The DON stated it was her expectation that the MDS be coded correctly. During an interview on 07/26/2024 at 9:04 AM, the Administrator stated he did not have anything to do with the MDS process, but expected the MDS to be coded correctly. 46258 2. An Admission Record revealed the facility admitted Resident #45 on 11/03/2022. According to the Admission Record the resident had a medical history that included a diagnosis of dementia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #45 did not take an antidepressant medication. Resident #45's Order Summary Report, with active orders as of 05/04/2024, revealed an order dated 04/02/2024, for escitalopram (an antidepressant medication) 10 milligrams, give one tablet by mouth one time a day for episode of self-isolation manifested by reduced social interaction. Resident #45's Medication Administration Record, for the timeframe 05/01/2024 to 05/31/2024, revealed staff documented they administered escitalopram to Resident #45 at 9:00 AM on 05/01/2024 to 05/03/2024 and 05/08/2024 to 05/31/2024. During an interview on 07/26/2024 at 8:28 AM, the MDS Coordinator stated the antidepressant medication for Resident #45 should have been coded on the resident's MDS. During an interview on 07/26/2024 at 8:54 AM, the Director of Nursing stated it was her expectation that the MDS be coded correctly. During an interview on 07/26/2024 at 9:04 AM, the Administrator stated he did not have anything to do with the MDS process, but expected the MDS to be coded correctly.

Based on interview and document review, the facility failed to ensure residents room' measured at least 80 square (sq) feet (ft) per resident in 19 (Rooms 1 - 8 and 11-21) 21 resident rooms in the facility. Findings included: The Client Accommodations Analysis, completed by the Administrator and dated 07/25/2024 revealed: - In room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 150 sq ft and two beds occupied the room, which yielded 75 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 150 sq ft and two beds occupied the room, which yielded 75 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 151.28 sq ft and two beds occupied the room, which yielded 75.64 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 152.4 sq ft and two beds occupied the room, which yielded 76.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 152.4 sq ft and two beds occupied the room, which yielded 76.2 sq ft for each resident. - In room [ROOM NUMBER], the total floor area measured 139.7 sq ft and two beds occupied the room, which yielded 69.85 sq ft for each resident. In an interview on 07/26/2024 at 7:55 AM, with the Director of Maintenance confirmed the room measurements were accurate, and added that most resident rooms did not meet the federal room regulation size. In an interview on 07/26/2024 at 8:55 AM, the Administrator stated there had been no issues with care in relation to the resident room size and the facility did not have a policy regarding room size.

Based on observation, interview, and record review, the facility failed to ensure a sanitary kitchen, when there where dead insects and cobwebs under the shelves in the dry storage and behind the stove. This had the potential to contaminate the food and food contact surfaces in a highly susceptible population of 43 residents. Findings: During an observation and interview on January 18, 2022, at 8:05 AM, under the shelf in the dry storage room on the east wall, there was cobwebs. Under the shelf on the west wall, there were dead insects on the floor under the shelf. The Dietary Supervisor stated the floors should be clean. During an observation on January 18, 2022, at 8:16 AM, there were cobwebs behind the stove and some debris on the floor under the stove. During a review of the FDA Federal Food Code 2017, 6-501.111 Controlling Pests, states: Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. And 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests, states Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - facility assessment tool), for three of three residents reviewed for resident assessment (Resident 5, 18, and 27) when: 1. One of Resident 5's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident 18's [MEDICATION(S)], an antiplatelet (medication that prevents blood cells from sticking together forming a clot) was coded as an anticoagulant (medication that prevents the formation of blood clots) in Resident 18's MDS, dated [DATE]. 3. Resident 27's [MEDICATION(S)], an antiplatelet was coded as anticoagulant in Resident 27's MDS, dated [DATE]. These failures had the potential to result in unmet care needs for Resident 5, 18, and 27 which can negatively affect their health and safety. Findings: 1. A review of Resident 5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's Progress Notes, dated January 6, 2022, indicated one of her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and review of Resident 5's clinical record was conducted with the Director of Nursing (DON) on January 20, 2022 at 9:10 AM. The DON reviewed Resident 5's MDS dated [DATE] and stated Resident 5's depression was not coded under Section I Active Diagnoses. He stated the MDS-LVN should have coded it. He stated, providing accurate assessment of the resident's status will help different health care disiplines be able to provide care dependent upon resident's status and needs. During a concurrent interview and record review with the DON, on January 20, 2020 at 9:39 AM, the DON reviewed Centers for Medicare and Medicaid Services' (CMS) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, under Section I, page I-1, which indicated Steps for Assessment 1. Indicate the resident's primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Include the primary medical condition coded in this item in Section I: Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. During a review of Resident 18's clinical record, the face sheet indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 18's Order Summary Report, dated January 19, 2022, indicated Resident 18 was prescribed, [MEDICATION(S)] 75 milligram (mg- unit of measurement) by mouth once a day for atherosclerosis (deposition of fatty materials) of the aorta (blood vessel) starting September 29, 2020. A concurrent interview and record review of Resident 18's MDS, dated [DATE], was conducted with MDS-LVN on January 19, 2022, at 2:11 PM. Section N indicated Resident 18 received anticoagulant for seven days. He stated Resident 18 was taking [MEDICATION(S)] but should not be coded as anticoagulant. He further stated he coded it incorrectly. 3. During a review of Resident 27's clinical record, the face sheet indicated Resident 27 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 27's Order Summary Report, dated January 19, 2022, indicated Resident 27 was prescribed by her physician [MEDICATION(S)] 75 milligram (mg- unit of measurement) by mouth once a day for stroke prevention starting May 8, 2021. A concurrent interview and record review of Resident 27's MDS, dated [DATE], was conducted with MDS-LVN on January 19, 2022, at 2:19 PM. Section N indicated Resident 27 received anticoagulant for 7 days. He stated Resident 27 was also taking [MEDICATION(S)] and made a mistake in coding these two assessments for Resident 18 and 27. A review of CMS's (Centers for Medicare and Medical Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, revised October 2019, N041E, Anticoagulant (e.g., [MEDICATION(S)], [MEDICATION(S)], or low-molecular weight [MEDICATION(S)]), indicated Record the number of days an anticoagulant medication was received at any time during the 7-day look back period (or since admission, entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyrimadole, or [MEDICATION(S)] here.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) were re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for three of three residents reviewed for PASRR (Residents 9, 18, and 33). These failures had the potential for Residents 9, 18, and 33 not to receive the care and services most appropriate for their needs. Findings: 1. During a review of Resident 9's clinical record, the face sheet (contains demographic and medical information) indicated Resident 9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and record review of Resident 9's MDS dated [DATE] was conducted with the MDS Coordinator (MDS-LVN) on January 20, 2022, at 2:05 PM. He stated Resident 9's SCSA was done because of a decline in Activities of Daily Living (ADLs). During an interview and review of Resident 9's clinical record with MDS-LVN, he stated Resident 9's most current PASRR was completed on January 12, 2021, and he was not re-evaluated for a new PASRR after the completion of this SCSA. 2. During a review of Resident 18's clinical record, the face sheet indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and review of Resident 18's MDS, dated [DATE], was conducted with MDS-LVN on January 20, 2022, at 1:54 PM. He stated Resident 18's SCSA was done because of a decline in ADLs and multiple elevated blood sugar levels and blood pressure readings. He further stated the latest PASSR on file was completed on September 28, 2020, and her PASRR was also not re-evaluated after the completion of the SCSA. 3. During a review of Resident 33's clinical record, the face sheet indicated Resident 33 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and record review of Resident 33's MDS, dated [DATE], was conducted with MDS-LVN on January 20, 2022, at 2:00 PM. He stated Resident 33's SCSA was done because of a change in the hospice (providing care for the sick and terminally ill) provider. He further stated the latest PASSR on file was completed on June 02, 2021, and her PASRR was not re-evaluated as well after the completion of the SCSA. During a follow up interview with MDS-LVN, on January 20, 2022 at 2:15 PM, he stated he did not know that PASRR had to be done after SCSA and the facility did not follow the PASRR Guidelines for Residents 9, 18 and 33. A review of the Department of Health Care Services Guide to Completing the PASRR Level I Screening, dated May 2018, indicated Select Resident Review (RR) (Status Change) if the individual has already been admitted to your facility and you are updating the existing PASRR on file for either of the following reasons .B. There is a significant change in an individual's physical or mental condition. According to the MDS 3.0 manual a significant change is a decline or improvement in an individual's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only) and 2. Impacts more than one area of the individual's health status and 3. Requires interdisciplinary review and/or revision of the care plan.

Based on observation and interview, the facility failed to ensure a safe infection control program when outdated supplies were available for resident use in the Medication/Supply Room. This failure had the potential for a universe of 43 residents to be treated with ineffective or deteriorated (reduced quality) supplies which could negatively impact wound healing. Findings: During an observation and concurrent interview on [DATE], at 9:50 AM, an inspection of the Medication/Supply Room was conducted with the Assistant Director of Nursing/Director of Staff Development (ADON/DSD). 1. During an observation and concurrent interview on [DATE], at 9:50 AM, the ADON/DSD acknowledged the following supplies in the First Aid Kit in the Medication/Supply Room were expired. a. Three (3) Roller Gauze Bandages (used to secure wound dressings) supplies were observed expired: 2017 11 01 [supply expired [DATE]], 2018 01 03 [supply expired [DATE]], and 2018 01 03 [supply expired [DATE]]. The supplies were approximately 48 months outdated. b. Four (4) Sterile (germ-free) Non-Woven Sponges (used for wound cleaning) supplies were observed expired: 2018 03 15 [supply expired [DATE]], 2018 03 15 [supply expired [DATE]], 2017 12 10 [supply expired [DATE]], and 2017 12 10 [supply expired [DATE]]. The supplies were approximately 48 months outdated. c. One (1) Combine Pad (used to absorb heavy draining wounds) was observed expired 2018 03 01 [supply expired [DATE]]. The supplies were approximately 46 months outdated. d. One (1) Eye Pad (used to cover and protect the eye wound) was observed expired 2017 12 [supply expired [DATE]]. The supplies were approximately 48 months outdated. 2. During an observation and concurrent interview on [DATE], at 9:50 AM, the ADON/DSD acknowledged the following supplies in the Medication/Supply Room were expired: multiple individual packets in the five (5) cartons of Universal Removal Wipes (used to clean and prepare the resident's skin) indicated an imprint of [DATE] [supply expired [DATE]. The supplies were approximately 17 months outdated. During an interview with the Director of Nursing (DON) on [DATE], at 3:10 PM, the DON stated the facility had no policies regarding outdated supplies when facility see expired supplies the staff removes it from stock. During an interview with the Infection Preventionist (IP) on [DATE], at 8:08 AM, the IP acknowledged the Infection Preventionist is involved in training staff. The IP stated that if licensed nurses found outdated medical supplies, such as sterile bandages or sponges, she would tell them to discard the supply because don't know the effectiveness or if safe to use.

Based on interview and record review, the facility failed to ensure an individualized comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated, for one resident reviewed for mood/behavior (Resident 5) when a care plan was not initiated for Resident 5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure had the potential to cause inadequate management of Resident 5's medical condition, affecting Resident 5's health and safety. Findings: A review of Resident 5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's Progress Notes, dated January 6, 2022, indicated one of her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and review of Resident 5's clinical record was conducted with the Assistant Director of Nursing (ADON) on January 20, 2022 at 8:59 AM. The ADON was unable to find documentation of a care plan addressing Resident 5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated it is important that care plan is developed so the facility can identify, set realistic goals, implement, and re-evaluate the needs of the resident. A concurrent interview and record review was conducted with the Director of Nursing (DON) on January 20, 2022 at 9:44 AM. He reviewed the facility's undated policy and procedure titled Using the Care Plan which indicated Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . and stated it was not followed.

Based on observation, interview, and record review, the facility failed to ensure care plans were updated and revised in a timely manner when there was a change in anti-anxiety medication for one of five residents (Resident 8). This failure had the potential to result in inadequate treatment and management of resident's overall clinical condition. Findings: During a concurrent observation and interview with Resident 8, on January 19, 2022 at 8:22 AM, in the dining room, Resident 8 was sitting up on her wheelchair. She was alert and oriented to self. She was calm and not in any acute distress. She stated she was fine. A review of Resident 8's clinical record indicated she was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and review of Resident 8's clinical record was conducted with the Assistant Director of Nursing (ADON) on January 20, 2022 at 2:05 PM. The ADON reviewed Resident 8's Care Plan for Anti-Anxiety medications, revised August 5, 2021, and stated it was for her use of [MEDICATION(S)] (anti-anxiety medication). She further stated it was not revised after her anti-anxiety medication was changed to [MEDICATION(S)] (more than a month ago). A concurrent interview and record review was conducted with the Director of Nursing (DON) on January 20, 2022 at 2:20 PM. He reviewed the facility's undated policy and procedure titled Using the Care Plan which indicated Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . and stated it was not followed. He further stated the care plan should have been revised so the facility can provide the appropriate care for their residents current medical condition.

Based on observation, interview, and record review, the facility failed to ensure an opened emergency drug kit (eKIT) containing Schedule II (two) controlled substances (drugs stored and handled with additional restrictions to prevent abuse, addictions, and unauthorized use) in the Medication/Supply Room was replaced in a timely manner in accordance with the facility's policy. This failure had the potential to result in increased risk of drug diversion (illegal distribution) and/or medication availability issues for a universe of 43 residents. Findings: During a concurrent observation and interview on January 18, 2022, at 9:43 AM, an inspection of the Medication/Supply Room was conducted with the Assistant Director of Nursing/Director of Staff Development (ADON/DSD). An opened eKIT was observed with a quantity of three (3) tablets of [MEDICATION(S)] (Schedule II combination of two drugs - [MEDICATION(S)] and acetaminophen) 5 milligrams (mg - a unit of measurement for dose)/325 mg. The list of contents indicated the eKIT should contain a quantity of four (4) tablets of [MEDICATION(S)] 5 mg/325 mg. The Emergency Drug Kit Slip in the opened eKIT indicated one tablet of [MEDICATION(S)] 5 mg/325 mg was removed on January 13, 2022 at 7 PM (time period appropriately 110 hours from the time of opening to the time of discovery). During a concurrent interview, the ADON/DSD acknowledged the eKIT slip indicated the eKIT was opened on January 13, 2022, at 7 PM, three (3) tablets of [MEDICATION(S)] 5 mg/325 mg were observed, and the list of contents indicated four (4) tablets of [MEDICATION(S)] 5/335 mg. The ADON/DSD stated the eKIT should have been replaced. During a concurrent interview and record review on January 18, 2022, at 10:25 AM, the policy was reviewed with the Director of Nursing (DON) and the ADON/DSD. The policy titled Policy and Procedure Manual - Section M. EMERGENCY KIT (E-KIT) USE reviewed October 1, 2021, indicated The pharmacy is to be notified as soon as possible that the E-Kit has been opened so it can be replaced within 72 hours. The DON and the ADON/DSD acknowledged the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. Two medication errors for Resident 3 occurred out of a total 34 medication pass opportunities. The medication administration error rate was 5.88%. This failure had the potential to expose residents to preventable medication errors which could adversely affect their health and safety. Findings: During a concurrent observation and interview on January 20, 2022, from 8:41 to 8:56 AM, a medication pass observation for Resident 3 was conducted with Licensed Vocational Nurse 1 (LVN 1). During a concurrent observation and interview on January 20, 2022, at 8:43 AM, LVN 1 was preparing Resident 3's medications which are as follows: 1. One tablet of [MEDICATION(S)] (antipsychotic) 20 mg (milligrams - a unit of measurement for dose) and one tablet of [MEDICATION(S)] 5 mg for a total dose of [MEDICATION(S)] 25 mg 2. One tablet of chewable aspirin (drug to prevent [CONDITION(S)] and stroke) 81 mg 3. One tablet of [MEDICATION(S)] (drug to treat anxiety) 5 mg 4. One tablet of Calcium (mineral supplement) 600 mg combined with Vitamin D 3 10 micrograms (mcg- a unit of measurement for dose) (400 International Units- IU- a unit of measurement for dose) 5. One tablet of [MEDICATION(S)] sodium (stool softener) 100 mg 6. One tablet of [MEDICATION(S)] (mineral supplement) 400 mg 7. Two tablets of sennosides (drug to treat constipation) 8.6 mg 8. One tablet of [MEDICATION(S)] (drug to treat anxiety) 1 mg. During a concurrent observation and interview on January 20, 2022, at 8:53 AM with LVN 1, ten pills were observed. LVN 1 stated she counted ten pills. The multivitamin/mineral tablet was not observed during the count. During an observation on January 20, 2022, at 8:54 AM, LVN 1 was observed administering 10 pills to Resident 3. During an observation on January 20, 2022, at 8:56 AM, LVN 1 stated she was done administering all the scheduled medications for Resident 3. During a concurrent observation, interview, and record review on January 20, 2022, at 9:42 AM, LVN 1 inspected the bottle of Calcium 600 mg/Vitamin D 3 10 mcg (400 IU) and compared it to the prescriber's order for Calcium-Vitamin D Tablet 600-200 MG-UNIT Give 1 tablet by mouth one time a day for supplement. LVN 1 acknowledged the prescriber's order for Resident 3, and stated she administered a different dose of Vitamin D than what was ordered. During a concurrent interview and record review on January 20, 2022, at 9:43 AM, LVN 1 reviewed the prescriber's order for Multi Vitamins/Mineral Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for Supplement. LVN 1 acknowledged the prescriber's order for Resident 3. During a review of the facility's Medication Administration Schedule, the document indicated the medication administration time for Once a Day (OD) - 0900. During a concurrent interview and record review on January 21, 2022, at 8:45 AM, the policy was reviewed with the Director of Nursing (DON). The policy titled Policy and Procedures for Med Pass -VII. PREPARATION FOR MEDICATION ADMINISTRATION . MEDICATION ADMINISTRATION - GENERAL GUIDELINES reviewed October 1, 2021, indicated Medications are administered in accordance with the written orders of the attending physician. The DON acknowledged the policy.

Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for 19 of 21 resident rooms. This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms. Findings: During an entrance conference interview with the Director of Nursing (DON), on January 18, 2022 at 8:19 AM, the DON stated the facility had resident rooms which had less than the required square footage (80 sq. ft. of livable space). During an environmental tour with the Maintenance Supervisor (MS), on January 19, 2022 at 9:57 AM, 19 of the 21 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows: Room 1 (4 beds) measured: 292.8 sq. ft. (73.2 sq. ft. per resident) Room 2 (4 beds) measured: 292.8 sq. ft. (73.2 sq. ft. per resident) Room 3 (4 beds) measured: 292.8 sq. ft. (73.2 sq. ft. per resident) Room 4 (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) Room 5 (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) Room 6 (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) Room 7 (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) Room 8 (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) Room 9 (3 beds) measured: 282 sq. ft. (94 sq. ft. per resident) Room 10 (3 beds) measured: 258 sq. ft. (86 sq. ft. per resident) Room 11 (2 beds) measured: 150 sq. ft. (75 sq. ft. per resident) Room 12 (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) Room 13 (2 beds) measured: 150 sq. ft. (75 sq. ft. per resident) Room 14 (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) Room 15 (2 beds) measured: 151.28 sq. ft. (75.64 sq. ft. per resident) Room 16 (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) Room 17 (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) Room 18 (2 beds) measured: 152.4 sq. ft. (76.2 sq. ft. per resident) Room 19 (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) Room 20 (2 beds) measured: 152.4 sq. ft. (76.2 sq. ft. per resident) Room 21 (2 beds) measured: 139.7 sq. ft. (69.85 sq. ft. per resident) These rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. During an interview with the Administrator, on January 20, 2022 at 9:15 AM, he confirmed the measurements for 21 of the 21 residents' rooms and 19 of these did not meet the required 80 square feet per resident requirement. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to ensure a sanitary kitchen, when there where dead insects and cobwebs under the shelves in the dry storage and behind the stove. This had the potential to contaminate the food and food contact surfaces in a highly susceptible population of 43 residents. Findings: During an observation and interview on January 18, 2022, at 8:05 AM, under the shelf in the dry storage room on the east wall, there was cobwebs. Under the shelf on the west wall, there were dead insects on the floor under the shelf. The Dietary Supervisor stated the floors should be clean. During an observation on January 18, 2022, at 8:16 AM, there were cobwebs behind the stove and some debris on the floor under the stove. During a review of the FDA Federal Food Code 2017, 6-501.111 Controlling Pests, states: Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. And 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests, states Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - facility assessment tool), for three of three residents reviewed for resident assessment (Resident 5, 18, and 27) when: 1. One of Resident 5's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident 18's [MEDICATION(S)], an antiplatelet (medication that prevents blood cells from sticking together forming a clot) was coded as an anticoagulant (medication that prevents the formation of blood clots) in Resident 18's MDS, dated [DATE]. 3. Resident 27's [MEDICATION(S)], an antiplatelet was coded as anticoagulant in Resident 27's MDS, dated [DATE]. These failures had the potential to result in unmet care needs for Resident 5, 18, and 27 which can negatively affect their health and safety. Findings: 1. A review of Resident 5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's Progress Notes, dated January 6, 2022, indicated one of her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and review of Resident 5's clinical record was conducted with the Director of Nursing (DON) on January 20, 2022 at 9:10 AM. The DON reviewed Resident 5's MDS dated [DATE] and stated Resident 5's depression was not coded under Section I Active Diagnoses. He stated the MDS-LVN should have coded it. He stated, providing accurate assessment of the resident's status will help different health care disiplines be able to provide care dependent upon resident's status and needs. During a concurrent interview and record review with the DON, on January 20, 2020 at 9:39 AM, the DON reviewed Centers for Medicare and Medicaid Services' (CMS) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, under Section I, page I-1, which indicated Steps for Assessment 1. Indicate the resident's primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Include the primary medical condition coded in this item in Section I: Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. During a review of Resident 18's clinical record, the face sheet indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 18's Order Summary Report, dated January 19, 2022, indicated Resident 18 was prescribed, [MEDICATION(S)] 75 milligram (mg- unit of measurement) by mouth once a day for atherosclerosis (deposition of fatty materials) of the aorta (blood vessel) starting September 29, 2020. A concurrent interview and record review of Resident 18's MDS, dated [DATE], was conducted with MDS-LVN on January 19, 2022, at 2:11 PM. Section N indicated Resident 18 received anticoagulant for seven days. He stated Resident 18 was taking [MEDICATION(S)] but should not be coded as anticoagulant. He further stated he coded it incorrectly. 3. During a review of Resident 27's clinical record, the face sheet indicated Resident 27 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 27's Order Summary Report, dated January 19, 2022, indicated Resident 27 was prescribed by her physician [MEDICATION(S)] 75 milligram (mg- unit of measurement) by mouth once a day for stroke prevention starting May 8, 2021. A concurrent interview and record review of Resident 27's MDS, dated [DATE], was conducted with MDS-LVN on January 19, 2022, at 2:19 PM. Section N indicated Resident 27 received anticoagulant for 7 days. He stated Resident 27 was also taking [MEDICATION(S)] and made a mistake in coding these two assessments for Resident 18 and 27. A review of CMS's (Centers for Medicare and Medical Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, revised October 2019, N041E, Anticoagulant (e.g., [MEDICATION(S)], [MEDICATION(S)], or low-molecular weight [MEDICATION(S)]), indicated Record the number of days an anticoagulant medication was received at any time during the 7-day look back period (or since admission, entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyrimadole, or [MEDICATION(S)] here.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) were re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for three of three residents reviewed for PASRR (Residents 9, 18, and 33). These failures had the potential for Residents 9, 18, and 33 not to receive the care and services most appropriate for their needs. Findings: 1. During a review of Resident 9's clinical record, the face sheet (contains demographic and medical information) indicated Resident 9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and record review of Resident 9's MDS dated [DATE] was conducted with the MDS Coordinator (MDS-LVN) on January 20, 2022, at 2:05 PM. He stated Resident 9's SCSA was done because of a decline in Activities of Daily Living (ADLs). During an interview and review of Resident 9's clinical record with MDS-LVN, he stated Resident 9's most current PASRR was completed on January 12, 2021, and he was not re-evaluated for a new PASRR after the completion of this SCSA. 2. During a review of Resident 18's clinical record, the face sheet indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and review of Resident 18's MDS, dated [DATE], was conducted with MDS-LVN on January 20, 2022, at 1:54 PM. He stated Resident 18's SCSA was done because of a decline in ADLs and multiple elevated blood sugar levels and blood pressure readings. He further stated the latest PASSR on file was completed on September 28, 2020, and her PASRR was also not re-evaluated after the completion of the SCSA. 3. During a review of Resident 33's clinical record, the face sheet indicated Resident 33 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A concurrent interview and record review of Resident 33's MDS, dated [DATE], was conducted with MDS-LVN on January 20, 2022, at 2:00 PM. He stated Resident 33's SCSA was done because of a change in the hospice (providing care for the sick and terminally ill) provider. He further stated the latest PASSR on file was completed on June 02, 2021, and her PASRR was not re-evaluated as well after the completion of the SCSA. During a follow up interview with MDS-LVN, on January 20, 2022 at 2:15 PM, he stated he did not know that PASRR had to be done after SCSA and the facility did not follow the PASRR Guidelines for Residents 9, 18 and 33. A review of the Department of Health Care Services Guide to Completing the PASRR Level I Screening, dated May 2018, indicated Select Resident Review (RR) (Status Change) if the individual has already been admitted to your facility and you are updating the existing PASRR on file for either of the following reasons .B. There is a significant change in an individual's physical or mental condition. According to the MDS 3.0 manual a significant change is a decline or improvement in an individual's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only) and 2. Impacts more than one area of the individual's health status and 3. Requires interdisciplinary review and/or revision of the care plan.

Based on interview and record review, the facility failed to monitor the resident for a loss of appetite that resulted in a significant weight loss, failed to notify the physician of a decrease in meal intake, weight loss, and increased weakness, failed to implement the care plan to address the change of condition (C[NAME]), and failed to notify the responsible party of a C[NAME] for one of three sampled residents, (Resident A). These failures resulted in an emergency transfer to the acute care hospital, where she later died . Findings: An abbreviated survey was conducted on (MONTH) 3, (YEAR) to investigate a complaint related to quality of care (Q[NAME]). A review of Resident A's facesheet (contains demographic information) indicated that she was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident A's nursing progress notes dated (MONTH) 14, (YEAR), indicated Resident A was transferred from the skilled nursing facility (SNF) to the acute care hospital on (MONTH) 14, (YEAR), for a complaint of chest pain. A review of the emergency room 's (ER) laboratory results dated (MONTH) 14, (YEAR) (tests of material from the human body to provide information to treat a disease), chest x-ray (CXR-picture of the upper chest) results, and electrocardiogram (EKG-test that measures heart beat rate & rhythm), indicated the findings were all within normal range and Resident A was returned to the facility. A review of the nursing admission record, dated (MONTH) 5, (YEAR), indicated Resident A's weight at admission was 96.6 lbs (pounds), height 57 inches. A review of the Weight Summary Report dated (MONTH) 20, (YEAR), indicated Resident A's weight for the week of (MONTH) 6, (YEAR) was 96 lbs. A review of the facility's tracking of the percentage of meals eaten by Resident A (from Missed Meals, meal percentages, Documentation Survey Reports) indicated: [DATE], (YEAR): breakfast 0, lunch 80%, dinner 0. [DATE], (YEAR): breakfast 0. lunch 0, dinner 0. [DATE], (YEAR): breakfast 0, lunch 80%, dinner 0. [DATE], (YEAR): breakfast 0, lunch 80%, dinner 0. [DATE], (YEAR): breakfast 0, lunch 0, dinner 40%. [DATE], (YEAR): breakfast 35%, lunch 100%, dinner 0. [DATE], (YEAR): breakfast 0%, lunch 80%, dinner 50%. [DATE], (YEAR): breakfast 100%, lunch 0, dinner 0. [DATE], (YEAR): breakfast 0, lunch 75%, dinner 0. [DATE], (YEAR): breakfast 0, lunch 80%, dinner 0. [DATE], (YEAR): breakfast 0, lunch 100%, dinner 0. [DATE], (YEAR): breakfast, lunch & dinner 0%, 50% of snack at 9:30 PM. [DATE], (YEAR): breakfast, lunch & dinner 0%. [DATE], (YEAR): breakfast, lunch & dinner 0%. [DATE], (YEAR): breakfast 0%, lunch-left the facility to the acute hospital. A review of the Registered Dietician (RD) weight note on (MONTH) 15, (YEAR), indicated, Resident's current weight 89 lbs (pounds) . She lost 6 lbs/- (negative) 6.3% in the last week. Unsure of reason for wt. (weight) loss. Recommendation 1) Continue diet with supplement 2) Continue to monitor. A review of the Weight Summary Report dated (MONTH) 20, (YEAR), indicated Resident A's weight for the week of (MONTH) 20, (YEAR) was 80 lbs, a change of -15 lbs. The RD noted the findings on (MONTH) 22, (YEAR), and documented, Will chart when the resident returns from the hospital. This was a 15 lb weight loss in two weeks from (MONTH) 6, (YEAR) to (MONTH) 20, (YEAR). During a telephone interview with the RD on (MONTH) 11, (YEAR) at 3:30 PM, she stated that she did not remember Resident A, and does not remember a resident whose weight decreased to 80 lbs. When asked if a resident had lost 15 lbs in 14 days what interventions would you incorporate, she stated, We would have an IDT (Interdisciplinary Team-a group of health-care professionals) meeting, see what the dietary supervisor would say, and asked to be kept informed. During an interview with the Director of Nursing (DON) on (MONTH) 3, (YEAR), at 5:05 PM, she stated, I remember her well. When asked was the family notified regarding the C[NAME]- regarding not eating, she stated that, IDT's meetings were not being done previously the right way , .I know we had done family phone calls, they were aware of her behaviors. The DON further stated, She was less responsive on (MONTH) 21, (YEAR), they (the family) were notified that she was going to the hospital. I was in my office, the daughter came and said something is wrong with my mom, I and the nurse went and looked at her .the nurse called 911. I had seen her up earlier in the day myself, no unusual complaints that I can remember. When asked were Resident A's extremities discolored, the DON stated that her hands and feet were discolored that day and stated, I would not say blue. During an interview with LVN 1 on (MONTH) 26, (YEAR) at 1:00 PM, she stated she did not remember Resident A's physical status prior to the 911 emergency transfer. LVN 1 stated, I don't remember that week if there were any changes, but for sure she did have blue tinged fingers, and legs, we were getting her up because her family was coming. During an interview with a Certified Nursing Assistant (CNA 1) on (MONTH) 26, (YEAR) at 2:30 PM, she stated, . she (Resident A) was in bed a lot towards the end, she used to be in the WC (wheelchair), go everywhere. During a telephone interview with Resident A's physician on (MONTH) 18, (YEAR) at 3:28 PM, when asked if he was notified regarding Resident A's, refusing to eat, weight loss, or hospital visit on (MONTH) 14, (YEAR), he stated, I don't want to say yes or no, I don't recall. During an interview with CNA 2 on (MONTH) 23, (YEAR) at 11:50 AM, she stated, She (Resident A) wouldn't open her mouth, she wouldn't drink anything, the three days that I was here before she passed. CNA 2 further stated that as a float (not assigned to a group of residents) one of her duties was to make sure Resident A ate, and stated The nurses were already aware that she was not eating at that point, she had not been eating good for a week, she ate well, but two weeks prior to her passing she went to eating half, that last week she went to not eating at all. When asked if the doctor had been made aware CNA 2 stated, You would think so, but I do not know. During an interview with CNA 3 on (MONTH) 23, (YEAR) at 12:52 PM, she stated, I know she (Resident A) didn't get out of bed that week . she wasn't coming to the DR (dining room). CNA 3 further stated, that Resident A used to come to the DR, in and out all day long. During an interview with CNA 4 on (MONTH) 23, (YEAR) at 1:12 PM, she stated that what she remembered about Resident A was that towards the end, she didn't want to eat, that she was in bed and weak. During an interview with LVN 3 on (MONTH) 23, (YEAR) at 1:24 PM, when asked what is the protocol when a resident has a C[NAME], she stated, .the LVN is suppose to do an assessment, depending on the C[NAME], contact the doctor, follow orders, put them on monitoring for the C[NAME] x 72 hours. During a telephone interview with a Licensed Vocational Nurse (LVN 2) on (MONTH) 24, (YEAR) at 11:25 AM, she stated, I can't remember her being a critical change of condition (C[NAME]), but I do remember her having a C[NAME]. During a telephone interview with CNA 5 on (MONTH) 30, (YEAR) at 9:43 AM- she stated, I know she (Resident A) wasn't acting the same, I knew something was wrong with her, she was declining . CNA 5 further stated, that she opened the gate for Resident A's daughter on (MONTH) 21, (YEAR), and informed her that Resident A was not doing good and her daughter stated that no one told her. During a concurrent interview and record review with the DON on (MONTH) 21, (YEAR) at 3:05 PM, she stated when a resident has an unwitnessed fall, neuro checks (a check for level of consciousness) are done for 72 hours. When asked to provide the neuro check charting for Resident A after her unwitnessed fall on (MONTH) 20, (YEAR), when found on the floor at 01:00 AM by the CNA, she stated, . I don't have it. A review of Resident A's Nutritional Care Plan with the DON, stated to minimize any unplanned weight changes daily, and the physician and the family were to be notified of any significant weight loss. When asked was the physician notified regarding Resident A's 6.3% weight loss from 96 lbs to 89 lbs noted for the week ending (MONTH) 14, (YEAR), the DON stated, I can't find that we notified him. When asked was the physician notified on (MONTH) 20, (YEAR), of Resident's weight of 80 lbs, she stated, at that time they were waiting for the IDT meeting scheduled for (MONTH) 22, (YEAR), and, I don't have any record of him being notified. A review and concurrent interview with the DON of Resident A's [MEDICAL CONDITION] bowel elimination record, indicated constipation for (MONTH) 20, (YEAR). When asked for documentation of notification to the charge nurse, the DON stated there was no record of notice. During an interview with the Dietary Manager on (MONTH) 25, (YEAR) at 10:40 AM, when asked after Resident A's was weighed on (MONTH) 20, (YEAR) and had lost 15 pounds in two weeks,what was done, she stated, At that time nothing, until we would have our meeting with the dietician on the 22nd ([DATE], (YEAR)). A review of the nurse's Progress Notes for Resident A, dated (MONTH) 15, (YEAR) through (MONTH) 20, (YEAR), reflects there was no documentation of any C[NAME], or that the doctor had been notified of her weight loss, or change of behavior. A review of the physician's note dated (MONTH) 18, (YEAR), there is no mention of Resident A's weight loss, not eating, or that she was sent to the emergency roiagnom on (MONTH) 14, (YEAR) with a complaint of chest pain. A review of the Nurse's Weekly Summary dated (MONTH) 19, (YEAR) at 10:24 PM, indicated, Blood Pressure ,[DATE], Pulse 100, Respirations 17, Temperature 97.9 (clinical measurement of a patient's essential body functions) date: (MONTH) 14, (YEAR). The record did not provide any documentation of weight loss, loss of appetite, or change in behavior. A review of Resident A's clinical record, did not indicate the daughter/responsible party (RP) was notified of Resident A's C[NAME] of not eating for consecutive days from (MONTH) 16, (YEAR) through (MONTH) 21, (YEAR), or about her weight loss, prior to her arrival on (MONTH) 21, (YEAR). A review of the nurse's Progress Notes for Resident A dated December, 21, (YEAR), indicated: a. 1:33 AM- @ (at) 0100 (1:00 AM) CNA came to report finding res (resident) on the floor in her room. Upon assessment, res was laying on her back, res had c/o (complained of) pain to buttocks.res appears weak and drowsy. MD (medical doctor) notified. will contact POA (power of attorney) in the morning. b. 08:41 AM (8:45 AM)- Reported to MD that Resident is showing signs of increase weakness, resident unable to sit up when asked .Also got report that resident is not eating and had one episode of vomiting from noc shift.it is unable to be determined if she is in pain r/t (related to) resident not responding when asked. Also got report that resident previously reported pain in back on noc (night) shift. Stat (now) CBC (complete blood count-test that measures the cells that make up your blood) w/diff (with differential) and BMP (a group of eight laboratory blood tests used as a screening tool) ordered. Also stat lumbar (spine) back and bilateral (both) hip x-ray ordered. c. 11:16 AM- Spoke with MD informing him lab technician is unable to get an adequate blood draw for labs as ordered due to C[NAME]. New orders: OK to send out to acute care-C[NAME]. d. 11:50 AM- Approximately 11:50 Resident left on gurney with EMT (emergency medical transport). Resident noted weak and unable to stand on her own or transfer self. Resident noted with peripheral (outer) cyanosis (bluish discoloration of the skin) to bilateral feet and hands.Unable to obtain O2 sat (oxygen saturation). Resident A's stat laboratory findings at the acute care hospital ER (emergency room ) on (MONTH) 21, (YEAR) indicated: Sodium 116 LL (low low-lethargy, confusion, severe death) (normal range ,[DATE]) Chloride 81 LL (low low-excessive fatigue, weakness, difficulty breathing) (normal range ,[DATE]) Carbon [MEDICATION NAME] 11 L (low- measures respiratory exchange (normal range ,[DATE]) BUN 132 HH (high high- water depletion due to decreased intake & excessive loss) (normal range ,[DATE]) Creatinine 5.7 H (high- kidneys aren't working well) (normal range 0XXX,[DATE].1) Glucose 180 H (high- excessive sugar in the blood) (normal range ,[DATE]) WBC 22.7 H (high- increased levels to fight an infection) (normal range 4XXX,[DATE].7) A review of the ER's physician notes, dated (MONTH) 21, (YEAR), for Resident A indicated, (arrival time 12:11 PM), Vital signs at 1:18 PM Temperature 33C (Celsius = 91 degrees Fahrenheit), P (Pulse) 99, R (Respirations) 20, BP (blood pressure) ,[DATE], pulse ox (oxygen saturation) 97% on 15L NRB (liters non-rebreather mask -oxygen concentration). History of Present Illness: 66 y/o (year old) female BIBA (brought in by ambulance) from SNF presents to the ER with AL[NAME] (altered level of consciousness), lethargy, and cyanosis today.reported patient has been having symptoms of loss of appetite and N/V (nausea & vomiting) few days. Staff had noted cyanotic appearance to pt's lips, hands and feet. Physical Exam: General: patient was not awake, not alert, not responsive to any stimuli. Skin was very pale, Patient is cachectic (weakened condition). Respiratory: Very labored breathing, bilateral air entry. Abdomen: Tense . no bowel sound. [MEDICAL CONDITION] (an artificial opening on the abdomen for bowel elimination) pouch with blood in it. Assessment and Plan: 1. Septic shock (severe infection of the body causing organs to shut down). 2. Small-bowel obstruction, questionable hernia (a protruding of the abdominal wall). 3. Acute hypoxic (deprived adequate oxygen) [MEDICAL CONDITION]. 4. Lactic acidosis (excessive acids in the blood). 5. Severe [MEDICAL CONDITION] (low sodium). 6. Acute kidney injury. 7. Altered level of consciousness. 8. Gastrointestinal (stomach & intestines) bleeding, bacteremia (infection). Plan: As per patient's family wishes, will keep patient on palliative approach (relief from distressing symptoms) to keep her comfortable. Start patient on [MEDICATION NAME] drip (intravenous pain medicine) and [MEDICATION NAME] prn (anti-anxiety medicine as necessary). A review of the Nurse's note dated (MONTH) 21, (YEAR), for Resident A in the ER: On arrival patient was undressed. [MEDICAL CONDITION] bag was leaking. A review of the Nurse's note dated (MONTH) 22, (YEAR), for Resident A indicated Pt (patient) passed away at 2045 (8:45) with her family at bedside. A review of Resident A's death certificate dated (MONTH) 11, (YEAR), indicated causes of death were: A. Septic shock, B. [MEDICAL CONDITION], C. Acute kidney injury, D. Small bowel obstruction. A review of the facility's care plans (individualized plans for the medical care of a resident) (not dated) for Resident A indicated: 1. Resident has an altercation in nutritional status .Interventions .Report significant weight loss and gain to MD and family 2. The resident has risk for dehydration .Interventions . Monitor and document intake and output as per facility policy. Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities, Monitor/document bowel sounds and frequency of BM. 3. The resident has a communication problem related to confusion, dementia .Interventions .Anticipate and meet needs .Monitor/document/report PRN (as necessary) any changes in: Ability to communicate . A review of the facility's policy and procedure titled Nutritional Care Management dated 2012, indicated, 12. If there is a five percent weight change in 30 days ., the Physician, dietary, and the resident plus interested representative will be notified and date placed in Weight Record. a. When the Physician is notified, the Licensed Nurse will document calling the physician and Physician's response in Nursing Progress Note. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status (Revised (MONTH) 2011) indicated, Our facility shall promptly, notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly;. Refusal of treatment . A review of the facility's policy titled Charting and Documentation (Revised (MONTH) 2008) indicated, 1. All observations, . must be documented in the resident's clinical records.3. All incidents, accidents, or changes in the resident's condition must be recorded.

Based on interview, and record review, the facility failed to ensure adequate monitoring for one of three sampled residents (Resident 1), when Resident 1 was found unconscious under direct sunlight, with abnormal vital signs and multiple blisters on his body. This failure resulted in Resident 1 requiring an acute care hospitalization for second-[MEDICAL CONDITION] to heat exposure. An unannounced onsite visit was conducted on (MONTH) 8, (YEAR), at 1:06 PM, to investigate a facility reported incident on resident abuse and neglect. Resident 1 was hospitalized at the acute care hospital (GACH 2) during the onsite visit for second- degree [MEDICAL CONDITION](also called as partial thickness burn that may include blistering, indicating damage has been done to the underlying layers of skin). Findings: A record review of Resident 1's face sheet (a record that provides the demographic data of the resident) indicated, an elderly resident who was admitted to the facility on (MONTH) 6, 2014, with [DIAGNOSES REDACTED]. A review of Resident 1's Transfer to Hospital Note dated (MONTH) 5, (YEAR), indicated, Resident was found outside at 3:50 PM, during change of shift. CNA reported to charge nurse resident was unconscious with labored breathing. VS (Vital Signs) 178/128 (Blood Pressure), 30, 28 ,102.0 O2 sat 51%. Oxygen administered, brought the O2 up to 62% pt. (Resident 1) still unconscious but breathing. Paramedics called. Sent to GACH 1(Name of the hospital) . During an interview with Licensed Vocational Nurse 1 (LVN 1) on (MONTH) 8, (YEAR), at 3:28 PM, she stated the assigned CNA 1 (CNA 1) for Resident 1 left his shift early without notifying her. She stated that she did not notify the Chain of Command (C[NAME]) when she realized that CNA 1 left the facility prior to the end of the shift. She stated that she assigned the run to another CNA 2 (CNA 2) to cover for CNA 1's residents, however she did not give any specific instructions or care needs of the patients whom she has to give care for. During a telephone interview with CNA 1, on (MONTH) 14, (YEAR), at 4:32 PM, he stated that he had an emergency on (MONTH) 5, (YEAR), that required for him to leave the shift early. He stated that he notified the Director of Staff Development (DSD) via text and the DSD did not approve the request. He stated he further notified his chain of command (LVN 1) about the refusal from DSD and his need to leave early. He stated he left around 1:30 PM on (MONTH) 5, (YEAR). During an interview with CNA 2 on (MONTH) 8, (YEAR), at 3:17 PM, she stated that she was busy with other residents' linen change and by the time she was done caring for them it was already change of shift. She further stated that, LVN 1 did not tell her what were the care needs of the residents for whom she had to care for. During an interview with the CNA 3 on (MONTH) 9, (YEAR), at 3:30 PM, she stated that she was looking for her residents after her change of shift around 3:45 PM. CNA 3 said she accidentally found Resident 1 sitting on a chair, leaning to right side in direct sun light, at the back patio. She further stated that she found him unresponsive to call or shake, drooling and he was very hot. After she notified LVN 2, with the help of another staff member, she transported Resident 1 to the front nursing station in a wheel chair. During an interview with LVN 2, on (MONTH) 8, (YEAR), at 3:45 PM, she stated after the change of shift around 3:45 PM, CNA 3 found Resident 1 sitting on a chair, at the back patio, unresponsive. When CNA 3 brought Resident 1 in, he was unresponsive, drooling, had labored breathing, with a 102 degree Fahrenheit body temperature, his skin was red and was very hot to touch. She stated she called 911 (emergency medical service) to transport the resident to the nearest hospital. Through multiple interviews with the staff members working on the alleged event day and time, it indicated that the last time Resident was observed was around 1:30 PM on (MONTH) 16, (YEAR). A review of Resident 1's Emergency Department (ED) records from the General Acute Care Hospital 1 (GACH 1), indicated that Resident 1 was transported at GACH 1 on (MONTH) 5, (YEAR), at 5:05 PM with altered level of consciousness, acute heat stroke and multiple areas of second degree burns. Further review of the ED records, indicated that after providing the emergency medical interventions, Resident 1 was transferred to GACH 2 on (MONTH) 5, (YEAR), at 6:16 PM in serious condition to seek for further medical interventions. A review of ED records from GACH 2, indicated that Resident 1 was admitted to GACH 2 on (MONTH) 5, (YEAR) (did not indicate time), with .core temperature of 104 F, second [MEDICAL CONDITION] abdomen and arms and <5% of surface area and blisters on his head . At GACH 2, Resident 1 was diagnosed with [REDACTED]. It results from the death of muscle fibers and release of their contents into the bloodstream. This can lead to serious complications such as renal (kidney) failure) and was treated extensively with IV fluids, supportive care and wound care. A review of Resident 1's wound care consult record at GACH 2, dated (MONTH) 6, (YEAR), indicated skin/ wound condition as follows: I. Top of head has large Bullae (a fluid-filled sac or lesion that appears when fluid is trapped under a thin layer of your skin and also called blister), 8x7 cm, II. Lt. Parietal area (upper central scalp) with large bullae 3x3x2 cm, III. Central frontal area has 2 open areas with [MEDICATION NAME] (top layer of the skin) loss and pink/red tissue exposed. The area is 2.5x5 cm. Area is weeping serous fluid. There is also periwound blistering still 6x6 cm, IV. Lt. eye lid has a denuded (swollen) area 2x2 cm. Both eyelid and face are [MEDICAL CONDITION], (swollen) V. Lt. Lateral neck has a small intact blister 1x1 cm in skin fold area, VI. Lt. hand has large bullae already partially broke and open. Bullae extends on the dorsal (back) hand from metacarpal (bones of the hands and fingers) area to above the wrist, 17x10 cm, VII. Abdomen has multiple bullae and some open partial thickness areas. Total area is 23x20 cm, VIII. Left dorsal foot has two open blisters each 2x2 cm dry, IX. Rt. Shin has intact blisters 17cm x 6 cm, X. Rt. Dorsal foot: bullae with partial thickness opening, pink/red tissue. Area 3.5x6.8cm. A review of Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool for mental status and cognitive level) dated (MONTH) 17, (YEAR), under section 'C 1000.Cognitive skills for Daily Decision Making indicated that his score was 3 (severely impaired- never or rarely made decisions). A review of Resident 1's Care Plan initiated on (MONTH) 28, (YEAR) and revised on (MONTH) 23, (YEAR), indicated that Resident 1 .is a wander risk r/t impaired safety awareness, disoriented to place. During an interview, and record review with the DON on (MONTH) 11, (YEAR) at 8:45 AM, she stated that Resident 1 was admitted to the facility prior to her employment with the facility. She further stated she was unable to find documented evidence that the risk of wandering assessment was done on Resident 1, during his stay at the facility. During an interview with the DSD on (MONTH) 9, (YEAR), at 2:54 PM, she stated the LVN had the responsibility to notify the C[NAME] when a CNA leaves prior to the end of shift without permission. She further stated LVN 1 did not notify her when CNA 1 left early. During an interview with the DON on (MONTH) 9, (YEAR), at 3:00 PM, she stated, if the CNA 1 (CNA 1) had not left the shift early, this incident would not have been happened . A review of the facility policy and procedure titled, Wandering, Unsafe Resident, revised on (MONTH) 2010, indicated .6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior . On (MONTH) 9, (YEAR), at 4:09 PM, after interviews and record reviews, an Immediate Jeopardy (IJ, a situation that had threatened or is likely to threaten the health and safety of a resident) was called in the presence of the Director of Nurses (DON) and Regional Nurse Consultant (RNC) for inadequate monitoring and supervision. The DON and the RNC were verbally notified of the IJ situation identified based on the facility's failure to ensure adequate monitoring for Resident 1, who has a history of wandering. On (MONTH) 5, (YEAR), around 3:45 PM, Resident 1 was found at the back patio, under direct sunlight, unconscious, with unstable vital signs and required an acute care hospitalization . The acute care hospital identified him with multiple second-[MEDICAL CONDITION] to exposure to the sunlight. The facility was notified that this failure had a potential to endanger a universe of 58 resident's health and safety. The corrective action plan provided by the facility indicated as: PLAN OF CORRECTION 1. HOW CORRECTIVE ACTIONS WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE The Resident was found to be unresponsive and immediately taken to the closest emergency room via Ambulance. CDPH, Ombudsman, and the San Bernardino County Sheriff's office was contacted to notify of the incident as soon as Mill Creek Manor was aware of the severity of the incident. The staff (CNA and LVN) that was assigned to this resident were placed on suspension pending investigation and if found to have deficient practices that resulted in the resident's injuries will be terminated from employment with Mill Creek Manor. 2. HOW THE FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN. Each resident will be identified on admission and quarterly for an elopement risk score with an assessment. The score will assist in determining the level of care to be provided to the resident for wandering and elopement risk. All residents will be placed on hourly monitoring and the CNA staff will keep a log of the monitoring that is being used. At the end of each shift the LVN assigned will ensure the monitoring is complete and placed in the log binder at the nurse's station. The log will address for each CNA the resident's location, It is the CNAs responsibility to alert the LVN or Charge Nurse on duty if the resident is noted to be changed from the resident's baseline status. A manager on duty program will be implemented to ensure that resident safety is maintained on weekends. The Manager on duty every weekend will assist the DSD and DON to maintain proper staffing and safety for all residents by performing safety checks every 2 hours and will be part of MOD duties. A huddle will be called by the Charge Nurse at the beginning of each shift to verify resident assignments, resident concerns being addressed, and CNA shift duties are assigned. When a change in staffing occurs for any reason scheduled or unscheduled change the Charge Nurse will call a huddle immediately and redistribute the resident load. The CNA and LVN staffing will be maintained by the staffing ladder to ensure the facility meets PPD Each Day in accordance with Title 22. If CNA staffing is short for any reason the facility will utilize overtime coverage with current staff members, a Per Diem/ On call CNA pool, staff from facilities under the same corporation, and registries. The Charge Nurse LVN will be instructed per Policy and Procedure to redistribute the assignment with the staff available in the building of Certified CNAs. The certified CNAs can be utilized from the RNA and activities programs to ensure resident safety during a shift if an unscheduled down staffing occurs. The Charge Nurse will be required to notify the DSD (or Manager on Duty if the DSD is unavailable) at any time a CNA leaves a shift without prior approval from the DSD, DON, or Administrator. The Charge Nurse is not to determine if a CNA can leave early from shift without permission from the DSD (or designated Manager on Duty). The DSD (or designated Manager on Duty) will determine ability of an approved down staffing prior to approval being given to the CNA by the Charge Nurse. The CNA staff are to receive assignments for the shift and start the rounding procedure to account for all assigned residents. Any time a change of assignment occurs the CNA will be given the assignment and complete a walking round to account for all residents. The LVN staff on shift will be responsible to do a walking round for change of shift hand off to account for all residents and receive a report from the nurse leaving shift. If at any time a resident is found not accounted for and is not found by staff during rounds. A huddle will be called and on Duty Manager will be notified of the missing resident. In the huddle a staff member will be assigned to each area of the building for a safety search until the resident is accounted for. All clinical staff and management staff will be in serviced on the policy and procedures for: Hourly Rounding, Staff Assignments for start of shift and down staffing, Start of shift hand off and walking rounds report. 3. WHAT MEASURES WILL BE PUT INTO PLACE OR WHAT SYSTEMIC CHANGES THE FACILITY WILL MAKE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR The policy and procedure for down staffing or the change in assignments will be provided to all staff members. All hourly rounding logs will be verified with the DON and DSD. The Charge Nurses will be held accountable for ensuring the safety of each resident is monitored for their shift. The charge nurse will notify the DSD/DON for assistance when needed with the assignment. All staff will receive an in-service on the policy and procedures being implemented on and the In-services will start on 05/9/2018 and complete on 05/11/2018 by end of day. An in-service has been provided to all clinical staff on Tuesday (MONTH) 8, (YEAR) in regard to Plan of Correction for Hot weather and Dehydration Evaluation. At start of first shift scheduled with the staff members on LOA or unavailable for in-service on the dates originally provided all P[NAME] in services will include dehydration evaluations, hydration measures, hot weather procedures, Hourly Rounding, Staff Assignments for start of shift and down staffing, Start of shift hand off and walking rounds report. All staff members are contacted during the in-service time frame of 05/09/2018 to 05/11/2018 to be made aware of the in-service compliance requirements prior to start of next scheduled shift or at start of next scheduled shift. The in-services will be provided annually to all staff and as part of the initial policy and procedure education upon hire. 4. HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED. THE FACILITY MUST DEVELOP A PLAN FOR ENSURING THAT CORRECTION IS ACHIEVED AND SUSTAINED, THIS PLAN MUST BE IMPLEMENTED, AND THE CORRECTIVE ACTION EVALUATED FOR ITS EFFECTIVENESS. THEN P[NAME] MUST BE INTEGRATED INTO THE QUALITY ASSURANCE SYSTEM This process will be discussed in the QA and QAPI meeting monthly. The QA will meet and ensure 100% completion of the logs for compliance with safety checks through 90 days from start of implementation. Every shift will be monitored for compliance with the facility daily audit process. After the 90 day compliance is met the QA team will monitor to ensure compliance is maintained every month. Each 24 hours will ensure that the PPD was met daily and assignments maintained. The PPD and staffing assignment will be discussed by DON/DSD in each morning meeting throughout the week. The corrective action plan was reviewed and accepted on (MONTH) 11, (YEAR), at 4:20 PM. But based on observation, interview, and record review, the facility was found to be in non-compliance with the corrective action plan to remove the potential for harm. The following were conducted: 1. During an observation and review of the facility hourly monitoring check log was done on (MONTH) 11, (YEAR), at 9:46 AM, it was observed that CNA 4, was doing hourly monitoring rounds. A concurrent record review was done on hourly rounding log with CNA 4. The review indicated that the hourly checking log was not filled out from (MONTH) 11, (YEAR), at 7:00 AM. A concurrent interview with CNA 1 stated that the hourly monitoring check list was handed over to her at that time. When inquired whether she received in-services on hourly monitoring, she stated she received the in-services recently. 2. An observation of CNA's hourly rounding and concurrent record review of the hourly rounding check list was done on (MONTH) 11, (YEAR), at 2:30 PM. Review of the hourly rounding sheets indicated that one out of three check in sheets was documented completely through 2:45 PM (Next scheduled time after 2 PM was 2:45 PM). During an interview with RNC, on (MONTH) 11, (YEAR), at 2:32 PM, she reviewed the record and stated, documenting ahead of time is not accepted. 3. On (MONTH) 11, (YEAR), at 3:06 PM, it was observed that three CNAs and two LVN's were standing at the nurse's station and giving hand off report to the next shift. The staff were not observed to do walking rounds during the change of shift. 4. On (MONTH) 11, (YEAR), at 3:11 PM, CNA 2, was observed to be leaving the facility with her bags. When asked she stated she was going home after her shift duty (7 AM- 3 PM). When asked whom did she give report to on the next shift (3 PM-11 PM), she stated she did not give report to anybody and she did not know who was coming to take over her residents for the next shift. A record review of the assignment sheet was conducted with LVN 4 and RN 1, on (MONTH) 11, (YEAR), at 3:18 PM, which indicated the assignment sheet was incomplete. LVN 4 stated that it was the LVN's responsibility to complete the assignment sheet prior to the shift change. 5. During an interview with CNA 4, on (MONTH) 11, (YEAR), at 3:20 PM, she stated that she did not do the walking rounds during the change of shift. She acknowledged that she received many in-services recently. When asked if the walking rounds were included in the in-services, she did not answer. After observations, interviews, and record reviews to confirm the corrective action plan had been implemented conducted the IJ was abated on (MONTH) 14, (YEAR), at 5:11 PM, in the presence of the Administrator, DON, RNC, Director of Clinical Operations 1(DCP 1) and RN 2.

Based on interview and record review, the facility failed to implement their care plan for one of three sampled residents (Resident A) for wandering into other residents' rooms and for grabbing snacks and putting them in his mouth. This failure resulted in Resident A wandering into another resident's room, where he grabbed a sandwich, choked and collapsed. Resident A required cardiopulmonary resuscitation (CPR- an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into the lungs) and is now on a ventilator (a machine that helps someone breathe) in the acute care hospital. Findings: The clinical record for Resident A was reviewed. A document titled, Admission Record dated [DATE], indicated Resident A was admitted on [DATE], with [DIAGNOSES REDACTED]. During an interview with Certified Nursing Assistant 1 (CNA 1) on [DATE] at 9:45 AM, she stated,He (Resident A) goes to everybody's room, gets other resident's food and had been doing that for a long time. He was not on one on one supervision. During an interview with CNA 2 on [DATE] at 3:30 PM, he stated, He goes from room to room. He gets trays from other residents during mealtime. Only the nurse on the floor supervises a section of the facility. He needs a one on one supervision. A review of Resident A's care plans reflected Resident A had been identified as being at risk for choking and had three episodes of choking as follows: a. Care plan dated [DATE], reflected Resident A .grabbing snacks from cart, will put all snacks in his mouth at one time. b. Care plan dated [DATE], (after the first choking incident) Resident (Resident A) at risk for choking, impulsive, eats fast. c. Care plan dated [DATE], indicated, . physical aggression, taking trays out of other resident's hands . d. A care plan titled Alteration in nutrition-risk for choking initiated [DATE], listed two incidents. 1. [DATE], choked on fish, interventions included diet changed to regular, chopped, no bread. 2. [DATE], choked on P and J (peanut butter and jelly) sandwich. Further review of Resident A's care plans indicated a behavior care plan initiated [DATE], for wandering. Interventions included: Will go in and out of other residents' room. Intervene as appropriate. The clinical record of Resident A was reviewed. A document titled Speech therapy dated [DATE], indicated, . Recommendations, Supervision for oral intake=close supervision . During a review of the clinical record of Resident A from the acute care hospital on [DATE], a document titled Patient Notes indicated, .Pt was seen choking by an RT (respiratory therapist), and [MEDICATION NAME] (emergency procedure to remove foreign object from the mouth) was attempted which was unsuccessful .CPR was initiated .foreign object was removed . A review of the clinical record for Resident A from the acute care hospital where he was transferred on [DATE], was conducted. A document titled Hospital course indicated, . (Resident A) has been known to take food from other residents in the facility .He has issues with choking and apparently choked while eating. The staff found the patient, unresponsive and called 911. When paramedics arrived, the patient was in full arrest (not breathing, no pulse) .Patient was intubated and CPR was performed. After ,[DATE] minutes there was return of spontaneous circulation .He underwent a [MEDICATION NAME] (a procedure to check the airways) with removal of the food particles from the tracheo-[MEDICATION NAME] tree (airways going to lungs) .He remains intubated on mechanical ventilation (machine that helps patient breathe) .patient has remained comatose (deep unconsciousness for prolonged or indefinite period, especially as a result of severe injury or illness). During an interview with the Director of Nursing (DON) on [DATE] at 3:00 PM, she stated, Resident A preferred to eat in his room during mealtimes and was not on one to one supervision. Only the nurse assigned on the floor supervised the rest of the residents who ate in their rooms. She stated the speech therapist did not have an in-service with the staff about his recommendations, after Resident A's first choking incident. The facility policy and procedure titled, Assistance with Meals, dated [DATE], indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each residents. An Immediate Jeopardy ((IJ), a crisis which has threatened or is likely to threaten the health and safety of a resident.) was called under 483.20, Resident Assessment (refer to F 279) on [DATE] at 3:47 PM, and verbally notified in the presence of the Director of Nursing when the facility failed to monitor one of three sampled residents (Resident A) and prevent him from wandering to another resident's room where he obtained a sandwich that had been left on the resident's table. Resident A choked on the sandwich, on [DATE] at 1:30 PM, requiring cardiopulmonary resuscitation (CPR-an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into lungs.). The corrective action plan included: a. Residents' snacks will be passed, they will be allowed ample time to consume them, and if they are not consumed within that time, snacks will be collected and discarded due to infection control and to protect wandering residents from potential choking hazards. Snacks will be available at residents' request. Snacks are kept on snack cart in locked break room after kitchen has closed. b. For residents that have impulsive eating behaviors, wandering, and with previous history of choking, the following protocol will be implemented: -Physician notification. -Request for speech therapy evaluation, specific interventions, identified by speech therapy or any other special services, will be added to residents care plan. -Dietician evaluation. -RNA (restorative nursing assistant-a nursing assistant with special rehabilitation training) feeding program. -Resident will be monitored as indicated to prevent future incidents. - Care plan will be initiated or updated accordingly, to include specific instructions identified by speech therapist such as 1:1 observations to prevent any future potential choking incident. -1:1 sitter during meal periods and snack times, to reduce risk of any unsupervised consumption of foods, and prevent any future choking episode. Resident care plan will reflect interventions so that plan of care will be evaluated per care plan schedule and as needed. c. All nursing staff were immediately given an in-service on [DATE]. The corrective action plan was reviewed and following observations, interviews, and record reviews, the IJ was lifted in the presence of the Director of Nursing and Regional Nurse Consultant on [DATE] at 12:37 PM.

Based on interview and record review, the facility failed to report to California Department of Public Health (CDPH) when one of the three sampled residents (Resident A) experienced three choking incidents within two months. Two of the choking incidents required cardiopulmonary resuscitation (CPR -an emergency procedure in which the heart and lungs are made to work by compressing the chest underlying the heart and forcing air into the lungs), the most recent resulting in Resident A being placed on a ventilator (a machine that helps some breathe). Findings: A review of Resident A's clinical record indicated he was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the nursing progress notes indicated Resident A had three incidents of choking as follows: a. On [DATE], .Staff noted patient was non responsive. Patient did not respond to verbal command, staff initiated the [MEDICATION NAME] maneuver (emergency procedure to remove foreign object from the mouth) was attempted which was unsuccessful . CPR was initiated , with no result. Code Blue (when pulse or respirations are not detected) called at 1:08 PM .chest compression initiated . b. On [DATE] , 2017, . he (Resident A) was choking .the [MEDICATION NAME] maneuver was initiated. Resident began to cough and food was ejected from resident's mouth . c. On [DATE], .Charge nurse assessed resident (Resident A) and noted he was choking on a sandwich .[MEDICATION NAME] maneuver was performed and was not successful .CPR initiated . An interview and concurrent review of the facility's policy and procedure titled, Unusual Occurrences, undated, was conducted with the Director of Nursing (DON) on [DATE], at 10:15 AM. The policy indicated, It is the policy of the facility to comply with California Code of Regulations, Title 22, Division 5, Chapter 3, Article 5,7254: Occurrences such as epidemic outbreaks, poisoning, fires, major accidents, death from unnatural causes or other catastrophes and and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours . The DON stated, that when Resident A had the repeated incidents of choking, and required cardiopulmonary resuscitation, I did not report the three incidents to CDPH (California Department of Public Health), I was not sure if it was reportable or not.

Based on observation, interview, and record review, the facility failed to develop a Communication Care Plan for one of three sampled residents (Resident 1) who was Spanish speaking only. This failure resulted in Resident 1's inability to communicate her safety needs after a fall incident occurred that resulted in a left eye injury. Findings: During an observation on July 28, 2016 at 3:30 PM, Resident 1 was observed ambulating in the front lobby with noticeable large bruising around her left eye. Resident 1 was alert and able to communicate only in Spanish. An interview was conducted with Resident 1 on July 28, 2016 at 3:30 PM, with the help of a Spanish interpreter (Staff Member 1). Resident 1 stated that the fall incident happened at 9 PM on July 23, 2016, when a gentleman (Resident 2) came to her room trying to pull her out of bed. Resident 1 stated that she got up out of bed and tried to get him (Resident 2) out of her room, but in the process of trying to get him out of her room they both (Resident 1 and Resident 2) fell to the floor. Resident 1 stated that she immediately went to the Nurses' Station to report the incident to the nurse on duty, but nothing was done until the next morning of July 24, 2016. During a review of Resident 1's clinical record, the face sheet and History and Physical revealed that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Resident Assessment Instrument (RAI- a comprehensive assessment), dated December 17, 2015, included the following: a. Preferred language was Spanish. b. Interpreter needed to communicate with a doctor or health care staff. During a review of Resident 1's nurses notes, dated July 24, 2016, revealed that a fall incident occurred on July 23, 2016, the time of the fall incident was not documented. It showed Resident 1 was sent to the emergency roiagnom on [DATE] at 7 AM, after a staff member noticed a large bruise on Resident 1's left eye. A review of Resident 1's clinical record failed to show documented evidence that a Communication Care Plan was developed to address Resident 1's language barrier and need for a Spanish interpreter. On July 28, 2016 at 3:55 PM, an interview was conducted with Licensed Vocational Nurse 2 (LVN 2) who was in charge on July 23, 2016 at 9 PM, when Resident 1 attempted to communicate the fall incident. LVN 2 stated they did not know what Resident 1 was talking about. LVN 2 stated the staff member that spoke Spanish left at 3 PM that day, and no one on the 3 PM to 11 PM shift could translate to English what Resident 1 was trying to communicate in Spanish. During an interview with the Registered Nurse Clinical Consultant (RNCC) on August 2, 2016 at 3:30 PM, she verified that a Communication Care Plan was not developed to address Resident 1's need for a Spanish interpreter to communicate with the facility's non-Spanish speaking staff. A review of the facility's policy and procedure titled, Care Planning- Interdisciplinary Team, indicated, Our facility's Care Planning Interdisciplinary Team is responsible for the development of an individual comprehensive care plan for each resident. 1. A comprehensive care plan for each resident is developed with in seven (7) days of completion of the resident assessment (MDS-Minimum Data Set).

Based on observation, interview, and record review, the facility failed to: 1. Transcribe new medication orders accurately from the resident's medical record to the Medication Administration Record [REDACTED]. Some of these transcription errors resulted in medication administration errors including a significant medication error. This failure of not transcribing orders accurately to the MAR indicated [REDACTED]. 2. Follow their policy & procedure which required that medications be administered within one hour before and one hour after the scheduled time. Three nurses were observed to be passing medications at least two hours after the facility's scheduled morning medication pass on three different occasions. This failure of giving medications outside of the facility's scheduled medication pass time increases the risk for medication interactions, increased adverse effects, and for medications to not be as effective as the prescriber or manufacturer intended. Findings: 1. On March 24, 2016, the medical records for the following residents were reviewed: Resident C, D, E, F, G, H, I, 3, and 10. 1 a. During a medical record review for Resident C on March 24, 2016, it was noted that an order for [REDACTED]. A concurrent review of Resident C's Medication Administration Record [REDACTED]. The first order was started on March 5, 2016, for 6 mg daily in the evening, and was initialed from March 5, 2016 to March 15, 2016. A second order was started on March 23, 2016, for warfarin 6 mg x 1 day (for 1 day) and was initialed as given for 1 day on March 23, 2016. A third order for warfarin 6 mg daily in the evening was on the MAR for March with a start date of February 20, 2016. However, this order was not initialed as given and there was an X for each day indicating the order should not and had not been given. No warfarin orders were found on the March MAR indicated [REDACTED]. During an interview with the Director of Nursing (DON) on March 24, 2016 at 3:00 PM, she confirmed that no orders for warfarin were transcribed to the MAR for March 16, 2016, to March 22, 2016. She stated that the facility team had found the discrepancy and that is why they had transcribed the order to the MAR indicated [REDACTED]. 1 b. During a medical record review for Resident D on March 24, 2016, it was noted that an order for [REDACTED]. A concurrent review of Resident D's MAR for March 2016, revealed one active order for quetiapine. This order was written as Seroquel (generic name quetiapine) tablet give 75 mg by mouth one time a day. The order had a start date of May 1, 2015 and was being initialed as given by nursing. The medication cart was inspected and one card of quetiapine was found with medication punched out indicating that it was used. The directions on the medication card's label stated, Quetiapine 25 mg tab; Take 3 tablets (75 mg) by mouth daily. During an interview with the DON on March 24, 2016, at 3:05 PM, she confirmed that the order was transcribed incorrectly and that the resident was not receiving the current order. She stated that they were going to contact the physician and the resident's responsible party to let them know of the error. 1 c. During a medical record review for Resident E on March 24, 2016, it was noted that an order for [REDACTED]. Also noted was an order for [REDACTED]. A concurrent review of Resident E's MAR for March 2016 revealed one active order for risperidone. This order was written as Risperdal tablet 0.5 mg give 1 tablet by mouth two times a day. The order had a start date of February 1, 2016 and was being initialed as given by nursing. The medication cart was inspected and two cards of risperidone were found with medication punched out indicating they were used. The directions on both card's labels were Risperidone 0.5 mg tab Take 1 tablet by mouth twice daily. During an interview with the DON on March 24, 2016, at 3:20 PM, she confirmed that the order was transcribed incorrectly and that the resident was not receiving the current order. She stated that they were going to contact the physician and the resident's responsible party to let them know of the error. A concurrent review of Resident E's MAR for March 2016 revealed that no order for Glucagon was transcribed to the MAR indicated [REDACTED]. During an interview with the DON on March 25, 2016, at 11:00 AM, she stated, That was on me, and that she was responsible for the transcription error because she was the one who placed the order in the resident's medical record. She stated that she had placed multiple Glucagon orders for multiple resident's in their respective health records over the weekend (Sunday, March 20, 2016) and had planned on transcribing the orders to the MARs on the following Monday, March 21, 2016. She then stated, But you guys came in (referring to the survey team) and I forgot. 1 d. During a medical record review for Resident I on March 24, 2016, it was noted that an order for [REDACTED]. A concurrent review of Resident I's MAR for March 2016 revealed that no order for Vitamin C was transcribed to the MAR indicated [REDACTED]. During an interview with Licensed Vocational Nurse (LVN 4) on March 24, 2016, at 11:30 AM, she confirmed that the medication order was not listed in the MARs and stated that she had not been giving the medication because it was not on the MARs. 1 e. During a medical record review for Resident F on March 24, 2016, it was noted that an order for [REDACTED]. A concurrent review of Resident F's MAR for March 2016 revealed that no order for Ativan was transcribed to the MAR indicated [REDACTED]. The medication cart containing Resident F's medications was inspected on March 24, 2016, at 11:30 AM. No medication cards containing Ativan for Resident F were located. During an interview with LVN 4 on March 24, 2016, at 11:30 AM, she confirmed that there was no active order for Ativan on the MARs and that no Ativan medication was in the cart for Resident F. 1 f. During a medical record review for Resident 10 on March 24, 2016, it was noted that an order for [REDACTED]. A concurrent review of Resident 10's MAR for March 2016 revealed that no order for Glucagon was transcribed to the MAR indicated [REDACTED]. During an interview with the DON on March 25, 2016, at 11:00 AM, she stated, That was on me, and that she was responsible for the transcription error because she was the one who placed the order in the resident's medical record. She stated that she had placed multiple Glucagon orders for multiple resident's in their respective health records over the weekend (Sunday, March 20, 2016) and had planned on transcribing the orders to the MARs on the following Monday, March 21, 2016. She then stated, But you guys came in (referring to the survey team) and I forgot. 1 g. During a medical record review for Resident G on March 24, 2016, it was noted that an order for [REDACTED]. A concurrent review of Resident G's MAR for March 2016 revealed that no order for Glucagon was transcribed to the MAR indicated [REDACTED]. During an interview with the DON on March 25, 2016, at 11:00 AM, she stated, That was on me, and that she was responsible for the transcription error because she was the one who placed the order in the resident's medical record. She stated that she had placed multiple Glucagon orders for multiple resident's in their respective health records over the weekend (Sunday, March 20, 2016) and had planned on transcribing the orders to the MARs on the following Monday, March 21, 2016. She then stated, But you guys came in (referring to the survey team) and I forgot. 1 h. During a medical record review for Resident H on March 24, 2016, it was noted that an order for [REDACTED]. A concurrent review of Resident H's MAR for March 2016 revealed that no order for Glucagon was transcribed to the MAR indicated [REDACTED]. During an interview with LVN 2 on March 24, 2016, at 2:05 PM, she confirmed there was no order listed on the MARs for Resident H. 1 i. During a review of the MAR's for Resident 3 on March 24, 2016, it was noted that there were orders for Glucagon as needed for [DIAGNOSES REDACTED] and Dextrose Gel (a gel used to raise a resident's blood sugar if critically low) 77.4% as needed for [DIAGNOSES REDACTED]. Both orders were active on the MAR's. The Glucagon had a start date listed as March 18, 2016 and the Dextrose Gel had a start date of August 17, 2015. A concurrent review of Resident 3's medical record revealed that the Dextrose Gel was discontinued on March 20, 2016, at 6:49 PM despite the fact that it still appeared as active on the MAR's. The discontinuation order is listed as confirmed by the DON. During an interview with the DON on March 24, 2016, at 2:00 PM, she confirmed that the order had not been discontinued on the MAR's and still appeared as active. She was asked what the process was for transcription of new medication orders. She stated that new orders are placed in the resident's physical paper chart by either the physician or the nurse (if a verbal order). The order is then entered in the resident's electronic medical record via a computer terminal. Once the order is input into the computer, a printed order and a Medication Administration Record [REDACTED] A review of the facility's policy & procedure manual, titled with the facility's contracted pharmacy name, was reviewed on March 24, 2016. A policy titled Prescriber Medication Orders, on page 2.1, showed, B. Documentation of the Medication Order. 1) Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the physician order [REDACTED]. In addition, the policy showed, 2) The following steps are initiated to complete documentation and receive the medications: [REDACTED]DC'd and the date and highlighting the entry in yellow). Enter the new order on the MAR/TAR. An Immediate Jeopardy (IJ) situation was called on March 24, 2016, at 4:15 PM, in the presence of the facility's Administrator and the Director of Nurses (DON) who were notified of the Immediate Jeopardy situation and the extended survey. Specific details of the Immediate Jeopardy situation including the residents at risk due to medications not being transcribed accurately from the physician orders [REDACTED]. During an interview with the DON on March 25, 2016, at 10:30 AM, she stated that they (facility personnel) had completed a 3-way audit (an audit in which new orders in the resident's medical record are compared with what is listed in the Medication Administration Record [REDACTED]. When asked if they had found more discrepancies, she confirmed that they did. She stated that the majority of errors were due to the nurse not printing out the new Medication Administration Record [REDACTED]. On March 25, 2016 at 10:30 AM, the IJ was removed in the presence of the Administrator after the team had interviewed facility's staff, conducted clinical record reviews, reviewed and accepted the facility's plan of correction. 2. On March 23, 2016, at 10:08 AM, LVN 4 was observed to be in the hallway handling a medication cart and administering medications to residents. When asked if she was passing medications that were scheduled for 8:00 AM, she stated, Yeah, and 9:00 AM too. I had a family emergency this morning. When asked how many residents she had left, she stated, Five. On March 23, 2016, at 10:20 AM, LVN 5 was observed to be in the hallway handling a medication cart and administering medications to residents. LVN 5 was observed to pass medications to Resident 11 at 10:30 AM. On March 24, 2016, at 10:15 AM, LVN 2 was observed to be in the hallway handling a medication cart and administering medications to residents. When asked if she was still passing 8:00 AM medications, she answered that she was. When asked why she was not done by 9:00 AM which was required by facility policy, she stated, I'm kind of new. I don't know my patients yet. On March 24, 2016, at 10:30 AM, LVN 2 stated, I just finished, referring to her 8:00 AM medication pass. A review of the facility's pharmacy policy & procedure handbook, which was labeled with the facility's contracted pharmacy provider, included a policy, on page 5.9, titled, Medication Administration - General Guidelines. Under section 10, the policy showed, Medications are administered within one hour before and one hour after the scheduled time . It further showed, Unless otherwise specified by the physician or pharmacist, routine medications are administered according to the established medication administration schedule for the facility. Further review of the policy & procedure handbook listed the QD (every day or daily) administration time as 0800 (8:00 AM).

Based on interview and record review, the facility failed to ensure 2 Residents (Resident B and C) were not subjected to abuse when the facility failed to ensure the physician's orders [REDACTED]. for a psychiatric evaluation. This failure resulted in Resident A's continued and increased aggressive and combative behavior towards multiple residents including injuries to the head and face of Residents B and C. Findings: On June 26, 2015, a review of the facility's abuse investigation report dated March 18, 2015 indicated on March 18, 2015, Resident A had physically assaulted two other residents (Residents B and C) in the facility. On March 18, 2015 at 8:25 AM, Resident C sustained two reddened areas and bumps (swollen areas) on the face after Resident A struck him on the right side of the face with closed fist. At 12:45 PM, Resident B sustained two hematomas (a bruise/collection of blood outside the blood vessel) on top of the head as a result from being punched by Resident A. A review of Resident A's clinical record on June 26, 2015 indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of Resident A's short term problems and care plan showed multiple incidents of the resident's aggressive and combative behavior towards other residents and staff. The incidents included the following: January 4, 2015- Resident A striking the charge nurse in the face. Care plan interventions included: provide Psychiatric Evaluation and Treatment; administer medications as ordered; and to redirect Resident A to activity. February 3, 2015- Resident A kicked at staff when asked question. Care plan interventions included: appointment with Psychologist (at behavioral hospital); re-direct resident to activity. February 10, 2015- (unwitnessed) Accusation of striking a peer (another resident). Care plan interventions included: monitor resident's behavior; and administer medications as ordered. February 15, 2015- Resident to Resident (involving Resident A and another resident) physical altercation. Care plan interventions included: monitor resident's behavior; medication as ordered; redirect as needed. March 18, 2015- Aggressive behavior (towards other residents; Resident A struck Resident B on the right side of the face with closed fist; Resident A punched Resident C on top of the head). Care plan interventions included: medication as ordered and monitor and document episodes of behavior. A review of the Psychologist's assessments and progress notes dated February 3, 6, 17 (prior to abuse incident on 3/18/15), and March 18, 2015 (after the incident) indicated Resident A continued to show aggressive and combative behavior towards other residents at the facility and had requested the need for Resident A to be seen and evaluated by a Psychiatrist as ordered. The Psychologist's progress notes included the following: February 3, 2015- The patient (Resident A) was referred (to Psychologist) due to an altercation with another female resident without serious injury. The patient was not responsive to the psychologist during the interview . The patient has [MEDICAL CONDITION] with poor judgement and impulse control . This patient should be seen by a Psychiatrist for a medication review for mood stabilization and impulse control . February 6, 2015- The patient (Resident A) was referred due to an altercation with another patient (resident) where it was alleged the patient (Resident A) went into another resident's room and hit him. The patient was not responsive to the psychologist during the interview . (the resident) need to be taken to a Psychiatrist for a medication review to help with impulsive control. February 17, 2015- The patient (Resident A) was referred because he hit another resident when he (Resident A) accidentally ran into him (another resident) with his wheelchair. The patient was not responsive to the psychologist during the interview. The patient's body language indicated he had no emotional distress over the incident . The patient (Resident A) should have a medication review by a Psychiatrist for medication to stabilize his mood. March 18, 2015 - The patient (Resident A) was referred because he hit another male resident (Resident C) in the TV room and a female resident (Resident B) in the dining room . The patient (Resident A) should be evaluated by a Psychiatrist for medication to increase impulse control. The patient appears to have no emotional distress or remorse over the altercation. There was no written evidence in Resident A's clinical record to show the resident was provided a psychiatric evaluation and treatment as indicated in the plan of care, despite the Psychologist's repeated recommendations for a Psychiatric Evaluation. There was no documentation by the interdisciplinary team (IDT- members include the Registered Nurse/Licensed Vocational Nurse, Social Services designee, and attending physician) of the reason why a psychiatric evaluation and treatment was not provided for Resident A as ordered for the past 41 days (from February 4, 2015 - March 18, 2015). Resident A was discharged to an acute hospital on March 18, 2015 after physically assaulting Residents B and C. The physician's discharge summary documentation indicated the resident was discharged to an acute hospital because of risks for health and safety of other residents in the facility due to combative behavior. In an interview with the facility Administrator on June 26, 2015 at 9:45 AM, he stated, I don't know about this incident, I wasn't here when the incident happened (stated he started 2 weeks ago). In an interview with the Director of Nursing (DON) on June 26, 2015 at 9:45 AM, he stated that Psych Eval referrals and appointments were handled by the Social Services Designee (SSD). The DON reviewed Resident A's clinical record and was unable to find documentation of a psychiatric evaluation and treatment results. There was no documentation by the SSD from February to March 2015 to indicate Resident A's Psych Eval order was followed up. The DON stated, We have a new SSD, the former SSD is no longer here. I'm new too (started 2 weeks ago), I wasn't here when the incident happened. During a follow up interview with the DON on June 30, 2015 at 11:05 AM, regarding the facility's policy on how to follow up with physician orders, referrals and recommendations, the DON stated, We could not find one.

Based on observation, interview, and record review, the facility failed to ensure 1 of 13 sampled residents (Resident 1) received an accurate and complete head to toe skin assessment. For Resident 1, the failure to provide the necessary care and services had the potential to negatively impact Resident l's ability to reach the highest practicable level of well-being. Findings: During an observation on July 8, 2014 at 4:30 PM, Resident 1 was observed to have 3 separate wounds to the right foot: 1. A laceration (straight linear cut), with redness noted along the wound edges, in the mid plantar (bottom) aspect, depth undefinable, extending from the inner to the outer side of the right foot. 2. A reddish- brown, dried, fluid filled blister to the outside of the right foot. 3. A wound with a dried, brownish-black, scab-like surface, on the heel of the right foot. During an interview on July 8, 2014 at 4:32 PM, Licensed Vocational Nurse 1 (LVN 1) stated she had not seen the wounds before, "...she had a cast on for a while." When asked what the facility policy is for skin assessments, she stated that a daily skin check should be completed and recorded in the "Nurses Weekly Progress Notes" document. During a concurrent interview with the afternoon shift Certified Nursing Assistant (CNA 1), he stated he had seen the wounds yesterday (July 7, 2014) around 5:00 PM, and told the evening shift Charge Nurse. During a concurrent interview with CNA 2, on July 8, 2014 at 4:33 PM, she stated Resident 1 was on Hospice, the hospice nurse would take care of the wounds. CNA 2 further stated that she had given Resident 1 a shower and did not notice the wounds on her foot. During an interview with the Director of Nursing (DON), on July 8, 2014 at 4:40 PM, the DON stated "I will get the treatment nurse to get something on it and call the doctor." The DON further stated, "...it is tender, I will start the investigation." During an observation on July 8, 2014 at 4:45 PM, when the facility Administrator touched the wound and the surrounding tissue area, Resident 1 immediately withdrew her leg and foot away. During a review of the clinical record for Resident 1, the facility document titled "Patient Change of Condition Notification & Documentation", dated July 8, 2014 at 9:00 PM, indicated the following: Assessment/Signs/Symptoms 1. 0.5 cm x 8.5 cm linear cut to the mid inner plantar aspect of the right foot. 2. 1.5 cm x 0.8 cm dry fluid filled blister to right lateral aspect of foot. 3. 2 cm x 0.8 cm black dry eschcar (dead tissue cast off from the surface of the skin) to posterior aspect of the heel. During an interview with Resident 1, on July 9, 2014 at 8:34 AM, when asked if she was having pain in her foot she responded she was having pain in her foot and all over her body. During an interview with the Director of Staff Development (DSD), on July 9, 2014 at 9:25 AM, she stated her first awareness of the wounds were when she saw them "...yesterday (July 8, 2014 at 4:33 PM), when they were shown to me." A review of the clinical record for Resident 1, dated July 3, 2014, titled "Nurses' Weekly Progress Notes, Skin Assessment-Comments" indicated "Skin intact other than a finger that has treatment order." During a review of the facilities Quality Assessment and Assurance with the administrator, on July 14, 2014 at 4:30 PM, she was asked about the issues of routine skin assessments. She stated, "There currently is not a policy related to skin assessment, but there will be (one)." A complete skin assessment is essential for early identification of risk factors and changes in the resident condition that affect the physical, mental, and psychosocial needs for positive resident outcomes.

Based on observation, interview, and record review, the facility failed to keep 1 out of a universe of 50 cognitively impaired (reduced thinking skills, including language use) residents (Resident 1) free from verbal and physical abuse. This failure resulted in Resident 1 sustaining a skin tear to the left knee and had the potential to cause Resident 1 physical pain and mental anguish. Findings: Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview with the Administrator on March 27, 2014, at 2:40 PM, she stated that on March 25, 2014, at approximately 6:15 AM, Licensed Vocation Nurse 1 (LVN 1) was asked by CNA (Certified Nurse Assistant) 1 to assist Resident 1 to transfer to a shower chair (A plastic and mesh chair on wheels that residents sit in while showering). At the bedside of Resident 1, CNA 1 was observed by Licensed Vocational Nurse 1 (LVN 1) saying, "I don't have time for this," and CNA 1 proceeded to "Roughly yank Resident 1's legs apart, rip off his diaper, and roughly push Resident 1 onto his left side." The Administrator stated that Resident 1 sustained a skin tear (traumatic injuries which can result in partial or full separation of the outer layers of the skin) to his left knee. The Administrator stated that after witnessing the verbal and physical abuse, LVN 1 allowed CNA 1 to complete her shift. During an observation and interview with CNA 2, on March 27, 2014, at 2:15 PM, Resident 1 was observed lying in bed. The bed was adjacent to a wall on Resident 1's left side. There were no side rails on the bed. CNA 2 stated, "He cannot turn over by himself, he needs help." After obtaining permission from Resident 1, CNA 2 lifted the bottom bedcovers and exposed Resident 1's left knee. A one inch skin tear was noted on the outer aspect of the left knee. An attempt was made to interview Resident 1, but he only mumbled. CNA 2 stated, "He can only answer in one or two words." During an interview with LVN 1, on March 27, 2014, at 2:55 PM, she stated, "At about 5:30 AM, on March 25, 2014, I was asked by CNA 1 to help transfer Resident 1 to the shower chair." LVN 1 indicated that she was standing at the foot of Resident 1's bed, when she witnessed CNA 1 say, "I don't have time for this[***]" She then witnessed CNA 1, rip Resident 1's legs apart, rip off Resident 1's diaper, and push Resident 1 against the wall. LVN 1 stated that she then assisted CNA 1 with the transfer of Resident 1 to the shower chair. LVN 1 stated that she noticed that Resident 1's left knee was bleeding and she proceeded to apply gauze to the wound. LVN 1 further stated, "I was in shock. I have never seen anything like that before." LVN 1 stated, "CNA 1 had a nasty attitude and I was afraid of her, which is why I did not ask her to clock out immediately. I thought she would hurt me." LVN 1 acknowledged that she allowed CNA 1 to continue her shift and take care of other residents for an hour and a half after the witnessed abuse. LVN 1 stated, "I should have clocked her out immediately." During a review of Resident 1's clinical record on March 27, 2014, a "Licensed Personnel Progress Note" indicated the following entry for Resident 1, dated March 25, 2014, at 7:40 AM, "SBAR (situation, background, assessment and request form)/incident report initiated for CNA to resident altercation with skin tear to left knee...will continue to monitor for emotional distress.'' A form titled "history and physical examination [REDACTED]." Also, a physician's orders [REDACTED]." During a review of the clinical record for Resident 1 on April 8, 2014, at 10:00 AM, the Quarterly minimum data set (MDS, a tool used by long-term care facilities for assessing and planning care for residents), dated March 12, 2014, was reviewed. Noted under "Section B, Hearing, Speech, Vision," that Resident 1 was coded as "Rarely or never is understood" and "Rarely or never understands others." This same MDS indicated under "Section C, Cognitive Patterns," that Resident 1 was coded as having a long term and short term memory problem. During an interview with the SSD (Social Services Director) on March 27, 2014, at 4:00 PM, she stated, "I want my staff to stand up when something like this happens, the CNA (CNA 1) should have been sent home immediately and the nurse (LVN 1) should have started the abuse protocol immediately." The SSD went on to say that LVN 1, "should have stopped the abuse when it was happening." A review of facility policy and procedures was conducted on March 27, 2014. A policy titled, "Abuse Prevention and Elder Justice Program," and dated 2013, defines abuse as, "The willful infliction of injury...or punishment with resulting physical harm, pain, or mental anguish." It noted under "Policy," This facility recognizes that each resident has the right to be free from all forms of abuse (verbal, physical...). The policy further notes, "All forms of abuse are strictly prohibited by this facility." During a follow up interview with the Administrator on March 27, 2014, at 4:20 PM, she stated that, "This (abuse) never should have happened."