Every finding on record at Valley Skilled Nursing Center

Based on interview and record review the facility failed to timely review and revise residents' comprehensive, person centered care plans after significant changes in condition and or behavior following a resident to resident aggression on 02/20/2026 and 02/21/2026 when: Three of four sampled residents ((Res) 1, Res 3, and Res 4), did not have care plan updates documented in accordance with the facility policy. 2. Two of four sampled residents (Res 1 and Res 2), had no interdisciplinary team (IDT - a collaborative group of professionals including nurses, doctors, therapists, social workers, and dietitians who meet regularly to plan and manage a resident's care) documentation after the significant incident on 2/20/26. 3. One of four sampled residents (Res 2), had lack of documented follow up on room change and safety measures after being followed by social services.These failures to timely reassess, implement interventions, and revise care plans placed Res 1, Res 2, Res 3, and Res 4 at risk for psychosocial distress (emotional suffering that may include fear, anxiety, agitation or decrease sense of safety resulting from unaddressed stressful events), and concerns for their physical wellbeing. Findings:During a review of the Res 1's (Physician (MD)/Nurse Practitioner (NP)) Progress note, dated 3/4/26, the MD/NP Progress note indicated Res 1 was a [AGE] year-old male who was admitted to the facility on [DATE] after hospitalization. Res 1 had a significant past medical history of high blood pressure (force of blood pushing against the walls of blood vessels is too high), hyperlipemia (high level of fat in blood), prostate cancer (cancer happens when cells in the prostate (small, walnut-sized gland that is part of the male reproductive system) start growing abnormally and uncontrollably), depression (common mood disorder causing persistent sadness, loss of interest, fatigue, and cognitive difficulties that impair daily functioning), dementia (decline in mental ability that is severe enough to interfere with a person's daily life, such as forgetting names, misplacing items, or losing the ability to perform familiar tasks), and Obstructive Sleep Apnea (OSA - common, serious disorder where breathing repeatedly stops and starts during sleep due to throat muscle relaxation, causing loud snoring, choking, and daytime fatigue). The MD/NP Progress note indicated RES 1 presented to [Hospital A] with altered mental status and had a recurrent right subdural hematoma (life-threatening collection of blood between the brain's outer covering (dura) and its surface) and was admitted for further evaluation and management.During a concurrent interview and record review on 3/10/26 at 12:08 p.m. with the Director of Nursing (DON) and the Medical Record Director (DMR), Res 1's electronic medical record (EMR), dated 2/20/26 through 2/23/26 were reviewed. The DON stated the Nurses note indicated on 2/20/26 at 7:36 p.m. Res 1 went in to Res 2's room and Res 1 . began throwing [Res 2's] items everywhere and then grabbed [Res 2] by ankles and began shaking [and] squeezing . [REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE (SOC 341)] completed. The DON stated Res 1 had another incident on 2/21/26 and the Nurses note on 2/21/26 at 7:05 p.m. indicated, .This writer was called in the [Res 1's] room [at 7:10 p.m.], resident was very aggressive behavior towards the roommate and the family member, resident also physically aggressive towards this writer, resident was redirected and moved away from other residents, [responsible party] was also notified and 911 was also called. The DON stated the Nurses note on 2/22/26 at 12:32 a.m. indicated, . At the start at shift. Resident was out in the hallway yelling and throwing walker, glove boxes, ice chest, and anything he could get his hands on at staff and other residents. Writer responded and wheeled residents away from [Res 1] to prevent injury in results of resident's aggressive behavior. When writer was responding resident spit on writers face and said . Multiple staff assisted with situating and [Res 1] eventually was redirected to his room. After speaking to resident's roommates' daughter, she stated that she was visiting with her father and resident started yelling at her and demanding that they get out of the room. [Res 1] then began to spit at them and throwing his walker towards resident, daughter got in between. per resident's daughter he hit her with his walker. MD notified, RP notified, 911 called. The DON stated the IDT notes on 2/23/26 at 2:11 p.m. did not indicate the first incident on 2/20/26 was discussed or reviewed in the IDT meeting. The DON stated the second incident on 2/21/26 was discussed along with interventions and recommendations. The DON stated the care plans were not updated after the first incident on 2/20/26, however, after the second incident, the care plan was reviewed and updated as needed along with IDT recommendations. The DON stated the care plans and IDT notes should have been updated after the first incident on 2/20/26. The DON stated it was important to update care plans and discuss each incident in the IDT meeting to ensure the appropriate precautions and interventions were in place to ensure resident safety and appropriate care. The DON stated the incident occurred on Friday and she was on the phone with the staff the same day, interventions were discussed and implemented, however, the documentation did not reflect any of that. The DON stated Res 1 was placed on close monitoring, and the facility had brought in extra staff for frequent monitoring and observation. The DON stated documentation did reflect Res 1 was observed throughout the night and after the second incident, Res 1 was placed with a sitter. The DON stated she expected facility nursing staff to update care plans after any unusual occurrences and also expected the IDT to discuss and make recommendations to ensure resident safety and appropriate care.During a review of the Res 2's MD/NP Progress note, dated 2/25/26, the MD/NP Progress note indicated Res 2 was a [AGE] year old male admitted to the facility initially on 08/02/24 after hospitalization and Res 2 had a significant past medical history that included Atrial fibrillation (A-fib - a common, irregular, and often rapid heart rate causing the heart's upper chambers to quiver instead of beating effectively), congestive heart failure (CHF - chronic, progressive condition where the heart pumps inefficiently, causing fluid backup (congestion) in the lungs or body and fatigue), Transient ischemic attack (TIA - temporary blockage of blood flow to the brain causing sudden, stroke like symptoms), sleep apnea (a common, serious disorder where breathing repeatedly stops and starts during sleep, leading to low blood oxygen levels), asthma (respiratory disease that causes inflammation, swelling, and tightening of the airways). Res 2 was readmitted to this facility on 11/19/25 after hospitalization for evaluation of shortness of breath.During a concurrent interview and record review on 3/10/26 at 12:45 p.m. with the DON and the DMR, Res 2's EMR, dated 2/20/26 through 2/23/26 were reviewed. The DMR stated the nurses note on 2/20/26 at 7:33 p.m. indicated, [Res 2] was lying in his room when offending resident came into his room via the bathroom. Resident said that the offending resident began throwing his items and grabbed him by his ankles and began squeezing shaking. Resident assessed for injury, No redness noted to affected site. Management notified. MD Notified. Family notified. Police notified. Ombudsman notified. SOC 341 completed. The DMR stated she was unable to find any IDT notes regarding this incident in Res 2's EMR. The DMR stated the care plan was updated after the incident on 2/20/26. The DMR also stated the social worker and social services note on 2/23/26 at 2:06 p.m. indicated, . Writer met with resident in his room to follow up on incident from 02/20/2026 involving another male resident. Writer greeted resident and asked how he was doing. Resident answered, I'm breathing. Resident conversed with resident for a while and asked him if he felt safe. Resident stated, As long as that idiot [Res 1] next door stays in his room. Writer asked resident what had occurred on Friday. Resident stated, He came out of the bathroom and asked me what I was doing in his room. I tried to tell him that this was my room but he grabbed me by the ankles and tried to pull me out of bed. I was going to kick him but I had no strength. Resident stated that the other resident [Res 1] then left the room and did not return. Resident continues to state he feels safe in his room as long as other resident [Res 1] does not come back in. IDT to discuss room changes or other measures to ensure resident safety and wellbeing. The DMR stated she was unable to find any documentation regarding the discussion of room changes or follow-up with the IDT team. The DON stated and validated that she was unable to find any IDT notes or any other documentation regarding the room change options or other measures to ensure resident safety was discussed or evaluated as recommended options to consider by social services notes or other staff members. The DON stated multiple discussions occurred and a sitter was placed for Res 1, however, the IDT failed to document in notes. The DON stated it was important to formally discuss an incident of abuse, and document the planned recommendations and interventions to ensure resident safety and to ensure care was personalized to each resident's needs.During an interview on 3/10/26 at 10:24 a.m. with Res 2, Res 2 stated Res 1 came to his room, through the shared bathroom between both of their rooms. Res 2 stated Res 1 grabbed him by the ankles and attempted to pull him off of his bed. Res 2 stated Res 1 was yelling, screaming and was using profanity at him. Res 2 stated Res 1 threw his blanket on the floor. Res 2 stated he did not feel safe with Res 1 being around him in the room next door with shared a bathroom. Res 2 stated his other room mate [Res 3] and him were using a wheelchair with locked wheels to block off the door to prevent Res 1 from entering their room and hurting them. Res 2 stated he had expressed his concerns to the case manager and facility staff. Res 2 stated Res 1 still had access to the bathroom and it opened on both sides, which meant Res 1 could enter their room any time. Res 2 stated he was not sure what the facility was doing to make sure he was safe in his room from Res 1 but Res 1 had not entered his room since the incident.During a phone interview on 3/12/26 at 2:40 p.m. with the Director of Social Services (DSS), the DSS stated she was familiar with Res 2. The DSS stated she had communicated the room change interventions to consider for Res 2 to the facility leadership team. The DSS stated she was unable to find any IDT notes. The DSS stated it was important to have the IDT meetings and document everything to ensure residents were receiving safe care. The DSS stated Res 2 felt safe and did not want to change his room when she followed up with Res 2. The DSS stated the IDT team met to discuss interventions and recommendations with the leadership team and developed appropriate care plans for the residents. The DSS stated she expected all the IDT interventions to be documented and care plans to be updated as needed, however, she would have to defer to nursing leadership for care plan expectations.During a review of Res 3's History and Physical (H&P), dated 8/31/24, the H &P indicated Res 3 was admitted to the skilled nursing facility for generalized weakness. Res 3's past medical history included hypothyroidism (condition where thyroid gland is underactive and does not make enough of its special hormones), osteoarthritis ( chronic degenerative joint disease where cartilage breaks down, causing pain, swelling, and reduced motion, commonly in the hands, hips, knees, and spine), anemia (condition characterized by a lack of body's ability to carry sufficient oxygen to body tissues, resulting in fatigue, weakness, and pale skin) and hyperlipemia (excess of fat in blood). The H&P indicated Res 3 had generalized weakness and was unable to take care of himself.During a concurrent interview and record review on 3/10/26 at 1:10 p.m. with the DON and the DMR, Res 3's EMR, dated 2/20/26 through 2/23/26 were reviewed. The DMR stated she was unable to find any IDT notes, care plan updates or nursing assessments regarding the incident on 2/20/26 when Res 2 went in to Res 1 & Res 3's room and grabbed resident Res 1 and attempted to pull him off the bed. The DMR stated the social services note indicated social services saw and evaluated resident on 2/23/26 at 2:18 p.m. The DON stated the DSS note on 2/23/26 at 2:18 p.m. indicated, Writer met with resident in his room regarding the event on 02/20/2026 involving his roommate and another resident. This resident states he feels safe in his room and he is doing fine but concerned for his roommate [Res 2]. Writer assured him this facility is taking steps to ensure safety of all residents. Resident expressed gratitude and continued to state he feels safe in his current room. SSD to continue to follow. The DON stated Res 3 was in the room and was a witness to the incident, however, the altercation occurred between Res 1 and Res 2. The DON stated and validated Res 3 was present, witnessed the entire incident and was also present when Res 1 was yelling, using profanity and screaming at Res 2, however, she was not aware if Res 1 said anything to Res 3. The DON stated she was unable to comment on why the nurses did not document and update his care plan as Res 3 was assessed after the incident on 2/20/26. The DON stated Res 3's care plan should have been updated, and she would have expected to see nursing assessments documented as Res 3 experienced yelling and screaming by another resident. The DON stated the documentation was important and although the staff informed her Res 3 was assessed for injuries and wellbeing, without documentation she was not able to confirm it was done. The DON stated social services assessed Res 3 and no concerns were observed.During a phone interview on 3/12/26 at 2:45 p.m. with the DSS, the DSS stated the social services team evaluated Res 3 on 2/23/26 after the incident on 2/20/26 and Res 3 did not express any concerns. The DSS reviewed her note from 2/23/26 at 2:18 p.m. and stated Res 3 felt safe, however, he did express concerns for his roommate [Res 2's ] safety. The DSS stated those concerns were shared with the IDT team. The DSS stated the care plan should have been updated as per the facility policy.During an interview on 3/10/26 at 2 p.m. with Res 3, Res 3 stated he was concerned about Res 1 coming into the room and hurting Res 2. Res 3 stated him and Res 2 had to keep the bathroom door secure by placing a wheelchair with locked wheels outside the bathroom door to prevent Res 1 from entering their room. Res 3 stated he was the president for resident council and was concerned for other residents' safety. Res 3 stated he felt safe for himself, but Res 2, his neighbor needed help. Res 3 stated Res 1 came in their room, started yelling profanity and screaming at both him and Res 2, but did not say anything to him or came close to him. Res 3 stated Res 1 was mostly in Res 2's personal space. During a review of Res 4's Progress Note, dated 9/4/25, the Progress note indicated Res 4 had dementia and used a wheelchair. Res 4 was admitted to the skilled nursing facility for generalized weakened. The Progress Note indicated Res 4's past medical history included Gastroesophageal Reflux Disease (GERD - a chronic condition where stomach acid frequently flows back into the esophagus, causing persistent heartburn, chest pain, and potential esophageal damage), high blood pressure, dementia, and benign prostatic hypertrophy (BPH - noncancerous enlargement of the prostate gland, common in men over 50, causing bladder outlet obstruction ).During a concurrent interview and record review on 3/10/26 at 1:10 p.m. with the DON and the DMR, Res 4's EMR, dated 2/21/26 was reviewed. The DON stated Res 4 was Res 1's roommate on 2/21/26 and this was the second incident with Res 1 that was reported for resident-to-resident aggression. The DON stated Res 4's daughter was visiting him and was present at bedside when Res 1 started to get aggressive and verbally hostile towards Res 4 and his daughter. The DON stated Res 4's daughter felt that Res 1 was going towards Res 4 and she placed herself in the middle to prevent any harm to Res 4. The DON stated staff intervened and had both Res 4 and his daughter removed to ensure safety. The DON stated Res 1 started to throw things at the residents and staff. The DON stated the situation was de-escalated, law enforcement and responsible parties were notified. The DON stated Res 4's daughter elected to take Res 4 home that day and it was arranged with the provider. The DON stated Res 4 returned the next day and was placed in a new room. The DON stated the DSS followed up, however, she was unable to find any updates to the care plan regarding the incident. The DON stated she expected staff to update care plans after any unusual occurrences. The DON stated it was important to update the care plan for Res 4 after the incident with Res 1 to ensure resident safety and resident centered care.During a phone interview on 3/12/26 at 2:50 p.m. with the DSS, the DSS stated the care plan for Res 4 should have been updated after the incident with Res 1 as per the facility's policy. The DSS stated the DON would be the best person to comment on the expectations for care plans. The DSS stated Res 4 was assessed for a room change and no issues were identified by social services.During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MOS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . The comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions . Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . The interdisciplinary team reviews and updates the care plan . when there has been a significant change in the resident's condition . when the desired outcome is not met .During a review of the facility's P&P titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, the P&P indicated, . The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care . As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations . The resident's usual patterns of cognition, mood and behavior . The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition . New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others . The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition . The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly . Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities . If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function . The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported .

Based on interview and record review, the facility failed to ensure medications were administered with adequate clinical indication and clear parameters for one of four sampled residents (Resident (Res) 1), when Res 1 had two active as needed medication orders for the same medication with different dosages and the same administration criteria, which required nurses to select the dose based on their personal judgment rather than physician directed parameters.This failure had the potential to result in over medication or undermedication of Res 1 and placed Res 1, an already vulnerable patient in a nursing home at risk of receiving an unnecessary medication dose.Findings:During a review of Res 1's [Physician (MD)/ Nurse Practitioners(NP)] Progress note, dated 3/4/26, the MD/NP Progress note indicated Res 1 was a [AGE] year old male who was admitted to the facility on [DATE] after hospitalization. The MD/NP Progress note indicated Res 1 had a significant past medical history of high blood pressure (force of blood pushing against the walls of blood vessels is too high), hyperlipemia (high level of fat in blood), prostate cancer (cancer happens when cells in the prostate (small, walnut-sized gland that is part of the male reproductive system) start growing abnormally and uncontrollably), depression (common mood disorder causing persistent sadness, loss of interest, fatigue, and cognitive difficulties that impair daily functioning), dementia (decline in mental ability that is severe enough to interfere with a person's daily life, such as forgetting names, misplacing items, or losing the ability to perform familiar tasks), and Obstructive Sleep Apnea (OSA - common, serious disorder where breathing repeatedly stops and starts during sleep due to throat muscle relaxation, causing loud snoring, choking, and daytime fatigue). The MD/NP Progress note indicated Res 1 presented to [Hospital A] with altered mental status and had a recurrent right subdural hematoma (life-threatening collection of blood between the brain's outer covering (dura) and its surface) and was admitted for further evaluation and management.During a concurrent interview and record review on 3/10/26 at 12:08 p.m. with the Director of Nursing (DON) and the Medical Record Director (DMR), Res 1's electronic medical record (EMR), dated 3/7/26 was reviewed for the current medication orders (MO) and medication administration records (MAR). The MO indicated two active orders for Lorazepam (prescription medication used to help people feel calm when they are extremely anxious, panicked, or having trouble sleeping). The DON stated the MO indicated, [brand name for Lorazepam] Oral Tablet 0.5 [milligram (MG -Unit of measurement)] (Lorazepam) Give 1 tablet by mouth every 12 hours as needed for anxiety [manifested by] aggressive behavior for 14 days. The DON stated the MO indicated [brand name for Lorazepam] Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth every 24 hours as needed for anxiety [manifested by] aggressive behavior for 14 days. The DON stated as far as she could tell, Res 1 had two active orders for Lorazepam. The DON stated the 1 mg Lorazepam order was started on 3/7/26 after the recent incident of aggression by Res 1 to Res 2. The DON stated the other active order of 0.5 mg Lorazepam was renewed on 3/7/26 and continued from previous 14 days. The DON stated both orders were for as needed administration for anxiety manifested by aggressive behavior. The DON stated the medication nurse would be the best to explain and confirm the rationale for two orders for Lorazepam. The DON stated and acknowledged that both orders used the same as needed indication and did not specify the administration criteria differentiating the two doses.During a concurrent interview and record review on 3/10/26 at 12:21 p.m. with the DON, the DMR, and Licensed Vocational Nurse (LVN) 1, Res1's MO for Lorazepam, dated 3/7/26 were reviewed. LVN 1 stated that she was the assigned medication nurse for the day and was familiar with Res 1. LVN 1 stated and validated that Res 1 had two active orders for Lorazepam. LVN 1 stated both MO were written for aggressive behavior and it was up to the nursing judgement to choose 0.5 MG every twelve hours or 1 mg every 24 hours as needed and administer for aggressive behavior. LVN 1 stated it was possible for nurses to select different dosages (0.5 MG or 1 MG) based on their experience and comfort level with the resident. The DON stated and acknowledged the order required clarification with the administration instructions and should not have been left up to nurses to decide whether to administrator 0.5 MG every 12 hours or 1 MG every 24 hours. The DON stated that she would need to call the physician and clarify the administration instructions for as needed administration for Lorazepam MO. The DON stated both orders have the same instructions, as needed for anxiety manifested by aggressive behavior for 14 days and it was confusing. During a concurrent interview and record review on 3/10/26 at 1:40 p.m. with LVN 2, Res 1's MO for Lorazepam, dated 3/7/26 were reviewed. LVN 2 stated she was the assigned nurse for Res 1. LVN 2 stated she was very familiar with Res 1. LVN 2 stated the MO indicated Lorazepam was ordered and she aware of the MO for Res 1. LVN 2 stated Res 1 had two orders for Lorazepam and nurses could choose which order to administer based on their nursing judgement of whether to administer 0.5 mg every 12 hours or 1 mg every 24 hours. LVN 2 stated and agreed that each nurse could decide and there was a potential for Res 1 to receive different dosages based on the nurse that was caring for Res 1. LVN 2 stated both orders were active and the administration instructions were the same, as needed for anxiety with aggressive behavior. LVN 2 stated the MAR indicated she had administered a 1 mg dose twice, once on 3/8/26 at 6:27 p.m. and earlier this morning at 9:55 a.m. LVN 2 was asked the rationale for using 1 MG instead of 0.5 MG dosage and LVN 2 stated she used her nursing judgement as the order administration instructions were the same for both orders. LVN 2 stated Res 1 was very agitated and was yelling in hallway, she felt Res 1 would benefit from a higher dose. LVN 2 stated Res 1's family wanted Res 1 comfortable, and family was made aware of the two doses ordered prior to administration and family were okay with the administration.During an interview on 3/10/26 at 2:05 p.m. with the DON, the DON stated she had spoken with MD 1, who was the primary physician for Res 1 and MD 1 informed her, he was going to review and modify the Lorazepam orders. The DON stated she agreed that current orders for Lorazepam had the potential for an error or unnecessary medication as it should have clear administration instructions and the nurses should not be making the decision for the administration dosage without any parameters. The DON stated she expected all as needed (PRN- as needed medication, not routinely scheduled) orders to have clear indications and parameters to guide nursing staff to determine when and what dose to administer.During a concurrent phone interview and record review on 3/12/26 at 2:21 p.m. with the pharmacist consultant (PHC) Res1's MO, dated 3/7/26 and MAR for Lorazepam, dated 3/7/26 to 3/10/26 were reviewed. The PHC stated he had finished monthly review for Res 1 on 3/5/26 and Res 1 only had one order for Lorazepam at the time of the monthly medication review by the pharmacist. The PHC stated the 1 MG order was added later on 3/7/26. The PHC stated Res 1 could potentially receive a total dosage of 2 MG in 24 hours if both orders were carried out. The PHC stated MD 1 should have discontinued one order or added more clarification under the administration instructions. The PHC stated the MO should not be a judgement call by nurses and rather should have clear defined parameters when and what dose the MO should be administered. The PHC stated the MAR indicated the 1 MG of Lorazepam was administered twice, on 3/8/26 and 3/10/26 and 0.5 mg was not administered since 3/7/26. The PHC stated the expectation was to always administer the lowest safe dosage for Psychotropic medications (chemical substances that affect brain function, altering perception, mood, consciousness, and behavior to treat mental health conditions) like Lorazepam. The PHC stated a MO without clear administration instructions which relied on judgement call could potentially cause harm to the residents. The PHC stated and agreed that Res 1's two as needed MO for Lorazepam with the same administration instructions with different dosages had the potential for Res 1 to be over-medicated or under-medicated.During a review of Res 1's MO for Lorazepam, dated 3/10/26, the MO indicated Lorazepam order for 0.5 mg was discontinued and Res 1 now only had one order for Lorazepam. The MO indicated . [brand name for Lorazepam] Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth every 24 hours as needed for Anxiety [manifested by] uncontrolled belligerent behaviors . Threatening or hitting staff or others, if behavior does not improve call MD .During a review of the facility's policy and procedures (P&P) titled, Medication Therapy, with a revise date of 2007, the P&P indicated, . Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . All medication orders will be supported by appropriate care processes and practices . The resident's clinical record must contain a written order for all prescription and over-the-counter medications taken by the resident . All decisions related to medications shall include appropriate elements of the care process . Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the Consultant Pharmacist) will review an individual's current medication regimen, to identify whether . There is a clear indication for treating that individual with the medication . The dosage is appropriate . The frequency of administration and duration of use are appropriate. Potential or suspected side effects are present .During a review of the facility's P&P titled, Administering Medications, with a revise date of April 2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed . As required or indicated for a medication, the individual administering the medication records in the resident's medical record . The date and time the medication was administered . The dosage . The route of administration . The injection site (if applicable) . Any complaints or symptoms for which the drug was administered . Any results achieved and when those results were observed; and . The signature and title of the person administering the drug . If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes for three of three sampled residents (Resident 1, 2, and 3), when:1. Resident 1 had an unwitnessed fall on [DATE] and there was no care plan following a left hip fracture.This failure had the potential to result in delayed detection of post-operative complications such as pain, infection and immobility to Resident 1's left hip following surgery.2. Resident 2 had an unwitnessed fall on [DATE] and the neuro check (a focused neurological evaluation used to monitor changes in a patient's functional status such as blood pressure, temperature, pulse, respiration, right pupil [the black, circular opening in the center of the eye that regulates the amount of light] size, left pupil size, right hand grip, and left hand grip) was not completed according to Resident 2's care plan and the Interdisciplinary Team (IDT - a group of staff members consisting of physicians, nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) note was not completed after the fall.This failure had the potential for delayed detection of neurological changes which could lead to irreversible functional impairment for Resident 2 and the IDT to miss opportunities to discuss, intervene, prevent, and care plan for the needs of Resident 2.3. Resident 3 had an unwitnessed fall on [DATE] and there was no documentation to validate Resident 3 was monitored every two hours according to Resident 3's care plan.This failure had the potential for unanticipated assistance from staff to check on Resident 3's pain, positioning, and toileting needs.Findings:During a concurrent observation and interview on [DATE] at 10 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed with an incision on the left hip. The incision was clean, dry, and intact. Resident 1 stated she spilled water on the floor, and when she stood up to go to the closet, she slipped on the floor with her legs split apart and fractured her left hip. Resident 1 stated she had surgery on the left hip. Resident 1 stated the pain to her left hip was 5 out of 10 (scale used to measure the level pain a person is experiencing with a score of 0 indicating no pain up to a score of 10 indicating worse pain imaginable).During a concurrent observation and interview on [DATE] at 10:12 a.m. with Resident 2, in Resident 2's room, Resident 2 was lying in bed. Resident 2 stated he fell a long time ago in the facility. Resident 2 was unable to provide information about the fall. Resident 2 denied pain or discomfort.During a concurrent observation and interview on [DATE] at 10:26 a.m. with Resident 3, Resident 3 was sitting in his wheelchair in the activities room. Resident 3 was escorted to the conference room for an interview. Resident 3 stated he fell a month ago while he was walking toward his bed. Resident 3 denied pain or discomfort.During a record review of Resident 1's admission Record, dated [DATE], the AR indicated Resident 1 had a diagnosis of Chronic Obstructive Pulmonary Disease (a progressive lung condition characterized by chronic respiratory symptoms and persistent irreversible airflow limitation), Peripheral Vascular Disease (condition in which narrowed arteries reduce blood flow to the arms or legs), Malignant Neoplasm of Anal Canal (a cancer that affects the tissues of the anus), Colostomy (a surgical procedure that creates an opening in the abdominal wall, connecting the colon to the outside of the body to allow stool to bypass a damaged or diseased part of the intestines), and Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking).During a record review of Resident 1's Minimum Data Set (MDS - process for clinical assessment of all residents of long term care nursing facilities). dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 14 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). Resident 1's Functional Abilities for Activities of Daily Living (ADL- dressing, toileting, washing, feeding, mobility, and transferring) score was 3, indicating Resident 1 required partial or moderate assistance and helper does less than half the effort.During a concurrent interview and record review on [DATE] at 10:40 a.m. with the Director of Nursing (DON), Resident 1's Post Fall Evaluation (PFE), dated [DATE] was reviewed. The PFE indicated Resident 1's pre-fall risk and post-fall risk score was not completed. The DON stated Resident 1's pre-fall risk and post-fall risk score should have been completed to determine Resident 1's fall risk status and it was not.During a record review of Resident 1's ER (emergency room) Transfer Out (ERTO), dated [DATE], the ERTO indicated, .received a phone call from resident, resident stated I'm in my room and I'm not ok. Upon arrival, resident was found sitting in the recliner chair, when asked what's going on, resident replied that she attempted to get up and slipped on a small puddle of water near her bed and did a full slip, and her left hip is hurting and she's not able to bear weight. Resident denied falling or hitting her head. attempted to assess the left hip, resident screamed in agony. NP (Nurse Practitioner) notified, ordered to send to ER for possible hip fracture.During a record review of Resident 1's IDT Post Incident Meeting (IDT), dated [DATE], the IDT indicated, Date of fall event: [DATE]. Immediate corrective action: Resident was assessed with injuries. Noted to have left foot turned outward slightly and complained of pain with mobility. Notifications to NP and son with orders processed for transfer to [name of hospital] ER. Root Cause Analysis: Resident elects to be independent in all ADLs (Activities of Daily Living; dressing, toileting, washing, feeding, mobility, and transferring). Initiates activities and ambulation. Resident identified water on the floor caused me to slip. A small cup of water spill on the floor was noted and presumed to be from her own water cup. Plan of Correction: Transfer to ER. Upon return will provide [name of Resident 1] with a water container that has a lid and straw attached to prevent spills. Upon her return, she will be instructed to ask for help with ADLs. Upon return will conduct frequent rounds.During a record review of Resident 1's Immediate Post Operative Note (IPON), dated [DATE], the IPON indicated, Pre-Procedure Diagnosis: Left femoral [upper leg bone] neck fracture. Procedure(s) Performed: Left hip hemiarthroplasty [a surgical procedure that replaces only one half of a joint, typically the femoral head in the hip while leaving the natural socket intact].During an interview on [DATE] at 12 p.m. with the DON, the DON stated the admitting nurse should have implemented a care plan for Resident 1 when Resident 1 returned from hospital and did not.During an interview on [DATE] at 1:08 p.m. with the Registered Nurse (RN), the RN stated he readmitted Resident 1 on [DATE] when Resident 1 returned from the hospital. The RN stated Resident 1 had a fall on [DATE] and fractured her left hip. The RN stated Resident 1 was transferred to the hospital after the fall and had hip surgery. The RN stated a care plan was required to be completed during the admission process and it was not. The RN stated the care plan should have been implemented to address Resident 1's needs after having hip surgery to ensure ongoing issues were resolved. The RN stated care plans should be resident specific and should be implemented immediately upon admission and when the resident had a change in condition.During an interview on [DATE] at 1:38 p.m. with Licensed Vocation Nurse (LVN) 1, LVN 1 stated care plans should be implemented immediately upon admission and any change in condition. LVN 1 stated any licensed staff could implement a care plan. LVN 1 stated the purpose of the care plan was to monitor the residents' progress, ensure continuity of care and anticipate the residents' needs.During a record review of Resident 2's AR, dated [DATE], the AR indicated Resident 1 had a diagnosis of Chronic Obstructive Pulmonary Disease, Schizophrenia (a chronic, severe brain disorder that causes individuals to lose touch with reality, disrupting their thoughts, emotions, and behaviors), Orthostatic Hypotension (a sudden drop in blood pressure when blood flow to the brain is temporarily reduced upon standing causing lightheadedness, dizziness, blurred vision, weakness, and fainting), and Unsteadiness on Feet (unable to stand or walk normally).During a record review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 2's BIMS score was 13. Resident 2's Functional Abilities for ADLs score was between 3 and 4, indicating Resident 1 required partial or moderate assistance and helper does less than half the effort.During a record review of Resident 2's PFE, dated [DATE], the PFE indicated Resident 2's pre-fall risk score was 75 and Resident 2's post-fall score was 80 indicating Resident 2 had a high risk of falling.During a record review of Resident 2's Care Plan Report (CPR), dated [DATE], the CPR indicated, [name of Resident 2] has had an actual fall with no injury. Unsteady gait/poor safety awareness. Interventions: Initiated Neuro checks 72 [hours].During an interview on [DATE] at 10:40 a.m. with the DON, the DON stated Resident 2's IDT record was not completed after the unwitnessed fall on [DATE]. The DON stated the IDT met to discuss Resident 2's fall but she did not document the meeting took place and should have.During a concurrent interview and record review on [DATE] at 10:40 a.m. with the DON, Resident 2's Neuro checks (NC), dated [DATE] was reviewed. The NC indicated the form was completed on [DATE] in the Electronic Medical Record (EMR). The DON stated the remaining neuro check from [DATE] through [DATE] should have been completed in paper form and uploaded to the EMR. The DON stated the remaining neuro check could not be located. The DON stated if the remaining documentation for the neuro check was not located, the neuro check was not completed.During an interview on [DATE] at 1:38 p.m. with LVN 2, LVN 2 stated Resident 2 can walk but was unsteady and had a high fall risk. LVN 2 stated neuro checks were required for all unwitnessed falls in case the resident had a head injury which could lead to severe neurological impairment. LVN 2 stated the neuro check was to make sure the vital signs (blood pressure, heart rate, respiratory rate and oxygen level), strength, pain, and pupils were stable. LVN 2 stated early changes could detect head injury. LVN 2 stated when the neuro check was completed, the nurse was required to place the neuro check form in the medical record box located at the nursing station for the Medical Record Director to scan and upload into the resident's EMR. LVN 2 stated medical records should be complete and accurate to reflect the care provided to the residents.During a record review of Resident 3's AR, dated [DATE], the AR indicated Resident 3 had a diagnosis of Chronic Obstructive Pulmonary Disease, Schizophrenia, Muscle Weakness, Malignant Neoplasm of Left Lung (a cancer that affects the tissues of the lung), Cervical Disc Disorder at C5-C6 level with Radiculopathy (damage to the lower neck compressing nerve roots, causing neck pain that radiates into the shoulder, arm, biceps, or thumb), and Unsteadiness on Feet.During a record review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's BIMS score was 11 . Resident 3's Functional Abilities for ADLs score was 3, indicating Resident 1 required partial or moderate assistance and helper does less than half the effort.During a record review of Resident 3's PFE, dated [DATE], the PFE indicated Resident 3's pre-fall risk score was 55 and Resident 3's post-fall score was 65 indicating Resident 3 had a high risk of falling.During a record review of Resident 3's IDT, dated [DATE], the IDT indicated, Description of Event: Unwitnessed fall event on [DATE] at approximately 3:30 p.m. [name of Resident 3] was found sitting on the floor by his bed. No injuries noted on observation of his skin. He initiated transfer from bed with intent to go to the bathroom. Outcomes of Physical Assessment: .Decrease urine output. Nursing observations, evaluation, and recommendations are: Patient lower abdomen is distended. LN [Licensed Nurse] check with bladder scanner noting 999 ml [milliliter - unit of measurement] of urine in bladder, attempted to straight cath [a procedure used to drain the bladder with a flexible hollow tube] patient to empty bladder was unsuccessful. NP gave order to send patient out to ER for evaluation.During a record review of Resident 3's CPR, dated [DATE], the CPR indicated, Unwitnessed fall even on [DATE] at approximately 3:30 p.m. [name of Resident 3] was found sitting on the floor by his bed. Interventions: Frequent rounding [every two hours] check for pain, placement, position, and toilet needs.During an interview on [DATE] at 10:40 a.m. with the DON, the DON stated the facility could not produce documentation that staff checked on Resident 3 every two hours. The DON stated if there was no documentation that staff checked on Resident 3 every two hours, staff did not check on Resident 3 every two hours.During an interview on [DATE] at 12:48 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated staff were required to check on a resident every two hours to see if the resident needed to go to the bathroom, needed the briefs changed, had pain or to see if the resident needed anything. CNA 1 stated checking on the residents frequently was required to prevent skin breakdowns, infections, and falls. CNA 1 stated when staff checked on a resident, staff documented the check in the resident's EMR. CNA 1 was unable to locate documentation when Resident 3 was last checked on.During an interview on [DATE] at 1:25 p.m. with CNA 2, CNA 2 stated staff was required to check on residents frequently to prevent skin breakdown from soiled briefs, prevent infection and falls. CNA 2 stated staff were required to check on Resident 3 at least two times an hour. CNA 2 stated when residents did not need assistance during the check, staff were required to select not applicable in the resident's ADL's section of Point of Care in the EMR. CNA 2 stated the program will date and time stamp the selection. CNA 2 was unable to locate documentation when Resident 3 was last checked on.During an interview on [DATE] at 2:09 p.m. with the Medical Records Director (MRD), the MRD stated she audited the EMR quarterly (every three months) to ensure care plans were updated when there was a change in condition, the physician's history and physical were completed monthly, order history and evaluations were uploaded. The MRD stated residents should have care plans specific to their needs and implemented during the admission process and when there is a change in condition. The MRD stated licensed nurses were required to submit the neuro check form once completed into the medical records inbox located at each nursing station to be uploaded into the resident's EMR. The MRD stated she was unable to locate Resident 2's neuro checks for [DATE] through [DATE]. The MRD stated licensed nurses were notified and an audit binder with the licensed nurse's name was required to locate or produce the [DATE] and [DATE] neuro checks for Resident 2. The MRD stated she could generate the percentage of staff checking on a resident every two hours to ensure the residents were checked on as required but was unable to locate documentation of when the resident was last checked on. The MRD stated maintaining complete and accurate documentation was required to stay in compliance with federal regulations and to ensure care was provided for the residents as ordered.During an interview on [DATE] at 2:19 p.m. with the DON, the DON stated care plans were required to ensure continuity of care for each resident. The DON stated a resident's care plan was implemented on admission and when there was a change in condition. The DON stated each department was responsible for developing specific care plans to meet the residents' needs. The DON stated neuro checks were required to be complete and accurate to detect changes in the residents' neurological status. The DON stated an IDT note was required to be documented to indicate the IDT met to discuss the incident, cause, and implement interventions for the care plan. The DON stated every two hourly check was required when there was a change in condition to reduce risk for falls, to check on the resident's bowel and bladder status, and to ensure the residents' needs were met. The DON stated the facility should be able to generate reports that staff checked on the residents evert two hours but could not. The DON stated medical records should be complete and accurate to reflect the care provided.During an interview on [DATE] at 2:40 p.m. with the Administrator (ADM), the ADM stated not implementing a care plan for Resident 1 upon return from the hospital after having surgery, missing the neuro check records and not completing the IDT note for Resident 2 after an unwitnessed fall, and not being able to provide documentation that Resident 3 was checked on every two hours according to the care plans were unacceptable. The ADM stated licensed nurses, the DON and the MRD were responsible for ensuring the completeness and accuracy of the residents' medical records. The ADM stated care plans should be resident specific and address the residents' preferences and orders to ensure the residents' needs were met. The ADM stated care plans should be implemented upon admission, return from the hospital and any change in the residents' condition. The ADM stated medical records should be complete and accurate to reflect the care provided.During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment, dated 3/2018, the P&P indicated, Policy Statement: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.During a review of the facility's P&P titled, Goals and Objectives, Care Plan, dated 4/2009, the P&P indicated, Policy Statement: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Policy Interpretation and Implementation: 1. Care plan goals and objectives are defined as the desired outcomes for a specific resident problem. 3. Care plan goals and objectives are driven from information contained in the resident's comprehensive assessment and: a. are resident oriented; b. are behaviorally stated; c. are measurable; and d. contain timetables to meet the resident's needs in accordance with the comprehensive assessment.During a review of the facility's P&P titled, Care Planning - Interdisciplinary Team, dated 3/2022, the P&P indicated, Policy Statement: The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation: .2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 4/2021, the P&P indicated, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: 1. Documentation in the medical record may be electronic, manual or a combination. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1) had the right to retain and use personal possessions when Resident 1 reported a missing pair of shoes and a hinged knee brace on 5/23/25 and staff did not follow facility policy to investigate and offer to replace or reimburse the missing items. This failure resulted in the loss of Resident 1 ' s pair of shoes and hinged knee brace without being replaced or reimbursed for the value of the items. Findings: During a review of Resident 1 ' s admission Record (AR- a document that provides resident contact details, a brief medical history), dated 6/13/25, the AR indicated Resident 1 had diagnoses which included .TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS [a disorder characterized by difficulty in blood sugar control and poor wound healing] .UNSTEADINESS ON FEET .ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] .DIFFICULTY IN WALKING . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 5/23/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 15 (0-7 severe cognitive impairment (an intense inability to think, remember, use judgement and make decisions), 8-12 moderate cognitive impairment (lessened ability to think, remember, use judgement and make decisions), 13-15 no cognitive impairment), which indicated Resident 1 had no cognitive impairment. During an interview on 6/13/25 at 10:29 a.m. with the Social Services Director (SSD), the SSD stated when a resident ' s personal belonging was reported missing, staff searched the resident ' s room, dining room, laundry room, outside and other common areas for the item. The SSD stated staff checked the resident ' s INVENTORY OF PERSONAL EFFECTS (IPE) to see what personal belongings had been reported upon admission by the resident. The SSD stated if the item was still missing after the search, a THEFT AND LOSS MONITORING (TLM) form was completed by the SSD. The SSD stated if the missing item was listed on the resident ' s IPE, it was easier to replace since there was evidence the resident had it upon admission. The SSD stated a missing item not listed on the resident ' s IPE required further investigation but still had the opportunity to be replaced by the facility. The SSD stated the missing item was eligible to be replaced with the same item, a similar item or cash. The SSD stated Resident 2 was discharged on 5/23/25 and had reported his missing items to the SSD during the discharge process. The SSD stated she could not find a TLM form for Resident 1. During a concurrent interview and record review on 6/13/25 at 10:43 a.m. with the Registered Nurse (RN), Resident 1 ' s IPE, dated 3/10/25 was reviewed. The IPE indicated, .At the time of admission, record the resident ' s personal belongings by indicating quantity of those items listed .The original copy shall be kept in the resident ' s medical record .Update as needed throughout the resident ' s stay by using the space provided. Upon discharge, use the [check mark symbol] columns to indicate that all personal belongings are accounted for .USE THIS SPACE TO RECORD MISCELLANEOUS INFORMATION (i.e. LOST, STOLEN, RETURNED/GIVEN TO FAMILY, ETC.) . The IPE indicated notes written below the miscellaneous information section was [Brand name of shoes]- Black lost and Hinged Knee Brace- lost. The RN stated an IPE was filled out on admission for each resident. The RN stated if an item was reported missing, the staff checked the IPE to see if the missing item was listed on the IPE. The RN stated Resident 1 ' s IPE was signed by Resident 1 and staff members on admission and discharge. The RN stated Resident 1 ' s IPE indicated Resident 1 was missing a black pair of (Brand name of shoes) shoes and a hinged knee brace. During an interview on 6/13/25 at 11:25 a.m. with the SSD, the SSD stated she did not have Resident 1 ' s TLM form and should have had one. The SSD stated she was responsible for the process of resolving missing resident belongings within ten days. The SSD stated she was past due on resolving Resident 1 ' s missing belongings since it was past the ten-day limit when the items were reported missing. The SSD stated when residents arrived to the facility, they were often in a difficult situation and should not have felt like their missing items were not taken seriously by the staff. The SSD stated Resident 1 ' s missing shoes and hinged knee brace was important to Resident 1 and may have had sentimental value. The SSD stated it was important to validate Resident 1 regarding the importance of the missing items. During a concurrent interview and record review on 6/13/25 at 2:30 p.m. with the Assistant Director of Nursing (ADON), Resident 1 ' s TLM, dated 6/13/25, and Resident 1 ' s Progress Notes (PN), dated 6/13/25 were reviewed. The TLM indicated, .[Resident 1] .DATE: 06/13/2025 .PERSON MAKING REPORT .[SSD] .DATE ITEM WENT MISSING: reported on 05/23/2025 .ITEM LOST .Black [Brand name of shoes] .resident aware .ESTIMATED VALUE OF MISSING ITEMS: ~$100 .ITEM FOUND .NO . The PN indicated, .Placed call to prior resident to follow up on missing black sketcher shoes and hinged knee brace .Writer initiated new theft and loss form .Author: [SSD] . The ADON stated if a resident reported a personal item was missing, the staff asked more questions to investigate the missing item and searched the resident ' s room. The ADON stated the staff referred to the resident ' s IPE for a list of the resident ' s belongings. The ADON stated the facility has replaced resident ' s missing items, even if it wasn ' t listed on the resident ' s IPE. The ADON stated a TLM was filled out for any resident missing items. The ADON stated there was no TLM created when Resident 1 reported the missing shoes and hinged knee brace to staff. The ADON stated the SSD created a new TLM on 6/13/25 which only mentioned the missing pair of shoes, however a PN was also created by SSD indicating Resident 1 was missing both a pair of shoes and a hinged knee brace. The ADON stated the facility should have replaced the missing items as soon as possible. The ADON stated Resident 1 considered the facility his home and Resident 1 ' s belongings should have been in the facility as long as he was. The ADON stated Resident 1 should have had the assurance his belongings were safe and would not have gone missing. During a phone interview on 6/18/25 at 2:47 p.m. with the Director of Nursing (DON), the DON stated when a resident ' s personal belongings were missing, staff searched around the resident ' s room with verbal permission from the resident. The DON stated the resident ' s missing item was then reported to the SSD. The DON stated the SSD was responsible for the process of replacing the missing item or providing a reimbursement if the missing item was not found. The DON stated the resident ' s IPE was referenced in the investigation of the missing item. The DON stated the resident ' s missing item investigation was discussed in the department head meetings. The DON stated Resident 1 reported his missing pair of shoes and hinged knee brace while being discharged on 5/23/25. The DON stated the process of investigating Resident 1 ' s missing items and offering a refund or replacement for the missing items should have been done as quickly as possible, but not longer than a week. The DON stated there was no theft and loss form completed for Resident 1 ' s missing items and there was no follow up after Resident 1 was discharged . The DON stated it was important to ensure Resident 1 had the right to retain and use his personal possessions to promote his emotional health and the usual routine he desired. During a review of the facility ' s policy and procedure (P&P) titled, THEFT & LOSS, undated, the P&P indicated, .While recognizing that the facility cannot safeguard all personal property and valuables that are in the possession of a resident, and that all theft and loss cannot be completely eliminated, the facility nevertheless will make reasonable efforts to safeguard resident ' s property and reduce the incidence of theft and loss .Any property with the value of $25 or more lost within [facility name acronym] must be reported to the Director of Nursing. This report will be handled as a normal Public Safety Department Incident Report which must include: (a) A description of the lost article (b) Estimated value (c) Date and time the loss as discovered (d) If determinable, the date and time the theft or loss occurred (e) Any action taken .A written resident personal property inventory is establishes upon admission with nursing and retained during the resident ' s stay in the long-term health-care and/or acute care facility .All reported losses will be documented and reported on the [facility name acronym] Occurrence/Incident Report .

Based on observation, interview, and record review, the facility failed to protect and secure protected health information (PHI) for residents and private information for staff when two of seven sheds (a simple roofed structure used as storage space) were broken into on 4/29/25 and was not secured until 5/6/25. This failure had the potential to result in loss, destruction, or unauthorized use of resident PHI and staff private information. Findings: During a concurrent observation and interview on 5/6/25 at 9:58 a.m. with the Environmental Service Director (ESD) outside behind the facility, two of seven sheds approximately 10 feet x 15 feet made of wood did not have locks and one shed did not have a door. The door to the first shed was missing and wide open with one 8 feet x 10 feet board made of wood standing at a 45 degree angle in front of the shed. The ESD stated the board was used to cover the entrance. Inside the first shed were two four feet high standard filing cabinets (specialized storage unit designed to organize and secure records, charts, and other sensitive information) with four drawers filled with resident medical records containing names, date of birth , social security number, and medical diagnosis (the patient ' s identified diseases and conditions) and one four feet high filing cabinet with four drawers four feet wide filled with employee files containing names, license and certification numbers, vaccination information, and salary (the amount of money a person is paid for working). The filing cabinets did not have a lock. There were over 200 files dated between 2017 and 2019. The second shed had a door but no lock and contained physical therapy equipment (devices and tools used to help patients recover from injuries, disabilities, or chronic conditions to improve mobility, strength, and overall physical function). The ESD stated the sheds were broken into during the night on 4/29/25. The ESD stated the sheds have remained unlocked since 4/29/25 and the facility planned to replace the sheds. The ESD stated he was unaware the sheds contained resident PHI and staff private information. The ESD stated the PHI and private information should be secured immediately and there was room in a metal shed with a lock located next to the wooden sheds where the filing cabinets can be stored. During a concurrent observation and interview on 5/6/25 at 10:38 a.m. with the Medical Records Director (MRD) inside the first shed, the filing cabinets were accessed with no lock. The MRD stated the files contained resident PHI and staff private information and should be kept confidential. The MRD stated it was unacceptable to store PHI and private information in an unsecured location. During an interview on 5/6/25 at 12:15 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she was not aware the filing cabinets in the shed contained resident PHI and staff private information. The ADON stated the facility was required to keep resident PHI and staff private information protected and secure because of HIPAA (Health Insurance Portability and Accountability Act - a federal law enacted in 1996 that establishes national standards for protecting the privacy of individuals' identifiable health information). The ADON stated it was unacceptable to store PHI and private information in an unprotected and unsecured location. During an interview on 5/6/25 at 12:17 p.m. with the Director of Nursing (DON), the DON stated the sheds were broken into on 4/29/25 and she was not aware the filing cabinets contained resident PHI and staff private information. The DON stated the sheds should have been secured immediately after it was discovered that the sheds were broken into. The DON stated anyone could have access to the files and it was unknown if files were stolen. The DON stated it was unacceptable to store PHI and private information in an unsecured location. During an interview on 5/6/25 at 11:52 a.m. with the Administrator (ADM), the ADM stated the sheds were broken into on 4/29/25 and the facility planned to replace the sheds. The ADM stated he was not aware the filing cabinets in the first shed contained resident PHI and staff private information. The ADM stated the previous Human Resources Manager informed him the sheds did not contain PHI and private information on 4/29/25. The ADM stated staff should have inspected the filing cabinets to ensure that all PHI and private information were protected and secure. The ADM stated PHI was regulated by HIPAA and the facility was required to protect and secure it. The ADM stated it was unacceptable not to secure the sheds and the filing cabinets immediately after the break in. During a concurrent observation and interview on 5/6/25 at 12:20 p.m. with the DON and ESD inside the metal shed located next to the wooden sheds, the filing cabinets with resident PHI and staff private information were relocated and stored. The metal shed was secured with a lock on the door. The DON stated the filing cabinets will remain in the metal shed to protect resident PHI and staff private information. The ESD stated the filing cabinets will remain in the metal shed until the facility replaced the broken sheds. During a review of the facility ' s policy and procedure (P&P) titled, Protected Health Information (PHI), Management and Protection of, dated 4/2014, the P&P indicated, Policy Statement: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state law. Policy Interpretation and Implementation: 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure . During a professional reference review retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/index.html#:~:text=The%20HIPAA%20Privacy%20Rule%20establishes,care%20providers%20that%20conduct%20certaintitled, The HIPAA Privacy Rule, dated 9/27/24, the professional reference indicated, The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other individually identifiable health information (collectively defined as protected health information) and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without an individual ' s authorization .

Based on interview and record review, the facility failed to ensure medications were administered to meet the needs of one of five sampled residents (Resident 1) when nursing staff did not administer lorazepam (medication used to treat anxiety [mental condition which causes intense and persistent worry]) at the specified time frame according to the physician's order. This failure resulted in Resident 1 to receive his medication earlier than the prescribed time and had the potential to cause respiratory depression (characterized by slow and ineffective breathing), drowsiness (tiredness), change in consciousness (how alert and awake someone is), dry mouth, loss of appetite, memory impairment, trouble sleeping, abnormal movements of the body, constipation, and weakness. Findings: During a review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history) , dated [DATE], the AR indicated, Resident 1 had diagnoses which included .TYPE 2 DIABETES MELLITUS [DM- a disorder characterized by difficulty in blood sugar control and poor wound healing] .UNSPECIFIED DEMENTIA [a progressive state of decline in mental abilities] .WITH ANXIETY .DEPRESSION [persistent state of sadness or loss of interest or pleasure in activities which interferes with daily life] .POST-TRAUMATIC STRESS DISORDER [PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event] . During an interview on [DATE] at 2:40 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, Resident 1 was admitted to the facility for respite care (temporary relief for caregivers, allowing them to take a break from their caregiving responsibilities). The ADON stated, a medication error occurred on [DATE] when Registered Nurse (RN) 2 incorrectly administered lorazepam to Resident 1. The ADON stated, the side effects of lorazepam included drowsiness, appetite change, memory impairment and respiratory depression. The ADON stated, staff should have made sure to administer medications according to physician's orders in order to avoid overdosing the resident and to give residents the correct medication for their care. During a phone interview on [DATE] at 9:41 a.m. with RN 2, RN 2 stated, he had administered lorazepam 0.5 milligrams (mg-unit of weight measurement) to Resident 1 on [DATE] at approximately 4:45 p.m. RN 2 stated, he realized he gave the lorazepam to Resident 1 too early according to MD orders when he went to chart the administration. RN 2 stated, he notified the physician promptly afterwards and was instructed to monitor Resident 1 to see if there were any reactions. RN 2 stated, prior to administration of lorazepam, he should have checked the five rights of medication administration including the right resident, right drug, right dose, right route and right time. RN 2 stated, side effects of lorazepam included drowsiness, changes in level of consciousness, sleep disturbances, abnormal body movements, and weakness. RN 2 stated, he should have followed the physician's orders when administering the lorazepam to Resident 1 to ensure the resident was being taken care of properly. During a concurrent phone interview and record review on [DATE] at 2:20 p.m. with the Director of Nursing (DON), Resident 1's Progress Notes (PN) , dated [DATE] was reviewed. The PN indicated, .[patient] accidentally given [lorazepam] [at] [4 pm] instead of Metformin [medication used to lower blood sugar]. [Patient] is assessed with no new changes present. Will continue to monitor . The DON stated, RN 2 had given a dose of lorazepam to Resident 1 on [DATE] in the afternoon. The DON stated, RN 2 had not verified when the last dose was previously administered due to being distracted during medication administration. The DON stated, RN 2 had administered the lorazepam to Resident 1 too early according to physician's orders. The DON stated, RN 2 should have checked the five rights of medication administration which included the right resident, right drug, right dose, right route and right time. The DON stated, side effects of lorazepam included lethargy (lack of energy), constipation (difficulty passing stool) and dry mouth. The DON stated, it was important to follow the physician's orders for continuity (unbroken and consistent operation) of care and to do the correct thing for the resident. During a concurrent phone interview and record review on [DATE] at 2:41 p.m. with the DON, Resident 1's Medication Administration Record (MAR) , dated [DATE] was reviewed. The MAR indicated, .[lorazepam] Oral Tablet 0.5 MG [unit of weight measurement] .Give 1 tablet by mouth every 8 hours as needed for anxiety -Order Date- [DATE] 1027 . The MAR indicated, Resident 1 was administered lorazepam on [DATE] at 11:27 a.m. and no other administrations of lorazepam were documented on [DATE]. The DON stated, RN 2 had documented on [DATE] the administration of Resident 1's lorazepam on the Controlled Substance Accountability Sheet (CSAS) at 4:43 p.m. but failed to document the administration on the MAR according to policy and procedure (P&P). The DON stated, it was important for RN 2 to document Resident 1's lorazepam administration on the MAR to make sure the physician's orders were followed correctly. During a review of Resident 1's Order Listing Report (OLR) , dated [DATE], the OLR indicated, .[lorazepam] Oral Tablet 0.5 MG .Give 1 tablet by mouth every 8 hours as needed for anxiety . During a review of Resident 1's CSAS , dated [DATE], the CSAS indicated .[Resident 1] .Medication Name/ Strength LORAZEPAM TAB 0.5 MG .Directions TAKE ONE TABLET BY MOUTH EVERY 8 HOURS AS NEEDED FOR ANXIETY .Charting on the medication record is required for each dose administered XXX[DATE] [4:43 p.m.] .Amount Administered 1 .Nurse Signature .[RN 1's initials] . During a review of RN 2's Documented Statement (DS) , dated [DATE], the DS indicated, .On [DATE] [at] approximately ,d+[DATE] pm as I was passing medication I was also attempting to redirect [Resident 1] from entering other rooms and singing louder thus, protecting the milieu [the physical or social setting] of my unit. I read [Resident 1] had [lorazepam] 0.5 mg ordered. My error was not confirming the last dose given, thereby I recognized the symptoms warranted the medication. I gave the medication [lorazepam] 0.5 mg when I checked the medication I realized he had received the dose earlier. The [medical doctor] was notified by phone and I promptly reported the error to her. New orders were given to monitor for any changes . During a review of Resident 1's PN , dated [DATE], the PN indicated, .Resident continues on monitoring for medication error . During a review of Resident 1's Care Plan Report (CPR) , undated, the CPR indicated, .The resident uses anti-anxiety [to reduce feelings of worry or fear] [lorazepam] 0.5 mg [related to] Anxiety disorder .Administer ANTI-ANXIETY medications as ordered by physician . During a review of the Mayo Clinic website, https://www.mayoclinic.org/drugs-supplements/lorazepam-oral-route/description/drg-20072296, dated [DATE], the website indicated, .Lorazepam is used to treat anxiety disorders .Take this medicine only as directed by your doctor. Do not take more of it, do not take it more often .This medicine may cause respiratory depression (serious breathing problem that can be life- threatening) .Side Effects .Drowsiness .Change in consciousness .Dry mouth .General feeling of tiredness or weakness .Loss of appetite .Problems with memory .Trouble sleeping .Twisting movements of body .Uncontrolled movements, especially of the face, neck and back .Constipation . During a review of the facility's P&P titled, MEDICATION ADMINISTRATION- GENERAL GUIDELINES , dated ,d+[DATE], the P&P indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices .FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered .The medication administration record (MAR) is always employed during medication administration the physician's orders are checked for the correct dosage schedule .Medications are administered in accordance with written orders of the prescriber .Medications are administered within [60 minutes] of scheduled time .The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented .When PRN [as needed] medications are administered, the following documented is provided .Date and time of administration, dose, route of administration (if other than oral) .Signature or initials of person recording administration .

Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for one of five sampled residents (Resident 1) when Resident 1's dose of lorazepam (medication used to treat anxiety [mental condition which causes intense and persistent worry])was not documented in the Medication Administration Record (MAR) on [DATE] and the complete record of the medication error was not documented in an incident report and Resident 1's clinical record. This failure had the potential to affect the delivery of care and services to Resident 1 and the potential to cause errors in medical treatment and plan of care. Findings: During a review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history) , dated [DATE], the AR indicated, Resident 1 had diagnoses which included .TYPE 2 DIABETES MELLITUS [DM- a disorder characterized by difficulty in blood sugar control and poor wound healing] .UNSPECIFIED DEMENTIA [a progressive state of decline in mental abilities] .WITH ANXIETY .DEPRESSION [persistent state of sadness or loss of interest or pleasure in activities which interferes with daily life] .POST-TRAUMATIC STRESS DISORDER [PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event] . During an interview on [DATE] at 2:40 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, Resident 1 was admitted to the facility for respite care (temporary relief for caregivers, allowing them to take a break from their caregiving responsibilities). The ADON stated, a medication error occurred on [DATE] when Registered Nurse (RN) 2 incorrectly administered lorazepam to Resident 1. The ADON stated, an incident report should have been completed due to the medication error that occurred on [DATE]. During a phone interview on [DATE] at 9:41 a.m. with Registered Nurse (RN) 2, RN 2 stated, he had administered lorazepam 0.5 milligrams (mg- unit of weight) to Resident 1 on [DATE] at approximately 4:45 p.m. RN 2 stated, he realized he gave the lorazepam to Resident 1 too early according to MD orders when he went to chart the administration. RN 2 stated, he notified the physician promptly afterwards and was instructed to monitor Resident 1 to see if there were any reactions. RN 2 stated, he did not document the call to the physician. During a phone interview on [DATE] at 10:01 a.m. with the Licensed Vocational Nurse (LVN), the LVN stated, if a medication error occurred, the physician and Director of Nursing (DON) should have been notified. The LVN stated, the physician would have given orders like obtaining blood work or monitoring for 72 hours for any adverse reactions (an undesirable and unexpected effect experienced as a result of taking a medication) to the medication. The LVN stated, risk management should have been notified of the medication error as well as the responsible party (RP). During a concurrent phone interview and record review on [DATE] at 2:20 p.m. with the DON, Resident 1's Progress Notes (PN) , dated [DATE] was reviewed. The PN indicated, .[patient] accidentally given [lorazepam] [at] [4 pm] instead of Metformin [medication used to lower blood sugar]. [Patient] is assessed with no new changes present. Will continue to monitor . The DON stated, RN 2 administered a dose of lorazepam to Resident 1 on [DATE] in the afternoon. The DON stated, RN 2 did not verify when the last dose was previously administered due to being distracted during medication administration. The DON stated, RN 2 administered the lorazepam to Resident 1 too early according to physician's orders. The DON stated, when the medication error occurred, the physician, DON or ADON and the RP should have been notified. The DON stated, physician's orders should have been followed and the oncoming staff should have been given report to know what to do. The DON stated, documentation in an incident report and in Resident 1's clinical record, including what the medication error was, notification of all parties, subsequent physician's orders and monitoring, should have been completed. The DON stated, the PN inadequately documented what the medication error was and did not include all the required documentation according to the policy and procedure (P&P). During a concurrent phone interview and record review on [DATE] at 2:41 p.m. with the DON, Resident 1's Medication Administration Record (MAR) , dated [DATE] was reviewed. The MAR indicated, .[lorazepam] Oral Tablet 0.5 MG [unit of weight measurement] .Give 1 tablet by mouth every 8 hours as needed for anxiety -Order Date- [DATE] [10:27 a.m.] . The MAR indicated, Resident 1 was administered lorazepam on [DATE] at 11:27 a.m. and no other administrations of lorazepam were documented on [DATE]. The DON indicated, RN 2 had documented on [DATE] the administration of Resident 1's lorazepam on the Controlled Substance Accountability Sheet (CSAS) but failed to document the administration on the MAR according to the P&P. The DON stated, it was important for RN 2 to document Resident 1's lorazepam administration on the MAR to make sure the physician's orders were followed correctly. The DON stated, there was not an incident report completed by RN 2. The DON stated, according to the Adverse Consequences and Medication Errors P&P, it was important to document an incident report and in the patient's clinical record an account of the medication error to ensure that the mistake was observed and corrected so it would not happen again. During a review of Resident 1's Order Listing Report (OLR) , dated [DATE], the OLR indicated, .[lorazepam] Oral Tablet 0.5 MG .Give 1 tablet by mouth every 8 hours as needed for anxiety . During a review of Resident 1's CSAS , dated [DATE], the CSAS indicated .[Resident 1] .Medication Name/ Strength LORAZEPAM TAB 0.5 MG .Directions TAKE ONE TABLET BY MOUTH EVERY 8 HOURS AS NEEDED FOR ANXIETY .Charting on the medication record is required for each dose administered XXX[DATE] [4:43 p.m.] .Amount Administered 1 .Nurse Signature .[RN 1's initials] . During a review of Resident 1's PN , dated [DATE], the PN indicated, .Resident continues on monitoring for medication error . During a review of RN 2's Documented Statement (DS) , dated [DATE], the DS indicated, .On [DATE] [at] approximately ,d+[DATE] pm as I was passing medication I was also attempting to redirect [Resident 1] from entering other rooms and singing louder thus, protecting the milieu [the physical or social setting] of my unit. I read [Resident 1] had [lorazepam] 0.5 mg ordered. My error was not confirming the last dose given, thereby I recognized the symptoms warranted the medication. I gave the medication [lorazepam] 0.5 mg when I checked the medication I realized he had received the dose earlier. The [medical doctor] was notified by phone and I promptly reported the error to her. New orders were given to monitor for any changes . During a review of Resident 1's Care Plan Report (CPR) , undated, the CPR indicated, .The resident uses anti-anxiety [to reduce feelings of worry or fear] [lorazepam] 0.5 mg [related to] Anxiety disorder .Administer ANTI-ANXIETY medications as ordered by physician . During a review of the facility's P&P titled, Documentation of Medication Administration , dated ,d+[DATE], the P&P indicated, .A medication administration record is used to document all medications administered .A nurse .documents all medications administered to each resident on the resident's medication administration record (MAR) .Administration of medication is documented immediately after it is given .Documentation of medication administration includes, as a minimum .the resident's name .name and strength of the drug .dosage .route of administration .date and time of administration .initials, signature and title of the person administering the medication . During a review of the facility's P&P titled, MEDICATION ADMINISTRATION- GENERAL GUIDELINES , dated ,d+[DATE], the P&P indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices .The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented .When PRN [as needed] medications are administered, the following documented is provided .Date and time of administration, dose, route of administration (if other than oral) .Signature or initials of person recording administration . During a review of the facility's P&P titled, Adverse Consequences and Medication Errors , dated ,d+[DATE], the P&P indicated, .A ' medication error' is defined as the preparation or administration of drugs .which is not in accordance with physician's orders .Examples of medication errors include .Wrong drug .Wrong time .Document the following information in an incident report and in the resident's clinical record .The resident's name and age .Medication, route, dose, date and time of administration .Factual description of the error .Name of provider and time notified .Provider's orders .Treatment therapy or interventions Resident's condition for 24 to 72 hours or as directed .

Based on interview and record review, the facility failed to report an injury of unknown origin in accordance with the facility's policy and procedure (P&P) and state regulations, for one of five sampled residents (Resident 1), when Resident 1 had a lump to the right shoulder, lump to the right side of the chest with bruising due to an unknown cause and it was not reported to the California Department of Public Health (CDPH, a government agency for the State of California in charge of protecting the public's health and helping shape positive health outcomes for individuals, families and communities) and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within 2 hours as required by law. This failure resulted in a delayed investigation of the injury of unknown origin and placed Resident 1 at risk for physical harm and delayed care. Findings: During a review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history) , dated 3/27/25, the AR indicated, Resident 1 had diagnoses which included .TRANSIENT CEREBRAL ISCHEMIA ATTACK [TIA- a temporary lack of blood flow to the brain] .ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] .MUSCLE WEAKNESS .NEED FOR ASSISTANCE WITH PERSONAL CARE . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) , dated 12/2/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation, and memory recall) indicated a score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During a phone interview on 4/3/25 at 11:00 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 came to her reporting pain to her right shoulder. LVN 1 stated, she assessed Resident 1's right shoulder and saw a lump that felt like a knot. LVN 1 stated, Resident 1 did not know how it happened, and staff also did not know what caused the injury. LVN 1 stated, an injury of unknown origin, abuse or neglect needed to be reported immediately but no longer than 2 hours to CDPH and the ombudsman. LVN 1 stated, prompt reporting of an injury of unknown origin, abuse and neglect was important because the matter was serious and needed to be investigated. During a phone interview on 4/3/25 at 11:33 a.m. with the Director of Staff Development (DSD), the DSD stated, after the discovery of an injury of unknown origin to a resident, the staff should have called CDPH and the ombudsman and filed an SOC 341 form (document used to report suspected cases of dependent adult and elder abuse and neglect) immediately but no later than 2 hours later. The DSD stated, prompt reporting of an injury of unknown origin, abuse or neglect was important to address the safety of the resident. During a concurrent phone interview and record review on 4/3/25 at 11:53 a.m. with the Director of Nursing (DON), Resident 1's fax sheet (FS) , dated 12/3/24 was reviewed. The FS indicated, Date: 12/3/24 .[Resident 1] .Nursing Concerns & Assessments: Please [evaluate] lump to [right upper chest (RUC)]. Measured 12 [centimeter (cm)- unit of length] x 7 cm. Deep purple bruise accompanied by [right (R)] shoulder pain. R shoulder x-ray [a medical imaging test commonly used to see the bones and other dense structures inside the body] clear .Pending ultrasound [a medical imaging test that uses sound waves to look at tissues and organs inside the body] report, but tech had stated it looked like a fluid filled sac .-Pectoralis [muscle in the chest] muscle tear .-Consult orthopedics [branch of medicine concerned with the bones and muscles] .12/3/24 . The DON stated, Resident 1 reported to staff that she was hurting and had bruising to the nurses. DON stated, Resident 1 had a lump to the right shoulder, a lump to the right side of her chest and bruising to her chest which extended under her right arm. The DON stated, Resident 1 and staff did not know the exact cause of the injury Resident 1 sustained. The DON stated, the doctor had ordered a right shoulder x-ray and a chest ultrasound. The DON stated, the FS indicated that the nurse had written an update about Resident 1's status to the doctor in the upper portion of the document. The DON stated, the FS indicated on the lower portion of the document that the doctor had a hand-written reply with a suspected pectoralis muscle tear diagnosis and orders to consult an orthopedic doctor on 12/3/24. The DON stated, the staff were expected to report any injury of unknown origin, abuse or neglect to the DON or to the Administrator (ADM), who is the abuse coordinator. The DON stated, CDPH and the ombudsman should have been promptly notified. The DON stated, the Abuse P&P speaks clearly to reporting immediately but no later than 2 hours after identification of an injury of unknown origin. The DON stated, the reporting of Resident 1's injury of unknown origin was not completed according to the facility P&P. During a review of Resident 1's SBAR Summary for Providers (SBAR) , dated 12/1/24, the SBAR indicated, .The Change in Condition [CIC]/s reported on this CIC Evaluation are/were: Pain .Resident came to [licensed nurse] this evening stating she had pain to the R shoulder, when LN assessed shoulder noticed a lump on the right shoulder. [Nurse Practitioner (NP)] was noticed via phone .NP gave order for [hydrocodone and acetaminophen- pain medication] 5/325 [milligram (mg)- unit of weight] q [every] 8 hours and xray to area . During a review of Resident 1's Progress Notes (PN) , dated 12/1/24, the PN indicated, .Lump to R chest is causing resident increased pain . During a review of Resident 1's PN, dated 12/2/24, the PN indicated, .[Resident (Res)] on [continued (cont)] monitoring due to Lump to RUC. LN asked to eval [evaluate] and measure, res agreed and complained of increased pain .Deep purple bruise noted to site .bruise noted to middle of chest and L [left] breast. Lump measured 12cm x 7cm. Res also complained of R shoulder pain with very minimal movement .NP notified and gave order for STAT [immediate] ultrasound to RUC and STAT x-ray to R shoulder . During a review of Resident 1's MD/NP Progress Notes (NPPN) , dated 12/2/24, the NPPN indicated, .Pain in right shoulder .Contusion [bruise] of right front wall of thorax [area between the neck and abdomen], initial encounter .Pain right shoulder: Xray ordered Pain medication adjusted .Right breast hematoma [a closed wound where blood collects and pools]: [ultrasound] ordered . During a review of Resident 1's Clinical Physician Orders (CPO) , undated, the CPO indicated .Refer to Ortho r/t suspected torn muscle fibers to RUC .STAT X-RAY of R shoulder .STAT ultrasound to RUC . During a review of Resident 1's Radiology Interpretation (RI) , dated 12/2/24, the RI indicated .HISTORY: LUMP AND A BRUISE IN THE RIGHT AXILA [armpit or underarm] .5.6 cm cyst [sac containing fluid]/hematoma .right axillary [pertaining to the armpit area] . The RI indicated a handwritten note, dated 12/3/24, Consult Orthopedics . During a review of Resident 1's PN, dated 12/3/24, the PN indicated, .Res is on cont monitoring due to Lump to RUC .Sent over ultrasound with significant find: Cyst and hematoma. Requested eval by MD today. MD evaluated. Bruising to area significantly worse and spread to R breast, chest, L breast, and upper abdomen. Res cont to [complain of (c/o)] pain .MD suspecting torn muscle fibers to pectoralis. Gave order for sling to R arm, referredres to Ortho, and to hold blood thinners x 3 days .Management made aware and updatedto situation . During a review of the facility's P&P titled, ABUSE REPORTING POLICY , dated 8/22, the P&P indicated, .To promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment .Type of Abuse: . ' Injury of unknow source' is defined as an injury that meets both the following conditions: (1) the source of the injury was not observed by any person or the source of the injury could not be explained by the resident .(2) the injury is suspicious because of the extent of the injury, the location of the injury .the number of injuries observed at one particular point in time, or the incidence of injuries over time . The facility shall conduct mandatory Facility Staff training programs during orientation, annually, and as needed on .Reporting .injuries of unknown sources .The facility's Abuse Prevention Coordinator/Designee shall initiate the investigation process immediately within the required time frame in accordance to regulation .The Facility shall report any and all allegation of abuse to the District CDPH, Local Ombudsman and Local Law enforcement .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled residents (Resident 1) when Resident 1 had a newly developed lump to the right shoulder and a lump to the right side of the chest with bruising and the care plan did not include thorough and individualized objectives, timeframes, goals, and interventions. This failure placed Resident 1 at risk for complications and delayed healing to her right shoulder and chest. Findings: During a review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history) , dated 3/27/25, the AR indicated, Resident 1 had diagnoses which included .TRANSIENT CEREBRAL ISCHEMIA ATTACK [TIA- a temporary lack of blood flow to the brain] .ESSENTIAL (PRIMARY) HYPERTENSION [high blood pressure] .MUSCLE WEAKNESS .NEED FOR ASSISTANCE WITH PERSONAL CARE . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) , dated 12/2/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation, and memory recall) indicated a score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During a concurrent interview and record review on 3/27/25 at 1:30 p.m. with the ADON, Resident 1's Care Plans (CP), undated were reviewed. The CP indicated, . [Resident 1] has a Lump to R [right] Chest .Interventions .Encourage good nutrition and hydration in order to promote healthier skin .Identify potential causative factors and eliminate/resolve when possible . The ADON stated, Resident 1 had complained of right shoulder pain to Licensed Vocational Nurse (LVN) 1. The ADON stated, LVN 1 had assessed Resident 1 and found a right shoulder lump. The ADON stated, LVN 1 called Resident 1's doctor, completed the change of condition (COC- a significant, clinically important deviation from a resident's baseline that requires intervention) documentation and an SBAR (a communication framework which stands for Situation, Background, Assessment and Recommendation). The ADON stated, Resident 1's doctor ordered an x-ray (a medical imaging test commonly used to see the bones and other dense structures inside the body), an ultrasound (a medical imaging test that uses sound waves to look at tissues and organs inside the body), and an orthopedic (branch of medicine concerned with bones and muscles) consult. The ADON stated, there was no comprehensive person-centered care plan regarding Resident 1's right shoulder lump. The ADON stated, a CP should have been developed and implemented for the right shoulder lump because a change in condition (CIC) was completed. The ADON stated, the CP was an individualized, patient- specific plan of care for the resident that the staff should have followed. During a phone interview on 4/1/25 at 10:48 a.m. with LVN 1, LVN 1 stated, Resident 1 had come to her, pointed to her right shoulder and stated it was hurting. LVN 1 stated, she assessed the right shoulder and a lump was identified. LVN 1 stated, she called the nurse practitioner (NP) and received an order for pain medication. LVN 1 stated, orders for an x-ray and an ultrasound were also received for Resident 1. LVN 1 stated, she completed the SBAR documentation, CIC documentation and started a CP. LVN 1 stated, the importance of a CP was to indicate that the staff had identified a problem, created a goal to solve it and formed ways to intervene if issues arose. LVN 1 stated, the CP was important to keep the issue from happening again and to help the issue improve. During a concurrent phone interview and record review on 4/2/25 at 12:41 p.m. with the Director of Nursing (DON), Resident 1's CPs, undated were reviewed. The CP indicated, . [Resident 1] has a Lump to [right] Chest .Interventions .Encourage good nutrition and hydration in order to promote healthier skin .Identify potential causative [contributing] factors and eliminate/resolve when possible . The DON stated, there was no care plan for the lump to the right shoulder or the bruising to her chest. The DON stated, the CP was very generic, needed more detail and was not sufficient to show what staff were doing or were needing to do. The DON stated, the purpose of a care plan was to identify a problem or a potential problem and required a resident-specific goal. The DON stated, a minimum of 3-4 resident- specific interventions should have been included to direct the staff to mitigate the problem from getting worse or to reduce the risk of the problem. During a review of Resident 1's SBAR Summary for Providers (SBAR) , dated 12/1/24, the SBAR indicated, .The Change in Condition [CIC]/s reported on this CIC Evaluation are/were: Pain .Resident came to [licensed nurse] this evening stating she had pain to the [Right (R)] shoulder, when LN assessed shoulder noticed a lump on the right shoulder. NP was noticed via phone .NP gave order for [hydrocodone and acetaminophen- pain medication] 5/325 [milligram (mg)- unit of weight] [every] 8 hours and xray to area . During a review of Resident 1's Progress Notes (PN) , dated 12/1/24, the PN indicated, .Lump to R chest is causing resident increased pain . During a review of Resident 1's PN, dated 12/2/24, the PN indicated, .[Resident (Res)] on [continued (cont)] monitoring due to Lump to [right upper chest (RUC)]. LN asked to [evaluate] and measure, res agreed and complained of increased pain .Deep purple bruise noted to site .bruise noted to middle of chest and [left] breast. Lump measured 12 [centimeter (cm)- unit of length] x 7cm. Res also complained of R shoulder pain with very minimal movement .NP notified and gave order for STAT [immediate] ultrasound to RUC and STAT x-ray to R shoulder . During a review of Resident 1's Medical Doctor (MD)/Nurse Practitioner (NP) Progress Notes (NPPN) , dated 12/2/24, the NPPN indicated, .Pain in right shoulder .Contusion [bruise] of right front wall of thorax [area between the neck and abdomen], initial encounter .Pain right shoulder: Xray ordered Pain medication adjusted .Right breast hematoma [a closed wound where blood collects and pools]: US [ultrasound] ordered . During a review of Resident 1's PN, dated 12/3/24, the PN indicated, .Res is on cont monitoring due to Lump to RUC .MD evaluated. Bruising to area significantly worse and spread to R breast, chest, L breast, and upper abdomen .MD suspecting torn muscle fibers to pectoralis [muscle in the chest]. Gave order for sling to R arm, referredres to Ortho, and to hold blood thinners x 3 days .Management made aware and updatedto situation . During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered , dated 3/22, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered a part of the comprehensive assessment .The comprehensive, person-centered care plan .includes measurable objectives and timeframes .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .interventions address the underlying source(s) of the problem areas(s), not just symptoms or triggers .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The interdisciplinary team reviews and updates the care plan .when there has been a significant change in the resident's condition .

Based on observation, interview, record review, and facility policy review, the facility failed to administer oxygen according to physician orders for 3 (Residents #6, #24, and #111) of 4 residents reviewed for respiratory therapy. Findings included: A facility policy titled, Oxygen Administration, revised October 2010, revealed, Preparation included, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. An Admission Record revealed the facility admitted Resident #111 on 01/22/2025 and most recently on 03/04/2025. According to the Admission Record, Resident #111 had a medical history that included diagnoses of hemiplegia (total or nearly complete inability to use one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, a history of coronavirus disease 2019 (COVID-19) (onset date 01/22/2025), unspecified heart failure, unspecified anemia, and morbid obesity. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2025, revealed Resident #111 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #111 received continuous oxygen therapy. Resident #111's Care Plan Report included a focus area initiated on 03/04/2025, that indicated the resident had congestive heart failure. Interventions directed staff to monitor the resident's vital signs every shift and to notify the physician of significant abnormalities (initiated 03/04/2025). Resident #111's Order Summary Report, with active orders as of 03/12/2025, revealed an order, with a start date of 03/04/2025, that indicated Resident #111 was to receive supplemental oxygen at 1 liter per minute (L/min) via nasal cannula (NC) as needed for shortness of breath. The Order Summary Report also revealed an order, with a start date of 03/04/2025, for supplemental oxygen to be administered at 2 L/min as needed for wheezing/shortness of breath. The Order Summary Report revealed an order, with a start date of 03/04/2025, that indicated staff were to check the resident's oxygen saturation every shift, and if it was less than 92%, staff were to apply supplemental oxygen. Resident #111's medication administration record (MAR), for the timeframe from 03/04/2025 through 03/11/2025, revealed a transcription of an order dated 03/04/2025, instructing staff to check the resident's oxygen saturation every shift, and if the value of the oxygen saturation was less than 92%, supplemental oxygen was to be applied. The MAR revealed staff documented that the order was followed from 03/05/2025 through 03/10/2025. The MAR also included a transcription of an order dated 03/04/2025, to check the resident's vital signs every shift and included a space to record the oxygen saturation. The MAR revealed that for the timeframe from 03/04/2025 through 03/10/2025, staff documented Resident #111's oxygen saturation ranged between 94% and 100%. The MAR revealed no values were recorded less than 92% in that portion of the MAR. The MAR revealed a transcription of an order dated 03/04/2025, for the resident to receive supplemental oxygen at 2 L/min via nasal cannula (NC) as needed for wheezing. The MAR revealed staff documented that the resident received oxygen therapy on 03/07/2025 at 12:42 AM for an oxygen saturation of 82%. Resident #111's O2 [Oxygen] Sats [Saturations] Summary, for the timeframe from 03/04/2025 through 03/12/2025, revealed staff documented Resident #111 received oxygen via NC on six of those days, and did not document an oxygen saturation lower than 92%, except on 03/07/2025 at 12:42 AM. Resident #111's Progress Notes, for the timeframe from 03/04/2025 through 03/11/2025, revealed no documentation that indicated the resident had a low oxygen saturation. An observation on 03/10/2025 at 10:57 AM revealed Resident #111's oxygen concentrator was set on 2.5 L/min, and the resident was receiving supplemental oxygen via NC. The residents MAR did not reflect this administration. An observation on 03/12/2025 at 12:48 PM revealed the resident's oxygen concentrator was set on 3.5 L/min, and the resident was receiving supplemental oxygen via NC. Licensed Vocational Nurse (LVN) #14 was interviewed on 03/12/2025 at 12:58 PM. LVN #14 stated the setting on an oxygen concentrator was determined by the physician's order. LVN #14 stated if increasing a resident's oxygen was needed, she would notify the physician regarding the resident's change in condition. LVN #14 reviewed Resident #111's physician orders and confirmed the resident had two orders for supplemental oxygen; one order was for 1 L/min and the other order was for 2 L/min. LVN #14 stated if the nurse followed the physician's order, the maximum amount of supplemental oxygen ordered for Resident #111 was 2 L/min. LVN #14 stated she had checked the resident's oxygen concentrator on 03/11/2025, and stated Resident #111 was receiving either 2.5 L/min or 3.5 L/min. She stated that she did not check the physician's orders since the resident was stable and the amount of supplemental oxygen the resident was receiving had not jumped out at her. LVN #14 went to the resident's room and confirmed the resident's concentrator was set at 3.5 L/min. LVN #14 then checked the resident's oxygen saturation, which was at 100%. The Director of Nursing (DON) was interviewed on 03/12/2025 at 2:07 PM. The DON stated that when a resident received an order for supplemental oxygen, she expected the nurses to follow the order given. The DON stated nurses were only able to increase and decrease supplemental oxygen within parameters given by the physician. The DON stated the oxygen concentrator should be set on the amount ordered by the physician. The DON stated that the nurse who took the two orders for supplemental oxygen on the same day should have clarified the orders. Resident #111's Order Summary Report, with active orders as of 03/12/2025, revealed an active order that the resident was to receive supplemental oxygen at 2 L/min via NC as needed for shortness of breath, with a start date 03/12/2025. The order indicated if the resident's oxygen saturation was less than 90%, the supplemental oxygen could be increased to 3 to 5 L/min via NC. An observation on 03/13/2025 at 10:08 AM revealed Resident #111 was in bed resting and receiving 3 liters of supplemental oxygen via NC. Resident #111's O2 Sats Summary, for the timeframe from 03/13/2025 through 03/14/2025, revealed staff documented Resident #111 received supplemental oxygen via NC on both days and did not document an oxygen saturation lower than 90%. LVN #4 was interviewed on 03/13/2025 at 10:19 AM. LVN #4 stated that she was assigned to provide care to Resident #111 that day. LVN #4 stated she usually checked the settings on oxygen concentrators during medication administration to make sure residents received the correct amount of supplemental oxygen. LVN #4 stated if a resident's oxygen saturation dropped, making it necessary to increase the flow of supplemental oxygen, the expectation was for the nurse to write a progress note about the respiratory assessment and the need to increase the supplemental oxygen. LVN #4 stated she would also notify the physician about the resident's change in condition. LVN #4 stated that when she received report that morning, she had not received any information that Resident #111 had a change in condition that made increasing the supplemental oxygen the resident received necessary. LVN #4 reviewed Resident #111's supplemental oxygen order and stated if the oxygen saturation were less than 90%, the supplemental oxygen could be increased, but added that if there had been no change in the resident's condition and the oxygen saturation was greater than 90%, then the oxygen concentrator should be set on 2 L/min. LVN #4 stated she had not looked at the resident's oxygen concentrator that morning to confirm the setting of how much supplemental oxygen the resident received. LVN #4 went to Resident #111's room and stated the oxygen concentrator was set to 3 L/min. LVN#4 reviewed the oxygen saturation values and progress notes and stated there had been no change in the resident's condition to warrant the concentrator being set on 3 L/min. LVN #4 stated the oxygen concentrator should be set to deliver 2 L/min to the resident. Medical Doctor (MD) #5 was interviewed on 03/14/2025 at 9:19 AM. MD #5 stated he expected orders for supplemental oxygen delivery to be followed. MD #5 stated giving too much oxygen could increase the resident's carbon dioxide level and depress the respiratory system, causing the resident harm. MD #5 stated oxygen should be titrated to keep the oxygen saturation greater than 90%. The DON was interviewed on 03/13/2025 at 1:00 PM. The DON stated she was disappointed the physician's oxygen orders for Resident #111 was still not followed. The Administrator was interviewed on 03/13/2025 at 1:21 PM. The Administrator stated he expected the physician's orders to be followed for the administration of supplemental oxygen for Resident #111 and stated that he expected staff to call the physician if clarification was needed. 46659 2. An Admission Record revealed the facility admitted Resident #24 on 02/18/2025. According to the Admission Record, the resident had a medical history that included acute respiratory failure with hypoxia, sleep apnea, and dependence on supplemental oxygen. A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2025, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #24 received respiratory treatments through a non-invasive mechanical ventilator. Resident #24's Care Plan Report included a focus area initiated 02/18/2025, that indicated the resident had shortness of breath related to hypoxia. Interventions directed staff to use a bilevel positive airway pressure (BiPAP) machine as appropriate and monitor for effectiveness (initiated 02/18/2025). Resident #24's Order Summary Report, with active orders as of 03/12/2025, revealed an order dated 02/18/2025, for supplemental oxygen at 2 liters per minute (L/min) via nasal cannula (NC) to be administered as needed when the resident's oxygen saturation was below 92%. The Order Summary Report also revealed an order dated 02/18/2025, for supplemental oxygen at 5 L/min via face mask every shift; and an order dated 02/18/2025, for supplemental oxygen at 5 L/min via NC when the resident's oxygen saturation level was below 92%. Resident #24's medication administration record (MAR), for the timeframe from 03/01/2025 through 03/14/2025, revealed staff documented the resident received supplemental oxygen at 5 L/min via face mask. The MAR revealed staff documented the resident's oxygen saturation was between 94% and 100% during that timeframe. An observation on 03/11/2025 at 2:20 PM revealed Resident #24 receiving supplemental oxygen via facemask, the supplemental oxygen setting was at 8 L/min. An observation on 03/13/2025 at 9:53 AM revealed Resident #24 receiving supplemental oxygen via NC, the supplemental oxygen setting was at 8-9 L/min. At 9:56 AM, Registered Nurse (RN) #9 confirmed the resident's supplemental oxygen was set between 8 L/min and 9 L/min. During an interview on 03/13/2025 at 9:59 AM, RN #9 stated Resident #24's supplemental oxygen order was 5 L/min. RN #9 stated the resident struggled the day prior after returning from dialysis, so he increased the supplemental oxygen to 8 to 9 L/min. During an interview on 03/13/2025 at 10:04 AM, RN #9 stated that the danger of too much oxygen was oxygen toxicity. RN #9 stated staff had to have an order to change the supplemental oxygen amount. RN #9 stated he did not talk to the doctor about changing the amount of supplemental oxygen for Resident #24. RN #9 stated it was important to follow the doctor's orders. During an interview on 03/14/2025 at 9:08 AM, Medical Doctor (MD) #5 stated that if a resident had an order for supplemental oxygen, then he expected staff to ensure the supplemental oxygen was set at the correct level. MD #5 stated if a resident got too much oxygen, it could be dangerous. MD stated 8-9 L/min should not be the normal amount of supplemental oxygen for Resident #24 unless there were orders to monitor and adjust the amount to keep the resident's oxygen saturation at 90%. He stated if the resident's oxygen saturation remained in the high 90s, then the supplemental oxygen should be lowered back down. MD #5 stated staff should always follow physician orders. During an interview on 03/14/2025 at 4:11 PM, the Director of Nursing (DON) stated she expected staff to follow physician orders, and the physician had to be called before staff could change the supplemental oxygen settings. During an interview on 03/14/2025 at 4:54 PM, the Administrator stated he expected staff to follow the facility policy related to physician orders for oxygen therapy. 52219 3. An Administration Record revealed the facility admitted Resident #6 on 06/04/2024 and readmitted the resident on 01/28/2025. According to the Admission Record, the resident had a medical history that included diagnoses of polymyositis with respiratory involvement, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, toxic effect of carbon dioxide, other pulmonary embolism (blood clot in a lung) without acute cor pulmonale (right side heart failure), unspecified systolic (congestive) heart failure, pleural effusion, shortness of breath, and unspecified asthma. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/03/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #6 had shortness of breath with exertion, when sitting at rest, and when lying flat. The MDS indicated the resident utilized a non-invasive mechanical ventilator for respiratory treatments while a resident. Resident #6's Care Plan Report included a focus area dated 09/10/2024, that indicated the resident had ineffective breathing, and indicated the resident used a bilevel positive airway pressure (BiPAP) machine. Interventions directed staff to check the resident's vital signs every shift and as needed (initiated 08/19/2024). Resident #6's Order Summary Report, with active orders as of 03/14/2025, revealed an active order dated 01/27/2025, to check the resident's oxygen saturation every shift and if less than 92%, supplemental oxygen was to be administered. The order did not include the amount of supplemental oxygen to be administered. Resident #6's medication administration record (MAR) for the timeframe from 03/01/2025 through 03/13/2025, revealed staff documented that they checked the resident's oxygen saturation. The MAR revealed staff documented the resident's oxygen saturation was 89% on 03/13/2025 during the 7:00 AM and 7:00 PM shift. The MAR revealed staff did not document the resident's oxygen saturation being lower than 92% on any other day. Resident #6's O2 [Oxygen] Sats [Saturations] Summary, revealed that Certified Nursing Assistant (CNA) #6 documented that Resident #6's oxygen saturation was 100% while receiving supplemental oxygen via nasal cannula (NC) on 03/09/2025 at 7:50 PM. Staff documented the resident received supplemental oxygen on 03/10/2025 at 6:56 AM and 7:20 PM, 03/12/2025 at 7:13 AM and 7:25 PM, and 03/13/2025 at 6:53 AM. Per the record, the resident's oxygen levels were only below 92% on 03/13/2025 at 6:53 AM. An observation on 03/11/2025 at 12:53 PM revealed Resident #6 in their room, seated in a wheelchair, eating lunch, and receiving supplemental oxygen via a NC. An observation on 03/12/2025 at 11:22 AM revealed Resident #6 in bed sleeping and receiving supplemental oxygen via a NC. Resident #6's Care Plan Report included a focus area dated 03/14/2025, that indicated the resident received supplemental oxygen at 2 liters via NC to keep the resident's oxygen saturation above 94%. Resident #6's Order Summary Report, with active orders as of 03/14/2025, revealed an active order with a start date of 03/14/2025, to administer supplemental oxygen via NC at 2 liters per minute (L/min) every shift, for shortness of breath, if the resident's oxygen saturation level was less than 92%. Resident #6's MAR revealed staff documented the resident's oxygen saturation on 03/14/2025 during the first shift was 99%. Resident #6's O2 Sats Summary revealed staff documented the resident's oxygen saturation on 03/14/2025 at 6:40 AM was 99% on room air. During a concurrent observation and interview on 03/14/2025 at 11:07 AM, Resident #6 was in bed and receiving supplemental oxygen via a NC at 2 L/min. Resident #6 stated they always received supplemental oxygen. Resident #6 stated it should be set at 2 L/min, and stated the nurses were the ones who administered the supplemental oxygen. During an interview on 03/12/2025 at 1:22 PM, CNA #6 stated Resident #6 always received supplemental oxygen. She stated that she always sees the resident receiving supplemental oxygen. During an interview on 03/14/2025 at 12:55 PM, Licensed Vocational Nurse (LVN) #7 stated she would know how much supplemental oxygen a resident should receive by reviewing the physician's order. LVN #7 stated she believed Resident #6 received 2 L/min. She stated if a physician's order did not provide the L/min, she would call the doctor to clarify the order. Medical Doctor (MD) #5 was interviewed on 03/14/2025 at 9:19 AM. MD #5 stated he expected orders for oxygen delivery to be followed. MD #5 stated giving too much oxygen could increase the resident's carbon dioxide level and depress the respiratory system, causing the resident harm. MD #5 stated oxygen should be titrated to keep the oxygen saturation greater than 90%. The Director of Nursing (DON) was interviewed on 03/12/2025 at 2:07 PM. The DON stated that when a resident received an order for supplemental oxygen, she expected the nurses to follow the order given. The DON stated nurses were only able to increase and decrease supplemental oxygen within parameters given by the physician. The DON stated the oxygen concentrator should be set on the amount ordered by the physician. During an interview on 03/14/2025 at 4:54 PM, the Administrator stated he expected staff to follow the facility policy related to physician orders for oxygen therapy.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBPs) were provided for 2 (Resident #111 and Resident #24) of 7 residents reviewed for transmission based precautions and failed to ensure staff followed infection control practices observed during medication administration for 1 (Resident #46) of 6 residents during medication administration and 1 (Resident #111) of 1 resident during wound care. Findings included: 1. A facility policy titled, Enhanced Barrier Precautions, dated 08/2022, revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-frug resistant organisms (MDROs) to residents. The policy revealed, 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy revealed, 3. Exampled of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. [et cetera; and so forth]); and h. wound care (any skin opening requiring a dressing. Per the policy, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. The policy revealed, 9. Staff are trained prior to caring for residents on EBPs. A facility policy titled, Handwashing/Hand Hygiene, revised 08/2019, revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy revealed, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: which included, b. before and after direct contact with residents; e. before and after handling invasive device (e.g. [exempli gratia, for example], urinary catheters, IV [intravenous] access sites); g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from contaminated body site to a clean body site during resident care; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves. The policy revealed, 8. Hand hygiene is the final step after removing and disposing or personal protective equipment. Per the policy, 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: b. When anticipating contact with blood or body fluids; and c. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. An Admission Record revealed the facility admitted Resident #111 on 01/22/2025 and most recently on 03/04/2025. According to the Admission Record, Resident #111 had a medical history that included hemiplegia (total or nearly complete inability to use one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, generalized muscle weakness, need for assistance with personal care, bacteremia, severe sepsis with septic shock, a personal history of other infectious and parasitic diseases, and unspecified malignant neoplasm of the colon (colon cancer). An admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2025, revealed Resident #111 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #111 was dependent on staff for toileting hygiene and required substantial/maximal assistance from staff with showering/bathing, personal hygiene, and dressing of the upper body and lower body. The MDS indicated Resident #111 was dependent on staff for transferring to and from bed. Resident #111's Care Plan Report included a focus area initiated on 03/05/2025 that indicated the resident required tube feeding (gastrostomy tube) related to swallowing problems. Interventions informed staff that the resident was dependent on tube feeding and water flushes (initiated 03/05/2025). The Care Plan Report included a focus area initiated 03/05/2025, that indicated Resident #111 had an indwelling urinary catheter due to urinary retention. Interventions directed staff to position the catheter bag below the level of the bladder (initiated 03/05/2025). The Care Plan Report included a focus area initiated 03/05/2025, that indicated the resident had potential/actual impairment to their skin integrity related to a coccyx wound cleanse. Interventions directed staff to monitor/document location, size, and treatment of skin injury (initiated 03/05/2025). On 03/11/2025 at 11:35 AM, an observation was made of Licensed Vocational Nurse (LVN) #14 administering medications to Resident #111 by the resident's gastrostomy tube. LVN #14 entered the resident's room, checked placement of the gastrostomy tube, flushed the gastrostomy tube, and gave the medications via gastrostomy tube. LVN #14 wore gloves but had not donned a gown prior to entering the resident's room. LVN #14 was interviewed on 03/11/2025 at 11:50 AM. LVN #14 stated she had not heard the term enhanced barrier precaution and had not received education instructing her to wear a gown when caring for a resident with a feeding tube or urinary catheter. LVN #14 stated she was unaware she should have worn a gown when administering medications to Resident #111 via gastrostomy tube. On 03/11/2025 at 11:40 AM, Certified Nursing Assistant (CNA) #1 was observed moving Resident #111's urinary catheter drainage bag from the foot of the bed to the side of the bed on a lower rail. CNA #1 donned gloves before moving the urinary catheter drainage bag but had not donned a gown. During a concurrent interview, CNA #1 stated he was unaware of the term enhanced barrier precaution and had not been taught that a gown was needed when caring for a resident with an indwelling urinary catheter. During an observation on 03/12/2025 at 8:53 AM, the Director of Staff Development (DSD), who was also the wound care nurse, changed a wound dressing for Resident #111. Resident #111's room had an EBP sign on the doorframe. The DSD used hand sanitizer prior to donning gown and gloves. CNA #1 assisted the DSD to turn the resident onto their right side. The DSD removed her gloves and donned clean gloves without using hand sanitizer or washing her hands. The DSD removed Resident #111's wound dressings. An outline of wound drainage was seen on the dressings. After cleaning the wound, the DSD removed her gloves and donned new gloves without using hand sanitizer or washing her hands. The DSD applied skin preparation (a product used to help protect the area of skin around the wound and to help the dressing adhere better to the resident's skin). The DSD removed her gloves and before donning clean gloves she was stopped. During a concurrent interview, the DSD stated she knew she should have cleaned her hands before donning new gloves but had been nervous and forgot. During an observation on 03/12/2025 at 8:53 AM, CNA #1 assisted the DSD with wound care for Resident #111. CNA #1 donned a gown and gloves prior to assisting the DSD with positioning of the resident. At 9:11 AM, CNA #1 began to provide Resident #111 with a bed bath without removing the gloves he used for assisting with wound care. CNA #1 washed Resident #111's face and upper body and provided catheter care for the resident without changing gloves. CNA #1 then washed the resident's buttocks and anal area. Without changing gloves, CNA #1 opened a container of moisture barrier and applied the moisture barrier to the resident's buttocks and anal area. CNA #1 did not change the gloves he was wearing. CNA #1 then applied a clean brief to Resident #111. CNA #1 touched the resident's pillow and bare arm and placed a clean gown on the resident. CNA #1 then emptied the resident's catheter drainage bag and placed the dirty linens and clothes in a bag. Wearing the same gloves, CNA #1 placed a blanket across Resident #111. CNA #1 removed his gown and gloves before leaving the room but failed to use hand sanitizer. CNA #1 went into the hall and requested assistance to reposition Resident #111, retrieved the dirty linen cart, and before entering the resident's room again donned a clean gown and gloves but did not use hand sanitizer or wash his hands. After repositioning Resident #111, CNA #1 removed their gown and gloves and, without using hand sanitizer, donned clean gloves to empty the resident's urinal after emptying the catheter drainage bag. CNA #1 then removed his gloves and used hand sanitizer. Without using gloves, CNA #1 emptied the dirty bath water, dried the wash basin with paper towels, and then used hand sanitizer. CNA #1 was interviewed on 03/12/2025 at 9:33 AM. CNA #1 stated he usually changed gloves between dirty and clean tasks but had not changed gloves during the resident's bath because he had been nervous. CNA #1 stated he had not used gloves to empty the bath water and stated he did not usually use gloves to empty dirty bath water. During an interview on 03/11/2025 at 11:55 AM, the Infection Preventionist (IP) stated she had read about EBP and knew staff should wear gowns and gloves when providing care for residents with gastrostomy tubes, indwelling urinary catheters, and wounds, but had not discussed what she had read with the Director of Nursing (DON). The IP confirmed the staff had not received any training on EBP and confirmed EBP signage had not been posted. The IP stated she was unsure if the facility had an EBP policy. The DON was interviewed on 03/11/2025 at 12:00 PM. The DON stated EBP should be used with any resident that had the potential to transmit body fluids to the staff. The DON stated these included residents that had urinary catheters, gastrostomy tubes, and wounds. The DON stated there had been no staff training on EBP. During an interview on 03/12/2025 at 9:58 AM, the DON stated that when gloves were removed the best practice was to use hand sanitizer before new gloves were donned, and gloves were expected to be changed between dirty and clean tasks. The DON stated she expected CNA #1 to remove their gloves after applying the moisture barrier to Resident #111's buttocks and before touching clean briefs or linens and expected the CNA to wear gloves when the dirty bath water was dumped. During an interview on 03/13/2025 at 1:27 PM, the Administrator stated he expected personal protective equipment (PPE) to be worn for residents that required EBP when care was provided. The Administrator stated he expected staff to wash or sanitize hands and change gloves between dirty and clean tasks and when involved in dirty tasks such as emptying bath water. The Administrator stated if nurses touched medications, he expected them to wear gloves to keep the medication from being absorbed through the skin. During an interview on 03/14/2025 at 9:27 AM, Medical Doctor (MD) #5 stated that when a resident required EBP he expected staff to wear PPE during the provision of care to prevent the spread of germs. MD #5 stated he expected gloves to be changed between dirty and clean tasks and added that after touching the catheter, CNA #1 should have removed their gloves and donned clean gloves. MD #5 stated any body cavity was a dirty area and CNA #1 should have changed gloves after applying cream to the resident's buttocks. 2. A facility policy titled, Enhanced Barrier Precautions, dated 08/2022, revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-frug resistant organisms (MDROs) to residents. The policy revealed, 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy revealed, 3. Exampled of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. [et cetera; and so forth]); and h. wound care (any skin opening requiring a dressing. Per the policy, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. The policy revealed, 9. Staff are trained prior to caring for residents on EBPs. An Admission Record revealed the facility admitted Resident #24 on 02/18/2025. According to the Admission Record, the resident had a medical history that included diagnoses of sepsis, need for assistance with personal care, disorder of the kidney and ureter, and dependence on renal dialysis. Resident #24's Care Plan Report, included a focus area initiated 01/17/2025, that indicated the resident needed dialysis related to renal failure. Interventions directed staff to check and change dressing daily at access site (initiated 01/17/2025). The Care Plan Report included a focus area initiated 02/18/2025, that indicated the resident had the potential impairment to skin integrity related to fragile skin. The focus area revealed the resident had an ulcer to their right toe and ischium. Interventions directed staff to provide treatment as ordered (initiated 03/10/2025). During an observation on 03/12/2025 at 8:14 AM, Certified Nursing Assistant (CNA) #20 entered Resident #24's room which had an enhanced barrier precaution (EBP) sign on the door. CNA #20 was observed assisting Resident #24 stand and pivot from the bed to the wheelchair. CNA #20 was holding the resident's arm with one hand and had her arm under the resident's other arm. CNA #20 wore no gloves and no gown when she placed the resident in the wheelchair during the transfer. When the transfer was completed, CNA #20 donned gloves but no gown and removed the linens from the resident's bed. CNA #20 was interviewed on 03/12/2025 at 8:38 AM. CNA #20 stated she had been taught if someone was on EBP she was supposed to wear personal protective equipment (PPE) when care was provided. CNA #20 stated the EBP sign on the door was for Resident #24. CNA #20 stated she had been told she did not have to wear a gown or gloves when a resident was transferred. CNA #20 stated she knew she should have worn a gown and gloves when removing linens, but she had forgotten to put a gown on to prevent from being exposed to germs. During an interview on 03/11/2025 at 11:55 AM, the Infection Preventionist (IP) stated she had read about EBP and knew staff should wear gowns and gloves when providing care for residents with gastrostomy tubes, indwelling urinary catheters, and wounds, but had not discussed what she had read with the Director of Nursing (DON). The IP confirmed the staff had not received any training on EBP and confirmed EBP signage had not been posted. The IP stated she was unsure if the facility had an EBP policy. The DON was interviewed on 03/11/2025 at 12:00 PM. The DON stated EBP should be used with any resident that had the potential to transmit body fluids to the staff. The DON stated these included residents that had urinary catheters, gastrostomy tubes, and wounds. The DON stated there had been no staff training on EBP. During an interview on 03/13/2025 at 1:27 PM, the Administrator stated he expected PPE to be worn for residents that required EBP when care was provided. During an interview on 03/14/2025 at 9:27 AM, Medical Doctor (MD) #5 stated that when a resident required EBP he expected staff to wear PPE during the provision of care to prevent the spread of germs. 3. A facility policy titled, Infection Control, revised 10/2028, revealed, This facility's infection control policies and practices are intended to facility maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. An observation was made on 03/12/2025 at 8:24 AM of Registered Nurse (RN) #9 preparing medications for Resident #46. During the preparation of medications, RN #9 punched losartan 25 milligrams (mg) 1/2 tablet out of the medication card and used his bare fingers to place the medication into a cup. RN #9 then removed a methadone 10 mg tablet out of the medication card and used his bare fingers to place the tablet into the medication cup. The medications were then crushed, mixed with applesauce, and given to the resident. During an interview on 03/12/2025 at 8:32 AM, RN #9 stated he had received no education indicating medications could not be touched with bare hands, but added he tried not to touch medications. During an interview on 03/12/2025 at 9:58 AM, the DON stated RN #9 was not expected to touch medication with their bare hands due to the risk of contamination.

Based on interview and facility document and policy review, the facility failed to protect Resident #44's right to be free from physical abuse perpetrated by another resident (Resident #259). This deficient practice affected 1 (Resident #44) of 2 sampled residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. An Admission Record revealed the facility admitted Resident #44 on 10/01/2024. According to the Admission Record, the resident had a medical history that included diagnoses of depression, major depressive disorder with severe psychotic symptoms, and legal blindness. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #44's Care Plan Report included a focus area, initiated 10/28/2024, that indicated on 10/26/2024, Resident #44's roommate (Resident #259) approached Resident #44 in their room as the resident sat in the wheelchair and suddenly slapped Resident #44 on the right side of their face. Resident #44's Progress Notes revealed a Health Status note, dated 10/26/2024, that indicated Certified Nursing Assistant (CNA) #1 brought Resident #44 to the nursing station and reported they witnessed Resident #259 strike Resident #44 on the face. An Admission Record revealed the facility admitted Resident #259 on 09/28/2024. According to the Admission Record, the resident had a medical history that included diagnoses of anoxic brain damage, schizophrenia, depression, and anxiety disorder. An admission MDS, with an ARD of 09/30/2024, revealed Resident #259 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. An untitled facility document summarizing the facility's investigation into the incident involving Resident #44 and Resident #259, dated 10/30/2024, revealed CNA #1 witnessed Resident #259 walk over to Resident #44 and slap Resident #44 on the face on 10/26/2024 at approximately 1:15 PM. According to the document, the facility concluded Resident #44 nor Resident #259 had any previous reports of aggression, and the unfortunate event between these 2 [two] residents was an isolated occurrence. A typed statement from CNA #1, dated 10/28/2024, revealed the CNA witnessed Resident #259 slap Resident #44 across the face. According to the statement, when Resident #259 slapped Resident #44, their hand contacted Resident #44's right cheek and right ear. During an interview on 03/14/2025 at 6:14 PM, the Director of Nursing (DON) stated Resident #44 and Resident #259 had not had any incidents prior to this event.

Based on interview, record review, and facility policy review, the facility failed to ensure Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a diagnosed serious mental illness for 1 (Resident #35) of 1 sampled resident reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #35's initial PASARR reflected that the resident had a diagnosis of depression. Findings included: A facility policy titled, Pre-Admission Screening and Resident Review, revised 12/2016, indicated, The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. An Admission Record indicated admitted Resident #35 on 11/30/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of depression (onset date 11/30/2024). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2024, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident's active diagnoses at the time of the assessment included depression. Resident #35's Level I PASARR, dated 11/30/2024, indicated Section III - Serious Mental Illness, question 9. diagnosed Serious Mental Illness. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance was answered, No. The resident's Level I PASARR indicated the results were negative, a Level II evaluation was not required, and the case was closed. During an interview on 03/13/2025 at 12:55 PM, the MDS Coordinator stated that when a resident was admitted to the facility, it was her responsibility to ensure their PASARR was accurate. After reviewing Resident #35's Level I PASARR, dated 11/30/2024, the MDS Coordinator stated it was inaccurate. The MDS Coordinator stated if a PASRR was not completed accurately, the resident might not get the care needed to help with their mental health diagnoses. During an interview on 03/14/2025 at 4:54 PM, the Administrator stated he expected staff to follow the facility's policy for PASSARs.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure staff assisted a dependent resident with activities of daily living (ADLs) for 1 (Resident #7) of 5 sampled residents reviewed for ADLs. Specifically, the facility failed to provide nail care for Resident #7. Findings included: A facility policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/2018, indicated, Residents will [sic] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. An Admission Record revealed the facility originally admitted Resident #7 on 02/02/2022 and most recently admitted the resident on 10/01/2024. According to the Admission Record, the resident had a medical history that included diagnoses of quadriplegia (loss of function in all four limbs), hemiplegia (a condition characterized by paralysis or weakness on one side of the body), and hemiparesis (weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting the right dominant side. The Admission Record did not reflect the resident had a diagnosis of diabetes. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #7 had short- and long-term memory problems and severely impaired cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). The MDS indicated the resident was dependent on staff for personal hygiene. Resident #7's Care Plan Report included a focus area, initiated 07/25/2023, that indicated the resident was dependent on staff for meeting their emotional, intellectual, physical, and social needs. The focus area further indicated the resident was non-verbal and unable to ambulate. An observation on 03/10/2025 at 2:38 PM revealed Resident #7 had long fingernails on both hands. The observation revealed Resident #7 had bilateral hand contractures, and their fingernails were close to touching the inner palm of both hands. An observation on 03/11/2025 at 12:51 PM revealed Resident #7's fingernails remained long. During an interview on 03/12/2025 at 1:05 PM, Certified Nursing Assistant (CNA) #11 stated CNAs were responsible for trimming non-diabetic residents' fingernails. CNA #11 stated Resident #7 received showers or baths twice a week and should have had their fingernails trimmed. During a concurrent observation and interview on 03/12/2025 at 1:32 PM, Registered Nurse (RN) #9 confirmed Resident #7's fingernails were long and needed to be trimmed. During a concurrent observation and interview on 03/12/2025 at 2:01 PM, CNA #18 stated the CNAs were responsible for cleaning and trimming fingernails for non-diabetic residents. CNA #18 observed Resident #7's fingernails and stated they were too long and needed to be trimmed. During an interview on 03/12/2025 at 2:33 PM, CNA #13 stated Sunday was nail care day, and the CNAs should be checking the fingernails every day and keeping them clean and trimmed. During an interview on 03/13/2025 at 9:41 AM, Restorative Nursing Assistant (RNA) #17 stated she tried to pay attention to the residents' fingernails when she put on their splints. RNA #17 stated she should have trimmed Resident #7's fingernails. During an interview on 03/14/2025 at 4:11 PM, the Director of Nursing (DON) stated she expected the staff to trim and cut residents' fingernails. During an interview on 03/14/2025 at 4:54 PM, the Administrator stated he expected staff to keep the residents' nails trimmed per their policy.

Based on interview, record review, and facility policy review, the facility failed to provide indwelling urinary catheter care per the facility's policy and accepted infection control standards and failed to maintain an indwelling urinary catheter bag below the level of the bladder for 1 (Resident #111) of 3 residents reviewed with an indwelling urinary catheter. Findings included: A facility policy titled, Catheter Care, Urinary, revised 08/2022, revealed the section titled Maintaining Unobstructed Urine Flow, included, 3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. The policy revealed the section titled Steps in the Procedure Routine Perineal Hygiene, included, c. Change the position of the washcloth (or wipe) with each cleansing stroke. d. With a clean washcloth (or wipe), rinse using the above technique. Further review revealed, 15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward. An Admission Record revealed the facility admitted Resident #111 on 01/22/2025 and most recently on 03/04/2025. According to the Admission Record, Resident #111 had a medical history that included hemiplegia (total or nearly complete inability to use one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, generalized muscle weakness, and unspecified malignant neoplasm of the colon (colon cancer). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2025, revealed Resident #111 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #111 was dependent on staff for toileting hygiene and required substantial/maximal assistance from staff with showering/bathing, personal hygiene, and dressing of the upper body and lower body. The MDS also indicated Resident #111 required substantial to moderate assistance from staff to roll from side to side in bed and was dependent on staff for transferring to and from bed. The MDS also indicated Resident #111 was always incontinent of bowel and bladder. Resident #111's Care Plan Report included a focus area initiated 03/05/2025, that indicated Resident #111 had an indwelling urinary catheter due to urinary retention. Interventions directed staff to position the catheter bag below the level of the bladder (initiated 03/05/2025). Resident #111's Order Summary Report with active orders as of 03/12/2025, contained an order dated 03/05/2025 for a Foley catheter 16 FR (French)/10 milliliters (ml) with instructions for staff to change the Foley catheter every month and as needed for displacement or non-functioning. The Order Summary Report revealed an order dated 03/05/2025 directing staff to change the resident's Foley catheter bag every week on the night shift. The order Summary Report revealed an order dated 03/12/2025 directing staff to change the resident's Foley catheter bag as needed. The Order Summary Report revealed an order dated 03/05/2025 directing staff to provide Foley catheter care every shift. During an observation on 03/11/2025 at 11:35 AM, Resident #111's urinary catheter drainage bag was hanging on the footboard of the resident's bed above the level of the resident's bladder. During an interview on 03/11/2025 at 11:40 AM, Certified Nursing Assistant (CNA) #1, who was assigned to care for Resident #111, stated he had placed the urinary catheter drainage bag on the footboard of the bed when the room had been cleaned earlier and had forgotten to move the drainage bag to the side of the bed onto a lower rail. CNA #1 stated he had been taught that the urinary catheter drainage bag should be placed lower than the resident's bladder but was unsure why. Licensed Vocational Nurse (LVN) #14 was interviewed on 03/11/2025 at 11:50 AM. LVN #14 stated she had not noticed the positioning of Resident #111's urinary catheter drainage bag when she had been in the resident's room. LVN #14 stated the danger of having the urinary catheter drainage bag higher than the resident's bladder would be the potential for the catheter tubing to be pulled, harming the resident's genital area or could potentially cause an infection. The Director of Nursing (DON) was interviewed on 03/11/2025 at 12:00 PM. The DON stated the urinary catheter drainage bag for Resident #111 should not have been hanging on the foot of the bed since a urinary catheter drainage bag that was placed higher than the resident's bladder could cause a backflow of urine, resulting in a urinary tract infection (UTI). Medical Doctor (MD) #5 was interviewed on 03/14/2025 at 9:19 AM. He stated a resident's urinary catheter drainage bag was expected to be kept below the level of the bladder to prevent infection from urine backflow. An observation was made on 03/12/2025 at 9:11 AM of CNA #1 providing a bath and catheter care to Resident #111. CNA #1 used a towel and poured water over the resident's genital area, covering the area where the urinary catheter tubing entered the resident's body. CNA #1 then took another damp towel and washed the resident's face and upper body. When CNA #1 completed washing the resident's upper body, he used a disposable cloth to clean the resident's genital area where the catheter was located. CNA #1 stated he had been taught to use a different part of the cloth for each cleansing stroke and stated, Oh, when it was pointed out that he had not changed the position of the disposable cloth while cleaning the resident's genital area. CNA #1 washed back and forth across the catheter entry site. When cleaning the catheter tubing, CNA #1 started at the distal part of the tubing and cleaned toward the catheter's entry point into the resident's body. CNA #1 stated he was unaware he was to start at the entry point and clean outward. The DON was interviewed on 03/12/2025 at 9:58 AM. The DON stated that when catheter care was provided, staff were expected to wipe from the cleanest area, which was near the insertion site, and use a clean part of the cloth for each cleansing wipe. The Administrator was interviewed on 03/13/2025 at 1:22 PM. The Administrator stated he expected the facility's policy for catheter care to be followed to decrease the risk of UTIs for Resident #111.

Based on observation, interview, and facility document and policy review, the facility failed to provide food that accommodated resident allergies and preferences for 2 (Resident #257 and Resident #41) of 3 residents sampled for food. Findings included: A facility policy titled, Food Allergies, dated 2023, revealed, Policy: Residents with food allergies will be identified upon admission. The policy also indicated, Procedure: 1. Allergies will be noted in the medical record. 2. All allergies will be communicated in writing directly to the FNS [Food and Nutrition Services] Director by Nursing. 3. Appropriate food substitutions will be offered for foods the resident cannot eat. 4. Refer to [Vendor Name] Diet Manual for food allergy information. 5. Allergies will be noted on the tray card, the resident diet profile, and posted in the kitchen and nursing station, if necessary. A facility policy titled, Food Preferences, dated 2023, revealed, Policy: Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. Condiments such as salt, pepper, and sugar are available at each meal unless contraindicated by the diet order. The policy also indicated, Procedure: Food preferences will be obtained as soon as possible through the initial resident screen. This screening must be completed within 7 days of admission by the FNS Director. Food preference can be obtained from the resident, family, or staff members. Updating of food preferences will be done as the resident's needs change and/or during the quarterly review. A facility policy titled, Food Allergies and Intolerances, revised August 2017, revealed, Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). The policy revealed, Assessment and Interventions: 1. Residents are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment. 2. All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan. Further review revealed, 5. Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat. 1. An Admission Record revealed the facility admitted Resident #257 on 02/25/2025. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified protein-calorie malnutrition, gastro-esophageal reflux disease without esophagitis, type 2 diabetes mellitus without complications, and a personal history of other diseases of the digestive system. The Admission Record indicated Resident #257 was allergic to bell pepper, broccoli, cauliflower, and eggs. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2025, revealed Resident #257 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident required setup or clean-up assistance with eating and received a mechanically altered and therapeutic diet during the assessment lookback period. Resident #257's Care Plan Report included a focus statement dated 03/05/2025, that indicated the resident was at risk for impaired nutritional status as well as increased risk for malnutrition related to carbohydrate consistent diet (CCHO) diet restrictions, requests for a mechanical soft diet related to missing teeth, a recent hospitalization for a fracture, and obesity with a body mass index (BMI) greater than 30. The focus statement revealed the resident was allergic to eggs, bell peppers, broccoli, and cauliflower. Interventions directed staff to provide and serve the resident's diet as ordered (initiated 03/05/2025). Resident #257's Registered Dietitian Nutrition Assessment, dated 03/05/2025, indicated the resident had an allergy to eggs, bell peppers, broccoli, cauliflower. A document titled Good For Your Health Menus revealed the facility menus for the timeframe from 03/10/2025 through 03/16/2025. The menus revealed that for 03/10/2025 the lunch served to residents was tarragon chicken with oven roasted potatoes, green beans with red peppers, broccoli salad, and a tropical fruit mold. A Diet Type Report, dated 03/11/2025, revealed Resident #257 had the following food allergies: bell pepper, broccoli, cauliflower, and eggs. An undated document titled, Tray Check cart 2 Lunch, revealed Resident #257 had a food allergy to broccoli, cauliflower, bell peppers, and eggs. An observation on 03/10/2025 at 12:39 PM revealed Resident #257 in their room, seated in a wheelchair. Resident #257's lunch was delivered by a staff member and placed on the tray table in front of the resident. The lunch meal included a small bowl of broccoli salad. Resident #257 asked the staff member to remove the broccoli salad because the resident could not eat it. The staff member removed the broccoli salad, left the room, and did not offer an alternative. The resident's tray card was observed on their tray and showed that the resident was allergic to broccoli. During an interview on 03/12/2025 at 12:17 PM, Resident #257 stated that the meals they received included whatever the facility had on the menu and staff did not provide a substitute when a mistake with their meal was made. During an interview on 03/12/2025 at 1:36 PM, Dietary Aide #12 stated she looked at the tray check list on the wall in the kitchen for a list of resident allergies, preferences, and dislikes. She stated the allergies, preferences, and dislikes were also on the tray cards. She stated that when plating a meal, the dietary aide looked at the tray cards and let her know what was on the card for the meal to include preferences, dislikes, and allergies. Dietary Aide #12 stated they would give the resident an alternative if the meal went on the tray and there was an error. During an interview on 03/12/2025 at 1:54 PM, the Dietary Manager stated she printed the tray card, and the dietary staff were to check them. She stated the allergies, food preferences, and dislikes were on the tray card and on the Diet Type Report that was printed three times per week on Mondays, Wednesdays, and Fridays. She stated the dietary aides wrote on the tray card if there was an allergy or dislike even though it was already printed on the tray card. She stated staff were supposed to double check. During an interview on 03/12/2025 at 3:49 PM, the Registered Dietician (RD) stated the original allergy lists were part of the medical record and were not able to be revised without a physician's order. The RD stated the Dietary Manager, and she would visit a new resident within the first couple of days and confirm a resident's likes and dislikes. The RD stated the dietary staff needed to double check the list and tray cards. The RD stated the staff member could have offered something different to Resident #257. On 03/13/2025 at 1:20 PM, the Director of Nursing (DON) stated staff needed to read the names and diet (on the tray cards) and if something was wrong with the meal, staff should take the meal back to the kitchen to get a proper meal for the resident. 2. An Admission Record revealed the facility admitted Resident #41 on 09/01/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of unspecified protein calorie malnutrition. The Admission Record indicated Resident #41 was allergic to mushrooms. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/03/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident was independent with eating and received a therapeutic diet during the assessment lookback period. Resident #41's Care Plan Report included a focus statement initiated 09/04/2024, that indicated the resident had a nutritional problem or potential nutritional problem related to a carbohydrate consistent diet (CCHO) diet, no added salt diet restrictions, and the resident was very particular about foods. The focus statement revealed the resident had an allergy to mushrooms and that the resident stated they had an allergy to eggs. Interventions indicated that the registered dietician would evaluate and make diet change recommendations as needed (initiated 09/04/2024). Resident #41's Progress Notes revealed a Nutrition/Dietary Note dated 12/18/2024 at 3:15 PM, that indicated the resident had an allergy to mushrooms listed in their electronic medical record. The note revealed the resident reported being allergic to eggs and any food that contained sulfur. The note revealed the resident's extensive list of preferences was provided to the dietary department. Per the note, the resident continued to have complaints regarding food and continued to change their preferences. The note revealed the resident refused all vegetables. The note indicated the resident would continue to provide preferences as needed, remained self-directed with intake, and frequently changed requests based on allergies. Resident #41's Progress Notes revealed a Nutrition/Dietary Note dated 01/08/2025 at 10:39 AM, that indicated the resident was particular about foods, did not receive vegetables, was allergic to mushrooms, and stated that they had an allergy to eggs. The note indicated that the resident's preferences were noted and honored. A Diet Type Report, dated 03/11/2025, revealed Resident #41 had a food allergy to mushrooms. An undated document titled Tray Check cart 2 Lunch revealed for Resident #41 there were instructions for staff to check the resident's dislikes, and NO VEGETABLES. The document revealed the resident was allergic to eggs and mushrooms. Resident #41's tray card for lunch, dated 03/13/2025, revealed Resident #41 was allergic to mushrooms and eggs. The tray card indicated Resident #41's dislikes included bread, eggs, and No Vegetables. During an interview on 03/10/2025 at 11:58 AM, Resident #41 was in their room, seated in a wheelchair. Resident #41 stated a list was given to the facility staff of foods the resident was unable to eat which included eggs, broccoli, and Brussel sprouts. Resident #41 stated they were allergic to foods with sulfur in it. Resident #41 stated if they ate any of the foods, they listed they would be fire engine red and itch constantly. Resident #41 stated they were very particular about what they ate. A document titled Good For Your Health Menus revealed the facility menus for the timeframe from 03/10/2025 through 03/16/2025. The menus revealed that for 03/12/2025 the lunch served to residents was sweet and sour chicken, sesame noodles, stir fry vegetables, mandarin Asian salad, and a lemon snow bar. An observation on 03/12/2025 at 12:12 PM revealed Resident #41 was in their room in a wheelchair, and a lunch tray was delivered by Certified Nursing Assistant (CNA) #6. During an observation on 03/12/2025 at 12:13 PM, Resident #41's meal tray revealed the resident was served stir fry vegetables. During a concurrent interview Resident #41 stated they did not eat the stir fry vegetables. An observation of Resident #41's tray card on their tray revealed no vegetables was circled with black marker. During an interview on 03/12/2025 at 12:21 PM, CNA #6 stated she looked at the food on the tray and the tray card. She stated Resident #41 had vegetables on their tray and the resident should not. During an interview on 03/12/2025 at 1:36 PM, Dietary Aide #12 stated she looked at the tray check list on the wall in the kitchen for a list of resident allergies, preferences, and dislikes. She stated the allergies, preferences, and dislikes were also on the tray cards. She stated that when plating a meal, the dietary aide looked at the tray cards and let her know what was on the card for the meal to include preferences, dislikes, and allergies. Dietary Aide #12 stated they would give the resident an alternative if the meal went on the tray and there was an error. During an interview on 03/12/2025 at 1:54 PM, the Dietary Manager stated she printed the tray card, and the dietary staff were to check them. She stated the allergies, food preferences, and dislikes were on the tray card and on the Diet Type Report that was printed three times per week on Mondays, Wednesdays, and Fridays. She stated the dietary aides wrote on the tray card if there was an allergy or dislike even though it was already printed on the tray card. She stated staff were supposed to double check. During an interview on 03/12/2025 at 3:49 PM, the Registered Dietician (RD) stated the original allergy lists were part of the medical record and were not able to be revised without a physician's order. The RD stated the Dietary Manager, and she would visit a new resident within the first couple of days and confirm a resident's likes and dislikes. The RD stated Resident #41's list was brought to the kitchen, and the staff must look at the list each time. Resident #41 should not receive vegetables. Resident #41 was allergic to sulfa antibiotics, so she put eggs as an allergy on the tray card as a precaution, and the resident stated being allergic to food items with sulfur in it. The RD stated the dietary staff needed to double check the list and tray cards. On 03/13/2025 at 1:20 PM, the Director of Nursing (DON) stated staff needed to read the names and diet (on the tray cards) and if something was wrong with the meal, staff should take the meal back to the kitchen to get a proper meal for the resident.

Based on interview and record review, the facility failed to follow their policies and procedures (P&P) titled, Psychotropic Medication Use,regarding the safe and appropriate prescribing and administering of psychotropic (used to treat psychosis- conditions that affect the mind, where there has been some loss of contact with reality) medication for one of five sampled residents (Resident 1) when Divalproex sodium (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and mental disorders and to prevent migraine headaches) was prescribed and administered prior to determining the appropriate indication for use. This failure increased Resident 1 ' s risk of serious side effects that included but were not limited to nausea, vomiting, headaches, liver complications, tardive dyskinesia (condition causing uncontrolled movements various body parts like the arms and legs or of the tongue in a chewing motion) and changes to mood, behaviors and thought processes. Findings: During a review of Resident 1 ' s Admission Record (AR- a document that provides resident contact details, a brief medical history), dated 1/15/25, the AR indicated, Resident 1 had diagnoses which included .VASCULAR DEMENTIA [decline in thinking, memory and judgement caused by an impaired supply of blood to the brain] .ANXIETY DISORDER [mental condition which causes intense and persistent worry] .CEREBRAL INFARCTION [a serious condition that occurs when blood flow to the brain is blocked causing damage to the tissue] .APHASIA [disorder affecting one ' s ability to communicate] .HISTORY OF TRANSIENT ISCHEMIC ATTACK [TIA- a temporary lack of blood flow to the brain] . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 1/4/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation, and memory recall) indicated a score of 6 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s Hospitalist Discharge Summary (HDS), dated 1/3/25, the HDS indicated, .past medical history significant for hypertension [high blood pressure], TIA, anxiety .and reported dementia who was brought to the ED [emergency department] (as a code stroke) on 12/30/2024 for slurred speech and confusion .and no reported history of seizures . During a concurrent interview and record review on 1/15/25 at 11:00 a.m. with Registered Nurse (RN) 2, Resident 1 ' s Order Summary Report (OSR), dated 1/3/25 was reviewed. The OSR indicated, . [Divalproex sodium] Oral Tablet Delayed Release 250 [milligram (MG - unit of measurement)] Give 1 tablet by mouth one time a day for seizure prevention . [Divalproex sodium] Oral Tablet Delayed Release 250 MG Give 2 tablet by mouth one time a day for seizure prevention . RN 2 stated, a possible side effect of Divalproex sodium were symptoms of tardive dyskinesia. During a concurrent interview and record review on 1/15/25 at 2:10 p.m. with the Director of Nursing (DON), Resident 1 ' s Medication Administration Record (MAR), dated 1/15/25 was reviewed. The MAR indicated, .[Divalproex sodium] Oral Tablet Delayed Release 250 MG .Give 1 tablet by mouth in the afternoon for seizure prevention -Order Date- 01/03/2025 [4:51 p.m.] - [discontinue (D/C)] Date- 01/05/2025 [10:49 a.m.] .[Divalproex sodium] Oral Tablet Delayed Release 250 MG . Give 2 tablet by mouth one time a day for seizure prevention -Order Date- 01/03/2025 [4:51 p.m.] -D/C Date- 01/05/2025 [10:49 a.m.] . The MAR indicated, Divalproex sodium was administered to Resident 1 on 1/4/25 at 9:00 a.m., 1/4/25 at 4:00 p.m. and 1/5/25 at 9:00 a.m. The DON stated, Divalproex sodium was administered to Resident 1 for seizure prevention on 1/4/25 at 9:00 a.m., 1/4/25 at 4:00 p.m. and 1/5/25 at 9:00 a.m. The DON stated, Resident 1 was not diagnosed with any seizure disorder. The DON stated, it was important to have the correct indication for use listed for Resident 1 ' s order for Divalproex sodium because otherwise it was an unnecessary medication and there was not a valid reason to administer it to Resident 1. The DON stated possible side effects of Divalproex sodium included gastrointestinal distress, headaches, and liver complications. The DON stated, Divalproex sodium potentially altered Resident 1 ' s behavior, mood and thought processes. During a phone interview on 1/16/25 at 4:32 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 ' s Inter-Facility Transfer Report (IFTR), was provided by the hospital to indicate which orders, including medications, Resident 1 should have continued upon admission to the facility. LVN 1 stated she administered Divalproex sodium on 1/5/25 at 9:00 a.m. to Resident 1 according to the medication orders. LVN 1 stated Resident 1 ' s responsible party (RP) asked for Divalproex sodium to be discontinued. LVN 1 stated she called Resident 1 ' s nurse practitioner (NP) and the NP ordered for the Divalproex sodium to be discontinued. During a phone interview on 1/17/25 at 3:00 p.m. with LVN 2, LVN 2 stated Divalproex sodium was prescribed to individuals as an anticonvulsant (to prevent seizures) medication and was also indicated to be used as a psychotropic medication. LVN 2 stated, it was important to administer the right medication with the appropriate indication according to the documented diagnoses of an individual. LVN 2 stated nurses should not administer an unnecessary medication like Divalproex sodium if Resident 1 did not have an appropriate diagnosis. During a phone interview on 1/17/25 at 3:45 p.m. with LVN 3, LVN 3 stated Resident 1 ' s RP was worried during a visit with Resident 1 on 1/4/25 because Resident 1 ' s mood was different than her usual self. LVN 3 stated Resident 1 ' s RP was upset after finding out Resident 1 was given Divalproex sodium because Resident 1 had not taken Divalproex sodium for a long time. LVN 3 stated a medication should only be given to Resident 1 for an appropriate diagnosis and not unnecessarily because there was a potential for Resident 1 to experience side effects. During a review of the facility ' s document titled, Psychotherapeutic [relating to the treatment of mental illness] Medication INFORMED CONSENT (PMIC), undated, the PMIC indicated, .MISCELLANEOUS MEDICATIONS . Depakote . DOCUMENTATION NEEDED IN CHART .Diagnosis and target behavior indicated in the medication order . During a review of the Mayo Clinic website, https://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/description/drg-20072886, dated 8/31/24, the website indicated, .Divalproex sodium .is used to treat certain types of seizures .also used to treat the manic (extremely elevated and excited mood) phase of bipolar (mental illness that causes intense shifts in mood, energy levels and behavior) disorder .elderly patients are more likely to have unwanted effects . Liver problems may occur while .using this medicine, and some may be serious .Side Effects .Confusion .Delusions (a false belief or judgement about external reality, despite evidence, occurring in mental conditions) of persecution, mistrust, suspiciousness, or combativeness .False beliefs that cannot be changed by facts .False or unusual sense of well-being .Headaches .Nausea .Problems with memory or speech .Rapidly changing moods .Sleepiness or unusual drowsiness .Trouble thinking and planning .Uncontrolled chewing movements .Uncontrolled movements of the arms and legs .Vomiting . During a review of the facility ' s P&P titled, Psychotropic Medication Use, 7/22, the P&P indicated, .Residents will not receive medications that are not clinically indicated to treat a specific condition .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use .Situations which may prompt an evaluation .of the resident include: a. admission .The evaluation may include .an evaluation of resident status (co-morbid conditions, symptoms, psychiatric diagnoses; etc.) . Based on interview and record review, the facility failed to follow their policies and procedures (P&P) titled, Psychotropic Medication Use ,regarding the safe and appropriate prescribing and administering of psychotropic (used to treat psychosis- conditions that affect the mind, where there has been some loss of contact with reality) medication for one of five sampled residents (Resident 1) when Divalproex sodium (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and mental disorders and to prevent migraine headaches) was prescribed and administered prior to determining the appropriate indication for use. This failure increased Resident 1's risk of serious side effects that included but were not limited to nausea, vomiting, headaches, liver complications, tardive dyskinesia (condition causing uncontrolled movements various body parts like the arms and legs or of the tongue in a chewing motion) and changes to mood, behaviors and thought processes. Findings: During a review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history) , dated 1/15/25, the AR indicated, Resident 1 had diagnoses which included .VASCULAR DEMENTIA [decline in thinking, memory and judgement caused by an impaired supply of blood to the brain] .ANXIETY DISORDER [mental condition which causes intense and persistent worry] .CEREBRAL INFARCTION [a serious condition that occurs when blood flow to the brain is blocked causing damage to the tissue] .APHASIA [disorder affecting one's ability to communicate] .HISTORY OF TRANSIENT ISCHEMIC ATTACK [TIA- a temporary lack of blood flow to the brain] . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) , dated 1/4/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation, and memory recall) indicated a score of 6 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment. During a review of Resident 1's Hospitalist Discharge Summary (HDS) , dated 1/3/25, the HDS indicated, .past medical history significant for hypertension [high blood pressure], TIA, anxiety .and reported dementia who was brought to the ED [emergency department] (as a code stroke) on 12/30/2024 for slurred speech and confusion .and no reported history of seizures . During a concurrent interview and record review on 1/15/25 at 11:00 a.m. with Registered Nurse (RN) 2, Resident 1's Order Summary Report (OSR) , dated 1/3/25 was reviewed. The OSR indicated, . [Divalproex sodium] Oral Tablet Delayed Release 250 [milligram (MG - unit of measurement)] Give 1 tablet by mouth one time a day for seizure prevention . [Divalproex sodium] Oral Tablet Delayed Release 250 MG Give 2 tablet by mouth one time a day for seizure prevention . RN 2 stated, a possible side effect of Divalproex sodium were symptoms of tardive dyskinesia. During a concurrent interview and record review on 1/15/25 at 2:10 p.m. with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR) , dated 1/15/25 was reviewed. The MAR indicated, .[Divalproex sodium] Oral Tablet Delayed Release 250 MG .Give 1 tablet by mouth in the afternoon for seizure prevention -Order Date- 01/03/2025 [4:51 p.m.] - [discontinue (D/C)] Date- 01/05/2025 [10:49 a.m.] .[Divalproex sodium] Oral Tablet Delayed Release 250 MG . Give 2 tablet by mouth one time a day for seizure prevention -Order Date- 01/03/2025 [4:51 p.m.] -D/C Date- 01/05/2025 [10:49 a.m.] . The MAR indicated, Divalproex sodium was administered to Resident 1 on 1/4/25 at 9:00 a.m., 1/4/25 at 4:00 p.m. and 1/5/25 at 9:00 a.m. The DON stated, Divalproex sodium was administered to Resident 1 for seizure prevention on 1/4/25 at 9:00 a.m., 1/4/25 at 4:00 p.m. and 1/5/25 at 9:00 a.m. The DON stated, Resident 1 was not diagnosed with any seizure disorder. The DON stated, it was important to have the correct indication for use listed for Resident 1's order for Divalproex sodium because otherwise it was an unnecessary medication and there was not a valid reason to administer it to Resident 1. The DON stated possible side effects of Divalproex sodium included gastrointestinal distress, headaches, and liver complications. The DON stated, Divalproex sodium potentially altered Resident 1's behavior, mood and thought processes. During a phone interview on 1/16/25 at 4:32 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1's Inter-Facility Transfer Report (IFTR) , was provided by the hospital to indicate which orders, including medications, Resident 1 should have continued upon admission to the facility. LVN 1 stated she administered Divalproex sodium on 1/5/25 at 9:00 a.m. to Resident 1 according to the medication orders. LVN 1 stated Resident 1's responsible party (RP) asked for Divalproex sodium to be discontinued. LVN 1 stated she called Resident 1's nurse practitioner (NP) and the NP ordered for the Divalproex sodium to be discontinued. During a phone interview on 1/17/25 at 3:00 p.m. with LVN 2, LVN 2 stated Divalproex sodium was prescribed to individuals as an anticonvulsant (to prevent seizures) medication and was also indicated to be used as a psychotropic medication. LVN 2 stated, it was important to administer the right medication with the appropriate indication according to the documented diagnoses of an individual. LVN 2 stated nurses should not administer an unnecessary medication like Divalproex sodium if Resident 1 did not have an appropriate diagnosis. During a phone interview on 1/17/25 at 3:45 p.m. with LVN 3, LVN 3 stated Resident 1's RP was worried during a visit with Resident 1 on 1/4/25 because Resident 1's mood was different than her usual self. LVN 3 stated Resident 1's RP was upset after finding out Resident 1 was given Divalproex sodium because Resident 1 had not taken Divalproex sodium for a long time. LVN 3 stated a medication should only be given to Resident 1 for an appropriate diagnosis and not unnecessarily because there was a potential for Resident 1 to experience side effects. During a review of the facility's document titled, Psychotherapeutic [relating to the treatment of mental illness] Medication INFORMED CONSENT (PMIC) , undated, the PMIC indicated, .MISCELLANEOUS MEDICATIONS . Depakote . DOCUMENTATION NEEDED IN CHART .Diagnosis and target behavior indicated in the medication order . During a review of the Mayo Clinic website, https://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/description/drg-20072886, dated 8/31/24, the website indicated, .Divalproex sodium .is used to treat certain types of seizures .also used to treat the manic (extremely elevated and excited mood) phase of bipolar (mental illness that causes intense shifts in mood, energy levels and behavior) disorder .elderly patients are more likely to have unwanted effects . Liver problems may occur while .using this medicine, and some may be serious .Side Effects .Confusion .Delusions (a false belief or judgement about external reality, despite evidence, occurring in mental conditions) of persecution, mistrust, suspiciousness, or combativeness .False beliefs that cannot be changed by facts .False or unusual sense of well-being .Headaches .Nausea .Problems with memory or speech .Rapidly changing moods .Sleepiness or unusual drowsiness .Trouble thinking and planning .Uncontrolled chewing movements .Uncontrolled movements of the arms and legs .Vomiting . During a review of the facility's P&P titled, Psychotropic Medication Use , 7/22, the P&P indicated, .Residents will not receive medications that are not clinically indicated to treat a specific condition .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use .Situations which may prompt an evaluation .of the resident include: a. admission .The evaluation may include .an evaluation of resident status (co-morbid conditions, symptoms, psychiatric diagnoses; etc.) .

Based on interview and record review, the facility failed to meet professional standards of quality for two of three sampled residents (Resident 1 and Resident 2), when: 1. Resident 1 had an unwitnessed fall on 7/24/24 and facility staff did not complete a change of condition (COC) assessment (used to describe situation, background, assessment of resident and physician recommendations). 2. Resident 2 had a change in urine patterns on 7/28/24, blood in urine on 7/30/24 and the facility did not complete a COC for both instances for Resident 2. These failures resulted in incomplete documentation for Resident 1 and Resident 2 putting Resident 1 at risk for falls and Resident 2 at risk for delay in care when there was no documentation of change in condition to inform other facility staff of changes in resident care. Findings: 1. During a record review of Resident 1 ' s Post Fall Evaluation (PFE), dated 7/25/24, the PFE indicated, Resident 1 had an unwitnessed fall on 7/24/24 resulting in fracture to the olecranon process/proximal ulna and radial neck (a bone injury in the elbow that can be caused by a direct blow or a fall). The PFE indicated, . fall was unwitnessed fall occurred in the bathroom. Resident was attempting to self-toilet at time of fall . injury redness left upper abdomen . During a concurrent interview and record review on 8/13/24 at 12:22 p.m. with Registered Nurse (RN) 1, Resident 1 ' s Post Fall Evaluation (PFE), dated 7/25/24, the PFE indicated Resident 1 had an unwitnessed fall on 7/24/24 resulting in fracture to the olecranon process/proximal ulna and radial neck. The PFE indicated, . fall was unwitnessed fall occurred in the bathroom. Resident was attempting to self-toilet at time of fall . injury redness left upper abdomen . RN 1 stated after review of Resident 1 ' s Electronic Medical Record (EMR), there was no change of condition report completed for Resident 1 ' s fall with fracture. RN 1 stated the facility process was for the charge nurse to complete a COC to ensure the circumstances were documented in Resident 1 ' s EMR. During an interview on 8/13/24 at 2:07 p.m. with the director of nursing (DON), the DON stated it was the facility process for the charge nurse on shift to complete a COC for all changes in resident health. The DON stated it was important to complete a COC because it gave more information of the circumstances and who was notified of the change. During a review of Resident 1's Admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of syncope (fainting), fall, unsteadiness (off balance) on feet. During a review of Resident 1's Minimum Data Set [MDS - a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/18/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0- 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 -12 moderate cognitive impairment, 13- 15 cognitively intact) which indicated Resident 1 was cognitively intact. During a review of the facility ' s policy and procedure (P&P) titled, Charting and Documentation, dated 07/2017, the P&P indicated, . all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record . the following information is to be documented in the resident medical record, objective observations, changes in the resident ' s condition, events, incidents or accidents involving the resident . documentation in the medical record will be objective, complete, and accurate . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient ' s chart with clear, concise statements of the nurse ' s decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician ' s orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician ' s . order properly . 2. During a review of Resident 2's the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of orthopedic aftercare (care and treatment received after surgery to recover and regain function) following surgical amputation (procedure that removes part of the body, such as arm or leg), osteomyelitis (a bone infection that causes swelling), muscle weakness, anemia (blood disorder that occurs when body doesn ' t have enough red blood cells to carry oxygen throughout the body), end stage renal disease (terminal condition when kidneys no longer function and don ' t filter waste from the blood), presence of urogenital implants (injection of material to help control urine leakage). During a record review of Resident 2 ' s Orders Administration Note (OAN), dated 7/30/24, the note indicated, . Blood in urine and bruising noted per MD hold [medication brand name] for 3 days . During a concurrent interview and record review on 8/13/24 at 12:39 p.m. with RN 1, Resident 2 ' s Progress note-Health status (PN), dated 7/28/24 and Resident 2 ' s OAN, dated 7/30/24 were reviewed. The PN indicated, . Burning during urination MD gave order to change foley catheter (device that drains urine from the bladder) if resident continues to have discomfort . The OAN indicated, . Blood in urine and bruising noted per MD hold [medication brand name] for 3 days . RN 1 stated the facility process was for the charge nurse on shift to complete a COC for any changes in resident status. RN 1 stated it was important for a COC to be completed to be aware of what was happening, what the change was, what time the incident occurred, instances and what interventions were implemented at the time of change in health. During an interview on 8/13/24 at 2:07 p.m. with the director of nursing (DON), the DON stated it was the facility process for the charge nurse on shift to complete a COC for all changes in resident health. The DON stated it was important to complete a COC because it gave more information of the circumstances and who was notified of the change. During a review of the facility ' s policy and procedure (P&P) titled, Charting and Documentation, dated 07/2017, the P&P indicated, . all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record . the following information is to be documented in the resident medical record, objective observations, changes in the resident ' s condition, events, incidents or accidents involving the resident . documentation in the medical record will be objective, complete, and accurate . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient ' s chart with clear, concise statements of the nurse ' s decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician ' s orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician ' s . order properly .

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan per facility ' s policy and procedure titled Care Planning-Interdisciplinary Team for one of three sampled residents (Resident 1), when Resident 1 sustained a fracture (broken bone) of left arm on 7/24/24 and there was no care plan created for Resident 1 ' s care of the fractured right arm. This failure had the potential for harm when the facility staff did not create a care plan with interventions to monitor Resident 1 ' s fractured right arm with bandage that could have led to skin breakdown, pain, and acute compartment syndrome (bandage or cast placed on injured arm or leg too tightly) causing swelling, numbness, weakness, difficulty moving the affected body part. Findings: During an observation on 8/13/24 at 11:22 a.m. of Resident 1 in Resident 1 ' s room. Resident 1 was observed walking around facility with four wheeled walker. Resident 1 was observed to have an arm brace to the right arm, the right arm was observed wrapped in bandage appearing as an arm cast. Resident was dressed, clean and groomed. During a review of Resident 1's Admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of syncope (fainting), fall, unsteadiness (off balance) on feet. During a review of Resident 1's Minimum Data Set [MDS - a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/18/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0- 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 -12 moderate cognitive impairment, 13- 15 cognitively intact) which indicated Resident 1 was cognitively intact. During a record review of Resident 1 ' s Acute Hospital radiology (x-ray) report, dated 7/24/24, the x-ray report indicated, . There are acute fractures of the olecranon process/proximal ulna and radial neck (a bone injury in the elbow that can be caused by a direct blow or a fall) . During a concurrent interview and record review on 8/13/24 at 12:22 p.m. with Registered Nurse (RN) 1, Resident 1 ' s Care Plan (CP), initiated date 2/20/24, the CP indicated, there was no care plan created for Resident 1 ' s fracture following unwitnessed fall on 7/24/24. RN 1 stated there was no care plan created for Resident 1 ' s fracture. RN 1 stated it was important to have a care plan in place to know what new interventions would be part of Resident 1 ' s care. RN 1 stated the facility expectation was for the charge nurse to initiate the care plan to monitor Resident 1 ' s cast and possible complications such as change in color and sensation. During an interview on 8/13/24 at 2:07 p.m. with the director of nursing (DON), the DON stated that the facility did not create and implement a care plan for Resident 1 ' s fracture resulting from the unwitnessed fall on 7/24/24. The DON stated it was the expectation for the facility to create a care plan for Resident 1 for the new fracture to ensure all staff were implementing the same interventions. During a review of the facility ' s policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, dated 03/2022, the P&P indicated, . the interdisciplinary team (IDT) is responsible for the development of resident care plans . comprehensive person-centered care plans are based on resident assessments and developed by an IDT. The IDT includes but not limited to the resident ' s attending physician, a registered nurse, a nursing assistant, a member of the food and nutrition services staff, to the extent practicable, the resident and/or the resident ' s representative and other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident . [

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurses (LVN) followed professional standards of practice for one of three sampled residents (Resident 2), when on 9/30/23 at 6:30 a.m., Resident 2's blood glucose (sugar) level was of 55 mg/dl [milligrams per deciliter [a unit of measurement]) and LVN did not communicate the result to Resident 2's physician and did not recheck Resident 2's blood glucose within 15 minutes as per the facility's Hypoglycemia (low blood glucose) policy. This failure increased the potential for Resident 2 to experience complications such as confusion, coma (a state of deep unconsciousness that lasts for a prolonged or indefinite period), headache and restlessness. Findings: During a review of Resident 2 ' s Face Sheet (FS- a document containing resident profile information), dated 10/17/23, the FS indicated, Resident 2 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus (body cannot properly use insulin [a hormone that regulates blood sugar]). During a concurrent interview and record review on 10/17/23 at 11:03 a.m. with LVN 1, Resident 2's Medication Administration Record (MAR), dated 9/2023 was reviewed. The MAR indicated, Resident 2 ' s blood glucose on 9/30/23 at 6:30 a.m. was 55 mg/dl. LVN 1 reviewed Resident 2's clinical record and was not able to find documentation Resident 2 ' s physician was notified regarding the low blood glucose and there was no blood glucose recheck in 15 minutes. LVN 1 stated there was no follow up blood glucose check done until the scheduled blood glucose check at 11:30 a.m LVN 1 stated, If it was not documented, it was not done. LVN 1 stated the importance of calling the physician and rechecking the blood glucose was to prevent complications of low blood glucose. During concurrent interview and record review on 10/17/23 at 12:31 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Management of Hypoglycemia dated 11/2020 indicated, .To provide guidelines for managing hypoglycemia .For .(<70 mg/dl) .Notify the provider immediately .Recheck blood glucose in 15 minutes .If blood sugar remains < (less than) 70 mg/dl repeat oral glucose and notify physician for further orders . The DON stated the purpose of rechecking the blood glucose was to ensure the blood glucose did not remain low. The DON stated per the facility policy the physician should have been notified but was not. During a review of the Professional Reference titled, Hypoglycemia (Low Blood Glucose) dated undated, retrieved from https://diabetes.org/living-with-diabetes/treatment-care/hypoglycemia, the professional reference indicated, .Low blood glucose is when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range. This is usually when your blood glucose is less than 70 mg/dL . If the blood sugar glucose continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. If blood glucose stays low for too long, starving the brain of glucose, it may lead to seizures, coma, and very rarely death . The 15-15 rule-have 15 grams of carbohydrate to raise your blood glucose and check it after 15 minutes . Based on interview and record review, the facility failed to ensure Licensed Vocational Nurses (LVN) followed professional standards of practice for one of three sampled residents (Resident 2), when on 9/30/23 at 6:30 a.m., Resident 2's blood glucose (sugar) level was of 55 mg/dl [milligrams per deciliter [a unit of measurement]) and LVN did not communicate the result to Resident 2's physician and did not recheck Resident 2's blood glucose within 15 minutes as per the facility's Hypoglycemia (low blood glucose) policy. This failure increased the potential for Resident 2 to experience complications such as confusion, coma (a state of deep unconsciousness that lasts for a prolonged or indefinite period), headache and restlessness. Findings: During a review of Resident 2's Face Sheet (FS- a document containing resident profile information), dated 10/17/23, the FS indicated, Resident 2 was admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus (body cannot properly use insulin [a hormone that regulates blood sugar]). During a concurrent interview and record review on 10/17/23 at 11:03 a.m. with LVN 1, Resident 2's Medication Administration Record (MAR), dated 9/2023 was reviewed. The MAR indicated, Resident 2's blood glucose on 9/30/23 at 6:30 a.m. was 55 mg/dl. LVN 1 reviewed Resident 2's clinical record and was not able to find documentation Resident 2's physician was notified regarding the low blood glucose and there was no blood glucose recheck in 15 minutes. LVN 1 stated there was no follow up blood glucose check done until the scheduled blood glucose check at 11:30 a.m LVN 1 stated, If it was not documented, it was not done. LVN 1 stated the importance of calling the physician and rechecking the blood glucose was to prevent complications of low blood glucose. During concurrent interview and record review on 10/17/23 at 12:31 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Management of Hypoglycemia dated 11/2020 indicated, .To provide guidelines for managing hypoglycemia .For .(<70 mg/dl) .Notify the provider immediately .Recheck blood glucose in 15 minutes .If blood sugar remains < (less than) 70 mg/dl repeat oral glucose and notify physician for further orders . The DON stated the purpose of rechecking the blood glucose was to ensure the blood glucose did not remain low. The DON stated per the facility policy the physician should have been notified but was not. During a review of the Professional Reference titled, Hypoglycemia (Low Blood Glucose) dated undated, retrieved from https://diabetes.org/living-with-diabetes/treatment-care/hypoglycemia, the professional reference indicated, .Low blood glucose is when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range. This is usually when your blood glucose is less than 70 mg/dL . If the blood sugar glucose continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. If blood glucose stays low for too long, starving the brain of glucose, it may lead to seizures, coma, and very rarely death . The 15-15 rule-have 15 grams of carbohydrate to raise your blood glucose and check it after 15 minutes .

Based on observation, interview and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of three residents (Resident 364) when Resident 364 was admitted on [DATE] with moderate to severe pain caused from her left leg [MEDICAL CONDITION] (infection affecting the inner layers of the skin) and effective pain relief medication was not administered. Resident 364 experienced uncontrolled moderate to severe pain from 8/15/19 through 8/20/19 and licensed nurses did not provide effective pain relief medication and did not reassess pain after administering pain medication. These failures resulted in Resident 364 experiencing pain and suffering for prolonged periods of time from 8/15/19 to 8/21/19 which led to Resident 364's inability to concentrate, sleep at night and enjoy pastimes such as reading and watching television because of the severe uncontrolled pain. An Immediate Jeopardy Situation (IJ) was called on 8/21/19, at 5:39 p.m., with the Administrator (ADM), Director of Nursing (DON) and Director of Operations because of the serious actual harm of uncontrolled pain in Resident 364. The IJ findings included Resident 364 who continued to suffer from severe, unrelieved pain for six days from 8/15/19 to 8/21/19. The Licensed Nurses (LN's) did not have an effective process for obtaining, ordering and administration of pain medications for severe pain. The facility ADM submitted an approved IJ Removal Plan which included developing and implementing a process of pain management for Resident 364 to ensure the resident was comfortable. Steps to ensure effective pain management for Resident 364 and all residents with pain were created and implemented. The Interdisciplinary Team (IDT- a team of healthcare providers including nurses, social services staff, dietary staff and physician who meet to plan resident care) implemented interventions for Resident 364, monitored Resident 364 every 30 minutes for pain for the first 24 hours, then hourly for the next 24 hours. The LN's were to notify the Medical Doctor (MD) if pain medication was ineffective; ensure MD's responded promptly, and ensure authorization to access the Emergency-Kit (E-Kit -a supply with a variety of medication available for administration when ordered by the MD) when needed to treat severe pain. In the absence of MD response, the admission nurse or the DON were to notify the discharging hospital to request the needed documentation in order for the pharmacy to timely fill a prescription for the residents' pain. The IJ Removal Plan was accepted on 8/23/19, at 9:51 a.m. The interventions to address the IJ situation on the Removal Plan were fully implemented and verified by the surveyor's onsite. The IJ was removed on 8/23/19, at 4:35 p.m. Findings: During a review of the clinical record for Resident 364, the face sheet (a document containing resident profile information and medical diagnosis) indicated Resident 364 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. of your heart and brain to narrow, block, or spasm), type 2 diabetes mellitus (a chronic disease associated with abnormally high levels of the sugar glucose in the blood) and essential hypertension (HTN- abnormally high blood pressure). Review of Resident 364's admission documentation dated 8/15/19, indicated Resident 364 was discharged from the acute care hospital with [MEDICATION NAME] (mild pain reliever). Resident 364 was admitted to the facility from the acute care hospital for physical therapy (treatments focused on movement and function of lower extremities), occupational therapy (treatments focus on the activities of everyday life and function of upper extremities), wound care of right leg below knee amputation and antibiotic administration for wound infection. During a concurrent observation and interview with Resident 364 in her room, on 8/18/19, at 4:15 p.m., Resident 364 sat on the side of the bed awake and with a bandage wrapped around her right stump and a swollen left foot with blackened toes. Resident 364 grimaced while she turned her head from side to side and verbalized being in pain. Resident 364 rated her pain as 10 out of 10 in a pain scale that ranged from 0 being no pain to 10 being the worst pain to both legs. Resident 364 stated she experienced intense and more severe (above 10) pain to her left leg. Resident 364 stated, I was yelling to staff all night (8/17/19) because of the pain, somebody please help me but nobody came. Resident 364 stated, I am going crazy. If they do not do anything (for my pain), I want to go to the hospital. A nurse told me that there are no doctors around. During an observation with Certified Nursing Assistant (CNA) 1, on 8/18/19, at 4:27 p.m., CNA 1 went into Resident 364's room. Resident 364 asked CNA 1 to call the nurse and to ask for pain medication. During an interview with Licensed Vocational Nurse (LVN) 1, on 8/18/19, at 4:58 p.m., LVN 1 stated Resident 364 was in pain on both legs with pain rated at 8 out of 10 (0 = no pain; 1-4 = mild pain; 5-7 = moderate pain; 8-10 = severe pain). LVN 1 stated she gave Resident 364 [MEDICATION NAME] (a medication used for moderate to severe pain), 50 milligram (mg) one tablet, at 9 a.m., the morning of 8/18/19. LVN 1 stated she administered [MEDICATION NAME] 50 mg to Resident 364 even though Resident 364's pain level was 10 out of 10. LVN 1 stated she should have treated Resident 364's pain with a stronger pain relief medication but there was nothing ordered to treat her severe pain higher than 6. LVN 1 stated [MEDICATION NAME] was prescribed for pain levels between 4 to 6 by the MD and was not meant to manage severe pain. LVN 1 stated she called the MD to request a telephone order for a stronger medication on 8/18/19 at 9 a.m., and received a new order from the MD on 8/18/19 at 11:30 a.m., for [MEDICATION NAME] (combination medication to treat severe pain) 5-325 mg 1 tab every six hours as needed for severe pain. LVN 1 stated the new pain medication prescribed by the MD was not available yet because the medication had not been delivered to the facility by the pharmacy. During a record review of Resident 364's physician orders [REDACTED]. During a concurrent observation and interview with Resident 364, on 8/19/19, at 8:20 a.m., in Resident 364's room, Resident 364 sat on the side of the bed with facial grimacing. Resident 364 stated she was in severe pain caused from her left leg, and rated her pain level 10 out of 10. Resident 364 stated she received a [MEDICATION NAME] tablet for her pain the morning of 8/19/19 at 8 a.m. During an observation and concurrent interview with CNA 2 in Resident 364's room, on 8/19/19, at 10:01 a.m., CNA 2 was asked by Resident 364 to call the nurse to ask for pain medication. CNA 2 stated Resident 364 looked very uncomfortable, anxious and in pain. During a concurrent interview and record review with the Assitant Director of Nursing (ADON), on 8/20/19, at 4:37 p.m., she reviewed Resident 364's medication administration record (MAR) dated 8/19. The MAR indicated Resident 364 experienced pain 6 out of 10 on the day of admission (8/15/19) at 9:15 p.m. The MAR indicated Resident 364 was treated with [MEDICATION NAME] two tablets of 325 mg (650 mg total) for her pain level of 6 out of 10. The ADON stated [MEDICATION NAME] was not the appropriate medication to provide relief for a pain level 6 out of 10. The ADON stated the LN who admitted Resident 364 should have called the MD or called the acute care hospital to ask for a stronger prescription pain relief medication, and did not. The ADON stated the LN did not reassess Resident 364's pain level after the [MEDICATION NAME] 650 mg was given for 6 out 10 pain on admission (8/15/19) at 9:15 p.m. The ADON reviewed the progress notes dated 8/16/19 at 11:51 a.m., which indicated, MD called to notify of (Resident 364) complain of pain to right ([MEDICAL CONDITION]) and to left foot, order for [MEDICATION NAME] 50 mg (as needed), Resident aware, order noted and faxed to pharmacy. The ADON reviewed Resident 364's MAR for 8/16/19 and stated Resident 364 received [MEDICATION NAME] 50 mg at 6:17 p.m., for a pain level of 7 out of 10. The ADON stated [MEDICATION NAME] 50 mg was ordered to be given every six hours for pain ranges between 4 to 6. The ADON stated Resident 364 received the first dose of [MEDICATION NAME] six and one half hours after the prescription was sent to the pharmacy. The ADON stated the prescription delivery was delayed because the MD did not submit a signed prescription to the facility. The ADON stated it was not appropriate to delay medication administration for pain management six and one half hours after the pain medication was ordered by the MD. The ADON stated the MD ordered [MEDICATION NAME] Extended Release (ER-formulated for medication to be released slowly over time.) 10 mg twice per day on 8/18/19 at 7 p.m. The ADON stated the MD did not provide a signed prescription to the facility for the pharmacy to fill the [MEDICATION NAME] ER 10 mg ordered. The ADON stated the first dose of [MEDICATION NAME] 10 mg was administered on 8/19/19 at 6:42 p.m., nearly 24 hours after being ordered by the MD. The ADON stated the LN should have notified the MD about Resident 364's uncontrolled pain and her need for a stronger pain medication. During a concurrent interview and record review with the ADON, on 8/20/19, at 4:50 p.m., Resident 364's MAR dated 8/16/19, indicated she received [MEDICATION NAME] 50 mg at 6:17 p.m., for pain level of 7. The ADON stated [MEDICATION NAME] was indicated for a pain level of 4-6 and was not appropriate medication for a pain level of 7. During a concurrent interview and record review with the ADON, on 8/20/19, at 4:51 p.m., Resident 364's MAR dated 8/17/19, indicated she received [MEDICATION NAME] 50 mg at 5:05 a.m., for pain level of 8. The ADON stated [MEDICATION NAME] was indicated for a pain level of 4 to 6 and was not appropriate medication for a pain level 8. During a concurrent interview and record review with the ADON, on 8/20/19, at 4:52 p.m., Resident 364's MAR dated 8/17/19, indicated she received [MEDICATION NAME] 50 mg at 10:45 a.m., for pain level of 7. The ADON stated [MEDICATION NAME] was indicated for a pain level of 4 to 6 and was not appropriate medication for a pain level of 7. During a concurrent interview and record review with the ADON, on 8/20/19, at 4:53 p.m., Resident 364's MAR dated 8/17/19, indicated she received [MEDICATION NAME] 50 mg at 5:52 p.m., for pain level of 8. The ADON stated [MEDICATION NAME] was indicated for a pain level of 4 to 6 and was not appropriate medication for a pain level of 8. During a concurrent interview and record review with the ADON, on 8/20/19, at 4:54 p.m., Resident 364's MAR dated 8/18/19, indicated she received [MEDICATION NAME] 50 mg at 9 a.m., for pain level of 8. The ADON stated [MEDICATION NAME] was indicated for a pain level of 4 to 6 and was not appropriate medication for a pain level of 8. During a concurrent interview and record review with the ADON, on 8/20/19, at 4:55 p.m., Resident 364's MAR dated 8/18/19, indicated she received [MEDICATION NAME] 50 mg at 8:19 p.m., for pain level of 10. The ADON stated [MEDICATION NAME] was indicated for a pain level of 4-6 and was not appropriate medication for a pain level of 10. During a concurrent interview and record review with the ADON, on 8/20/19, at 4:55 p.m., Resident 364's MAR dated 8/19/19, indicated she received [MEDICATION NAME] 50 mg at 8:19 p.m., for pain level of 8. The ADON stated [MEDICATION NAME] was indicated for a pain level of 4 to 6 and was not appropriate medication for a pain level of 8. During an interview and record review with the ADON, on 8/20/19, at 5:30 p.m., she stated the facility experienced communication problems with the MD and with the pharmacy when narcotics (strong pain medications requiring MD prescription) were ordered. The ADON stated she did not know the MD's respond time to licensed nurses requesting pain medication for residents. The ADON stated the MD was required to give a signed written prescription to the facility and to the pharmacy prior to opening the E-kit. The ADON stated this was necessary in order for the pharmacy to give the licensed nurse an authorization code to open the E-kit. The ADON stated a licensed nurse could not open the E-kit and take any narcotic medication for a resident without the pharmacy authorization code. The ADON stated, The E-kit was so hard to access during emergency situations because of the poor process. During an interview with LVN 1, on 8/20/19, at 5:45 p.m., LVN 1 reviewed the progress notes and MAR for Resident 364, dated 8/20/19 at 9 a.m. LVN 1 stated Resident 364 complained of severe pain when a dose of [MEDICATION NAME] 10 mg ER by mouth was administered for a pain level of 10 out of 10. LVN 1 stated Resident 364's pain was reassessed at 10:28 a.m., and the resident still complained of pain of 10 out of 10 on the pain scale. LVN 1 stated Resident 364 had uncontrolled pain for the last six days from 8/15/19 to 8/20/19. LVN 1 stated Resident 364's pain was consistently described as severe as 10 out of 10 on the pain scale. LVN 1 stated, I should have referred to MD for further pain evaluation and better management to avoid prolonged suffering of (Resident 364). During a review of Resident 364's MAR dated 8/19, indicated Resident 364's pain level was 10 out of 10 on 8/19/19 at 8:09 p.m., 8/20/19 at 3:38 a.m., 10:28 a.m., and on 4:09 p.m. During a concurrent observation and interview with Resident 364, on 8/20/19, at 6:45 p.m., Resident 364 was in the front of the lobby of the facility with LVN 1. Resident 364 stated her pain had not been controlled since her admission to the facility (on 8/15/19). Resident 364 stated she often sat in her room and was unable to sleep during the nights because of her severe pain. Resident 364 stated she was unable to read books and could not concentrate or enjoy watching her favorite television shows because of the severe pain she experienced. During a concurrent interview and record review with Registered Nurse (RN) 1, on 8/21/19, at 11:02 a.m., she reviewed the progress notes of Resident 364 dated 8/15/19 at 9:15 p.m., and stated the progress note indicated Resident 364 complained of pain 6 out of 10 and [MEDICATION NAME] 325 mg two tablets were given. RN 1 stated, I did not call the MD because I was in the middle of a medication pass. RN 1 stated she did not think Resident 364's pain was a priority at that time. RN 1 stated she did not assess Resident 364's pain location or description prior to medicating her with [MEDICATION NAME] 650 mg. RN 1 stated she did not assess Resident 364's pain level after medicating her with [MEDICATION NAME] 650 mg and she did not know if the pain medication was effective. RN 1 stated the Resident 364's pain level should have been assessed 45 minutes after receiving pain medication to evaluate the effectiveness of the medication. RN 1 stated, I should have assessed and evaluated (Resident 364's) pain location and description of the pain. RN 1 stated she should have checked the discharge summary from the acute care hospital about what pain medication was administered in the hospital and what medication had been ordered for the facility. RN 1 stated she should have phoned the MD to inform the physician of the unavailability of medication to treat Resident 364's pain. During a concurrent interview and record review with LVN 1, on 8/21/19, at 11:47 a.m., LVN 1 stated he was the admitting nurse for Resident 364 on 8/15/19 at 3:30 p.m. LVN 1 stated Resident 364 complained of pain of 6 out of 10 on admission and was given [MEDICATION NAME] 650 mg total at time of admission. LVN 1 stated he did not document the [MEDICATION NAME] that was given at time of admission on Resident 364's MAR. LVN 1 stated a second dose of [MEDICATION NAME] was administered by another licensed nurse on 8/15/19 at 9:15 p.m. LVN 1 stated he did not document the initial pain assessment on Resident 364's MAR and a reassessment was not documented after [MEDICATION NAME] was administered. LVN 1 stated he did not call the physician to request a stronger pain medication at that time. LVN 1 stated [MEDICATION NAME] was not an appropriate pain medication for Resident 364's moderate pain. During an interview with the DON, on 8/21/19, at 3:30 p.m., the DON stated pain medications needed to be anticipated for new residents by getting an order from the facility MD or from the acute hospital for at least a three day supply of strong pain medication. The DON stated this process did not happen for Resident 364. The facility policy and procedure titled, Pain Assessment and Management dated 3/2015, indicated, Purpose The purpose of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines .2 Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals 5. Conduct a comprehensive pain assessment upon admission to the facility .6 Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels .Recognizing pain1. Observe the resident (during rest and movements) for physiological and behavioral (non- verbal) signs of pain 2. Possible Behavioral signs of pain: a. verbal expression such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; .d. Behavior such as resisting care, irritability, depression, decreased participation in usual participation in usual activities; h. [MEDICAL CONDITION] .5. Review the medication administration record to determine how often the individual request and receives pain medication and to what extent the administered medication relieve the resident's pain. Assessing Pain: 1. During the comprehensive pain assessment gathered .a. History of pain and its treatment, including pharmacological and non-pharmacological interventions; b. Characteristic of pain (1) Intensity of pain (as measured on a standard pain scale); (2) Descriptors of pain (3) Pattern of pain (e.g., constant or intermittent); (4) Location and [MEDICAL CONDITION] of pain; and (5) Frequency, timing and duration of pain. C. Impact of pain on quality of life .

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for two of three sampled residents (Residents 18 and 19) when: 1. The SSD and Administrator issued Resident 19 a 30-day eviction notice to discharge from the facility and was unable to provide a proper reason for the proposed 30-day discharge. This failure resulted in Resident 19 experiencing feelings of frustration, worry, and self-isolation. 2. The SSD informed Resident 18 out in the hallway in front of staff and other residents that his stay in the facility was denied by health insurance and would need to come up with his own discharge plan. This failure caused Resident 18 embarrassment, feelings of harassment, and anxiety. Findings: 1. During a telephone interview with the Complainant, on 8/20/19, at 5:15 p.m., she stated Resident 19 expressed concerns regarding his pending discharge from the facility. The Complainant stated Resident 19 yelled at staff and was given a 30-day eviction notice to leave the facility. The Complainant stated she then spoke to the SSD and was told the reason for discharge was because Resident 19 broke facility smoking rules. The Complainant stated Resident 19 lived in a group home prior to admission at the facility and was not presented with his right to appeal the 30-day discharge. During an observation and concurrent interview with Resident 19, on 8/21/19, at 8:50 a.m., in Resident 19's room, he laid in bed awake. The room was dark and the privacy curtains were drawn around the bed. Resident 19 stated he received an eviction notice from the facility and had to leave the facility within 30 days of the notice given to him. Resident 19 stated he was admitted to the facility a couple months ago and prior to that he lived on the streets. Resident 19 stated he did not have a home prior to residing in the facility, and did not have family to help him with the care he needed if he was to be discharged from the facility. Resident 19 stated he began to stay in his room hoping no one would notice him but staying in his room caused him to feel sad, worried, and lonesome. Resident 19 stated prior to the 30-day eviction notice he would be eating his meal in the dining room and would be out of his room socializing with others. Resident 19 stated he did not sign the eviction notice, was not provided information about his rights to appeal the notice, and was not provided a clear explanation or reason why he needed to leave the facility within 30 days. Resident 19 stated he was a victim in a previous altercation with another resident, but did not have any other altercations with other residents. Resident 19 stated he would sometimes raise his voice towards staff because he felt the facility did not listen to him. Resident 19 stated he was a smoker, but used an Electronic E- Cigarette and the licensed nurses kept his paraphernalia at the nurse station so he could not understand why the facility wanted him to leave. During an interview with CNA 1, on 8/21/19, at 10:49 a.m., and concurrent review of Resident 19 face sheet (a document with personal information), she verified Resident 19 was admitted to the facility on [DATE]. CNA 1 stated Resident 19 was alert, oriented, able to make his needs known, required minimal assistance with activities of daily living, and propelled himself in the wheelchair. CNA 1 stated Resident 19 was a smoker and CNAs and Activity Staff supervised residents during smoke breaks. CNA 1 stated Resident 19 did not want to leave the facility and verbalized he felt nervous and scared about the plan for him to be discharged out of the facility. During an interview with CNA 4, on 8/21/19 at 11:34 a.m., she stated residents were not allowed to keep smoking materials in their possession. CNA 4 stated smoking materials were kept in a locked box at the nurses' station. CNA 4 stated the facility had designated five smoke breaks posted in the nurses' station. CNA 4 stated residents who smoked were limited to five smoking breaks. During a concurrent observation and interview with Resident 19, on 8/21/19, at 12:06 p.m., in the resident's room, Resident 19's door was partly closed, room was dark and the curtains were drawn around the bed. Resident 19 sat up in bed and stated he was waiting for his lunch meal tray. Resident 19 stated he used to eat his meals in the social dining room and now he ate his meals in his room. During an interview with LVN 1, on 8/21/19, at 6:19 p.m., he stated smoking assessments were conducted upon admission to determine if a resident was a smoker and to determine if a resident required supervision for safety while smoking. LVN 1 stated Resident 19 was a smoker. LVN 1 stated Resident 19 had episodes of agitation with staff and was verbally loud. LVN 1 stated Resident 19 verbalized feeling depressed and was monitored for his behaviors of isolation after he was given the 30-day eviction notice. LVN 1 stated Resident 19 would keep his door closed, curtain drawn around the bed, and preferred his room dark. LVN 1 stated prior to Resident 19 isolating himself he would have visitors and would go out on outings with them to the store and now he no longer went out with his visitors. LVN 1 stated the SSD was the staff member responsible for arranging resident discharge planning in the facility. LVN 1 stated licensed nurses were informed by the SSD the day before a pending resident's discharge in order to prepare the resident for discharge. During a concurrent observation and interview with Resident 19, on 8/22/19, at 10:13 a.m., Resident 19's door was partly closed, the room was dark and his privacy room curtains drawn around the bed and the room was dark. Resident 19 laid in bed and stated he felt anxious and depressed about his pending discharge from the facility because he had nowhere to go. During a concurrent interview and record review with Registered Nurse Supervisor (RNS) 1, on 8/22/19, at 10:16 a.m., RNS 1 reviewed Resident 19's Smoking Safety Screening (assessment), dated 6/14/19, which indicated Resident 19 smoked six to eight cigarettes a day and required supervision for safety while smoking. RNS 1 stated CNAs and Activity Staff supervised residents during smoke breaks and residents were not allowed to keep smoking paraphernalia (cigarettes, lighter, matches) at their bedside. RNS 1 stated the facility allowed only five smoking breaks for residents who smoked. RNS 1 reviewed Resident 19's clinical record and was unable to find documentation Resident 19 did not adhere to facility smoking rules. RNS 1 stated Resident 19 did not have behaviors or manifestations of paranoia (involves intense anxious or fearful feelings and thoughts often related to persecution), delusions (beliefs that conflict with reality), hallucinations (sensory experience in which a person can see, hear, smell, taste, or feel something that is not there), and/or behaviors of endangering self and/or other residents. RNS 1 reviewed the clinical record for Resident 19, the Progress Note dated, 8/12/19, at 9:59 a.m., indicated Resident 19 was involved in a resident to resident altercation and he was named as the victim (by the interdisciplinary team) (IDT-a group made up of a licensed nurse, social worker, activity staff and a doctor). RNS 1 verified there were no other documentation of altercations where Resident 19 was the perpetrator or the victim. RNS 1 reviewed Resident 19's Psychiatry Note dated 8/13/19, indicated Resident 19's current disturbance in mental health included, despairing, hopeless/helpless, fearful, agitated (at times), distractible, and self-care deficit. RNS 1 verified there was no documentation or indication by a physician Resident 19 was a danger to self or others. RNS 1 reviewed Resident 19's care plans and progress notes from 6/15/19 through 8/22/19, and was unable to find documentation of behaviors and manifestations related to endangerment of self and others. During a concurrent interview and record review with the SSD on 8/22/19, at 1:09 p.m., the SSD stated Resident 19 was homeless prior to his admission to the facility and did not own a home or apartment. The SSD reviewed the clinical record for Resident 19, the Admission Record, undated, indicated Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The SSD stated Resident 19 spent most of his time in his room lately because he was experiencing a down episode, and stated Resident 19 refused to leave his room and isolated himself. The SSD stated she did not know why Resident 19 was isolating himself because he used to be very active socializing in the facility. The SSD stated the Social Services Department was responsible in issuing 30-day notice to residents in the facility. The SSD reviewed the clinical record for Resident 19, the Notice of Transfer or Discharge, dated 7/24/19, indicated Resident 19 was to be discharged from the facility to his home on 8/24/19, for the following reasons: The health of individuals in the facility would be endangered by the resident's being here. The SSD reviewed Resident 19's clinical record and was unable to show documentation or indication by a physician Resident 19 was a danger to self or others. The SSD verified the clinical record failed to show documentation the resident exhibited or was monitored for endangering self and/or other residents. The SSD verified the address indicated in the 30-day notice was a shelter for the homeless and not the resident's home. The SSD was asked if the shelter would be able to provide the care and services the resident required after discharge, the SSD did not reply. The SSD stated the planned discharge to the shelter would be an inappropriate discharge. The SSD stated the resident continued to violate facility smoking rules and violating rules was a determination for discharge from the facility and an issuance of the 30-day notice. The SSD reviewed Resident 19's clinical record and was unable to show documentation Resident 19 violated facility smoking rules. The SSD stated Resident 19 was not provided with information on how to appeal his 30-day eviction discharge notice. The SSD stated Resident 19 did not qualify to have an appeal based on his insurance policy. The SSD stated appealing a facility initiated discharge was not a resident right. During an interview with the Administrator, on 8/22/19, at 1:45 p.m., he stated Resident 19 violated facility smoking rules and he instructed his staff to issue Resident 19 a 30-day eviction notice to deterrent (intended to discourage someone from doing something) Resident 19 from violating facility rules. The Administrator stated the 30-day notice was used to make the resident become compliant with facility rules. During an observation and concurrent interview with Resident 19, on 8/23/19, at 2:05 p.m., in Resident 19's room, Resident 19's door was partly closed, the room was dark and the curtains were drawn around Resident 19's bed. Resident 19 laid in bed and stated he isolated himself and stayed in the room because he was scared if facility staff saw him outside his room he would get kicked out of the facility. During a review of the facility policy and procedure titled, Resident Rights, dated 12/2016, indicated .Federal and state laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to . a dignified existence . be treated with respect, kindness, and dignity . retain and use personal possessions to the maximum extent that space and safety permit . 2. During an interview with Resident 18, on 8/20/19, at 5p.m., he stated the SSD approached him in the hallway in front of nursing station one. Resident 18 stated there were staff and other residents present in nursing station one when the SSD told him that his stay in the facility was denied by Medicaid (a federal system of health insurance for those requiring financial assistance). Resident 18 stated SSD told him that he would need to come up with his own discharge plan. Resident 18 stated that he was very embarrassed with everyone hearing the conversation. Resident 18 stated he felt he was being harassed by the SSD. Resident 18 stated that he would have appreciated being spoken too in a private area and not in from of other residents, staff and visitors. Resident 18 stated the conversation with SSD was embarrassing and caused him to become very anxious. Resident 18 stated his anxiety was so bad that LVN 2 had to take him outside the facility to help him calm down. During a review of Resident 18's face sheet indicated Resident 18 had the following Diagnoses: [REDACTED]. During an interview with LVN 2, on 8/20/19, at 5:20 p.m., LVN 2 stated that he saw the SSD talking to Resident 18 at nursing station one about his insurance and his denial to stay in the facility. LVN 2 stated Resident 18 was getting loud and anxious. LVN 2 stated that he took Resident 18 outside the facility to calm him down. LVN stated Resident 18 had anxiety problems and gave Resident 18 his scheduled [MEDICATION NAME] 0.5 mg for anxiety to help calm him. During a review of Resident 18's Order Summary Report dated 6/13/19, indicated [MEDICATION NAME] Concentrate (medication used to treat anxiety and produce a calming effect) 2 MG/ML (unit of measurement) Give 0.5 ml by mouth every 8 hours for anxiety . During an interview with the SSD, on 8/20/19, at 5:24 p.m., the SSD stated that she told Resident 18 that she received a noticed from Medicaid that Resident 18's stay in the facility was denied. The SSD stated that Resident 18 became upset. The SSD stated other residents, staff and visitors were in the area when she was speaking with Resident 18 and hear the conversation she had with Resident 18. The SSD stated that she should have talked to Resident 18 inside her office and not in the hallway in front of others. SSD stated .I should have not done that. During a concurrent interview and record review with the DON, on 8/21/19, at 9:12 a.m., the DON reviewed the facility policy and procedure Quality of Life- Dignity dated 8/2009, indicated .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect . Residents shall be treated with dignity and respect at all times . Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . Staff shall promote, maintain and protect resident privacy . The DON stated the facility policy and procedure for Quality of Life- Dignity was not followed when the SSD spoke to Resident 40 out in the presence of others. DON stated the SSD should have talked to Resident 18 in SSD's office or in Resident 18's room and not in the hallway around staff and other residents to prevent embarrassment and maintain Resident 18's privacy and dignity.

Based on interview, and record review, the facility failed to permit residents to remain in the facility, and not transfer or discharge unless for a necessary and/or appropriate need for one of nine sampled residents (Resident 46) when Resident 46 was discharged from the facility, transported in a non-medical transport van, dropped off and checked into the Emergency Department (ED) of a general acute care hospital (GACH) 45 miles from the facility without a medical need for hospitalization and without notifying hospital staff in advance. This failure resulted in Resident 46 being abruptly left in an unfamiliar environment without explanation, the family members of Resident 46 not being notified in advance of the discharge, an extended 41-day stay in the GACH, was displaced, lost his home like environment and had the potential to be unnecessarily exposed to hospital acquired infections. Findings: During an interview with the GACH Care Coordinator (CC), on [DATE], at 11:53 a.m., the CC stated Resident 46 was dropped off by unknown persons in a transportation van, checked into the Emergency Department (ED) on [DATE] at 4:34 p.m. The CC stated the unknown persons who transported Resident 46 immediately left the hospital after dropping him off. The CC stated Resident 46 was confused and unable to answer questions on why he was dropped off in the ED. The CC stated Resident 46 was evaluated in the ED and was admitted to the hospital even though Resident 46 did not have a medical need to be hospitalized . The CC stated the Skilled Nursing Facility (SNF) refuse to allow Resident 46 to return to the facility on [DATE]. The CC stated she continued looking for Skilled Nursing Facility (SNF) placement for Resident 46 while in the hospital. During an interview with the facility Assistant Director of Nurses (ADON) 1, on [DATE], at 2:19 p.m., the ADON 1 reviewed Resident 46's clinical record and stated Resident 46 was involved in an altercation with another resident on [DATE] and on [DATE]. The ADON 1 stated the Hospice Medical Director (HMD) 1 was notified of the altercations and came to see Resident 46 on [DATE]. The HMD 1 contacted Resident 46's Family Member (FM) 1 over the phone and gave the order to transfer Resident 46 to the GACH on [DATE]. The ADON 1 stated she thought HMD 1 gave the order to transfer Resident 46 to the GACH as a request from FM 1. The ADON 1 stated she did not speak with the HMD 1 to ask for the medical need to transfer Resident 46 to the GACH. The ADON 1 stated she did not speak to FM 1 to notify her of Resident 46's transfer to the GACH. The ADON 1 stated Resident 46 was transferred to the GACH on [DATE]. The ADON 1 stated Resident 46 was taken to the GACH in a non-medical transport van but she did not know who accompanied Resident 46 nor who the transportation van belonged to. During a review of Resident 46's clinical record titled, Admission Record (document containing resident demographic and medical [DIAGNOSES REDACTED]. changes, and impaired reasoning) with behavioral disturbance (changes in behavior). During a review of the clinical record for Resident 46, the Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs) dated [DATE], indicated Resident 46 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 3 (,[DATE] severe cognitive impairment, ,[DATE] moderate cognitive impairment, ,[DATE] no cognitive impairment). During an interview with the social services designee (SS), on [DATE], at 2:35 p.m., she stated Resident 46 was admitted to the facility under hospice services (services provided for terminal ill patients) on [DATE] from the acute care hospital. The SS stated Resident 46 arrived in a wheelchair in restraints (strap or device attached to a limb limiting freedom of movement). The SS stated two days after admission to the facility, Resident 46 had behaviors of wandering, threatening other residents and being aggressive with staff and residents. The SS stated the hospice agency contacted the Director of Nursing (DON) requesting to discontinue hospice services. The SS stated the facility planned to discharge Resident 46 to another facility because the facility did not consider Resident 46 to be safe. The SS stated Resident 46 was threatening and aggressive and required to have supervisors walk with him and provide supervision. The SS stated two days ([DATE]) before Resident 46 was discharged to the GACH ([DATE]), she spoke with FM 1 and notified her the facility could not keep Resident 46 in the facility because of his behaviors of agitation and combativeness. SS stated FM 1 informed SS that she was unable to provide care to Resident 46 in her home. During an interview with the DON, on [DATE], at 3 p.m., she stated Resident 46's aggressive behaviors of striking out resulted in an altercation with another other resident on [DATE] and on [DATE]. The DON stated the HMD 1 came into the facility to visit Resident 46 on [DATE]. The DON stated she spoke to HMD 1 on [DATE] and requested he do something about Resident 46's behaviors. The DON stated she received a group text from the facility corporate office on [DATE] which gave her the instruction to transfer Resident 46 to the GACH at FM 1's request. The DON stated Resident 46's hospice staff arranged for Resident 46 to be transferred to the GACH in a transportation van. The DON stated she did not know who accompanied Resident 46 to the GACH and did not know who the van belonged to. The DON stated she did not speak with FM 1 and was not aware if FM 1 had requested Resident 46's be transferred to the GACH. During an interview with Resident 46's FM 1, on [DATE], at 11:06 a.m., she stated she did not request for Resident 46 to be transferred to the GACH on [DATE]. FM 1 stated she was the responsible party for Resident 46 and did not know Resident 46 was transferred to the GACH until she was contacted by the GACH staff in the ED. FM 46 stated she did not know why Resident 46 was transferred to the furthest hospital from the facility (44.6 miles away). FM 1 stated she did not know what was the medical emergency that required Resident 46's transfer to the ED. FM 1 stated she never made any type of request for Resident 46 to be transferred or discharged from the facility. FM 1 stated she was contacted by a Hospice Marketer (HM 1), on [DATE] and notified her HMD 1 made the request to transfer Resident 46 to the GACH. FM 1 stated the HM 1 never called her prior to Resident 46's transfer, and did not explain a medical need for a transfer. FM 1 stated she was upset about Resident 46's unnecessary transfer to the hospital. FM 1 stated on [DATE] a Hospice Nurse (HN 1) contacted her to sign papers releasing Resident 46 from hospice care. FM 1 stated HN 1 apologized for Resident 46's transfer on [DATE] to the GACH ED because there was no medical need for the transfer. During an interview with the DON, on [DATE], at 12:07 p.m., the DON stated she did not verify with Resident 46's FM 46 if she wanted him discharged to the GACH because he was under hospice care. The DON stated, as far as she was aware, the hospice agency was responsible to manage and care for the discharges of hospice residents. The DON stated Resident 46's behaviors were discussed in a daily standup meeting but did not hold a separate interdisciplinary (a group of healthcare workers) team meeting to discuss and plan Resident 46's need for a safe transfer. The DON stated the medical need and reason for the discharge was Resident 46's wandering and combative behavior. The DON stated Resident 46 was not sent to the local GACH (approximately 1.1 miles away from the facility) because she thought FM 1 wanted him to go to the GACH in another county (44.6 miles away from the facility). The DON stated she did not know who transported Resident 46 to the GACH. During a review of Resident 46's Skilled Nursing Facility .Admission Agreement dated [DATE], indicated, .Transfers and Discharges .written notice of transfer to another facility or discharge against your wish will be provided 30 days in advance .our written notice will include the effective date, the location to which you will be transferred or discharged and the reason the action is necessary .we will advise you that you have the right to appeal the transfer or discharge if you are transferred or discharged against your wishes, we will provide transfer and discharge planning as required by law . During a telephone interview with HMD 1, on [DATE], at 12:35 p.m., HMD 1 stated he ordered Resident 46's transfer to the GACH on [DATE]. HMD 1 stated the DON presented him with a text message from the facility corporate office indicating Resident 46 should be transferred to the GACH because FM 1 was requesting Resident 46's transfer. HMD 1 stated he agreed to order Resident 46's transfer to the GACH on [DATE] for evaluation based on the text message shared to him by the DON. HMD 1 stated he did not call or communicate with FM 1 himself. HMD 1 stated Resident 46 did not have a medical need requiring hospitalization . During a review of the clinical record for Resident 46, the Physicians Progress Notes from the SNF dated [DATE] at 10:15 a.m., indicated, Change of Plans: Family wants pt. (patient) sent to (GACH) ASAP (as soon as possible). I agree. Case discussed (with) DON &(and) case manager. During a concurrent interview and record review with ADON 2, on [DATE], at 2:09 p.m., she reviewed Resident 46's clinical record and was unable to find documentation of an interdisciplinary team meeting note regarding Resident 46's discharge plan or GACH transfer. The ADON 2 reviewed Resident 46's clinical record and stated the DON wrote a note on [DATE], which indicated, Just spoke with Hospice administrator regarding D/C (discharge) plan. Resident (46) continues to wander, (wander guard ((alarm devise) in place), wanders into other resident rooms, urinating in inappropriate places, refusing care (ambulating in wet pants with soiled, wet brief, hanging out of pant leg and dragging down hallway. He is attempting to ram other residents with chair. Hospice administrator is pursuing discharge (from the facility) asap (as soon as possible) . During a concurrent interview with ADON 1 and clinical record review for Resident 46, on [DATE], at 3:51 p.m., the ADON 1 reviewed Resident 46's clinical record and was unable to find documentation of arranged and pending safe discharge plans. The ADON 1 reviewed the clinical record and stated Resident 46 was admitted to the facility for long term care (without discharge plans). The ADON 1 reviewed Resident 46's clinical record and stated a multidisciplinary care conference was conducted on [DATE] at 12:07 p.m., and indicated, Discharge goals Resident is long term care and is on hospice care. He will remain in facility for care . During an interview with the Administrator (ADM), on [DATE], at 4:09 p.m., the ADM stated she was not in the facility on [DATE]. The ADM stated she was notified of FM 1's request for Resident 46's GACH transfer by the DON on [DATE]. The ADM stated transportation was arranged through hospice. The ADM stated the hospice was responsible for discharging Resident 46 and not the facility. During a concurrent interview and record review with the ADM, on [DATE] at 4:20 p.m., the ADM reviewed the Hospice Services Agreement dated [DATE]. The agreement indicated, THIS SERVICE AGREEMENT is entered into as of [DATE] by and between (hospice agency) and (SNF) .2. RESPONSIBILITIES OF FACILITY a) Facility shall be solely responsible for admitting and discharging Residents to Facility as appropriate in accordance with Facility's policies and procedures . Facility shall meet the Resident's personal care and nursing needs in accordance with the Hospice representative, and ensure that the level of care provided is appropriately based on the individual Resident's needs . Facility shall continue to provide to Residents who are under Hospice's care, notwithstanding their admission to Hospice, all services normally provided to Residents who are not under Hospice care, based on each Resident's plan of care, except those services that are otherwise being provided pursuant to the hospice plan of care . Billing/Reimbursement for Services . All services provided by the facility must be in compliance with the professional standards, regulations, and licensure requirements . The ADM stated, I guess (the SNF) is responsible for (discharging the residents). If he comes to the facility and is hitting other residents he can't be here. During a telephone interview with the DON, on [DATE] at 9:30 a.m., the DON stated Resident 46 did not have a discharge plan in place because he was a hospice resident and the plan was for Resident 46 to be in the facility until he expired. The DON stated there was no discharge care plan initiated and the facility had not planned or facilitated a discharge plan. The DON stated HMD 1 discharged Resident 46 for the facility and Resident 46 was not allowed to return to the facility. During an interview with the CC, on [DATE], at 1:15 p.m., she stated Resident 46 remained in the GACH (a total of 25 days) because Resident 46 was not allowed to return to the SNF. The CC stated Resident 46's stay in the GACH was lengthened because of the difficulty in finding Resident 46 placement at another SNF. The CC stated Resident 46 required a sitter because of his wandering tendencies due to his confusion and was not safe wandering around in the hospital. The CC stated Resident 46 was in his room most of the time and watched television with a sitter at his side. The CC stated the GACH did not have the capability or availability to offer Resident 46 activities of choice because it was a different environment from his home like environment in the SNF. The CC stated Resident 46 would watch television and walk outside the hallway as his only daily activity. During a concurrent interview with the Hospital ED Registered Nurse (RN) 1 and hospital ED Nursing Notes, on [DATE], at 7:37 a.m., RN 1 reviewed the hospital Nursing Notes and stated Resident 46 arrived to the ED on [DATE], at 4:49 p.m. RN 1 stated she received report from the day shift in which she was notified Resident 46 was dropped off at the ED triage area (hospital area in the ED where medical staff prioritize patients according to the reason for the ED visit) by an unknown medical transport team with a packet of paperwork from the Skilled Nursing Facility (SNF). RN 1 stated Resident 46 was confused, not oriented and was cooperative. RN 1 stated Resident 46 was not given any medication during his stay in the ED. RN 1 stated on [DATE] at 7:35 p.m., she called the SNF and spoke to Licensed Vocational Nurse (LVN) 3 to ask for Resident 46's medical need for ED evaluation. RN 1 stated LVN 3 informed her Resident 46 was sent to the ED to comply with FM 1's request. RN 1 stated she spoke with HMD 1, on [DATE] around 8:55 p.m., and HMD stated the reason for Resident 46's transfer to the ED was because of Resident 46's unmanageable behaviors in the SNF. RN 1 sated on [DATE] a follow-up call was made to the SNF, and she spoke to LVN 4 and informed her Resident 46 was medically cleared and had a discharge order to return to the SNF. RN 1 stated LVN 4 refused to allow Resident 46 to return to the SNF. RN 1 stated LVN 4 stated Resident 46 was discharged from the facility and the facility could not take Resident 46 back. RN 1 stated follow up calls were made to the facility on [DATE] well past 10 p.m., without answer or a facility staff member contacting the hospital. RN 1 stated the SNF staff hung up on her five separate times when phone calls were attempted. During a review of the clinical record for Resident 46, the ED Nursing Note dated [DATE], at 11:51 p.m., indicated, . The staff at SNF hung up on primary nurse 5 times when attempting to give report back to the nurse in charge. Physician (GACHMD 2) called and spoke to charge nurse who stated the DON was refusing calls. The charge nurse stated the DON was texting her back with responses but forwarding calls to voicemail. This RN spoke with the charge nurse who said We are no longer caring for that patient, you will need to call .hospice for find a place. During an interview with the Minimum Data Set Coordinator (MDSC), on [DATE], at 8:11 a.m., she stated Resident 46 was admitted to the SNF on [DATE]. The MDSC stated Resident 46 was discharged to the GACH on [DATE] and returned to the SNF on [DATE] (a total of 41 days after the SNF discharge) from the GACH. During a review of the GACH clinical record titled, Transition Planning Progress Note dated [DATE], at 10:52 a.m., the Note indicated, Social service referral for pt (patient) who was dropped off in the (ED) lobby by (SNF). Per RN (registered nurse), facility is not willing to accept pt back. However, after (HMD 1) was notified regarding pt being dumped doctor wanted pt transferred back. Staff from facility would accept if pt returned within 24 hours which expired at 10 a.m. today. However, when staff attempted to reach facility staff, calls were not being answered and were unable to get through and speak with staff members. Pt. currently has discharge orders. During a review of the clinical record for Resident 46, the ED Nursing Note dated [DATE], at 5:34 p.m., indicated, Pt dropped off to ED lobby by medical transportation staff w(with)/ folder from (SNF). Pt is on hospice per medical records form SNF, growing increasingly agitated and refusing antianxiety medications as (ordered) by PCP (primary care provider). Per note by PCP, pt family requested pt to be seen at this facility for evaluation. No prior report or information given prior to pt arrival. Pt . left alone in lobby after drop off . During a review of the clinical record for Resident 46, the ED Nursing Note dated [DATE], at 7:31 p.m., indicated, Called (SNF) where the patient was a resident. Patient is unable to answer any questions, very confused. ED staff is unaware about why patient was sent to the ED. (LVN 3) at the SNF is also unaware as to why the patient was sent . During a review of the clinical record for Resident 46, the ED Nursing Note dated [DATE], at 8:43 p.m., indicated, Spoke to (HMD 1) who was the hospice physician to assess the patient today. Doctor states he did not intend for the patient to be dumped here and was apologetic for lack of transfer of care. (HMD 1) wrote an order this morning to have the patient transferred . Primary RN called the SNF back to update them that the daughter was finally contacted, and upon normal medical clearance, the patient will be (discharged back)to the facility. (LVN 4) night shift nurse stated he has been discharged from our facility and we actually cannot take him back. The facility policy and procedure titled, Transfer or Discharge, Emergency dated ,[DATE], indicated, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: b. notify the receiving facility that the transfer is being made; c. prepare the resident for transfer; e. Notify the representative (sponsor) or other family member; f. assist in obtaining transportation .

Based on interview and record review, the facility failed to ensure residents who were hospitalized were permitted to return to the facility for one of nine sampled residents (Resident 46) when the facility refused to take Resident 46 back after Resident 46 was medically cleared (stable) to return to the facility from the general acute care hospital (GACH). This failure resulted in Resident 46' extended 41-day stay in the GACH, was displaced, lost his home like environment and had the potential to be unnecessarily exposed to hospital acquired infections. Findings: During an interview with the GACH Care Coordinator (CC), on [DATE], at 11:53 a.m., the CC stated Resident 46 was dropped off by unknown persons in a transportation van, checked into the Emergency Department (ED) on [DATE] at 4:34 p.m. The CC stated the unknown persons who transported Resident 46 immediately left the hospital after dropping him off. The CC stated Resident 46 was confused and unable to answer questions on why he was dropped off in the ED. The CC stated Resident 46 was evaluated in the ED and was admitted to the hospital even though Resident 46 did not have a medical need to be hospitalized . The CC stated the Skilled Nursing Facility (SNF) refuse to allow Resident 46 to return to the facility on [DATE]. The CC stated she continued looking for Skilled Nursing Facility (SNF) placement for Resident 46 while in the hospital. During an interview with the facility Assistant Director of Nurses (ADON) 1, on [DATE], at 2:19 p.m., the ADON 1 reviewed Resident 46's clinical record and stated Resident 46 was involved in an altercation with another resident on [DATE] and on [DATE]. The ADON 1 stated the Hospice Medical Director (HMD) 1 was notified of the altercations and came to see Resident 46 on [DATE] The HMD 1 contacted Resident 46's Family Member (FM) 1 over the phone and gave the order to transfer Resident 46 to the GACH on [DATE]. The ADON 1 stated she thought HMD 1 gave the order to transfer Resident 46 to the GACH as a request from FM 1. The ADON 1 stated she did not speak with the HMD 1 to ask for the medical need to transfer Resident 46 to the GACH. The ADON 1 stated she did not speak to FM 1 to notify her of Resident 46's transfer to the GACH. The ADON 1 stated Resident 46 was transferred to the GACH on [DATE]. The ADON 1 stated Resident 46 was taken to the GACH in a non-medical transport van but she did not know who accompanied Resident 46 nor who the transportation van belonged to. During a review of Resident 46's clinical record titled, Admission Record (document containing resident demographic and medical [DIAGNOSES REDACTED]. changes, and impaired reasoning) with behavioral disturbance (changes in behavior). During a review of the clinical record for Resident 46, the Minimum Data Set (MDS) assessment (an evaluation used to identify resident care needs) dated [DATE], indicated Resident 46 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) (an evaluation of attention, orientation and memory recall) score of 3 (,[DATE] severe cognitive impairment, ,[DATE] moderate cognitive impairment, ,[DATE] no cognitive impairment). During an interview with the social services designee (SS), on [DATE], at 2:35 p.m., she stated Resident 46 was admitted to the facility under hospice services (services provided for terminal ill patients) on [DATE] from the acute care hospital. The SS stated Resident 46 arrived in a wheelchair in restraints (strap or device attached to a limb limiting freedom of movement). The SS stated two days after admission to the facility, Resident 46 had behaviors of wandering, threatening other residents and being aggressive with staff and residents. The SS stated the hospice agency contacted the Director of Nursing (DON) requesting to discontinue hospice services. The SS stated the facility planned to discharge Resident 46 to another facility because the facility did not consider Resident 46 to be safe. The SS stated Resident 46 was threatening and aggressive and required to have supervisors walk with him and provide supervision. The SS stated two days ([DATE]) before Resident 46 was discharged to the GACH ([DATE]), she spoke with FM 1 and notified her the facility could not keep Resident 46 in the facility because of his behaviors of agitation and combativeness. SS stated FM 1 informed SS that she was unable to provide care to Resident 46 in her home. During an interview with the DON, on [DATE], at 3 p.m., she stated Resident 46's aggressive behaviors of striking out resulted in an altercation with another other resident on [DATE] and on [DATE]. The DON stated the HMD 1 came into the facility to visit Resident 46 on [DATE]. The DON stated she spoke to HMD 1 on [DATE] and requested he do something about Resident 46's behaviors. The DON stated she received a group text from the facility corporate office on [DATE] which gave her the instruction to transfer Resident 46 to the GACH at FM 1's request. The DON stated Resident 46's hospice staff arranged for Resident 46 to be transferred to the GACH in a transportation van. The DON stated she did not know who accompanied Resident 46 to the GACH and did not know who the van belonged to. The DON stated she did not speak with FM 1 and was not aware if FM 1 had requested Resident 46's be transferred to the GACH. During an interview with Resident 46's FM 1, on [DATE], at 11:06 a.m., she stated she did not request for Resident 46 to be transferred to the GACH on [DATE]. FM 1 stated she was the responsible party for Resident 46 and did not know Resident 46 was transferred to the GACH until she was contacted by the GACH staff in the ED. FM 1 stated she did not know why Resident 46 was transferred to the furthest hospital from the facility (44.6 miles away). FM 1 stated she did not know what was the medical emergency that required Resident 46's transfer to the ED. FM 1 stated she never made any type of request for Resident 46 to be transferred or discharged from the facility. FM 1 stated she was contacted by a Hospice Marketer (HM 1), on [DATE] and notified her HMD 1 made the request to transfer Resident 46 to the GACH. FM 1 stated the HM 1 never called her prior to Resident 46's transfer, and did not explain a medical need for a transfer. FM 1 stated she was upset about Resident 46's unnecessary transfer to the hospital. FM 1 stated on [DATE] a Hospice Nurse (HN 1) contacted her to sign papers releasing Resident 46 from hospice care. FM 1 stated HN 1 apologized for Resident 46's transfer on [DATE] to the GACH ED because there was no medical need for the transfer. During an interview with the DON, on [DATE], at 12:07 p.m., the DON stated she did not verify with Resident 46's FM 1 if she wanted him discharged to the GACH because he was under hospice care. The DON stated, as far as she was aware, the hospice agency was responsible to manage and care for the discharges of hospice residents. The DON stated Resident 46's behaviors were discussed in a daily standup meeting but did not hold a separate interdisciplinary (a group of healthcare workers) team meeting to discuss and plan Resident 46's need for a safe transfer. The DON stated the medical need and reason for the discharge was Resident 46's wandering and combative behavior. The DON stated Resident 46 was not sent to the local GACH (approximately 1.1 miles away from the facility) because she thought FM 1 wanted him to go to the GACH in another county (44.6 miles away from the facility). The DON stated she did not know who transported Resident 46 to the GACH. During a review of Resident 46's Skilled Nursing Facility .Admission Agreement dated [DATE], indicated, .Transfers and Discharges .written notice of transfer to another facility or discharge against your wish will be provided 30 days in advance .our written notice will include the effective date, the location to which you will be transferred or discharged and the reason the action is necessary .we will advise you that you have the right to appeal the transfer or discharge if you are transferred or discharged against your wishes, we will provide transfer and discharge planning as required by law . During a telephone interview with HMD 1, on [DATE], at 12:35 p.m., HMD 1 stated he ordered Resident 46's transfer to the GACH on [DATE]. HMD 1 stated the DON presented him with a text message from the facility corporate office indicating Resident 46 should be transferred to the GACH because FM 1 was requesting Resident 46's transfer. HMD 1 stated he agreed to order Resident 46's transfer to the GACH on [DATE] for evaluation based on the text message shared to him by the DON. HMD 1 stated he did not call or communicate with FM 1 himself. HMD 1 stated Resident 46 did not have a medical need requiring hospitalization . During a review of the clinical record for Resident 46, the Physicians Progress Notes from the SNF dated [DATE] at 10:15 a.m., indicated, Change of Plans: Family wants pt. (patient) sent to (GACH) ASAP (as soon as possible). I agree. Case discussed (with) DON &(and) case manager. During a concurrent interview and record review with ADON 2, on [DATE], at 2:09 p.m., she reviewed Resident 46's clinical record and was unable to find documentation of an interdisciplinary team meeting note regarding Resident 46's discharge plan or GACH transfer. The ADON 2 reviewed Resident 46's clinical record and stated the DON wrote a note on [DATE], which indicated, Just spoke with Hospice administrator regarding D/C (discharge) plan. Resident (46) continues to wander, (wander guard ((alarm devise) in place), wanders into other resident rooms, urinating in inappropriate places, refusing care (ambulating in wet pants with soiled, wet brief, hanging out of pant leg and dragging down hallway. He is attempting to ram other residents with chair. Hospice administrator is pursuing discharge (from the facility) asap (as soon as possible) . During a concurrent interview with ADON 1 and clinical record review for Resident 46, on [DATE], at 3:51 p.m., the ADON 1 reviewed Resident 46's clinical record and was unable to find documentation of arranged and pending safe discharge plans. The ADON 1 reviewed the clinical record and stated Resident 46 was admitted to the facility for long term care (without discharge plans). The ADON 1 reviewed Resident 46's clinical record and stated a multidisciplinary care conference was conducted on [DATE] at 12:07 p.m., and indicated, Discharge goals Resident is long term care and is on hospice care. He will remain in facility for care . During an interview with the Administrator (ADM), on [DATE], at 4:09 p.m., the ADM stated she was not in the facility on [DATE]. The ADM stated she was notified of FM 1's request for Resident 46's GACH transfer by the DON on [DATE]. The ADM stated transportation was arranged through hospice. The ADM stated the hospice was responsible for discharging Resident 46 and not the facility. During a concurrent interview and record review with the ADM, on [DATE] at 4:20 p.m., the ADM reviewed the Hospice Services Agreement dated [DATE]. The agreement indicated, THIS SERVICE AFREEMENT is entered into as of [DATE] by and between (hospice agency) and (SNF) .2. RESPONSIBILITIES OF FACILITY a) Facility shall be solely responsible for admitting and discharging Residents to Facility as appropriate in accordance with Facility's policies and procedures . Facility shall meet the Resident's personal care and nursing needs in accordance with the Hospice representative, and ensure that the level of care provided is appropriately based on the individual Resident's needs . Facility shall continue to provide to Residents who are under Hospice's care, notwithstanding their admission to Hospice, all services normally provided to Residents who are not under Hospice care, based on each Resident's plan of care, except those services that are otherwise being provided pursuant to the hospice plan of care . Billing/Reimbursement for Services . All services provided by the facility must be in compliance with the professional standards, regulations, and licensure requirements . The ADM stated, I guess (the SNF) is responsible for (discharging the residents). If he comes to the facility and is hitting other residents he can't be here. During a telephone interview with the DON, on [DATE] at 9:30 a.m., the DON stated Resident 46 did not have a discharge plan in place because he was a hospice resident and the plan was for Resident 46 to be in the facility until he expired. The DON stated there was no discharge care plan initiated and the facility had not planned or facilitated a discharge plan. The DON stated HMD 1 discharged Resident 46 for the facility and Resident 46 was not allowed to return to the facility. During an interview with the CC, on [DATE], at 1:15 p.m., she stated Resident 46 continued to remain in the GACH (a total 25 days) because Resident 46 was not being allowed to return to the SNF. The CC stated Resident 46's stay in the GACH was lengthened because of the difficulty in finding Resident 46 placement at another SNF. The CC stated Resident 46 required a sitter because of his wandering tendencies due to his confusion and was not safe wandering around in the hospital. The CC stated Resident 46 was in his room most of the time and watched television with a sitter at his side. The CC stated the GACH did not have the capability or availability to offer Resident 46 activities of choice because it was a different environment from his home like environment in the SNF. The CC stated Resident 46 would watch television and walk outside the hallway as his only daily activity. During a concurrent interview with the Hospital ED Registered Nurse (RN) 1 and hospital ED Nursing Notes, on [DATE], at 7:37 a.m., RN 1 reviewed the hospital Nursing Notes and stated Resident 46 arrived to the ED on [DATE], at 4:49 p.m. RN 1 stated she received report from the day shift in which she was notified Resident 46 was dropped off at the ED triage area (hospital area in the ED where medical staff prioritize patients according to the reason for the ED visit) by an unknown medical transport team with a packet of paperwork from the Skilled Nursing Facility (SNF). RN 1 stated Resident 46 was confused, not oriented and was cooperative. RN 1 stated Resident 46 was not given any medication during his stay in the ED. RN 1 stated on [DATE] at 7:35 p.m., she called the SNF and spoke to Licensed Vocational Nurse (LVN) 3 to ask for Resident 46's medical need for ED evaluation. RN 1 stated LVN 3 informed her Resident 46 was sent to the ED to comply with FM 1's request. RN 1 stated she spoke with HMD 1, on [DATE] around 8:55 p.m., and HMD stated the reason for Resident 46's transfer to the ED was because of Resident 46's unmanageable behaviors in the SNF. RN 1 sated on [DATE] a follow-up call was made to the SNF, and she spoke to LVN 4 and informed her Resident 46 was medically cleared and had a discharge order to return to the SNF. RN 1 stated LVN 4 refused to allow Resident 46 to return to the SNF. RN 1 stated LVN 4 stated Resident 46 was discharged from the facility and the facility could not take Resident 46 back. RN 1 stated follow up calls were made to the facility on [DATE] well past 10 p.m., without answer or a facility staff member contacting the hospital. RN 1 stated the SNF staff hung up on her five separate times when phone calls were attempted. During a review of the clinical record for Resident 46, the ED Nursing Note dated [DATE], at 11:51 p.m., indicated, . The staff at SNF hung up on primary nurse 5 times when attempting to give report back to the nurse in charge. Physician (GACHMD 2) called and spoke to charge nurse who stated the DON was refusing calls. The charge nurse stated the DON was texting her back with responses but forwarding calls to voicemail. This RN spoke with the charge nurse who said We are no longer caring for that patient, you will need to call .hospice for find a place. During an interview with the Minimum Data Set Coordinator (MDSC), on [DATE], at 8:11 a.m., she stated Resident 46 was admitted to the SNF on [DATE]. The MDSC stated Resident 46 was discharged to the GACH on [DATE] and returned to the SNF on [DATE] (a total of 41 days after the SNF discharge) from the GACH. During a review of the GACH clinical record titled, Transition Planning Progress Note dated [DATE], at 10:52 a.m., the Note indicated, Social service referral for pt (patient) who was dropped off in the (ED) lobby by (SNF). Per RN (registered nurse), facility is not willing to accept pt back. However, after (HMD 1) was notified regarding pt being dumped doctor wanted pt transferred back. Staff from facility would accept if pt returned within 24 hours which expired at 10 a.m. today. However, when staff attempted to reach facility staff, calls were not being answered and were unable to get through and speak with staff members. Pt. currently has discharge orders. During a review of the clinical record for Resident 46, the ED Nursing Note dated [DATE], at 5:34 p.m., indicated, Pt dropped off to ED lobby by medical transportation staff w(with)/ folder from (SNF). Pt is on hospice per medical records form SNF, growing increasingly agitated and refusing antianxiety medications as (ordered) by PCP (primary care provider). Per note by PCP, pt family requested pt to be seen at this facility for evaluation. No prior report or information given prior to pt arrival. Pt . left alone in lobby after drop off . During a review of the clinical record for Resident 46, the ED Nursing Note dated [DATE], at 7:31 p.m., indicated, Called (SNF) where the patient was a resident. Patient is unable to answer any questions, very confused. ED staff is unaware about why patient was sent to the ED. (LVN 3) at the SNF is also unaware as to why the patient was sent . During a review of the clinical record for Resident 46, the ED Nursing Note dated [DATE], at 8:43 p.m., indicated, Spoke to (HMD 1) who was the hospice physician to assess the patient today. Doctor states he did not intend for the patient to be dumped here and was apologetic for lack of transfer of care. (HMD 1) wrote an order this morning to have the patient transferred . Primary RN called the SNF back to update them that the daughter was finally contacted, and upon normal medical clearance, the patient will be (discharged back)to the facility. (LVN 4) night shift nurse stated he has been discharged from our facility and we actually cannot take him back. The facility policy and procedure titled, Transfer or Discharge, Emergency dated ,[DATE], indicated, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: b. notify the receiving facility that the transfer is being made; c. prepare the resident for transfer; e. Notify the representative (sponsor) or other family member; f. assist in obtaining transportation .

Based on interview and record review, the facility failed to ensure one of three sampled residents, Resident 1, received necessary [MEDICAL TREATMENT] (treatment for [REDACTED]. plan when: 1. Necessary assessments of Resident 1's condition were not completed as required by the facility policies. 2. Resident 1 did not receive [MEDICAL TREATMENT] treatments as indicated in the care plan. 3. Resident 1's physician was not notified of the missed [MEDICAL TREATMENT] treatments. These failures resulted in missed [MEDICAL TREATMENT] treatments for Resident 1, worsening of Resident 1's medical condition, and transfer to the general acute care hospital (GACH) for emergent (needed immediately) [MEDICAL TREATMENT] and inpatient treatment. Findings: 1. Review of Resident 1's clinical record titled, Admission Record (document containing resident personal information) indicated Resident 1 was [AGE] years old and was readmitted to the skilled nursing facility (SNF) on [DATE] with [DIAGNOSES REDACTED]. chest to control abnormal heart beats), primary [MEDICAL CONDITION] hypertension ( high blood pressure in the arteries of the lungs resulting in heart failure), end stage [MEDICAL CONDITION] ([MEDICAL CONDITION], kidney failure requiring treatment with an artificial kidney or kidney transplant in order to maintain life). Review of Resident 1's Online Referral transfer form from the GACH to the SNF dated [DATE], indicated, Nephrology (kidney disease specialist) Progress Note: Assessment: [MEDICAL CONDITION] due to malignant hypertension (very high and difficult to control blood pressure) on maintenance (regularly scheduled treatments) [MEDICAL TREATMENT] (a machine filters wastes, salts, and fluids from the blood through an artificial kidney in order to maintain life when the kidneys no longer work). Review of Resident 1's clinical record titled, Progress Notes dated [DATE] indicated, PT (patient) admitted to facility alert and oriented X (times) 3 (knows who he is, where he is and what date it is) at 1600 (4 p.m.) via (by way of) ambulance gurney, transferred from (GACH), no c/o (complaints of) pain, no respiratory distress (no difficulty breathing), pt. placed on 2 L (liters, a measurement of volume) of O 2 (oxygen), sutures (stitches) clean and dry and intact to right wrist amputation (surgical removal), no drainage noted. AV (arterio-venous) fistula (an artery and a vein are surgically connected to create a large blood vessel which can deliver a high flow of blood) to left arm, bruit (whooshing sound made as the blood flows through the fistula) and thrill (buzzing felt over the fistula indicating that the fistula is working) present, no drainage noted. PT is own RP (responsible party), consent to treat and POLST (document indicating resident wishes for end of life care) signed by pt. list of medications faxed to pharmacy and (Medical Director, MDR) and (MDR) made aware of admission, noted orders for PT (physical therapy), OT (occupational therapy) ST (speech therapy) RD (registered dietician), Pt educated about room and call light placed within reach. The progress note was electronically signed by Licensed Nurse (LN) 12. Review of Resident 1's care plan dated [DATE] indicated, Focus, The resident needs [MEDICAL TREATMENT]. The resident will have immediate intervention should any s/sx (signs or symptoms) of complications from [MEDICAL TREATMENT] occur through the review date. Interventions/Tasks, AV fistula to left arm, Check and change dressing daily at access site. Document. Monitor intake and output. Monitor labs and report to doctor as needed. Pt uses (name and address of [MEDICAL TREATMENT] clinic) tues (Tuesday), thurs (Thursday), sat (Saturday) at 7:30 a.m. chair time (time scheduled to be at the clinic and ready for [MEDICAL TREATMENT]). (Name, address and phone number of transportation company) will pick up. Date initiated: [DATE]. On [DATE] during an interview, the Director of Nursing (DON) stated LN 9 was the nurse assigned to Resident 1 during the day shift on [DATE], [DATE] and [DATE]. On [DATE] at 10:15 a.m. a telephone call was placed to LN 9 to clarify the manner in which he had assessed Resident 1 during his stay between [DATE] and [DATE]. The call was not answered and the request for a return call was not honored. On [DATE] at 11:16 a.m., during an interview, LN 12 stated she was the nurse that admitted Resident 1 to the SNF on [DATE]. LN 12 stated, When the resident is admitted I do a quick assessment. Social Services makes the arrangements for [MEDICAL TREATMENT]. I don't remember arranging anything about his [MEDICAL TREATMENT], I just passed on (to the on-coming shift) what I assessed and what I know about the patient's orders. LN 12 stated she had not contacted anyone regarding Resident 1's scheduled [MEDICAL TREATMENT] times or days. On [DATE] at 11:38 a.m., during an interview and concurrent record review, the DON stated the expectation was the admitting nurse would do a complete head to toe assessment on the admission or re-admission of a resident. The DON stated for a [MEDICAL TREATMENT] resident the assessment should include the Admission Assessment packet, a head to toe assessment, status of the [MEDICAL TREATMENT] AV fistula, lung sounds and presence of [MEDICAL CONDITION] (build-up of fluid in the body). The DON stated the nurse assigned to the resident should know what care the resident required. The DON reviewed Resident 1's Admission assessment dated [DATE]. The DON stated the assessment was incomplete; it did not include the Admit/Readmit Screener, a document that included a head to toe assessment, special equipment required, language spoken and other resident specific information. The DON reviewed the Progress Notes dated from [DATE] through [DATE]. The DON stated the Progress Notes were not complete. The DON stated the nurse assigned to Resident 1 should have done a complete head to toe assessment at the beginning of each shift and documented the assessment in the progress notes and that had not been done. The DON stated after the initial admission entry on [DATE] there was no further assessment of Resident 1's [MEDICAL TREATMENT] status, AV fistula, presence of [MEDICAL CONDITION] or lung sounds documented in Resident 1's record. Review of facility document titled, Licensed Practical/Vocational Nurse Job Description dated revised [DATE], indicated, Duties and Responsibilities. 1. Responsibilities to the Patient. A. Participates in an on-going systematic assessment of the physical, emotional, social, educational, and functional needs of the patient through interview, observation and physical examination .H. Provides nursing care to meet patient needs: a. Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools . Review of facility document titled, Registered Nurse (SNF) Job Description dated revised [DATE], indicated, Duties and Responsibilities. 1. Responsibilities to the Patient. A. Participates in an on-going systematic assessment of the physical, emotional, social, educational, and functional needs of the patient through interview, observation and physical examination. 1. Receives admissions and/or transfers to the unit. 2. Completes nursing admission notes within 24 hours .J. Provides nursing care to meet patient needs: a. Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools . Review of facility document titled, Care of the [MEDICAL TREATMENT] Resident dated [DATE], indicated, 1. Check shunt ([MEDICAL TREATMENT] access such as AV fistula) for bruit every 4 hours for the first 24 hours post [MEDICAL TREATMENT] .and then once per shift. 2. Review of Resident 1's care plan dated [DATE] indicated, Focus, The resident needs [MEDICAL TREATMENT]. The resident will have immediate intervention should any s/sx of complications from [MEDICAL TREATMENT] occur through the review date. Interventions/Tasks, AV fistula to left arm, Check and change dressing daily at access site. Document. Monitor intake and output. Monitor labs and report to doctor as needed. Pt uses (name and address of [MEDICAL TREATMENT] clinic) tues (Tuesday), thurs (Thursday), sat (Saturday) at 7:30 a.m. chair time (time scheduled to be at the clinic and ready for [MEDICAL TREATMENT]). (Name, address and phone number of transportation company) will pick up. Date initiated: [DATE]. Review of Resident 1's Interdisciplinary Team ( IDT, a team of healthcare providers including nurses, social services staff, dietary staff, activities staff and physicians) Note dated [DATE] at 8:47 a.m., indicated, 1. Pertinent Diagnosis, Acute [MEDICAL CONDITIONS], coronary artery bypass (surgery to bypass an obstructed heart artery), [MEDICAL CONDITION]. 2. Problem . [MEDICAL TREATMENT] with AV shunt (fistula) to left arm. 2A. IDT recommendations, Continue orders per MD (physician). HD ([MEDICAL TREATMENT]) on scheduled days. C. IDT attendees: C1. Attendees: DON, MDS (Minimum Data Set, a resident assessment tool used to plan resident care) nurse, DSD (Director of Staff Development), SSD (Social Services Director), DSM (Dietary Services Manager). The IDT note was electronically signed by the DON. Review of Resident 1's clinical record titled, Progress Note dated, Late entry, Effective Date [DATE] at 8:40 a.m. indicated, Resident (Resident 1) arrived to the facility late in the evening on the 23rd (Wednesday, [DATE]). When social services arrived to the facility on the 24 (Thursday [DATE]), social services was informed that resident had [MEDICAL TREATMENT] on Thursday and was supposed to be there at 7:15 a.m. Social services called [MEDICAL TREATMENT] center to see if they could accept the resident. The [MEDICAL TREATMENT] center could accept the resident at 3:15 p.m. that day .Social services called the [MEDICAL TREATMENT] center and informed them that we could not find transportation for this resident at 3:15. So the [MEDICAL TREATMENT] center was able to have the resident come in on Friday the 25 at 11:30 .On Friday the 25 (transportation company) called the facility at 10:30 and stated they would not be able to pick the resident up and canceled the transportation .Social services called the [MEDICAL TREATMENT] center and informed them that we couldn't find any last minute transportation .(transportation company) said that they could transport the resident to and from [MEDICAL TREATMENT] starting on Saturday the 26 .They would be here at 7 a.m. to pick resident up and transport him to [MEDICAL TREATMENT] on Saturday the 26 . The Progress Note was electronically signed by the SSD. On [DATE] at 12:31 p.m., during an interview, the SSD stated she had attempted to schedule Resident 1's [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) treatments on [DATE], [DATE] and [DATE] but had difficulties with obtaining transportation to the [MEDICAL TREATMENT] unit. The SSD stated she was unable to find a company who could provide transportation on [DATE] and the company scheduled for [DATE] called that morning and canceled their transportation appointment. The SSD stated on [DATE] a transportation company arrived to take Resident 1 to [MEDICAL TREATMENT] but was informed by a nurse that he required transportation by gurney, which they were unable to provide, and they left the SNF. The SSD stated Resident 1 did not receive his [MEDICAL TREATMENT] treatment on [DATE], [DATE] or [DATE]. On [DATE] at 1:57 p.m., during an interview, LN 7 stated it was very important to for residents to receive [MEDICAL TREATMENT] treatments as scheduled. LN 7 stated, If there is a problem getting the resident dialyzed for whatever reason, I report that to my DON and call the medical doctor to see if he wants the resident to go to acute care (GACH). On [DATE] at 2:48 p.m., during a telephone interview, LN 2 stated she had worked at the SNF during Resident 1's stay at the facility. LN 2 stated, [MEDICAL TREATMENT] is extremely important. The resident can't afford to miss any (treatments); especially (Resident 1). He was already compromised medically. On [DATE] at 3:30 p.m., during an interview, LN 1 stated, As a licensed staff, for the [MEDICAL TREATMENT] patients, I make sure there is an appointment ([MEDICAL TREATMENT] appointment) made. I make sure there's transportation. The SSD arranges the transportation. All LNs can call for transportation arrangements. Our corporation has our own transportation .Resident [MEDICAL TREATMENT] is extremely important and can't be missed .it's detrimental. On [DATE] at 2:19 p.m. during an interview, the SSD stated she informed Resident 1's nurse, LN 9, on [DATE] that Resident 1 missed his [MEDICAL TREATMENT] treatment due to the unavailability of transportation. The SSD stated she informed LN 9 again on [DATE] that Resident 1 missed his [MEDICAL TREATMENT] treatment on that day due to transportation problems. The SSD stated she did not document that she informed LN 9 regarding the missed [MEDICAL TREATMENT] treatments. On [DATE] at 9:01 a.m., during a telephone interview, LN 9 stated, When it comes to [MEDICAL TREATMENT], we go to the SSD; she has the information. I don't remember (the SSD) telling me that (Resident 1)'s [MEDICAL TREATMENT] appointment had any problems. If that was relayed to me I could have done something to help .I remember sending (Resident 1) on [DATE] (to the GACH) for abdominal pain and I came to find out he had not had his [MEDICAL TREATMENT] for a few days. The Resident told me. (Resident 1) told me (on [DATE]) that he had not had his [MEDICAL TREATMENT] in 3 days. On [DATE] at 4:50 p.m., during an interview, the DON stated, I expect the licensed nurses to know that [MEDICAL TREATMENT] is very important. If there was no transportation arrangement that can be arranged then that should have been reported to the doctor so an order to be sent to ER (emergency room ) could have been gotten. If I was here I would have sent him (Resident 1) to the ER to be dialyzed. On [DATE] at 12:41 p.m., during an interview, the SSD stated, (LN 9) came to me at least a couple of times to ask if arrangement was done for (Resident 1's) transportation. I know the nurse (LN 9) was aware. The DON knew that I couldn't get any transportation on that first day, [DATE]. All of the nursing staff knew about the missed [MEDICAL TREATMENT] on ,[DATE] because we talked about it at our 9 am morning report. 3. Review of Resident 1's care plan dated [DATE] indicated, Focus, The resident needs [MEDICAL TREATMENT]. The resident will have immediate intervention should any s/sx of complications from [MEDICAL TREATMENT] occur .Date initiated: [DATE]. Review of Resident 1's IDT Note dated [DATE] at 8:47 a.m., indicated, .2. Problem . [MEDICAL TREATMENT] with AV shunt to left arm. 2A. IDT recommendations, Continue orders per MD (physician). HD ([MEDICAL TREATMENT]) on scheduled days. C. IDT attendees: C1. Attendees: DON, MDS nurse, DSD, SSD, DSM. The IDT note was electronically signed by the DON. On [DATE] at 12:31 p.m., during an interview, the Social Services Director (SSD) stated she had attempted to schedule Resident 1's [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) treatments on [DATE], [DATE] and [DATE] but had difficulties with obtaining transportation to the [MEDICAL TREATMENT] unit for Resident 1. The SSD stated she was unable to find a company who could provide transportation on [DATE] and the company scheduled for [DATE] called that morning and canceled their transportation appointment. The SSD stated on [DATE] a transportation company arrived to take Resident 1 to [MEDICAL TREATMENT] but was informed by a nurse that he required transportation by gurney, which they were unable to provide, and they left the SNF. The SSD stated Resident 1 did not receive his [MEDICAL TREATMENT] treatment on [DATE], [DATE] or [DATE]. On [DATE] at 2:19 p.m. during an interview, the SSD stated she informed Resident 1's nurse, LN 9, on [DATE] that Resident 1 missed his [MEDICAL TREATMENT] treatment due to the unavailability of transportation. The SSD stated she informed LN 9 again on [DATE] that Resident 1 missed his [MEDICAL TREATMENT] treatment on that day due to transportation problems. The SSD stated she did not document that she informed LN 9 regarding the missed [MEDICAL TREATMENT] treatments. On [DATE] at 9:01 a.m., during a telephone interview, LN 9 stated, When it comes to [MEDICAL TREATMENT], we go to the SSD; she has the information. I don't remember (the SSD) telling me that (Resident 1)'s [MEDICAL TREATMENT] appointment had any problems. If that was relayed to me I could have done something to help .I remember sending (Resident 1) on [DATE] (to the GACH) for abdominal pain and I came to find out he had not had his [MEDICAL TREATMENT] for a few days. The Resident told me. (Resident 1) told me (on [DATE]) that he had not had his [MEDICAL TREATMENT] in 3 days. On [DATE] at 4:50 p.m., during an interview, the DON stated, I expect the licensed nurses to know that [MEDICAL TREATMENT] is very important. If there was no transportation arrangement that can be arranged then that should have been reported to the doctor so an order to be sent to ER (emergency room ) could have been gotten. If I was here I would have sent him (Resident 1) to the ER to be dialyzed. On [DATE] at 1:06 p.m., during an interview, the DON stated she reviewed the packet of information received from the GACH on [DATE] for Resident 1. The DON stated staff were aware Resident 1 required [MEDICAL TREATMENT]. The DON stated staff talked about two of Resident 1's missed [MEDICAL TREATMENT] treatments during stand-up meetings (staff meetings held at the beginning of the morning shift and beginning of the afternoon shift). The DON stated, We were all aware (of Resident 1's missed [MEDICAL TREATMENT] appointments). The DON stated LN 9 had informed her regarding Resident 1's missed [MEDICAL TREATMENT] appointments during stand-up meetings on [DATE]. The DON stated her understanding was LN 9 would notify the Medical Director (MDR) regarding the missed appointments. On [DATE] at 5:14 p.m., during an interview, the MDR stated Resident 1 was his patient and had many medical problems. The MDR stated he was not aware Resident 1 had not dialyzed between [DATE] and [DATE] while at the SNF. The MDR stated, No, I didn't know that he missed his [MEDICAL TREATMENT]. Nobody told me. It is very important for a [MEDICAL TREATMENT] patient to get their [MEDICAL TREATMENT] especially with (Resident 1). He can't afford to miss any of his [MEDICAL TREATMENT] treatments. The facility should have called me so I could have ordered to get him dialyzed. Nobody notified me that he missed at least 3 days of [MEDICAL TREATMENT]. (Resident 1) was already compromised health wise. Or call the patient's nephrologist (kidney specialist) and get an order to send him out to the hospital. When a patient like (Resident 1) missed his [MEDICAL TREATMENT], potassium (salt in the blood which can have a direct effect on the heart muscle if the level is too high or too low) level goes up to a dangerous level. The [MEDICAL CONDITION] (swelling from retention of fluid in the body) gets worse and (Resident 1) had significant swelling already. Again, I did not get any notification of any kind about (Resident 1) missing his [MEDICAL TREATMENT] and I should have. Review of facility policy titled, Notification dated [DATE] indicated, Staff informs the resident, consults with their attending physician, and notifies the resident's surrogates when: .The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present risk to the health, safety or security of the residents .Treatment needs to be altered significantly . Review of Resident 1's clinical record titled, Progress Note dated [DATE] at 12:40 p.m., indicated, At approx (approximately) 11 a.m. resident (Resident 1) complaint of SOB (shortness of breath), nurse assessed resident and determined he would benefit from being sent to ER (emergency room ) .Ambulance arrived at 11:15 to transport to ER . The Progress Note was electronically signed by LN 9. Review of the GACH clinical record titled, ED (emergency department) Dictation, Final Report dated [DATE] indicated, Date of Service: [DATE]. Chief Complaint: Severe upper sternal (breastbone area) pain and shortness of breath .History of Present Illness: Apparently, due to scheduling problems, his (SNF) has been unable to arrange for any [MEDICAL TREATMENT] for him over the last week of admission. He has had increasing shortness of breath .He says he feels like something is going to explode inside .He does have increasing swelling of his ankles. He is markedly orthopneic (needs to sit upright to breathe) .He is mouth breathing (breathing through open mouth) .Interventions: As luck would have it, the [MEDICAL TREATMENT] nurse was immediately available, so we sent the patient up directly to [MEDICAL TREATMENT] .Final Diagnosis: [REDACTED]. 2. Missed [MEDICAL TREATMENT] appointments. 3. Pleural effusion (collection of fluid between the two membranes that surround the lungs). 4. [MEDICAL CONDITION] . Review of the GACH clinical record titled, History and Physical dated [DATE], indicated, .for unclear reasons he has not had any [MEDICAL TREATMENT] since his transfer to (SNF) on [DATE]. Today the patient developed acute shortness of breath with pain with inspiration (breathing in) .was transferred to the ER for evaluation. Upon arriving here he was found to be in acute [MEDICAL CONDITIONS] and sent to the [MEDICAL TREATMENT] unit for emergent (needed immediately) [MEDICAL TREATMENT] and we have been called to admit him (to the GACH) .Assessment: Acute [MEDICAL CONDITIONS] due to missed [MEDICAL TREATMENT] . Review of the GACH clinical record titled, Discharge Summary dated [DATE] indicated Resident 1 .was readmitted basically due to unable to have [MEDICAL TREATMENT] (at the SNF). The Discharge Summary indicated Resident 1 had a cardiopulmonary arrest (heart and breathing stop) on [DATE] and expired at the GACH. The Discharge Summary indicated, .I (physician) was notified that the patient had a code blue (cardiopulmonary arrest) .unfortunately not able to make it . Review of [MEDICAL TREATMENT] patient education material [MEDICAL TREATMENT] Connection @www.nwkidney.org vol. 2, issue 1, Winter 2013, indicated, Missing [MEDICAL TREATMENT] can be deadly .[MEDICAL TREATMENT] replaces your kidney function and removes fluid and wastes that build up in your blood .Shortening or skipping treatments has serious risks. When you miss [MEDICAL TREATMENT], fluids, toxins and potassium build up in your bloodstream, making you feel weak .Fluid overload and high potassium levels can lead to trips to the hospital, a need for emergency [MEDICAL TREATMENT] and heart complications.

Based on observation, interview and record review, the facility failed to provide a safe and functional environment for residents, staff and the public, when 10 of 10 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) were exposed to an unsafe and unoccupiable facility interior environment. The facility environment was noted to have unprotected wiring, unfinished construction and unsafe conditions due to interior building construction changes that were unauthorized and performed without the benefit of appropriate permits from local or state planning and development authorities. This failure resulted in placing residents in an unsafe, dangerous, and hazardous environment and had the potential for injuries and accidents to all residents. Due to the serious potential harm of exposing all residents to an unsafe facility environment, an Immediate Jeopardy (IJ) was called and the Facility Chief Executive Officer (CEO) was verbally notified on 9/1/16 at 10:45 a.m. The facility building interior was subsequently identified as unsafe and not fit for occupancy by the Office of Statewide Health Planning and Development (OSHPD) and residents were immediately transferred to a nearby facility in order to avoid injury and harm. The facility submitted an acceptable Plan of Action addressing the IJ situation and implemented actions to address the immediacy. The IJ was removed on 9/2/16 at 3:40 p.m. in the presence of the Administrator. Findings: On 9/1/16 at 10:00 a.m., during the initial tour of the building interior with the OSHPD inspectors, the east wing was observed to be under construction and remodeling work was in progress. The construction work being done on the east wing was observed to include the following: 1. Shipping boxes contained new electrical wiring and outlet boxes which were ready to be used. Shipping boxes were observed to contain wiring, electrical circuits, a nurse call system and television cabling. The current nurse call system was partly dismantled, exposing the electrical circuits and unprotected wiring. Television cabling was hanging free from the wall. 2. The rooms and corridors ceiling and wall lighting were newly installed. 3. Along the east wing corridor, wall and ceiling, gypsum wall board (unfinished wall material) had been cut and removed to create access for the electrical work in progress. Two to three areas had dry wall removed and [MEDICATION NAME] piping exposed. 4. Along the east wing corridor, walls were covered with protective plastic from ceiling to floor. On 9/1/16 at 10:00 a.m., when entering the west wing, through the north exterior door, the current nurse call system was in the process of having work done and was not functional. There was exposed wiring and electrical work in progress on the call light system. By the nurse's station, located between the east and the west wing, a panel with exposed wires was observed on the wall across from the nurse's station. The west wing was occupied by two residents (Resident 9 and Resident 10) in Room 33. Room 33's call light located on top of the door was missing and instead had exposed wiring with no light fixture; exposed electrical wires were hanging from the top part of the door down to the opening of the door. There was no call light button or cord present to use for Resident 9 and Resident 10 located in Room 33. On 9/1/16 at 10:05 a.m., during an interview at the nurses station located between the central wing and the west wing, the Medical Records Assistant (MRA), the only staff available at the nurse's station, stated she was aware of the interior construction occurring, but could not provide any specific date as to when the construction started. When asked about the call light system, the MRA stated the call light for Room 33 did not function while pointing to the unprotected wiring hanging near Room 33. The MRA verified there was no call light system in Room 33. The MRA stated she did not know how long the call light system had not been working. On 9/1/16 at 10:30 a.m., an observation was made on the central wing. Four rooms were occupied by residents. Resident 1 was in Room 16. Resident 2 and Resident 3 were in Room 18, Resident 6 and Resident 7 were in Room 19, and Resident 8 was in Room 20 . A test of the nurse call system was conducted in the central wing of the facility by the OSHPD Inspector and the California Department of Public Health, Licensing and Certification (CDPH L&C) surveyor. There was no nurse call system in the west wing where two residents (Resident 9 and Resident 10) resided. Testing of the call system in the shower room located on the central wing was not working, no light illuminated on the call system panel at the nurse's station when the call button was pushed. There was no working call light system for Room 17 and Room 18, in that there was no illumination observed on the system panel at the nurse's station for Room 17 or Room 18 when the call light button was pushed. When Room 16's call light was pushed, it lit up on the fixture above Room 17 and on the call system panel for Room 17 at the nurse's station. On 9/1/16 at 10:34 a.m., during a concurrent interview with OSHPD and CDPH staff, the CEO stated the Licensing and Certification office had not been notified of the planned construction. The CEO was not aware if a local building or an OSHPD permit was obtained for the work in progress. The CEO stated all she knew was that a design professional was hired and all contractors were licensed. On 9/1/16 at 10:45 a.m. during an interview, the OSHPD Inspector notified the CEO that plans for construction were required to be approved by CDPH and OSHPD prior to beginning work at the facility. Interior construction work was required to be authorized by OSHPD by submitting a request for a construction permit. The Regional Compliance Officer (RCO) for OSHPD explained without the benefit of appropriate permits and approvals for construction there was no method to verify the safety of the building construction. The RCO stated because there was no assurance the work was constructed in a safe manner, the RCO declared the building unoccupiable (not approved for the residents residence). The RCO also explained the serious concern of not having a functional call light system. The RCO notified the CEO of the direction to stop construction immediately and the CEO agreed to voluntarily stop construction. The CEO agreed to submit to OSHPD the appropriate scope of work and architectural plans needed to obtain approval for construction. The CEO agreed to vacate and transfer the residents as soon as possible. Because of the serious potential harm and possible injury to residents related to occupying a building unsafe for occupancy, an Immediate Jeopardy was called with the CEO at 10:45 a.m. The CEO submitted an acceptable written Action Plan that addressed the unsafe nature of the building and implemented the process to safely transfer residents to a local facility. The facility implemented actions to address the immediate potential risk to the residents jeopardy. The IJ was removed on 9/2/16 at 3:40 p.m. in the presence of the Administrator. On 9/1/16 at 11:50 a.m., during an interview, Resident 1 stated the call light in which the room Resident 1 resided was not answered right away, and sometimes it took an hour before it was answered by staff. On 9/1/16 at 11:57 a.m., Resident 5 had a little bell on her bedside table to use as a call light. Resident 5 did not answer when spoken to. Resident 5's Brief Interview for Mental Status (BIMS) score was 6 (severe impairment) on a scale of 0-15 with 15 scored as no cognitive deficit according to the Minimum Data Set (MDS) assessment (a cognitive and functional assessment of residents' abilities) dated 8/20/16. On 9/1/16 at 12:11 p.m., during an interview, Resident 4 stated staff sometimes answered the call light, but not all the time. On 9/1/16 at 12:37 p.m., Resident 9 stated she had no call light in her room (Room 33). On 9/1/16 at 12:37 p.m., Resident 10 stated she had no call light in her room (Room 33). On 9/1/16 at 2:40 p.m., during an interview in response to the need to transfer residents to another skilled nursing facility because the building was no longer safe for residents' occupancy, the CEO stated prior to transferring the residents, patient representatives, physicians, pharmacists, and all decision makers were notified by telephone and a notice provided by way of a letter that residents would be transferred to a different facility. On 9/2/16 at 9:30 a.m. during an interview, the Facility Operations Manager (FOM) stated he was out on an extended leave of absence and when he returned on 7/1/16 he found construction already in progress. In a report dated 9/1/16 with reference number U 2-50-00, the OSHPD Regional Compliance Officer wrote: . FDD (Facilities Development Division of OSHPD) informed the CEO and CDPH L&C that because the scope of the work of construction was unknown, unpermitted, and uninspected by an Independent Certified Hospital Inspector, OSHPD FDD could not make a recommendation of re-occupancy of the apparent completed construction or the current work of construction witnessed in progress .It was requested that all construction work currently in progress . be stopped and not completed until a Building Permit for the work was obtained from FDD. The work was voluntarily stopped .

Based on observation, staff, resident and family interview, clinical record, and administrative document review, the facility failed to permit residents to remain in the facility (Skilled Nursing Facility 1) (SNF) and not transfer or discharge (T and D) unless the T and D was necessary to meet the welfare and needs of the residents when the facility acted upon a business decision to T and D residents without implementation of an appropriate and safe discharge planning process. The business decision and practice to T and D residents in order to empty the building of current residents, was to accommodate the alleged plan of a potential new owner to convert the facility solely to a specialized type of nursing service provided to residents who require subacute care (needing complex care or rehabilitation). The failure to evaluate each resident's need for healthcare services and the decision to cease admission of new residents, potentially affected 64 residents, and negatively affected 29 residents (Resident 1, Resident 2 and Residents 8 through 34) beginning 6/1/15. These unsafe practices created an environment of confusion, intimidation, anxiety, mistreatment, bullying, and emotional distress for potentially all 64 residents when the decision was made to T and D current residents out of the facility to accommodate the plans of the potential new owner. Because of the potential serious harm related to the facility practice of promoting unsafe T and D and the imminent plan to transfer four of seven residents (Resident 1, Resident 2, Resident 3, Resident 4) and the possible transfer of the three remaining residents (Resident 5, Resident 6, and Resident 7), an Immediate Jeopardy (IJ) situation was called on 12/10/15 at 12:10 p.m., with the Interim Administrator (IA), the Clinical Nurse Liaison (CNL), and the Regional Nurse Consultant (RNC). The facility submitted an acceptable action plan which addressed to fully evaluate the need to T and D, and to start admissions (the facility had stopped admitting residents on 6/1/15). The facility fully implemented the action plan and the IJ was removed on site on 12/17/15 at 5:40 p.m., with the IA and the Regional Director of Operations (RDO) in attendance. These failures resulted in residents' expressions of fear of losing their familiar place of residence and anxiety when residents were unsure where they would live. The displacement from their home, family and familiar routines and loss of established social networks caused residents emotional distress, weight loss, and psychological harm. Findings: 1. On 12/9/15 at 9:40 a.m., during a tour of the SNF 1 and concurrent interview with the IA, there were no residents observed in the hallways. No residents were observed in the rooms and dining area located in the west wing of the facility. Four residents were observed sitting in the east wing main dining room watching television. The facility IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the west wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day (12/9/15) due to a change of ownership of the facility. On 12/9/15 at 11:45 a.m., during an observation and concurrent interview in the east wing, Resident 1 was sitting in a wheelchair in his room. Resident 1 stated he was going to be leaving the facility at 3:30 p.m. that day because he was scheduled to transfer to another facility. Resident 1 stated he had been scheduled for transfer because, Some new people bought this place. They aren't taking (keeping) people like me. Review of Resident 1's clinical record titled, Face Sheet indicated Resident 1 had resided in the facility since 2/9/15. Review of Resident 1's clinical record titled, Departmental Notes dated 12/9/15 at 3:37 p.m., indicated, Social Service discharge note: .Resident said bye to staff . On 12/9/15 at 12:15 p.m., during a staff interview in the east wing hallway, Licensed Nurse (LN) 1 stated residents who had resided in the facility were transferred out of the facility due to new ownership to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that had transferred were sad and had not wanted to leave as the facility had been their home for a long time. LN 1 stated one resident was transferred to the state of Washington and that resident had not been happy about the transfer, though the resident had gone anyway. LN 1 stated that resident (Resident 8) had not requested to move to Washington and had not had a change of condition that required a different level of care other than what was already provided in the facility. LN 1 stated the resident was transferred because the new owners were not going to run a long term care facility. On 12/9/15 at 12:49 p.m., during a telephone interview, Resident 2's Responsible Party (RP) 1 stated she lived out of state and handled Resident 2's affairs. RP 1 stated she was contacted by telephone in late October or early November (2015) by facility staff and was told SNF 1 was changing hands and would not be doing skilled nursing any longer. RP 1 stated she had not requested Resident 2 transfer to another facility. RP 1 stated, I was told by the facility that it (the transfer) needed to be done. I was given a list of places (to call for possible transfer). RP 1 stated she did not receive any written notice of the reason necessitating the transfer of Resident 2. RP 1 stated she had not been provided information regarding orientation to the new facility. Review of Resident 2's clinical record titled, Face Sheet indicated Resident 2 had resided in SNF 1 since 6/20/13. Review of Resident 2's clinical record titled, MDS 3.0 Assessment (Minimum Data Set, a tool to collect resident assessment data), indicated Resident 2's cognitive skills for decision making were, Severely impaired-never/rarely made decisions. Review of Resident 2's clinical record titled, Departmental Notes dated 12/9/15 at 3:52 p.m., indicated, Social Service discharge note: Resident discharge on 12/9/15 to (SNF 2) .at 1:30 (p.m.). On 12/9/15 at 12:50 p.m., during an observation in the east wing hallway near the nurse's station, Resident 3 was wheeling himself down the hallway, yelling loudly at no one in particular. Resident 3 was unable to communicate in coherent sentences. On 12/9/15 at 12:56 p.m., during a telephone interview, Resident 3's Family Member (FM) 1 stated approximately a week ago he had been notified by SNF 1 staff of Resident 3's pending transfer to another SNF. FM 1 stated neither Resident 3 nor any family had requested the transfer. FM 1 stated he was told the facility was getting rid of all their patients because it would be providing a different kind of care. FM 1 stated SNF 1 had given him two choices to transfer Resident 3 to; both were out of his current town of residence. FM 1 stated Resident 3 had lived in the current town for thirty years and he did not want him moved outside of town. FM 1 stated he had not received any written notice of the reason for Resident 3's transfer to another SNF. Review of Resident 3's clinical record titled, Face Sheet indicated Resident 3 had resided in SNF 1 since 4/24/15. Review of Resident 3's clinical record titled, Departmental Notes dated 12/8/15 at 2:42 p.m., indicated, Social Service pre-discharge note: Resident anticipated discharge on 12/9/15 to (SNF 3). Review of website www.Mapquest.com, indicated SNF 3 (where Resident 3 was scheduled to be transferred) was located 52.3 miles from Resident 3's current residence. On 12/9/15 at 1:10 p.m., during an observation and concurrent interview, Resident 4 was lying in bed, pale and breathing heavily. The head of the bed was elevated. Resident 4 had a tube which delivered oxygen placed in her nose and a tube to supply fluid and medication through the vein in her left arm. Resident 4 stated she was sick. Resident 4 stated she had been informed about a month ago by the Social Services Director SSD) that she would have to leave the facility. Resident 4 stated the facility was being sold and all residents were being transferred to other facilities. Resident 4 stated, I don't know where I'm going .I don't know if I want to go. Review of Resident 4's clinical record titled, Face Sheet indicated Resident 4 had resided in SNF 1 since 2/13/14. Review of Resident 4's clinical record titled, MDS 3.0 Assessment dated 11/4/15, indicated Resident 4's cognitive skills for daily decision making were Independent-decisions consistent/reasonable. Review of Resident 4's clinical record titled, Quarterly Social Services Discharge Planning Note dated 12/2/15, indicated 5. Discharge Imminent? Yes. On 12/9/15 at 1:30 p.m., during an interview in the social services office, the Social Services Director (SSD) stated SNF 1 had been purchased by a new owner. The SSD stated she did not know what the new owner had planned for the facility. The SSD stated some residents had been transferred out of the facility. The SSD stated some of the residents who were transferred had not wanted to transfer to a different facility because they had been a resident in the facility for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner moved in. The SSD stated she had not been able to tell the residents what would happen when the new owner moved in because she did not know. The SSD stated information regarding the new owner was spread through word of mouth and there had been no official discussion of the change of ownership with the residents. On 12/9/15 at 2:30 p.m., during a telephone interview, the facility Medical Director (MD) 1 stated he understood the facility building had been sold to a new owner and residents were transferred out for that reason. MD 1 stated he was not directly involved with the transfers of residents. MD 1 stated, I don't have the skills or the time to be directly involved in the transfers - that's social services responsibility. In our On 12/9/15 at 4 p.m., during a concurrent interview and administrative document review, when the IA was asked for the facility policy and procedure on transfer and discharge, the IA provided a document titled, Lippincott Procedures (Standard Nursing Procedure book not specific to any one facility)- Transfer to long-term care facility, dated January 9, 2015. The IA stated she was unable to locate a facility transfer policy and procedure that met federal regulations for qualifying conditions which would indicate under what conditions residents could be transferred or discharged and when a 30 day written notice of transfer would be required. The IA stated, I don't think we have that policy. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided Resident 1 or Resident 2 or any other resident that had been transferred during the past five months a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, We didn't do those. Review of the facility's administrative policy titled California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities pages eight to nine, dated 5/11 provided to all SNF 1 residents on admission indicated, VI. Transfers and Discharges .Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance .Our written notice will include the effective day, the location to which you will be transferred or discharged , and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us . In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman. On 12/9/15 at 4:25 p.m., during a telephone interview, Resident 8's Responsible (RP) 2 party stated Resident 8 had been transferred out of SNF 1 on December 2, 2015. RP 2 stated she did not request Resident 8 be transferred out of the facility. RP 2 stated the SSD called her in October 2015 and told her Resident 8 had to be out of the facility by November 30, 2015. RP 2 stated the SSD told her another company had purchased the facility and Resident 8 did not qualify for the type of care the new company provided. RP 2 stated, I was scared. I only had 30 days to find a place for (Resident 8). I kept calling (the SSD) and she would just tell me she still had another 14 residents to place. So I started looking on my own. I was told he had to be out by November 30 (2015). I found a place in Washington .I was afraid of what would happen after November 30. I felt bullied and scared. I was worried about (Resident 8) and where he would end up. The facility (SNF 1) was no help at all. RP 2 stated a family member drove Resident 8 to the airport and another family member accompanied him on the flight to SNF 4 in Washington State. RP 2 stated she had not received any written notice in advance explaining the reason for the transfer to another facility. The RP stated the situation had been very stressful for everyone. On 12/10/15 at 8:40 a.m., during a tour of the facility, the Interim Director of Nursing (IDON) 1 stated when residents in the facility had asked what would happen when the new company came in, the staff told the residents they really didn't know and couldn't say. The IDON 1 stated the facility was not accepting any new admissions because the new company would be running a sub-acute facility instead of a long term care facility and they (new owners) wanted the building to be emptied of the current residents. On 12/10/15 at 9:30 a.m., during an interview in the Administrator's office, the CNL stated the facility had not taken new admissions since June 2015 because they did not know what the new owner would do with the building. The CNL stated when residents had asked what would happen (to them) when the new owners came into the building, the staff told them they didn't know. Review of the facility report titled, Census List, dated 6/1/15 under Summary Information, indicated, Total beds: 70. Occupied Beds: 61. Review of the facility report titled, Census List dated 12/9/15 indicated a list of seven names (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 7). Because of the potential serious harm related to the facility practice of promoting unsafe T and D and the imminent plan to transfer four of seven residents (Resident 1, Resident 2, Resident 3, Resident 4) and the possible transfer of the three remaining residents (Resident 5, Resident 6, and Resident 7), an IJ situation was called on 12/10/15 at 12:10 p.m., with the IA, the CNL, and the RNC. The facility submitted an acceptable action plan which addressed to fully evaluate the need to T and D, and to start admissions (the facility had stopped admitting residents on 6/1/15) and was observed on-site to have implemented corrective actions that addressed the immediate jeopardy situation and the IJ was removed on 12/17/15 at 5:40 p.m. The RDO and the IA were present and notified the IJ was removed and the investigation would be ongoing. 2. On 12/16/15 at 3 p.m., during a staff interview, the Social Services Director (SSD) stated she had worked for the facility for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she was assigned responsibilities for discharging residents that was previously a nursing services responsibility. She stated in June 2015 the CNL began assisting her in the discharging of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed them they could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. She stated families were given the instruction discharge was inevitable sooner or later as the type of patients accepted would change. The SSD stated the residents were fast tracked to discharge as part of the change in the process. She stated, The majority of families wanted to seek placement out of fear, not knowing what was going to happen .how could they not be (fearful)? As an employee it was very difficult .they (the facility) were not communicating properly .I felt pressured .that's been very stressful. She further stated the facility had stopped admitting new residents in June 2015. On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role in the transition was to discharge residents from the facility. She stated she learned of an ownership transition in a staff meeting and received direction from the RDO to discharge residents. She stated, I wasn't aware of the regulations .I was stuck in between .it ' s been a nightmare. The CNL stated, If they (the residents) asked (what would happen to them), we told them about the change of ownership .don't know when it's going to happen .there was the feeling of uncertainty. On 12/17/15 at 1:30 p.m., during an interview, the IA, stated she had started to work at the facility on 9/4/15 and the west wing hallway of the facility was empty of residents. The IA stated she contacted the facility RDO who informed her there was a pending sale of the skilled nursing license. The IA stated her role in the transition was to talk to concerned families, seek availability of beds at other facilities for the transfer of residents, and assist the staff in discharging residents. She stated her directive from the RDO was to discharge residents when an appropriate facility had an available bed. She stated her job was to make sure discharges happened. The IA stated, Shame on us in hindsight, we let (the pending owner) run it. We would do it differently if we could do it again .We (the IA and the RDO) were caught in the middle. Review of Resident 8's clinical record titled, Face Sheet indicated Resident 8 had resided at the facility since 9/24/14 and had [DIAGNOSES REDACTED]. Review of Resident 8's clinical record titled, MDS 3.0 Assessment, dated 9/22/15, indicated Resident 8's cognitive (pertaining to comprehension, memory and reasoning ability) skills for daily decision making were Moderately impaired-decisions poor, and he required Extensive assistance to transfer between surfaces such as chair to wheelchair. Review of Resident 8's clinical record titled, Departmental Notes, dated 9/24/15 at 11:08 a.m., indicated, Resident wanders from room to lobby .Resident removes alarm, disrobes himself and tries to get out of bed without assistance. Resident receives Quetiapine (a medication to treat [MEDICAL CONDITION]) 50 mg (milligrams, a dosage measurement) po (by mouth) QPM (every evening) for auditory hallucinations, [MEDICAL CONDITION] .[MEDICATION NAME] (a medication to treat anxiety) 0.25 mg po BID (twice a day) for agitation . Review of Resident 8's clinical record titled, Transfer/Discharge Summary dated 12/2/15, contained an area to document Reason for Transfer/Discharge with choices including, Resident condition improved; No longer needs Nursing Facility Care; Resident needs SMF(skilled medical facility)/Hospital care; Resident/Family request; safety/health of individuals in facility endangered; Other, Please Explain. The box indicating Other, Please Explain was the single box checked and Long term was written on the line next to the box. Review of Resident 8's clinical record titled, Physician Orders dated December 2015, indicated medication orders were for the following: [MEDICATION NAME] (medication to treat anxiety) to be given twice a day; [MEDICATION NAME] (medication to treat depression) to be given every morning; [MEDICATION NAME] ( antipsychotic medication used to treat Resident 8's [MEDICAL CONDITION] and auditory hallucinations) to be given every evening; [MEDICATION NAME] (medication to treat high blood pressure) to be given four times a day; [MEDICATION NAME] (medication to treat high blood pressure) to be given every 12 hours; [MEDICATION NAME] (an iron supplement to treat [MEDICAL CONDITION]) to be given by mouth three times per day; [MEDICATION NAME]-[MEDICATION NAME] (a medication to treat [MEDICAL CONDITION], a neurological disorder) to be given by mouth three times per day; [MEDICATION NAME] (medication to [MEDICAL CONDITION]) to be taken every morning; [MEDICATION NAME] (medication to treat acid reflux) to be given at bedtime; Donepezil (medication to treat Alzheimer's dementia) to be given at bedtime; Fludrocortisone (a hormone) to be taken every morning; Aspirin (to treat [MEDICAL CONDITION]) to be taken every morning; Folic Acid (vitamin to treat [MEDICAL CONDITION] ) to be taken every morning; Vitamin C to be taken every morning; Multivitamin to be taken every morning; [MEDICATION NAME] Sodium (to treat constipation) to be taken twice a day. On 1/6/16 at 2:10 p.m., during a follow-up telephone interview, Resident 8's Responsible Party (RP) 2 stated SNF 1's SSD had contacted her by phone near the end of October 2015. RP 2 stated the SSD told her SNF 1 had been sold and Resident 8 needed to move out by November 30, 2015. She stated the SSD told her they did not know what would happen if Resident 8 stayed at the facility; the new owner could do whatever they wanted and could move him anywhere they wanted. RP 2 stated she was very worried about what would happen to Resident 8. RP 2 stated she had spent countless hours trying to find a facility in the area, without success, and finally a family member helped her find a place, but it was in the state of Washington and away from most of Resident 8's extended family. RP 2 stated there were 10 extended family members near SNF 1 who would visit four to five times per week, bring Resident 8 snacks and visit. RP 2 stated she did Resident 8's laundry and visited him frequently. RP 2 stated there was only one family member near the Washington state facility to visit the resident. RP 2 stated she had purchased a one-way airline ticket for Resident 8 to fly to the new facility and a one-way ticket for Family Member (FM) 2 to accompany him on the flight. She stated the money for the tickets, parking and travel expenses had been paid out of Resident 8 ' s checking account and were about $600. RP 2 stated another family member had paid for FM 2's return ticket home and expenses which was about $400. RP 2 stated, We don't have much money. (FM 2) had to stay with the relative out of state until we could get the money together for the return ticket. RP 2 stated Resident 8 did not have identification required to fly so she had applied for a copy of his birth certificate, which cost $46. RP 2 stated because of the short time frame of the request she had not been sure if it would arrive in time for the scheduled flight. RP 2 stated the airline tickets were not refundable and she had worried what would happen if the birth certificate hadn't arrived on time. RP 2 stated the birth certificate arrived the day before the scheduled flight. RP 2 stated SNF 1 was no help in planning the discharge. She stated, The only concern they had was what time we would pick him up to take him to the airport. I felt like they didn't want anything to do with him. RP 2 stated she had purchased new clothing for Resident 8 for his trip because the weather was colder in the new location and he only was able to take the belongings that would fit in his check-in baggage. She stated, It was so stressful I felt physically sick. I was so worried what would happen to him. It was horrible. If I ever have to do this again, just kill me now! On 1/8/16 at 2:15 p.m., during a staff interview and concurrent clinical record review in the SNF 1 social services office, the SSD stated Resident 8's family was aware of the pending transition of facility ownership and was worried about what would happen. The SSD stated Resident 8 transferred to SNF 4 on 12/2/15. The SSD stated Resident 8 did not require any special care that could not have been provided at SNF 1, and SNF 4 provided the same level of care as SNF 1. The SSD stated SNF 1's Interdisciplinary Team (IDT, a resident care team including nursing dietary, social services and activity staff) did not meet prior to Resident 8's transfer to discuss whether it was a safe and appropriate transfer. The SSD stated the discharge care plan had not been updated to plan for the transfer to SNF 4. The SSD stated a 30 day notice of transfer that included the reason for transfer, the dated of the transfer, the location transferring to, the right to appeal the transfer and the name and phone number of the state ombudsman had not been provided to Resident 8 or his Responsible Party. On 1/11/16 at 9:45 a.m., during a telephone interview, Licensed Nurse, (LN) 2 stated she was on duty on 12/2/15 when Resident 8 was discharged for transfer to SNF 4. LN 2 stated the family arrived at the facility before 6 a.m. on 12/2/15 to transport Resident 8 to the airport. LN 2 stated she had not administered Resident 8's medications that morning because they were scheduled to be given at 8 a.m. and he left by 6 a.m. LN 2 stated nurses would sometimes contact the physician to get an order to give medications earlier than scheduled if there was an unusual circumstance which required a resident to be gone during the scheduled time; but she had not contacted Resident 8's physician. LN 2 stated she had placed Resident 8's transfer paperwork into a large manila envelope and placed his medications into a zip lock bag and then placed the zip lock bag into the manila envelope. She stated the manila envelope was then closed with metal tabs. LN 2 stated she had not provided Resident 8's family members written or verbal instructions to administer the medications. LN 2 stated she did not provide teaching on what the medications were ordered to treat or how or when to administer the medications. LN 2 stated Resident 8 had problems with incontinence and behavior issues and would often refuse care. LN 2 stated she did not provide Resident 8's family information on how to handle Resident 8's issues with incontinence. LN 2 stated she did not provide teaching on how to handle Resident 8's identified behaviors issues during the transport to SNF 4. LN 2 stated no other nurses provided information or teaching to Resident 8's family regarding medications, incontinence care or handling identified behavior issues. On 1/11/16 at 10:25 a.m., during a telephone interview, LN 3 stated she was the admitting nurse when Resident 8 arrived at SNF 4. LN 3 stated when admitted to SNF 4, Resident 8 had excoriated (reddened and broken) skin on his buttocks and perineal areas, most likely due to sitting in a soiled brief for a prolonged period. LN 3 stated she could not administer medications that had were not supplied and labeled by the pharmacy that serviced SNF 4, and she had to destroy the medications sent without administering them to Resident 8. LN 3 stated Resident 8 had been very quiet and withdrawn, had difficulty sleeping and did not eat well for the first week he was at SNF 4. On 1/11/16 at 4:15 p.m., during a telephone interview, Resident 8's FM 2 stated she had accompanied Resident 8 on the trip to SNF 4. FM 2 stated Resident 8 was transferred from SNF 1 to SNF 4 because the facility was sold and the family was told he had to leave. She stated she had accompanied RP 2 on 12/2/15 to pick up Resident 8 for the trip. FM 2 stated the family had made arrangements to pick him up early, just before 6 a.m., so that he could make the flight on time. FM 2 stated, They (the facility staff) had not packed his bags, he had not been given breakfast or a snack. He hadn't been given his morning medications. I requested some briefs in case he needed to be changed during the trip, but I wasn't given any. FM 2 stated the nurse had sent an envelope with paperwork for the new facility and a zip lock bag containing medications with Resident 8. FM 2 stated she was not given verbal or written instructions to administer any medications. FM 2 stated, There were no instructions to give them (the medications). I was afraid to give anything because I didn't know what I was supposed to do or what they were for. FM 2 stated she was not given verbal or written instructions on how to handle Resident 8's behavior issues or incontinence issues during the trip. FM 2 stated they were detained by security at the airport because Resident 8 had become very restless and started pulling his clothing off. FM 2 stated, He was flipping a wig because he hadn't had his medication. FM 2 stated Resident 8 became angry with her for taking him away from the facility. She stated Resident 8 pulled a blanket over his head and started crying when he got settled on the plane. He refused to eat or drink anything during the trip. FM 2 stated when they arrived at SNF 4, about 12 hours after leaving SNF 1, Resident 8 was still wearing the same brief, which was wet and soiled. FM 2 stated, It was embarrassing. If he was more aware he would have been humiliated. FM 2 stated SNF 4's admitting nurse had told her Resident 8 had some skin redness from sitting in a wet brief for so long. FM 2 stated the admitting nurse informed her they could not administer medications that their pharmacy had not provided and the medications in the manila envelope were destroyed. FM 2 stated Resident 8 did not receive any of his medications that day. FM 2 stated SNF 1 wanted Resident 8 to move by November 30 but the airline ticket prices were extremely high due to the Thanksgiving holiday and they waited until prices went down on 12/2/15 to get tickets; but then they received a bill for December from SNF 1. FM 2 stated Resident 8 also lost his Medi-Cal coverage because he moved out of state. FM 2 stated it was crazy expensive to make the trip; one way airline tickets, parking and travel expenses to the new SNF were about $600 for Resident 8 and herself. FM 2 stated the money was taken out of Resident 8's checking account. FM 2 stated her return trip was paid by another family member but she had to stay with family in Washington until the money could be raised for the return trip. FM 2 stated she visited Resident 8 every day at SNF 4 before she flew home. FM 2 stated Resident 8 had a difficult time adjusting to the move and refused to eat hardly anything. FM 2 stated Resident 8 was upset, He cried and his chin was quivering. He said he wanted to go home. FM 2 stated, I adore (Resident 8) but when I told him I was leaving to go home he said he hated me for making him leave home. It hurt me. I don't have the money to fly there any time again soon. It's probably the last thing I'll ever hear him say to me. Review of commercial airline receipt dated 12/2/15 issued for Resident 8 and airline receipt dated 12/2/15 for FM 2 indicated ticket cost of $222.60 for each ticket with additional charges of $25.00 per first checked bag and $35 per second checked bag. The ticket receipts indicated the tickets were n

Based on observation, interview, clinical records and administrative documents review, the skilled nursing facility (SNF) 1 failed to protect and honor Residents' rights when a 30 day written notice was not provided to residents or their responsible parties before transfer or discharge for 26 of 64 sampled residents, (Residents 8 through 15, Resident 17, Residents 19 through 30, Resident 2, Residents 31 through 33, and Resident 1). The facility did not provide residents a 30 day written notice in advance of the pending discharge or transfer which should have included the following information: the reason for the transfer or discharge; the effective date of the transfer or discharge; the location to which the residents were transferred or discharged ; a statement that the residents had the right to appeal the action to the State; and the name and phone number of the State long term care ombudsman. Residents were not afforded their rights to appeal the transfer or discharge decision and were not notified of the ombudsman's availability to advocate in their behalf. This failure resulted in expressed feelings of helplessness and fear when resident ' s rights were not afforded; led to emotional distress and psychological harm from being displaced from their home without adequate notice, discharge planning or preparation. Findings: On 12/9/15 at 9:40 a.m., during a facility tour and concurrent interview with the Interim Administrator (IA), no residents were seen in the West Wing of the building. The West Wing was closed off and all resident rooms were empty. The IA stated the current facility census was seven of 70 licensed beds occupied by residents. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day (12/9/15) due to a Change of ownership. On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated SNF 1 was purchased by a new owner. The SSD stated some residents had been transferred out of the facility. The SSD stated some of the residents who were transferred did not want to transfer to a different facility because they had been a resident in the facility for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner moved in. The SSD stated she had not been able to tell the residents what would happen when the new owner moved in because she did not know. The SSD stated information regarding the new owner was spread through word of mouth and there had been no official discussion of the change of ownership with the residents. On 12/9/15 at 2:30 p.m., during a telephone interview with the facility Medical Director (MD) 1, MD 1 stated he understood the facility had been sold to a new owner and residents had been transferred out for that reason. MD 1 stated he was not directly involved with the transfer of residents. MD 1 stated, I don't have the skills or the time to be directly involved in the transfers - that's social services responsibility. On 12/9/15 at 4 p.m., during a concurrent interview and administrative document review with the IA, the IA was asked for the facility policy and procedure on transfer and discharge. The IA provided a document titled, Lippincott Procedures (Standard Nursing Procedure book not specific to any one facility)- Transfer to long-term care facility, dated 1/9/15. The IA stated she was unable to locate a facility transfer policy and procedure that met federal regulations for qualifying conditions which would indicate under what conditions residents could be transferred or discharged and when a 30 day written notice of transfer would be required. The IA stated, I don't think we have that policy. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident who had been transferred or discharged from SNF 1, since June 2015, a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, We didn't do those. A Review of the facility's administrative policy titled, California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities pages eight to nine, dated 5/11 and provided to all SNF 1 residents on admission indicated, VI. Transfers and Discharges .Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance .Our written notice will include the effective day, the location to which you will be transferred or discharged , and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us . In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman. On 12/16/15 at 3 p.m., during a staff interview, the Social Services Director (SSD) stated she had worked for the facility for the past seven years. The SSD stated she had been assigned responsibilities for discharging residents. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her in the discharging of residents. The SSD stated when approached by families or residents she had discussed the pending transition, and informed them they could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the information resident discharges would be inevitable sooner or later, because the type of patients cared for in the facility would change. The SSD stated the residents were fast tracked to be discharged as part of the change in the process. The SSD stated, The majority of families wanted to seek placement out of fear, not knowing what was going to happen .how could they not be (fearful)? On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role in the transition of ownership was to discharge residents from the facility. She stated, I wasn't aware of the regulations .I was stuck in between .it ' s been a nightmare. The CNL stated, If they (the residents) asked (what would happen to them), we told them about the change of ownership .don't know when it ' s going to happen .there was the feeling of uncertainty. On 12/17/15 at 1:30 p.m., during an interview, the IA stated she had started work at the facility on 9/4/15 and at that time the West Wing hallway of the facility was empty of residents. The IA stated she contacted the facility Regional Director of Operations (RDO) who informed her there was a pending sale of the skilled nursing license. The IA stated her role in the transition was to talk to concerned families, seek availability of beds at other facilities for the transfer of residents, and assist the staff in discharging residents. She stated her directive from the RDO was to discharge residents when an appropriate facility had an available bed. She stated her job was to make sure discharges happened. The IA stated, Shame on us in hindsight, we let (the pending owner) run it. We would do it differently if we could do it again .We (the IA and the RDO) were caught in the middle. A review of Resident 8's clinical record titled, Face Sheet indicated Resident 8 had resided at the facility since 9/24/14 and had [DIAGNOSES REDACTED]. A review of Resident 8's clinical record titled MDS 3.0 Assessment dated 9/22/15, indicated Resident 8's cognitive (pertaining to memory, reasoning and judgement) skills for daily decision making were Moderately impaired-decisions poor, and he required Extensive assistance to transfer between surfaces such as chair to wheelchair. A review of Resident 8's SNF 1 clinical record titled Departmental Notes dated 9/24/15 at 11:08 a.m., indicated Resident wanders from room to lobby .Resident removes alarm, disrobes and tries to get out of bed without assistance. Resident receives Quetiapine (a medication to treat [MEDICAL CONDITION]) 50 mg (milligrams, a dosage measurement) po(by mouth) QPM (every evening) for auditory hallucinations, [MEDICAL CONDITION] .[MEDICATION NAME] (a medication to treat anxiety) 0.25 mg po BID (twice a day) for agitation . A review of Resident 8's SNF 1clinical record titled Transfer/Discharge Summary dated 12/2/15, contained an area to document Reason for Transfer/Discharge with choices including, Resident condition improved; No longer needs Nursing Facility Care; Resident needs SMF/Hospital care; Resident/Family request; safety/health of individuals in facility endangered; Other, Please Explain. The box indicating Other, Please Explain was the single box checked and Long term was written on the line next to the box. On 12/9/15 at 4:25 p.m., during a telephone interview, Resident 8's Responsible (RP) 2 party stated Resident 8 had been transferred out of SNF 1 on December 2, 2015. RP 2 stated she had not requested Resident 8 be transferred out of the facility. RP 2 stated the SSD had called her in October 2015 and told her Resident 8 had to be out of the facility by November 30, 2015. RP 2 stated, I was scared. I only had 30 days to find a place for (Resident 8). I kept calling (the SSD) and she would just tell me she still had another 14 residents to place. So I started looking on my own. I was told he had to be out by November 30 (2015). I found a place in Washington .I was afraid of what would happen after November 30. I felt bullied and scared. I was worried about (Resident 8) and where he would end up. The facility was no help at all. RP 2 stated a family member drove Resident 8 to the airport and another family member accompanied him on the flight to SNF 4 in Washington State. RP 2 stated she had not received any 30 day written notice in advance explaining the reason for the transfer to another facility. The RP stated the situation had been very stressful for everyone. On 1/6/16 at 2:10 p.m., during a telephone interview, Resident 8's Responsible Party (RP) 2, expanded on her experience during the transfer of Resident 8. She stated the SNF 1 Social Services Director (SSD) had contacted her by phone near the end of October 2015 and informed her the new owner could do whatever they wanted and could move Resident 8 anywhere they wanted. RP 2 stated she was very worried about what would happen to Resident 8. RP 2 stated she had spent countless hours trying to find a facility in the area, without success, and finally a family member helped her find a place, but it was in the state of Washington and away from most of Resident 8's extended family. RP 2 stated there was only one family member near the Washington state facility to visit the resident. RP 2 stated she had purchased a one-way airline ticket for Resident 8 to fly to the new facility and a one-way ticket for Family Member (FM) 2 to accompany him on the flight. She stated the money for the tickets, parking and travel expenses was paid out of Resident 8's checking account and was about $600. RP 2 stated SNF 1 was no help in planning the discharge. She stated, The only concern they had was what time we would pick him up to take him to the airport. I felt like they didn't want anything to do with him. RP 2 stated she had purchased new clothing for Resident 8 for his trip because the weather was colder in the new location and he only was able to take the belongings that would fit in his check-in baggage. She stated, It was so stressful I felt physically sick. I was so worried what would happen to him. It was horrible. If I ever have to do this again, just kill me now! On 1/8/16 at 2:15 p.m., during a staff interview and concurrent clinical record review in the SNF 1 social services office, the SSD stated Resident 8's family was aware of the pending transition of facility ownership and was worried about what would happen. The SSD stated Resident 8 transferred to SNF 4 on 12/2/15. The SSD stated Resident 8 did not require any special care that could not have been provided at SNF 1. The SSD stated SNF 1's Interdisciplinary Team (IDT) did not meet to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated prior to the transfer to SNF 4. The SSD confirmed a 30 day notice of transfer that included the reason for transfer, the date of the transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman had not been provided to Resident 8 or his Responsible Party. On 1/11/16 at 9:45 a.m., during a telephone interview, Licensed Nurse, (LN) 2 stated she was on duty on 12/2/15 when Resident 8 was discharged for transfer to SNF 4. LN 2 stated the family arrived at the facility before 6 a.m. to transport Resident 8 to the airport. LN 2 stated she had not administered Resident 8's medications that morning because they were scheduled to be given at 8 a.m. and he left by 6 a.m. LN 2 stated nurses would sometimes contact the physician to get an order to give medications earlier than scheduled if there was an unusual circumstance which required a resident to be gone during the scheduled time; but she had not contacted Resident 8's physician. LN 2 stated she had placed Resident 8's transfer paperwork into a large manila envelope and placed his medications into a zip lock bag and then placed the zip lock bag into the manila envelope. She stated the manila envelope was then closed with metal tabs. LN 2 stated she had not provided Resident 8's family members written or verbal instructions to administer the medications. LN 2 stated she did not provide teaching on what conditions the medications were ordered to treat or how or when to administer the medications. Review of Resident 8's clinical record, titled, Physician order [REDACTED]. LN 2 stated Resident 8 had problems with incontinence and behavior issues and would often refuse care. LN 2 stated she had not provided Resident 8's family with information on how to handle Resident 8's incontinence. LN 2 stated she had not provided instruction on how to handle Resident 8's identified behavior issues during the transport to SNF 4. LN 2 stated there were no other nurses at SNF 1 who provided information or instruction to Resident 8's family regarding medications, incontinence care or handling identified behavior issues. On 1/11/16 at 10:25 a.m., during a telephone interview, LN 3 stated she was the admitting nurse when Resident 8 arrived at SNF 4. LN 3 stated when admitted to SNF 4, Resident 8 had excoriated (reddened and broken) skin on his buttocks and perineal areas, most likely due to sitting in a soiled brief for a prolonged period. LN 3 stated she could not administer medications that had were not supplied and labeled by the pharmacy that serviced SNF 4, and she had to destroy the medications sent. LN 3 stated Resident 8 was very quiet and withdrawn, had difficulty sleeping and did not eat well for the first week he was at SNF 4. On 1/11/16 at 4:15 p.m., during a telephone interview, Resident 8's Family Member (FM) 2 stated she had accompanied Resident 8 on the plane trip to SNF 4. FM 2 stated, They (the facility staff) had not packed his bags, he had not been given breakfast or a snack. He hadn't been given his morning medications. I requested some briefs in case he needed to be changed during the trip, but I wasn't given any. FM 2 stated the nurse had sent an envelope with paperwork for the new facility and a zip lock bag containing medications with Resident 8. FM 2 stated she was not given verbal or written instructions to administer any medications. FM 2 stated, There were no instructions to give them (the medications). I was afraid to give anything because I didn't know what I was supposed to do or what they were for. FM 2 stated she was not given verbal or written instructions on how to handle Resident 8's behavior issues or incontinence during the trip. FM 2 stated they were detained by security at the airport because Resident 8 was very restless and starting pulling his clothing off. FM 2 stated, He was flipping a wig (behavior was out of control) because he hadn't had his medication. FM 2 stated Resident 8 became angry with her for taking him away from the facility. She stated Resident 8 pulled a blanket over his head and started crying when he got settled on the plane. He refused to eat or drink anything during the trip. FM 2 stated when they arrived at SNF 4, about 12 hours after leaving SNF 1, Resident 8 was still wearing the same brief, which was wet and soiled. FM 2 stated, It was embarrassing. If he (resident 8) was more aware he would have been humiliated. FM 2 stated Resident 8 did not receive any of his medications the day of transfer. FM 2 stated it was crazy expensive to make the trip. FM 2 stated the expenses incurred included two one way airline tickets (one for Resident 8 and one for FM 2). FM 2 stated parking and travel expenses to and from the airport to the new SNF cost about $600 for Resident 8 and herself. FM 2 stated the trip and expenses were paid from Resident 8's checking account. FM 2 stated the return trip for herself had to be paid by an extended family member and it took a while before there was enough money for her return trip. FM 2 stated she visited Resident 8 every day at SNF 4 before she returned home. FM 2 stated Resident 8 had a difficult time adjusting to the move and refused to eat hardly anything. FM 2 stated Resident 8 was upset, He cried and his chin was quivering. He said he wanted to go home. FM 2 stated, I adore (Resident 8) but when I told him I was leaving to go home he said he hated me for making him leave home. It hurt me. I don't have the money to fly there any time again soon. It's probably the last thing I'll ever hear him say to me. A review of the commercial airline receipt dated 12/2/15 issued for Resident 8, and the airline receipt dated 12/2/15 for FM 2 indicated the ticket cost $222.60 for each ticket with additional charges of $25.00 for the first checked bag and $35 for the second bag. The ticket receipts indicated the tickets were non-refundable. A review of the commercial airline receipt dated 12/5/15 issued for FM 2 indicated a ticket cost of $241.60 with additional charges of $25 for the first bag checked and $35 for the second bag. The receipt indicated the ticket was non-refundable. A review of website www.Mapquest.com indicated SNF 4 was located 904 miles from SNF 1. A review of Resident 9's record titled, Face Sheet indicated Resident 9 resided at SNF 1 beginning 6/26/02 with [DIAGNOSES REDACTED]. A review of Resident 9's clinical record from SNF 1 titled, Transfer/Discharge Summary dated 10/5/15, contained an area to document Reason for Transfer/Discharge with choices including, Resident condition improved; No longer needs Nursing Facility Care; Resident needs SNF/Hospital care; Resident/Family request; safety/health of individuals in facility endangered; Other, Please Explain. The box on the form that indicated Other, Please Explain was the single box checked, and Facility Transfer was written on the line next to the box. A review of Resident 9's clinical record from SNF 5, titled, MDS 3.0 Assessment, dated 10/12/15, indicated Resident 9's Brief Interview for Mental Status (BIMS) score was 15 on a scale of 0 to 15 which indicated Resident 9 had no cognitive deficits The section of the MDS under functional ability indicated Resident 9 was totally dependent on staff for bed mobility, dressing, bathing and hygiene. A review of Resident 9's clinical record from SNF 5, titled, Physician Orders, dated December 2015, indicated Resident 9 was capable of participation in her plan of care and capable of understanding and exercising her rights. On 12/29/15 at 8 a.m., during an interview at SNF 5, the Interim Director of Nursing (IDON) 2 stated Resident 9 was transferred to SNF 5 on 10/5/15 from SNF 1, but was transferred back to SNF 1 again on 12/22/15. The IDON 2 stated Resident 9 had not liked being a resident at SNF 5. The IDON 2 stated, She (Resident 9) expressed many times she was not happy here. She didn't know why she ended up here and she called her mother about it several times. She was angry and went on a starvation protest for a while. On 12/29/15 at 8:25 a.m., during a staff interview in SNF 5's hallway, Licensed Nurse (LN) 4 stated she had cared for Resident 9 during the two months she resided at SNF 5. LN 4 stated, She (Resident 9) didn't want to be here. She wasn't happy. She didn't leave her room, didn't go to activities or the dining room. On 12/29/15 at 9:05 a.m., during an interview, SNF 5's Admission Coordinator (AC) 1 stated Resident 9 had a very particular way of doing everything. The change in her routine was very upsetting (for Resident 9). On 12/30/15 at 9:30 a.m., during a staff interview and concurrent clinical record review at SNF 1 in the social services office, the SSD stated Resident 9 was transferred to SNF 5 on 10/5/15. The SSD stated Resident 9 had not requested to be moved and had not initiated a conversation regarding a move. The SSD stated SNF 5 was first contacted to request a transfer for Resident 9 four days prior to her transfer. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of the transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 9 or her Responsible Party. On 12/30/15 at 9:50 a.m., during an interview in Resident 9's room at SNF 1, Resident 9 was awake and alert, lying on her side in bed holding a white letter board for spelling. Resident 9 was able to speak with difficulty and spell out words when needed. Resident 9 stated she had lived at SNF 1 for [AGE] years and had not wanted to leave. She stated the SSD had visited her in her room four days before the transfer and told her she would be going to SNF 5 because SNF 1 was closing. Resident 9 stated, I didn't ask to go. I didn't want to go. When they told me I had to move I was scared. I was worried. I didn't know what to think. I didn't have a choice. Resident 9 stated she hated being at SNF 5 and I stopped eating for a while. I lost weight. Resident 9 stated when given the opportunity to leave SNF 5 and return to SNF 1 she immediately requested to return. Resident 9 stated she had not been provided any advance written notice of the pending transfer or her right to appeal the transfer or the information needed to contact the ombudsman. On 1/7/16 at 7:30 a.m., during a telephone interview, Resident 9's Responsible Party (RP) 3 stated she lived out of state and was responsible for Resident 9's financial affairs. RP 3 stated she had received a phone call from the SNF 1 Interim Administrator (IA) around the first of October 2015 informing her SNF 1 was closing. RP 3 stated the IA told her they would try to move Resident 9 to a facility near her. RP 3 stated she had just started looking for facilities near her but by that weekend Resident 9 had been moved to SNF 5. RP 3 stated Resident 9 was emotionally fragile and had not adjusted to the move. She stated, She did nothing but cry after the move to (SNF 5). She had the nurse assistant call me on the phone three or four times per day .she cried and I would try to comfort her . RP 3 stated Resident 9 never really adjusted to the move. She just got quiet after a while. I think she was depressed. RP 3 stated she had not received any advanced written notice of the pending transfer or of the right to appeal the transfer. A review of Resident 9's clinical record from SNF 5 titled, Departmental Notes dated 10/5/15, indicated At admission resident noted to be agitated, home sick and tearful. A review of 9's clinical record from SNF 1, titled, Weight Change Comparison dated 10/5/15, indicated Resident 9 left SNF 1 weighing 137.7 pounds. A review of Resident 9's clinical record from SNF 5 titled, Vital Sign Data dated 11/5/15, indicated Resident 9's weight was 125.8 pounds; a weight loss of 11.9 pounds or 8.6 percent of her body weight in the one month period after leaving SNF 1. A review of Resident 10's clinical record at SNF 1, titled, Face Sheet (a document with the residents personal information and medical diagnoses) indicated Resident 10 had resided at SNF 1 since 3/31/15. Resident 10 's [DIAGNOSES REDACTED]. Resident 10's clinical record titled, MDS 3.0 Assessment, dated 9/21/2015, indicated Resident 10 required a two person assist with bed mobility,was totally dependent on staff for transfer, did not walk, required the assistance of one staff for toileting, and was at high risk of developing a pressure ulcer (breakdown of the skin from pressure). The document indicated Resident 10 used a pressure reducing device for both chair and bed, and received care for a pressure ulcer. Resident 10's Physician Communication Fax Request dated 10/12/15, indicated under Request:, Resident discharge home on 10/20/15 ( a previous date of 10/17/15 lined through and revised). Home Health with Physical Therapy and Occupational therapy. Needed a Hospital bed, standard Wheelchair, (mechanical) lift. Under MD Response it indicated, OK. The form was signed by a Licensed Nurse and Medical Director (MD) 1. Resident 10's Social Service Note dated 10/20/15 at 4:49 p.m., indicated, Social Service discharge note: Resident discharged to home .with daughter and son-in-law. (Vendor) transport- pick up at 4 p.m Family training provided. All medical equipment delivered to home . The note was electronically signed by the Social Services Director (SSD). Resident 10's Transfer/Discharge Summary-Post Discharge Plan of Care dated 10/20/15 indicated under Skin Assessment, pressure sore (at) left buttock .skin redness on both elbows, 1.5 cm (centimeter) wound blister medial aspect of R (Right) foot. There was yes marked in the section under Pressure Ulcers and indicated a Stage II Pressure Ulcer Under equipment needed, the form indicated, Hospital Bed, (mechanical) lift. Under Resident Teaching For Home this section indicated, Provided medication administration teaching, provided [MEDICAL CONDITION] care teaching, provided treatment care, resident and family had been instructed to contact a primary physician for continuation of medication and treatment as necessary. A review of Resident 10's record from SNF 1 titled, Transfer/Discharge Summary dated 10/20/15 contained an area to document Reason for Transfer/Discharge . no reason for the discharge was documented on the record. On 12/23/15 at 3:25 p.m., during a phone interview, FM 9 stated Resident 10 was Spanish speaking and currently living at her home. She spoke in a distressed tone, stated she was pregnant, near term, and the family was concerned regarding their ability to continue care for the resident. On 12/30/15 at 1:10 p.m., during a concurrent observation and interview with FM 10 and Resident 10 at Resident 10's home, he was found covered with a blanket, lying on a bath towel, spread horizontally over a fitted sheet, which was stretched over a plastic mattress. He was found in a small room at the rear of the mobile home. No pressure reducing/relieving bed devices were found. A mechanical lift was observed sitting in the corner of the room. FM 10 stated she was called by the facility Social Services Director (SSD) in October 2015 to inform her the facility was being renovated and the resident was ready for discharge. When asked about participation in discharge planning, the FM 9 stated she went to the facility to observe his physical therapy session. She stated she was shown the mechanical lift but denied having used the lift before discharge and stated the home health agency trained them to operate it after admission to home health services upon Resident 10 ' s return home. She stated she did receive verbal instruction on maintaining the resident's [MEDICAL CONDITION], and how to change the [MEDICAL CONDITION] bag, but the nurse did not demonstrate how to change the bag or dressing, nor did FM 10 provide return demonstration of the procedure to verify a correct understanding of how to perform the procedure. FM 10 stated she was given two cases of [MEDICAL CONDITION] bags; one case was the wrong size, so she was unable to use it. FM 10 stated on the date of discharge Resident 10 was transported to the home, but the van driver who transported him, refused to assist the family in moving the resident up the ramp and into the house. FM 10 stated, It was a struggle to get him up (the ramp). FM 10 then attempted to reposition Resident 10 in bed. He grimaced and moved slowly to his right side, grabbing the side rail, stating the turning was painful. Resident 10's left heel was observed with a large black circular closed wound measuring approximately 1 1/4 in. (inch) by 1 1/4 in. A second smaller dark discolored area was noted on the lateral aspect of his left foot. A large open circular wound which measured approximately 3 cm. (centimeters) by 2 cm. was observed on his right hip. Resident 10's coccyx (tailbone) area skin was observed bright red, skin peeling, with multiple small open areas of broken skin. FM 10 looked at the resident's coccyx area and stated, It 's the moisture .his skin sweats. She then became tearful and stated, I don't feel that he was ready (for discharge) .it's been really hard on me and my sister. The resident's elbows were found bright red, with patches of peeling skin. FM 10 stated the family had not been able to transport her father to a physician since discharge. When asked, Resident 10 stated he felt he had physically declined since discharge, his skin was broken down, and he was not feeling well. On 12/31/15 a

Based on observation, staff and resident interview, clinical record and administrative document review, the Medical Director (MD) 1 failed to ensure resident care policies, related to transfer and discharge, were implemented when 26 of 64 sampled residents (Residents 8 through 10, Resident 1, Resident 2, Residents 11 through 15, Resident 17, Residents 19 through 33) were transferred or discharged out of the facility between 6/1/15 and 12/9/15 without medical justification as necessary for the health and welfare of the residents and without a 30 day written notice that included the reason for the transfer or discharge, the effective date of the transfer or discharge, the location to which the resident was transferred or discharged , notice of the right to appeal the transfer or discharge or the address and phone number of the State Long-Term Care Ombudsman (contact person who may advocate for the resident rights). This failure placed all residents in the facility at risk for unnecessary dislocation from their home environment, emotional distress, psychological harm, physical harm and loss of their resident right to appeal the transfer/discharge and the right to be represented by a resident advocate. Findings: On 12/9/15 at 9:40 a.m., during a facility tour and concurrent interview with the Interim Administrator (IA), there were no residents observed in the hallways. The west wing of the facility building was closed and all resident rooms and the west wing dining room were empty. Four residents were observed sitting in the east wing main dining room watching television. The facility IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the west wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day (12/9/15) due to a Change of ownership of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the east wing hallway, Licensed Nurse (LN) 1 stated residents who had resided in the facility had been transferred out of the facility due to new ownership to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner would not be taking long term care residents as he would not be running a long term care facility. LN 1 stated most residents that had transferred had not wanted to leave as the facility had been their home for a long time. LN 1 stated those residents were sad to leave. LN 1 stated one resident (Resident 8) had been transferred to Washington State and that resident had not been happy about the transfer, though the resident had gone anyway. LN 1 stated that resident had not requested to move to Washington and had not had a change of condition that required a different level of care other than what was already provided in the facility. LN 1 stated the resident was transferred because the new owners were not going to run a long term care facility. Review of Review of the facility report titled, Census List, dated 6/1/2015, under Summary Information, indicated, Total beds: 70. Occupied Beds: 61. Review of the facility report titled, Census List dated 12/9/2015, under Summary Information, indicated, Total beds: 70. Occupied Beds: 7. On 12/9/15 at 2:30 p.m., during a telephone interview, the facility Medical Director (MD) 1, stated he was aware many residents had been transferred out of the facility. MD 1 stated his understanding was the building had been sold and residents had been transferred for that reason. MD 1 stated he was not directly involved with transfers of residents out of the facility. MD 1 stated, I don't have the skills or the time to be directly involved in the transfers - that's social services responsibility. Social services notifies me if they are going to transfer (residents). I have no objection. MD 1 stated, They (social services staff) do keep me informed. I know where my residents are going. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided to any residents that had been transferred/discharged during the time between 6/1/15 and 12/9/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge, the right to appeal the transfer or discharge, or the address and phone number of the State Long-Term Care Ombudsman. The IA stated, We didn't do those. Review of Resident 8's clinical record titled, Face Sheet indicated Resident 8 had resided at the facility since 9/24/14 and had [DIAGNOSES REDACTED]. Review of Resident 8's clinical record titled MDS 3.0 Assessment, dated 9/22/15, indicated Resident 8's cognitive (pertaining to comprehension, reasoning and memory) skills for daily decision making were Moderately impaired-decisions poor, and he required Extensive assistance to transfer between surfaces such as chair to wheelchair. Review of Resident 8's clinical record titled Departmental Notes dated 9/24/15 at 11:08 a.m., indicated Resident wanders from room to lobby .Resident removes alarm, disrobes himself and tries to get out of bed without assistance. Resident receives Quetiapine (a medication to treat [MEDICAL CONDITION]) 50 mg (milligrams, a dosage measurement) po (by mouth) QPM (every evening) for auditory hallucinations, [MEDICAL CONDITION] .[MEDICATION NAME] (a medication to treat anxiety) 0.25 mg po BID (twice a day) for agitation . Review of Resident 8's clinical record titled Transfer/Discharge Summary dated 12/2/15 contained an area to document Reason for Transfer/Discharge with choices including, Resident condition improved; No longer needs Nursing Facility Care; Resident needs SMF(skilled medical facility)/Hospital care; Resident/Family request; safety/health of individuals in facility endangered; Other, Please Explain. The box indicating Other, Please Explain was the single box checked and Long term was written on the line next to the box. On 12/9/15 at 4:25 p.m., during a telephone interview, Resident 8's Responsible (RP) 2 party stated Resident 8 had been transferred out of SNF 1 on December 2, 2015. RP 2 stated she had not requested Resident 8 be transferred out of the facility. RP 2 stated the SSD had called her in October 2015 and told her Resident 8 had to be out of the facility by November 30, 2015. RP 2 stated no written notice describing the pending discharge was provided by the facility. RP 2 stated, I was scared. I only had 30 days to find a place for (Resident 8). I kept calling (the SSD) and she would just tell me she still had another 14 residents to place. So I started looking on my own. I was told he had to be out by November 30 (2015). I found a place in Washington .I was afraid of what would happen after November 30. I felt bullied and scared. I was worried about (Resident 8) and where he would end up. The facility was no help at all. RP 2 stated a family member drove Resident 8 to the airport and another family member accompanied him on the flight to SNF 4 in Washington State. RP 2 stated she had not received any written notice in advance explaining the reason for the transfer to another facility. The RP stated the situation had been very stressful for everyone. On 1/6/16 at 2:10 p.m., during a telephone interview, Resident 8's Responsible Party (RP) 2, expanded on her experience during the transfer of Resident 8. She stated the SNF 1 Social Services Director (SSD) had contacted her by phone near the end of October 2015 and informed her, the new owner could do whatever they wanted and could move Resident 8 anywhere they wanted. RP 2 stated she was very worried about what would happen to Resident 8. RP 2 stated she had spent countless hours trying to find a facility in the area, without success, and finally a family member helped her find a place, but it was in the State of Washington and away from most of Resident 8's extended family. RP 2 stated there was only one family member near the Washington State facility to visit the resident. RP 2 stated she had purchased a one-way airline ticket for Resident 8 to fly to the new facility and a one-way ticket for Family Member (FM) 2 to accompany him on the flight. She stated the money for the tickets, parking and travel expenses was paid out of Resident 8's checking account and was about $600. RP 2 stated SNF 1 was no help in planning the discharge. She stated, The only concern they had was what time we would pick him up to take him to the airport. I felt like they didn't want anything to do with him. RP 2 stated she had purchased new clothing for Resident 8 for his trip because the weather was colder in the new location and he only was able to take the belongings that would fit in his check-in baggage. She stated, It was so stressful I felt physically sick. I was so worried what would happen to him. It was horrible. If I ever have to do this again, just kill me now! On 1/8/16 at 2:15 p.m., during a staff interview and concurrent clinical record review in the SNF 1 social services office, the SSD stated Resident 8's family was aware of the pending transition of facility ownership and was worried about what would happen. The SSD stated Resident 8 transferred to SNF 4 on 12/2/15. The SSD stated Resident 8 did not require any special care that could not have been provided at SNF 1, and SNF 4 provided the same level of care as SNF 1. The SSD stated SNF 1's Interdisciplinary Team (IDT, a resident care team including nursing dietary, social services and activity staff) did not meet prior to Resident 8's transfer to discuss whether it was a safe and appropriate transfer. The SSD stated the discharge care plan had not been updated to plan for the transfer to SNF 4. The SSD confirmed a 30 day written notice of transfer that included the reason for transfer, the dated of the transfer, the location transferring to, the right to appeal the transfer and the name and phone number of the state ombudsman had not been provided to Resident 8 or his Responsible Party. On 1/11/16 at 9:45 a.m., during a telephone interview, Licensed Nurse, (LN) 2 stated she was on duty on 12/2/15 when Resident 8 was discharged for transfer to SNF 4. LN 2 stated the family arrived at the facility before 6 a.m. on 12/2/15 to transport Resident 8 to the airport. LN 2 stated she had not administered Resident 8's medications that morning because they were scheduled to be given at 8 a.m. and he left by 6 a.m. LN 2 stated nurses would sometimes contact the physician to get an order to give medications earlier than scheduled if there was an unusual circumstance which required a resident to be gone during the scheduled time; but she had not contacted Resident 8's physician. LN 2 stated she had placed Resident 8's transfer paperwork into a large manila envelope and placed his medications into a zip lock bag and then placed the zip lock bag into the manila envelope. She stated the manila envelope was then closed with metal tabs. LN 2 stated she had not provided Resident 8's family members written or verbal instructions to administer the medications. LN 2 stated she did not provide teaching on what the medications were ordered to treat or how or when to administer the medications. LN 2 stated Resident 8 had problems with incontinence and behavior issues and would often refuse care. LN 2 stated she did not provide Resident 8's family information on how to handle Resident 8's issues with incontinence. LN 2 stated she did not provide teaching on how to handle Resident 8's identified behaviors issues during the transport to SNF 4. LN 2 stated no other nurses provided information or teaching to Resident 8's family regarding medications, incontinence care or handling identified behavior issues. Review of Resident 8's clinical record titled, Physician Orders dated December 2015, indicated medication orders were for: [MEDICATION NAME] (medication to treat anxiety) to be given twice a day; [MEDICATION NAME] (medication to treat depression) to be given every morning; [MEDICATION NAME] ( antipsychotic medication used to treat Resident 8's [MEDICAL CONDITION] and auditory hallucinations) to be given every evening; [MEDICATION NAME] (medication to treat high blood pressure) to be given four times a day; [MEDICATION NAME] (medication to treat high blood pressure) to be given every 12 hours; [MEDICATION NAME] (an iron supplement to treat [MEDICAL CONDITION]) to be given three times per day; [MEDICATION NAME]-[MEDICATION NAME] (a medication to treat [MEDICAL CONDITION], a neurological disorder) to be given three times per day; [MEDICATION NAME] (medication to [MEDICAL CONDITION]) to be taken every morning; [MEDICATION NAME] (medication to treat acid reflux) to be given at bedtime; Donepezil (medication to treat Alzheimer's dementia) to be given at bedtime; Fludrocortisone (a hormone) to be taken every morning; Aspirin (to treat [MEDICAL CONDITION]) to be taken every morning; Folic Acid (vitamin to treat [MEDICAL CONDITION] ) to be taken every morning; Vitamin C to be taken every morning; Multivitamin to be taken every morning; [MEDICATION NAME] Sodium (to treat constipation) to be taken twice a day. On 1/11/16 at 10:25 a.m., during a telephone interview, LN 3 stated she was the admitting nurse when Resident 8 arrived at SNF 4. LN 3 stated when admitted to SNF 4, Resident 8 had excoriated (reddened and broken) skin on his buttocks and perineal areas, most likely due to sitting in a soiled brief for a prolonged period. LN 3 stated she could not administer medications that were not supplied and labeled by the pharmacy that serviced SNF 4, and she had to destroy the medications sent without administering them to Resident 8. LN 3 stated Resident 8 had been very quiet and withdrawn, had difficulty sleeping and did not eat well for the first week he was at SNF 4. On 1/11/16 at 4:15 p.m., during a telephone interview, Resident 8's Family Member (FM) 2 stated she had accompanied Resident 8 on the trip to SNF 4. FM 2 stated, They (the facility staff) had not packed his bags, he had not been given breakfast or a snack. He hadn't been given his morning medications. I requested some briefs in case he needed to be changed during the trip, but I wasn't given any. FM 2 stated the nurse had sent an envelope with paperwork for the new facility and a zip lock bag containing medications with Resident 8. FM 2 stated she was not given verbal or written instructions to administer any medications. FM 2 stated, There were no instructions to give them (the medications). I was afraid to give anything because I didn't know what I was supposed to do or what they were for. FM 2 stated she was not given verbal or written instructions on how to handle Resident 8's behavior issues or incontinence issues during the trip. FM 2 stated they were detained by security at the airport because Resident 8 had become very restless and started pulling his clothing off. FM 2 stated, He was flipping a wig (his behavior was out of control) because he hadn't had his medication. FM 2 stated Resident 8 became angry with her for taking him away from the facility. She stated Resident 8 pulled a blanket over his head and started crying when he got settled on the plane. He refused to eat or drink anything during the trip. FM 2 stated when they arrived at SNF 4, about 12 hours after leaving SNF 1, Resident 8 was still wearing the same brief, which was wet and soiled. FM 2 stated, It was embarrassing. If he was more aware he would have been humiliated. FM 2 stated Resident 8 did not receive any of his medications that day. FM 2 stated it was crazy expensive to make the trip; one way airline tickets, parking and travel expenses to the new SNF were about $600 for Resident 8 and herself. FM 2 stated the money was taken out of Resident 8's checking account. FM 2 stated her return trip was paid by another family member but she had to stay with family in Washington until the money could be raised for the return trip. FM 2 stated she visited Resident 8 every day at SNF 4 before she flew home. FM 2 stated Resident 8 had a difficult time adjusting to the move and refused to eat hardly anything. FM 2 stated Resident 8 was upset, He cried and his chin was quivering. He said he wanted to go home. FM 2 stated, I adore (Resident 8) but when I told him I was leaving to go home he said he hated me for making him leave home. It hurt me. I don't have the money to fly there any time again soon. It's probably the last thing I'll ever hear him say to me. Review of commercial airline receipt dated 12/2/15 issued for Resident 8 and airline receipt dated 12/2/15 for FM 2 indicated ticket cost of $222.60 for each ticket with additional charges of $25.00 per first checked bag and $35 per second checked bag. The ticket receipts indicated the tickets were non-refundable. Review of commercial airline receipt dated 12/5/15 issued for FM 2 indicated a ticket cost of $241.60 with additional charges of $25 per first checked bag and $35 per second checked bag. The receipt indicated the ticket was non-refundable. Review of website www.Mapquest.com indicated SNF 4 was located 904 miles from SNF 1. Review of Resident 8's clinical record titled, Physician Communication Fax Request dated, 11/30/15 and faxed to MD 1 indicated, Nursing Concern: Resident (Resident 8) is medically cleared to fly on an airplane from Sacramento, CA to Washington State on 12/2/15. This will be a one way trip. Recommend/requesting approval .MD Response: (Resident 8) is medically cleared to travel by air from Sacramento CA to Washington State on 12/2/15. This will be a one way trip. The MD Response section was dated 11/30/15 and signed by MD 1. Review of Resident 9's clinical record titled, Face Sheet indicated Resident 9 resided at SNF 1 since 6/26/02 with [DIAGNOSES REDACTED]. Review of Resident 9's SNF 1 clinical record titled Transfer/Discharge Summary dated 10/5/15 contained an area to document Reason for Transfer/Discharge with choices including, Resident condition improved; No longer needs Nursing Facility Care; Resident needs SMF/Hospital care; Resident/Family request; safety/health of individuals in facility endangered; Other, Please Explain. The box indicating Other, Please Explain was the single box checked and Facility Transfer was written on the line next to the box. Review of Resident 9's SNF 5 clinical record titled MDS 3.0 Assessment, dated 10/12/15, indicated Resident 9's Brief Interview for Mental Status (BIMS) score was 15 on a scale of 0 to 15 with 15 indicating the resident was cognitively (pertaining to comprehension, memory and reasoning ability) intact. The section of Resident 9's MDS assessment under functional ability indicated Resident 9 was totally dependent on staff for bed mobility, dressing, bathing and hygiene. Review of Resident 9's SNF 5 clinical record titled, Physician Orders dated December 2015 indicated she was Capable of participating in her own plan of care and Capable of understanding and exercising her rights. On 12/29/15 at 8 a.m., during an interview at SNF 5, the Interim Director of Nursing (IDON) 2 stated Resident 9 was transferred to SNF 5 on 10/5/15 from SNF 1, but was transferred back to SNF 1 again on 12/22/15. The IDON 2 stated Resident 9 never liked being at SNF 5. The IDON 2 stated, She (Resident 9) expressed many times she was not happy here. She didn't know why she ended up here and she called her mother about it several times. She was angry and went on a starvation protest for a while. On 12/29/15 at 8:25 a.m., during a staff interview in SNF 5's hallway, Licensed Nurse (LN) 4 stated she had cared for Resident 9 during the two months she resided at SNF 5. LN 4 stated, She (Resident 9) didn't want to be here. She wasn't happy. She didn't leave her room, didn't go to activities or the dining room. On 12/29/15 at 9:05 a.m., during an interview, SNF 5's Admission Coordinator (AC) 1 stated Resident 9 had a very particular way of doing everything. The change in her routines were very upsetting (for Resident 9). On 12/30/15 at 9:30 a.m., during a staff interview and concurrent clinical record review in the social services office at SNF 1, the Social Services Director (SSD) stated Resident 9 was transferred to SNF 5 on 10/5/15. The SSD stated Resident 9 had not requested to be moved and had not initiated a conversation regarding a move. The SSD stated the SNF 1 Interdisciplinary Team (IDT, a resident care team including nursing dietary, social services and activity staff) did not meet prior to Resident 9's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 5. The SSD stated SNF 5 was first contacted to request a transfer for Resident 9 four days prior to her transfer. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of the transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 9 or her Responsible Party. The SSD stated SNF 5 did not provide any services that were not available at SNF 1. On 12/30/15 at 9:50 a.m., during an interview in Resident 9's room at SNF 1, Resident 9 was awake and alert, lying on her side in bed holding a white letter board for spelling. Resident 9 was able to speak with difficulty and spell out words when needed. Resident 9 stated she had lived at SNF 1 for [AGE] years and had not wanted to leave. She stated the SSD had visited her in her room four days before the transfer and told her she would be going to SNF 5 because SNF 1 was closing. Resident 9 stated, I didn't ask to go. I didn't want to go. When they told me I had to move I was scared. I was worried. I didn't know what to think. I didn't have a choice. Resident 9 stated she hated being at SNF 5 and I stopped eating for a while. I lost weight. Resident 9 stated when given the opportunity to leave SNF 5 and return to SNF 1 she immediately requested to return. Resident 9 stated she had not been provided any advance written notice of the pending transfer or her right to appeal the transfer or the information needed to contact the ombudsman. On 1/7/16 at 7:30 a.m., during a telephone interview, Resident 9's Responsible Party (RP) 3 stated she lived out of state and was responsible for Resident 9's financial affairs. RP 3 stated she had received a phone call from the SNF 1 Interim Administrator (IA) around the first of October 2015 informing her SNF 1 was closing. RP 3 stated the IA told her they would try to move Resident 9 near her. RP 3 stated she had just started looking for facilities near her but by that weekend Resident 9 had been moved to SNF 5. RP 3 stated Resident 9 was emotionally fragile and did not adjust to the move. She stated, She did nothing but cry after the move to (SNF 5). She had the nurse assistant call me on the phone three or four times per day .she cried and I would try to comfort her . RP 3 stated Resident 9 never really adjusted to the move. She just got quiet after a while. I think she was depressed. RP 3 stated she had not received any advanced written notice of the pending transfer or of the right to appeal the transfer. Review of Resident 9's clinical record from SNF 5 titled, Departmental Notes dated 10/5/15, indicated At admission resident noted to be agitated, home sick and tearful. Review of 9's clinical record from SNF 1, titled, Weight Change Comparison dated 10/5/15, indicated Resident 9 left SNF 1 weighing 137.7 pounds. Review of Resident 9's clinical record from SNF 5 titled, Vital Sign Data dated 11/5/15, indicated Resident 9's weight was 125.8 pounds; a weight loss of 11.9 pounds or 8.6 percent of her body weight in the one month period after leaving SNF 1. Review of Resident 9's clinical record titled, Physician Communication Fax Request, dated 10/1/15 and faxed to MD 1 indicated, Request: Resident discharge to (SNF 5) on 10/2/15. MD Response: Approved. The MD Response section was dated 10/1/15 and signed by MD 1. Review of Resident 10's SNF 1 clinical record titled, Face Sheet indicated he resided at the facility since 3/31/15, with [DIAGNOSES REDACTED]. Resident 10's clinical record titled, MDS 3.0 Assessment, dated 9/21/2015, indicated Resident 10 required a two person assist with bed mobility, was totally dependent on staff for transfer, did not walk, required the assistance of one staff for toileting, and was at high risk of developing a pressure ulcer (a sore or damaged area of the skin caused by pressure). The document indicated Resident 10 used a pressure reducing device for both chair and bed, and received care for a pressure ulcer. An untitled care plan (CP) dated 8/05/15, indicated under Problem/Need, Resident has redness to bottom. Under Goal and Target Date it indicated, Will have no complications related to impaired skin integrity through next review. Under Approaches it indicated, .Encourage staff to reposition resident q (every) 2 hrs (hours) prn (as needed). Resident 10's Physician Communication Fax Request dated 8/6/15, indicated under Nursing Concern, Redness to buttocks has large rash, skin peeling off. Resident has order for A&D (ointment) but is not working. A Physician Communication Fax Request dated 8/15/15, indicated under Nursing concern, Closed blister Stage II (involving the upper layers of skin, the epidermis and dermis) to ABD (abdomen) midline. The facility document titled, Pressure Sore Staging Protocol revised 1/10, indicated under Pressure Sore Staging Protocol, A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear or friction. Under Stage II it indicated, Partial thickness loss of dermis (outer layer of skin) presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slo(u)gh or bruising. Under 3. it indicated, This staging system should be used only to describe pressure ulcers. Wounds from other causes should not be staged using this system. Resident 10's Social Service (SS) Notes dated 10/5/15, indicated, Social Service pre-discharge note: IDT (Interdisciplinary Team) and Therapy director (Physical Therapy aide) conducted a care plan meeting on 10/5/15 with resident and FM (Family Member) .Recommendations family training on lift (mechanical lifting device used to transfer people who cannot do so on their own) .Recommended a Hospital bed, wheelchair, (mechanical) lift Resident 10's Physician Communication Fax Request dated 10/12/15, indicated under Request:, Resident discharge home on 10/20/15 ( a previous date of 10/17/15 lined through and revised). Home Health with Physical Therapy and Occupational therapy. Needed a Hospital bed, standard Wheelchair, (mechanical) lift. Under MD Response it indicated, OK. The form was signed by a Licensed Nurse and Medical Director (MD) 1. Resident 10's PT Discharge Summary dated 10/19/15, indicated under Discharge, residents family educated in the use of the (mechanical lift). Under Comments: it indicated, Training for safety and use of the (mechanical lift). Under D/C (Discharge) Reason: it indicated, All Goals Met. Under D/C Recs (recommendations) it indicated, Discharge Recommendations: family performed well .family trained on returning home. The document was signed electronically by Physical Therapist (PT) 1. Resident 10's SS Note dated 10/20/15 at 4:49 p.m., indicated, Social Service discharge note: Resident discharged to home .with daughter and son-in-law. (Vendor) transport pick up at 4 p.m Family training provided. All medical equipment delivered to home .(vendor) Home Health in place. The note was electronically signed by the Social Services Director (SSD). Review of Resident 10's SNF 1 clinical record titled Transfer/Discharge Summary dated 10/20/15 contained an area to document Reason for Transfer/Discharge .no reason for the discharge was documented on the record. On 12/23/15 at 3:25 p.m., during a phone interview, FM 9 stated Resident 10 was Spanish speaking and currently lived at her home. She spoke in a distressed tone, stated she was pregnant, near term, and the family was concerned regarding their ability to continue care for the resident. On 12/30/15 at 1:10 p.m., during an observation and interview at Resident 10's home, he was found covered with a blanket, lying on a bath towel, spread horizontally over a fitted sheet, which was stretched over a plastic mattress. He was found in a small room at the rear of the mobile home. No pressure reducing/relieving bed devices were found. A mechanical lift was observed sitting in the corner of the room. FM 10 stated she was called by the facility Social Services Director (SSD) in October 2015 to inform her, the facility was being renovated and the resident was ready for discharge. When asked about participation in discharge planning, the FM 9 stated she went to the facility to observe his physical therapy session. She stated she was shown the mechanical lift but denied having used the lift before discharge and stated the home health agency trained them to operate it after admission to home health services. She stated she received verbal instruction on maintaining the resident's [MEDICAL CONDITION], and how to change the [MEDICAL CONDITION] bag, but the nurse did not demonstrate how to change the bag or dressing, nor did FM 10 provide return demonstration of the procedure. She stated she was given two cases of [MEDICAL CONDITION] bags, one case was the wrong size, so she was unable to use it. FM 10 stated the facility had not conducted a pre discharge home evaluation. She further stated on the date of discharge he was transported to the home, but the van driver refused to assist the family in moving the resident up the ramp and into the house. FM 10 stated, It was a struggle to get him up (the ramp). FM 10 then attempted to reposition Resident 10 in bed. He grimaced and moved slowly to his right side, grabbing the side rail, stating the turning was painful. Resident 10's left heel was observed with a large black circular closed wound measuring approximately 1 1/4 in. (inch) by 1 1/4 in. A second smaller dark discolored area was noted on the lateral aspect of his left foot. A large open circular wound which measured approximately 3 cm. (centimeters) by 2 cm. was observed on his right hip. Resident 10's coccyx area skin was observed bright red, skin peeling, with multiple small open areas of broken skin FM 10 looked at the resident's coccyx area and stated, It 's the moisture .his skin sweats. She then became tearful and stated, I don't feel that he was ready (for discharge) .it's been really hard on me and my sister. The resident's elbows were bright red, with patches of peeling skin. FM 10 stated the family had not been able to transport her father to a physician since discharge. When asked, Resident 10 stated he felt he had physically declined since discharge, his skin was broken down, and he was not feeling well. On 12/31/15 at 9:15 a.m., during an interview and concurrent record review, the SSD stated she participated in Resident 10's discharge planning. When asked whether a pressure relieving device was ordered for his bed, she stated, I would order it if he needed it .no, he didn't need a (pressure relieving) mattress. There was no documented evidence nursing staff had participated in a discharge meeting. When asked if a home evaluation was conducted for safety or planning purposes, she stated, If it's not in the notes, it didn't happen. On 12/31/15 at 10:15 a.m., during an interview, LN 10 st

Entity Reported Incident: CA 431 Based on staff interview, clinical record, and administrative document review, the facility failed to ensure one of fifteen sampled residents (Resident 8) was provided the necessary care to maintain the highest practicable physical well being in accordance with Resident 8's plan of care when Certified Nursing Assistant, (CNA) 2 and CNA 3 failed to use a mechanical lift when transferring Resident 8 from her bed to a wheelchair. This failure resulted in Resident 8 sustaining a right mid clavicle fracture. Findings: The facility policy/procedure titled "FACILITY SAFE HANDLING POLICY" undated, indicated "...All resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident's Care Plan. To accomplish this a No-Lift, Safe, Patient Handling Program will be implemented in order to ensure required infrastructure is in place to comply with the components of this safe, patient handling and movement policy...Use patient handling equipment and other approved patient handling aids for high risk patient handling and movement tasks except when absolutely necessary, such as in a medical emergency..." On 12/15/13, an Entity Reported Incident (ERI) CA 431 was received which indicated on 12/13/13 Resident 8 was being transferred from her bed to a wheelchair after receiving care by CNA 2 and CNA 3, using a gait belt when they heard a pop and Resident 8 screamed. The ERI further indicated, "CNA's were to use a lift but instead choose to transfer the resident without the equipment. The facility is a lift use only with a policy stating this." Resident 8's Minimum Data Set (MDS) ( a federally mandated assessment of residents in a nursing home to identify functional abilities and health problems) dated 7/22/13, indicated Resident 8 had significantly impaired cognition. Resident 8 required extensive assistance of two persons for transferring (bed to wheelchair, wheelchair to toilet and back again). Resident 8's falls assessment titled "Fall Risk Evaluation," indicated "A resident who scores a 10 or higher is at risk (for falls(. Resident 8 scored at 16. Resident 8's "Impaired Mobility Care Plan" dated 11/29/13, indicated (Resident 8) "Needs extensive assist with bed mobility and total dependent with transfers, uses lift with 2 person assist with transfers." On 12/31/13 at 10:15 a.m., during an interview the Director of Nurses (DON), stated, she was aware of the incident and during her investigation of the incident with CNA 2 and CNA 3 they were aware of the no lift policy and should have used a lift for transferring. The DON further stated (Resident 8) is total lift (meaning she does not bear any weight.) The DON stated during her investigation (CNA 2) stated, "they (CNA 2 and CNA 3) were in a hurry, they heard a pop and placed the resident back on the bed and notified the charge nurse." On 1/14/14 at 2:45 p.m., during an interview, CNA 2 stated, "On the day of the incident there were only four CNA's working. After report (information given between shifts changing) CNA 2 was doing his usual activities when CNA 3 asked for help to transfer (Resident 8). Usually we would use the Hoyer lift but it was very busy with showers so we took a short cut." CNA 2 further stated, he (CNA 2) told CNA 3 "Let's just do it." We sat the resident on the bed in a dangle position, CNA 2 counted to three. Both (CNA 2 and CNA 3) were suppose to lift (Resident 8) on the count of three. CNA 3 did not hear the count and did not lift when CNA 2 lifted. As CNA 2 lifted, (Resident 8) fell back onto the bed. On 1/14/14 at 3:00 p.m., during an interview at the facility, CNA 3 stated, (Resident 8) likes to be up for activities. We (CNA 2 and CNA 3) were getting prepared to get the resident up when CNA 2 said lets just get her up, so instead of using the Hoyer lift CNA 3 placed a gait belt (belt used to assist in walking residents) around the resident and explained to her what they were going to do. "As we both lifted, I heard a pop and the resident screamed. I know I should have used the machine. Our facility is a no lift facility." CNA 3 called the charge nurse and Resident 8 was medicated for pain in her right shoulder. Resident 8 was not interviewable and not able to recall the incident. An X-ray report dated 12/13/13, indicated "... a transverse mildly displaced fracture of the right mid clavicle with slight downward displacement of the distal segment..." The facility's failure to implement the plan of care and policy for using a mechanical lift during a transfer resulted in an injury (right mid clavicle fracture) and causing immediate pain to her right arm.