Every finding on record at Vasona Creek Healthcare Center

Based on interview and record review, the facility failed to ensure to have access to prescribed medication (any substance used to diagnose, treat, relieve, or prevent diseases, and requires a written or verbal order from a licensed healthcare professional to be legally dispensed) to administer for one of three sampled resident (Resident 1).This failure had the potential to affect Resident 1's medical condition and well-being.Findings:During a telephone interview with Resident 1's significant family member (SFM) on 7/24/2026 at 1:06 p.m., SFM stated she received a phone call from facility nurse during night on 7/11/2026 to inform nurse unable to access medication zolpidem (a prescribed controlled medication [ a drug that government strictly regulates due to risk of misuse] used to treat insomnia [a common sleep disorder that makes it hard to fall asleep]) from narcotic box (separate locked box to store controlled medications inside the medication cart [a movable cart used to store, organize, transport and administer medications for residents]) due to missing key to narcotic box. SFM also stated she end up going to facility to give Resident 1's home supply of zolpidem that night. SFM further stated Resident 1 informed her Resident 1 was not able to sleep until received this medication that night.During an interview with Resident 1 on 7/27/2026 at 10:35 a.m., Resident 1 stated was not able to sleep until received zolpidem late night on 7/11/2026 after his SFM brought medication from home. Resident 1 also stated nurse informed Resident 1 she was unable to access medication due to issue with key for medication cart where this medication was stored.Review of Resident 1's face sheet (FS, a document that provides resident's information at a quick glance) indicated Resident 1 was admitted to facility on 5/1/2026. Review of Resident 1's diagnoses included insomnia.Review of Resident 1's order summary report indicated an order for zolpidem 5 mg (milligrams, a unit of mass, equal to one thousandth of a gram), 1 tablet by mouth at bedtime for insomnia, dated 7/6/2026 for 7 days.Review of Resident 1's electronic medication administration record (EMAR, a digital version used by healthcare professionals to schedule, track and document medications administration to resident) for July 2026 indicated on 7/11/2026 at 9:00 p.m., medication zolpidem was held. Further review of medication administration notes dated 7/11/2026 at 23:39 indicated no documented evidence for the reason to withhold this medication.Review of controlled drug record for zolpidem for Resident 1 indicated no documentation for time and amount given on 7/11/2026.During an interview with licensed vocational nurse A (LVN A) on 7/27/2026 at 12:35 p.m., LVN A confirmed Resident alert to name, place and situation.During a record review of Resident 1's controlled drug record for zolpidem with facility's medical record director (MRD) on 8/19/2026 at 2:40 p.m., MRD reviewed and confirmed controlled drug record for zolpidem was not documented for administration to Resident 1 on 7/11/2026. During an interview with facility's interim director of nursing/assistant director of nursing (IDON/ADON) on 8/19/2026 at 3:35 p.m., IDON/ADON stated not aware of key concern for narcotic box for PM (evening shift) shift on 7/11/2026. IDON/ADON also stated possibility of access to zolpidem due to missing key to narcotic box was the reason to hold on 7/11/2026 at 9:00 p.m. IDON/ADON confirmed there was no documented evidence to hold the medication and licensed nurse (LN) should have documented the reason to hold zolpidem for Resident 1 on 7/11/2026. IDON/ADON further stated LN should have reached over to pharmacy or DON for assistance for narcotic box's key that night. Review of facility's policy and procedure (P&P) titled, Pharmacy Services Overview, undated, the P&P indicated, The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice and meet state and federal requirements . Pharmacy services are available to residents 24 hours a day, seven days a week.

Based on interview and record review, the facility failed to notify the responsible party (RP, an individual who controls, manages, and directs the care received by the resident in the facility) in a timely manner for one of three sampled residents (Resident 2) when the resident had a change in skin condition. This failure resulted in a delay concerning the RP's involvement in the provision of care for Resident 2.Findings: A review of Resident 2's clinical records indicated he had diagnoses that included type 2 diabetes mellitus (a chronic metabolic condition characterized by persistent high blood sugar) without complications; unspecified dementia (a decline in mental abilities), unspecified severity, with agitation; Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), unspecified; chronic systolic (congestive) heart failure (the heart cannot pump enough blood). Resident 2 was diagnosed with right partial traumatic amputation of right great toe during a subsequent encounter on 2/10/26. Resident 2's daughter was designated as the responsible party (RP). A review of Resident 2's progress note dated 1/1/26 22:00, the EMAR - Order Administration Note indicated, Patient [resident] assessed with diabetic ulcer to the right hallux [the big toe] wound cleansed using appropriate wound cleanser and aseptic technique. Furthermore, the progress note dated 1/1/26 22:00 did not prompt the Change in Condition (CIC/COC) in the SBAR [Situation, Background, Assessment, Recommendation - standardized communication tool] and there was no indication that the RP was informed until 1/15/26 12:10 SBAR. During an interview with the license nurse (LN) A on 5/26/26 at 11:49 a.m., LN A confirmed that he did not initiate the change in skin condition in the SBAR nor inform the RP, as he thought it had already been addressed. LN A further stated that nurses are expected to complete a COC. During a concurrent interview and record review on 6/2/26 at 3:51p.m. with the Director of Nurses (DON), Resident 2's progress note was reviewed. The progress note indicated, on 1/1/26 22:00, LN A mentioned assessment and treatment of the right hallux. The DON stated that the progress notes also did not indicate RP notification and did not have SBAR until 1/15/26 12:10. The DON further stated that if there is any change in resident's condition, the nurse should prepare an SBAR and inform the resident or responsible party within 24 hours, to reflect in resident medical record. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised February 2021, the P&P indicated, the facility shall promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The Policy further indicated, Except in medical emergencies, notifications will be made within twenty-four (24) hours of change occurring the resident's medical/medical condition or status, and the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by Interact SBAR Communication Form.

Based on interview and record review, the facility failed to ensure a psychiatric consultation (psych consult, an evaluation conducted by a psychiatrist or psychologist to assess a person's mental health) was completed as ordered for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to identify Resident 1's mental health needs and implement interventions for it.Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizophrenia (a mental illness that is characterized by disturbances in thought). Review of Resident 1's physician orders indicated she had an order, dated 9/28/25, to, refer to psych consult. Review of Resident 1's Progress Note, dated 10/10/25, indicated, Referral sent for in-house psych consult. Psych will arrive 10/13/25. There was no documentation in the medical record that a psych consult was completed for Resident 1 on 10/13/25. Review of an email between the facility and the in-house psych provider, dated 10/24/25, indicated the facility followed up on the psych consult that needed to be completed for Resident 1. Further review of the email indicated the in-house psych provider replied and asked the facility to, Please provide the reasons for each referral. There was no documentation in the email, or in Resident 1's medical record, that indicated the facility provided the in-house psych provider with the reason for Resident 1's referral. Further review of Resident 1's medical record indicated there was no further documentation regarding Resident 1's psych consult until 12/1/25 (more than a month after the in-house psych provider asked the facility to provide the reason for Resident 1's referral). Review of Resident 1's Progress Note, dated 12/1/25, indicated, Resident was referred for psych consult but denied due to insurance. Asked to refer to DMH [Department of Mental Health]. There was no documentation in the medical record that indicated the facility ever sent a referral for Resident 1 to DMH. During an interview and concurrent record review with social services staff A (SS A) on 5/27/26, at 11:19 a.m., SS A confirmed the following: There was no documentation that a psych consult was completed for Resident 1 as planned on 10/13/25;There was no documentation that the facility replied to the in-house psych provider's emailed request, dated 10/24/25, asking the reason for Resident 1's referral. According to SS A, the in-house psych provider must have a valid reason to evaluate the resident;There was no documentation that the facility sent a referral to DMH after Resident 1's psych consult was denied due to insurance as indicated in the Progress Note dated 12/1/25; and,There was no documentation of any further follow-ups regarding Resident 1's psych consult after 12/1/25.During the same interview, SS A explained that if a resident's in-house psych consult is denied due to insurance, there are other things the facility can do: 1.) The facility can reach out to psych providers outside the facility and ask if they can evaluate the resident; 2.) The facility can ask the resident or responsible party if they would be willing to pay out-of-pocket for the psych consult and schedule an appointment accordingly; and 3.) The facility itself can pay for the in-house psych consult by signing a letter of agreement (LOA) with the in-house psych provider. SS A confirmed there was no documentation that indicated any of these things were attempted for Resident 1. SS A further confirmed there was no documentation that a psych consult was completed for Resident 1 after 9/28/25 (the date of the psych consult order). Review of the facility's policy titled Referrals, Social Services, dated 2001, indicated, Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.

Based on observation and interview, the facility failed to ensure the environment was as free of accident hazards as possible when the alarm to an emergency door was turned off. This failure had the potential to allow residents to exit the facility undetected and without permission. Findings:During an observation on 3/6/26, at 12:32 p.m., there was a door located next to resident room that led to the outside of the facility. There was a sign on this door that indicated, EMERGENCY EXIT ONLY ALARM WILL SOUND. There was another sign on this door that indicated, DO NOT OPEN ALARM IS ON PLEASE USE [another] EXIT.During an interview with the maintenance director (MD) on 3/11/26, at 1:48 p.m., the MD confirmed the door mentioned above was only supposed to be used during emergencies. The MD also confirmed an alarm would sound if this door was opened. During an observation and concurrent interview with the director of nursing (DON) on 3/26/26, at 2:31 p.m., the alarm for the above emergency door was tested. The DON opened the emergency door, but there was no alarm sound. The DON stated she would find out why the alarm was off.During an interview with the MD on 3/26/26, at 2:43 p.m., the MD explained that social services staff turned off the emergency door alarm so they could have a conference outside. The MD confirmed staff were not supposed to turn off the alarm to the emergency door, and stated the alarm should be on at all times.

Based on observation, interview, and document review, facility staff failed to refrain from using an alarmed emergency door during non-emergencies. This failure had the potential to compromise the facility's ability to maintain comfortable sound levels for the residents. Findings:During an observation on 3/6/26, at 12:32 p.m., there was a door located next to a resident room that led to the outside of the facility. There was a sign on this door that indicated, EMERGENCY EXIT ONLY ALARM WILL SOUND. There was another sign on this door that indicated, DO NOT OPEN ALARM IS ON PLEASE USE [another] EXIT.During an interview with the maintenance director (MD) on 3/11/26, at 1:48 p.m., the MD confirmed the door mentioned above was only supposed to be used during emergencies. The MD also confirmed an alarm would sound if this door was opened. The MD stated staff were aware that this door was only to be used during emergencies.During an interview with the director of nursing (DON) on 3/26/26, at 2:31 p.m., the DON confirmed the door mentioned above was only supposed to be used during emergencies, but stated that some staff did use this door to enter and exit the facility during non-emergencies. The DON confirmed this door made a loud alarm sound when opened.Review of the facility's policy titled Homelike Environment, revised 2/2021, indicated the facility maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable sound levels.

Based on interview and record review, the facility failed to follow its own policies and procedures to ensure social services carried out physician orders for referrals for one of three sampled residents (Resident 1). This failure resulted in referral delays for Resident 1.Findings:Review of Resident 1's clinical record indicated she was admitted [DATE] with diagnoses including chronic pain syndrome and rheumatoid arthritis (chronic disease that occurs when the body's immune system attacks its own tissues, usually affecting small joints in the hands and feet). A review of Resident 1's Order Summary Report indicated a physician order, dated 5/8/25, for Referral for retinal screening. A second physician order, dated 5/16/25, indicated a referral to Consult Rheumatology. During a concurrent interview and record review of Resident 1's physician orders on 7/7/25 at 1:30 p.m. with the social service assistant (SSA), she confirmed Resident 1 had physician orders on the above-mentioned dates for referrals. The SSA stated she could find no evidence in Resident 1's clinical record that the physician orders for the two consultations had been carried out. The SSA further stated there was no documentation in Resident 1's clinical record to indicate that Resident 1 had been seen by any physicians for a rheumatology consult or a retinal screening. The SSA confirmed she is the person who arranges the consults and transportation to the appointments. The SSA stated I must have missed those consult orders. During a concurrent interview and record review of Resident 1's physician orders on 7/7/25 at 2:43 p.m. with the assistant director of nursing (ADON), she confirmed resident 1 had physician orders for a rheumatology consult and a referral for retinal screening. The ADON stated the physician orders should have been carried out and arrangements should have been made for Resident 1 to have the rheumatology consult and retinal screening referral as ordered by the physician. Review of the facility's policy Referrals, Social Services, dated 2001, indicated social services shall coordinate resident referrals that have been prescribed by the physician. Social Services will document the referral in the resident's medical record and arrange transportation to outside agencies.

Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of three residents (Resident 1) when the facility failed to follow up Resident 1's physician orders for Psychiatrist and Dermatology consultations, and failure to provide nail care for Resident 1's long fingernails. These failures had the potential to negatively affect the residents' health, safety and well-being. Findings: Review of Resident 1's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, schizophrenia (mental illness that impacts a person's thoughts, feelings, and behaviors), adult failure to thrive (a decline in an adult's overall health and well-being), and need for assistance with personal care. Review of Resident 1's minimum data set (MDS, an assessment tool), dated 2/13/25, indicated she needed partial/moderate assistance for personal hygiene and substantial/maximal assistance for bathing and toileting. During an observation on 3/14/25 at 12:10 p.m., Resident 1 was lying in bed with both hands by her side. Resident 1 was observed with long fingernails on 5 digits of her left hand and 3 digits on her right hand. There was overgrowth of skin on the thumb and index fingers of both hands and the skin surrounding all the nails appeared dry. During an observation and concurrent interview with the assistant director of nursing (ADON) on 3/14/25 at 12:20 p.m., she confirmed Resident 1's fingernails were long. The ADON stated Resident 1's fingernails needed to be trimmed. A review of Resident 1's Order Summary Report, an order dated 3/26/24, indicated Consult - Psychiatrist Eval and Treatment with follow-up as indicated. A second physician order, dated 10/22/24, indicated Psych consult to be done 10/23/24. A third physician order, dated 10/22/24, indicated Dermatology consult to be done 10/23/24. During a concurrent interview and record review of Resident 1's physician orders on 4/16/25 at 1:55 p.m. with LVN A, she stated she recalled the physician ordering a psychiatric consult on 10/23/24. LVN A stated Resident 1 had been refusing some medications and refusing to eat at times. LVN A stated she communicated the physician order for the psychiatric consult to the social service department. LVN A stated she was unaware if the psychiatrist consultation was done. During a concurrent interview and record review of Resident 1's physician orders on 4/17/25 at 2:30 p.m. with the social service assistant (SSA), she confirmed Resident 1 had physician orders for psychiatrist and dermatology consults on the above-mentioned dates. The SSA stated she could find no evidence that the physician orders for the 3 consults had been carried out. The SSA further stated there was no documentation in Resident 1's clinical record to indicate that Resident 1 had been seen by a dermatologist or a psychiatrist. During a concurrent interview and record review of Resident 1's physician orders on 4/17/25 at 3:45 p.m. with the director of nursing (DON) she confirmed resident 1 had physician orders for dermatology and psychiatrist consultations. The DON stated the physician orders should have been followed and arrangements should have been made for Resident 1 to been seen by a dermatologist and psychiatrist as ordered by the physician. During a review of the facility's 2001 procedure titled Care of Fingernails/Toenails indicated, Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on interview and record review, the facility failed to ensure physicians orders were carried out or documented as written for one out of four sampled residents (Resident 1), when three doses of intravenous (through the veins) vancomycin (an antibiotic) were not documented on three separate days. This had the potential to compromise the resident's health and well-being. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] for a diagnosis of functional quadriplegia (a nervous system disorder which results in being unable to move your arms or legs), aphasia (unable to speak), and osteomyelitis of the sacrum (an infection in the lower back). Review of Resident 1's order summary indicated she had a physician order, dated 3/24/25, for Vancomycin HCL Intravenous Infusion 500 mg/100 mL 0.5 gram intravenously three times a day for sepsis until 4/1/23 at 13:59. Review of Resident 1's medication administration record (MAR) indicated that the Vancomycin was ordered for 5:00 AM, 1:00 PM and 9:00 PM. Review of Resident 1's MAR further indicated there was no documentation for 3/25/26 at 5:00 AM, no documentation for 3/26/25 at 1:00 PM, and no documentation for 3/28/25 at 9:00 PM. During an interview and concurrent record review with the director of nursing (DON) on 3/20/25 at 12:57 PM, the DON reviewed the clinical record for Resident 1, and confirmed the documentation for the dates and times mentioned above was missing. The DON further said if a dose of a medication is missed, then the nurse should notify the provider and document it in a progress note. Review of facility policy titled Administering Medications, dated 2001, indicated . Medications are administered in accordance with prescriber orders . The policy further indicated . 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 signature and title of the person administering the drug.

Based on interview and record review, the facility failed to carry out and implement a physician ' s order in a timely manner for one of three sampled residents (Resident 1). This failure had the potential to compromise Resident 1 ' s health and well-being. Findings: Review of Resident 1 ' s medical record indicated he was admitted on [DATE] and had diagnoses including hypothyroidism (a condition in which the thyroid gland does not produce enough hormones which are essential for metabolism and other bodily functions). Review of Resident 1 ' s physician ' s orders indicated he had an order, dated 7/5/24, for levothyroxine sodium (medication used to treat hypothyroidism) 50 micrograms (mcg, unit of dose measurement) by mouth in the morning. Review of Resident 1 ' s Tele Visit Encounter Progress Note, dated 7/10/24, indicated he had a telephone visit with an endocrine clinic (clinic that specializes in conditions of the endocrine system, such as hypothyroidism). The progress note indicated the endocrine clinic doctor gave an order to, Increase levothyroxine to 150mcg one tablet daily. Review of Resident 1 ' s medication administration record (MAR) indicated Resident 1 continued to receive levothyroxine sodium 50 mcg daily until 8/1/24. The MAR indicated Resident 1 received levothyroxine sodium 75 mcg daily from 8/2/24 to 1/14/25. Further review of the MAR indicated Resident 1 ' s levothyroxine sodium was not increased to 150 mcg daily until 1/15/25. During an interview and concurrent record review with licensed nurse A (LN A) on 3/17/25 at 9:30 a.m., LN A reviewed Resident 1 ' s medical record and confirmed that on 7/10/24, the endocrine clinic doctor gave an order to increase levothyroxine to 150 mcg daily. LN A confirmed the facility did not increase Resident 1 ' s levothyroxine sodium to 150 mcg daily until 1/15/25. LN A acknowledged that Resident 1 ' s nurse should have carried out the order when it was given by the endocrine clinic doctor. The facility ' s policy titled Administering Medications, dated 2001, indicated, Medications are administered in accordance with prescriber ' s orders. Based on interview and record review, the facility failed to carry out and implement a physician's order in a timely manner for one of three sampled residents (Resident 1). This failure had the potential to compromise Resident 1's health and well-being. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including hypothyroidism (a condition in which the thyroid gland does not produce enough hormones which are essential for metabolism and other bodily functions). Review of Resident 1's physician's orders indicated he had an order, dated 7/5/24, for levothyroxine sodium (medication used to treat hypothyroidism) 50 micrograms (mcg, unit of dose measurement) by mouth in the morning. Review of Resident 1's Tele Visit Encounter Progress Note, dated 7/10/24, indicated he had a telephone visit with an endocrine clinic (clinic that specializes in conditions of the endocrine system, such as hypothyroidism). The progress note indicated the endocrine clinic doctor gave an order to, Increase levothyroxine to 150mcg one tablet daily. Review of Resident 1's medication administration record (MAR) indicated Resident 1 continued to receive levothyroxine sodium 50 mcg daily until 8/1/24. The MAR indicated Resident 1 received levothyroxine sodium 75 mcg daily from 8/2/24 to 1/14/25. Further review of the MAR indicated Resident 1's levothyroxine sodium was not increased to 150 mcg daily until 1/15/25. During an interview and concurrent record review with licensed nurse A (LN A) on 3/17/25 at 9:30 a.m., LN A reviewed Resident 1's medical record and confirmed that on 7/10/24, the endocrine clinic doctor gave an order to increase levothyroxine to 150 mcg daily. LN A confirmed the facility did not increase Resident 1's levothyroxine sodium to 150 mcg daily until 1/15/25. LN A acknowledged that Resident 1's nurse should have carried out the order when it was given by the endocrine clinic doctor. The facility's policy titled Administering Medications, dated 2001, indicated, Medications are administered in accordance with prescriber's orders.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored in 3 of 6 medication carts when: 1. Discontinued medications for 3 residents (Residents 2, 3, and 4) were not removed from active stock; and 2. An insulin pen (a pre-filled pen containing multiple doses of insulin for the treatment of high blood sugar) was not labeled with patient-specific information and not dated with an open date. These failures had the potential for medication errors; spread of infection due to being mixed up with another resident's insulin pen; and insulin given past its effective date. Findings: a. On 1/24/25 at 10:15 a.m., at Medication Cart 3A with Licensed Vocational Nurse (LVN) D, a multi-dose vial of insulin lispro (a short-acting insulin), with the expiration date of 1/11/25, was identified in the medication cart. LVN D stated it belonged to Resident 2 who was no longer residing in the facility. A review of Resident 2's clinical record indicated she was discharged from the facility on 12/18/24, more than a month ago. b. On 1/24/25 at 10:20 a.m., at Medication Cart 1A with LVN E, a Humulin N (a long-acting insulin) belonging to Resident 3 and a Lantus (a long-acting insulin) vial for Resident 4, were identified in the cart. LVN E stated both residents were not here. She acknowledged they should have been removed from the cart. A review of Resident 3's clinical record indicated she was discharged from the facility on 1/11/25, or 13 days ago. A review of Resident 4's clinical record indicated the resident was discharged from the facility on 12/19/24, more than a month ago. c. On 1/24/25 at 10:32 a.m., at Station 4 Medication Cart with LVN F, an insulin glargine-yfgn pen (a pre-filled pen containing long-acting type of insulin that works slowly, over about 24 hours) was identified without any patient-specific labeling and without an open date. LVN F stated he did not know whom the pen belonged to and when it was opened. A review of the manufacturer's Prescribing Information (detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for insulin glargine-yfgn, dated 7/2021, indicated to discard the pen 28 days after opening. During an interview with the Director of Nursing on 1/24/25 at 5:02 p.m., she stated medications belonging to discharged residents are to be removed from the medication carts when they are discharged , to prevent them from being given in error; and insulin pens need to have resident name on it and an open date. A review of the facility's undated policy and procedures titled, Medication Labeling and Storage indicated, The nursing staff is responsible for maintaining medication storage .in a .safe .manner . If the facility has discontinued .medications . the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial If the medication containers have missing, incomplete, improper .labels, contact the dispensing pharmacy for instructions .

Based on interview and record review, the facility failed to ensure practices that met professional standards of quality and facility policy and procedures (P&P) for one of 3 sampled residents (Resident 1) when: 1. Resident 1 received two insulin (an injectable medication for the treatment of high blood glucose/sugar) orders and was diagnosed with diabetes (disease that impairs the body's ability to regulate blood sugar [BS]) by Physician B without documented evidence of laboratory results and/or symptoms that met the diagnostic criteria for diabetes according to the American Diabetes Association (ADA). The failure resulted in the resident being diagnosed with diabetes and receiving insulin orders without supporting evidence for the diagnosis and the medications, and had the potential for adverse effects, such as severely low BS that could lead to confusion, blurred vision, fall, tremors, loss of consciousness, etc. 2. Resident 1 received new orders for treatment without staff informing his responsible party (RP, person designated to make decisions on behalf of the resident) of the changes in treatment. The failure resulted in the resident/RP not being informed and participated in the resident's care. Findings: 1. On 1/10/25, the California Department of Public Health received an anonymous complaint indicating Resident 1 was receiving insulin treatment while he was not diabetic, and he was noticed to be really sleepy and lethargic. A review of the American Diabetes Association's (ADA) online publication titled Understanding Diabetes Diagnosis, accessed 2/10/25, indicated: There are several ways to diagnose diabetes. Each way usually needs to be repeated on a second day to diagnose diabetes. when: a. A1c (hemoglobin A1c, average blood glucose for the past two to three months) level of 6.5% or higher (normal value is <5.7%); b. Fasting Plasma Glucose (FPG) Test: a fasting blood sugar level of 126 milligrams/deciLiter (mg/dL, unit of measurement) or higher; c. Oral Glucose Tolerance Test (OGTT): A 2-hour plasma glucose level of 200 mg/dL or higher during an OGTT after consuming a sugary drink; d. Random Plasma Glucose Test: random blood sugar level of 200 mg/dL or higher, along with symptoms of diabetes (such as excessive thirst, urination, or weight loss). On 1/24/25, a review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including aphasia (disorder that affects a person's ability to communicate) following a cerebral infarction (stroke) and urinary tract infection. The list of admitting diagnoses did not include diabetes. A review of Resident 1's Minimum Data Set (MDS, an assessment and screening tool), dated 8/24/24, indicated he had a BIMS score of 9 [(Brief Interview for Mental Status, a test given by medical professionals to determine a patient's cognitive understanding that can be scored from 1 to 15, a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] ), which indicated his cognitive condition was moderately impaired. The medical record indicated a family member was the resident's RP. A review of the prior-to-admission records indicated the resident was hospitalized from 8/8/24 until 8/22/24. The records indicated Resident 1 did not have a diagnosis of diabetes nor did he receive any insulin administration during the hospitalization or prior to hospitalization . A review of Physician A's progress notes, dated 8/22/24 (day of admission to the facility), indicated no diagnosis of diabetes in the physician's assessment. A review of the physician's orders indicated Resident 1 received two insulin orders, made by phone, by Physician A. They were entered into the computer system by Registered Nurse C (RN C) on 8/28/24 at 22:28 (10:28 p.m.), as follows: - Humalog solution (a short-acting insulin), inject 3 units subcutaneously (under the skin) three times a day before meals for diabetes; and - Humulin N (insulin NPH, a long-acting insulin), inject 5 units subcutaneously two times a day before breakfast and dinner. A review of Resident 1's August and September 2024 Medication Administration Records (MAR) indicated Resident 1 received these two medications from 8/29/24 to 9/2/24 (total of 5 days). Resident 1's clinical record indicated the nursing staff obtained the resident's BS three times a day starting on 8/29/24 at 7:35 a.m., at around the first dose of insulin was administered. There was no documented evidence of BS being obtained prior to 8/29/24. Further review of Resident 1's clinical record indicated it did not contain documented evidence Resident 1 exhibited symptoms consistent with diabetes such as excessive thirst, frequent urination, or weight loss. During a concurrent interview and record review with RN C on 1/24/25 at 3:28 p.m., she stated she received the above orders as endorsed by the morning nurse and entered them into the computer system. She said she recalled the resident had a BS reading of moderately high and that was the reason why the physician prescribed the two insulin orders. RN C reviewed Resident 1's clinical record and could not find the BS reading she was talking about, as there was no BS reading prior to 8/29/24 at 7:35 a.m. She reviewed the resident's lab results (which were not available in Resident 1's clinical record) via the contracted laboratory website and stated he had the A1c of 5.4% on 8/27/24, and 5.5% on 8/28/24. She acknowledged those A1c levels were normal (as defined by the ADA above, a value of less than 5.7%). During a concurrent telephone interview and record review with Assistant Director of Nursing (ADON) A on 1/24/25 on 4:02 p.m., she stated she received an order from Physician A to discontinue the insulin orders on 9/2/24 after Resident 1's RP insisting on them being discontinued because the resident was not diabetic. When asked if she could find any BS readings prior to 8/29/24 (the day the insulin was started), ADON C stated, I don't see any. During an interview with Physician A on 1/24/25 at 4:32 p.m., he stated he was the attending physician for Resident 1 when he was first admitted , but he did not prescribe the insulin orders. He explained he was on leave during that time, and the covering physician (Physician B) prescribed the insulin orders. He stated he recalled the resident's family member getting really upset when she found out Resident 1 was receiving insulin injections, so he ordered to discontinue them on 9/2/24. Physician A stated he recalled looking into this and I did not know why insulin was ordered; the thought was that maybe the patient was on steroid use or had high blood sugar, but there was no record of blood sugar checks. He reviewed the physician's progress notes (his and those of Physician B's) and stated he could not see any notes regarding the reason for diabetes or insulin. He stated, When this insulin happened, I looked at hospital record; A1c was normal. Physician A confirmed the resident was not receiving any steroid medications. A review of the laboratory reports indicated Resident 1 had an A1c reading of 5.4% on 8/27/24; and 5.5% on 8/28/24, the day the insulin orders were made. During a concurrent interview and record review with Licensed Vocational Nurse (LVN F) on 1/30/25 at 11:16 a.m., he stated he worked the morning shift on 8/28/24 and received the insulin orders for Resident 1 over the phone from Physician B towards the end of his shift. He endorsed the orders to the oncoming nurse, RN C, who carried out the orders. He stated Physician B explained to him the reason for the orders, that the blood sugar was too high. LVN F reviewed the resident's clinical record and stated he could not locate the said BS. During another interview with LVN F on 1/30/25 at 11:37 a.m., when asked whether he obtained the BS for Resident 1 the day the insulin orders were made, he stated, I don't recall. A concurrent interview and record review was conducted with ADON B on 1/30/25 at 11:48 a.m. A review of Physician B's progress notes, written on 8/28/24 at 16:31 (4:31 p.m.), indicated no diagnosis of diabetes nor a BS reading or any notation about insulin orders. During a telephone interview with Physician B on 2/10/25 at 11:25 a.m., in the presence of ADON A and the Administrator, he stated he examined the resident on 8/18/24, the day he made the orders for insulin. He explained, I reacted to the fasting blood sugar of about 160. I was given that information even thought they didn't have the diagnosis of diabetes. When pointed out that his progress notes did not have any notation of diabetes diagnosis or of high BS reading, Physician B stated, I didn't document on the note; it's just the timing. A concurrent interview and record review was conducted with ADON A on 2/10/25 at 11:45 a.m. She reviewed Resident 1's clinical record and confirmed there was no documentation of Resident 1 having a high BS reading prior to the insulin orders being made; and his A1c levels were 5.4 and 5.5% on 8/27 and 8/28, respectively. There was no documented evidence to support the diagnosis of diabetes and the necessity for the insulin orders. A review of the facility's P&P titled Physician Visits, revised 4/2013, indicated, The attending physician must perform relevant tasks at the time of each visit, including review of the resident's total program of care and appropriate documentation. 2. A review of Resident 1's clinical record indicated it had no evidence the facility staff informing the resident's RP of the new insulin orders. During a concurrent interview and record review with LVN F on 1/24/25 at 3:28 p.m., she stated the resident's RP is here most of the time during the PM shift. If she was here, she would be notified. When asked to provide documented evidence the RP was notified, LVN F reviewed Resident 1's clinical record and stated, I don't see it. I think she was notified in person but it was not translated in progress notes. During a telephone interview with ADON A on 1/24/25 at 4:02 p.m., ADON A was asked to review Resident 1's clinical record remotely. After a few moments, she stated, I didn't see any progress notes the [RP] was informed. They should be notified. During a concurrent interview and record review with ADON B on 1/30/25 at 11:48 a.m., ADON B reviewed Resident 1's clinical record and stated, I don't see anything that family was informed. Family should have been informed. A review of Physician A's progress notes, written on 9/3/24 at 2012 (8:12 p.m.), indicated Physician A Discussed with family in hallway they were upset that insulin was given. During a telephone interview with Resident 1's RP on 1/30/25 at 3:50 p.m., when asked if she was informed about the resident's insulin orders, the RP stated, No, they never called and let me know about the insulin. She explained she found out accidentally from a staff after Resident 1 kept asking her Why am I so sick? She stated, I asked the staff; they said it's because the blood sugar was too low. A review of the facility's P&P titled Resident Rights, revised 2/2021, indicated, Federal and stated laws guarantee certain basic rights to all residents of their facility. These rights include the resident's right to . be notified of his or her medical condition and of any changes in his or her condition. A review of the facility's P&P titled Change in a Resident's Condition or Status, revised 2/2021, indicated the facility promptly notifies the resident . and the resident representative of changes in the resident's medical condition and/or status .

Based on interview and record review, the facility failed to maintain a complete medical record for one of three sampled residents (Resident 1) when: 1. The facility treated a wound to Resident 1's coccyx (tailbone) that was present upon admission, but did not document that they obtained a physician's order for wound treatment until eight days after admission; 2. The facility did not document treatments of Resident 1's coccyx wound until eight days after admission; and, 3. There was one week during which the facility did not document the assessment of Resident 1's coccyx wound. These failures had the potential to compromise the facility's ability to ensure Resident 1's wound was treated and monitored. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including overactive bladder (a condition that causes the sudden urge to urinate) and enterocolitis due to clostridium difficile (inflammation of the intestines that causes watery stools). Review of Resident 1's nursing admission assessment, dated 10/3/24, indicated Resident 1 had non blanchable redness (redness that does not turn white when pressed) with open skin on the coccyx. During an interview with Resident 1's family member (FM) on 1/24/25 at 3:10 p.m., the FM confirmed Resident 1's coccyx wound was present upon admission. The FM explained that once the facility saw the wound was present, they implemented routine wound treatments. During an interview and concurrent record review with the wound treatment nurse (WTN) on 1/27/25 at 9:55 a.m., the WTN explained that if a resident has a wound upon admission, the admitting nurse should obtain a physician's order for wound treatment, and the wound treatments should be documented on the treatment administration record (TAR). The WTN further explained that for residents with wounds, there should be wound assessments documented in the medical record weekly. The WTN reviewed Resident 1's medical record and confirmed the resident had a coccyx wound upon admission. The WTN confirmed there was no documentation that the facility obtained a wound treatment order, and no documentation that wound treatments were performed until 10/11/25. The WTN also confirmed there was no documentation of weekly wound assessments in Resident 1's electronic health record, but stated he would check with the assistant director of nursing (ADON) to see if she had the assessments. During an interview and concurrent record review with the ADON on 1/27/25 at 2:12 p.m., the ADON presented weekly wound assessments for Resident 1's coccyx wound. The wound assessments indicated Resident 1's wound was classified as moisture-associated skin damage (caused by prolonged exposure to various sources of moisture, including urine or stool). There was no weekly wound assessment for the week after Resident 1's admission to the facility. The ADON confirmed there were no weekly wound assessments for Resident 1 until 10/17/24 (two weeks after the resident was admitted to the facility). The facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 2001, indicated the physician will authorize pertinent orders related to wound treatments. The facility's policy titled Charting and Documentation, revised 12/2019, indicated the services provided to the resident should be documented in the resident's medical record. The policy further indicated documentation of procedures and treatments includes details such as the date and time the procedure/treatment was provided, the name and title of the individual who provided the care, assessment data, and physician notification.

Based on interview and record review the facility failed to follow physician's orders for Resident 1 when Resident 1's physician's steroid tapering (process of slowly decreasing a steroid dosage over time) orders were not carried out correctly. This resulted in Resident 1 receiving a larger dosage than prescribed for six days, and Resident 1 missing one steroid dose entirely. These failures resulted in Resident 1 not receiving proper treatment, and had the potential to compromise Resident 1's health and well-being. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden worsening in airway function), pulmonary hypertension (high blood pressure in the lungs), bronchiectasis (damage to tubes that carry air in/out of the lungs), and bacterial pneumonia (infection in the lungs caused by bacteria). Review of Resident 1's physician order dated 8/15/24, indicated to administer, prednisone (steroid drug used to reduce inflammation) 10 mg (mg/unit of measure) Give 3 tablet by mouth in the morning for inflammation [30 mg]. Review of Resident 1's physician order dated 9/3/24, indicated to decrease prednisone to 25 mg by mouth daily for seven days, indicating specific dates from 9/4 to 9/11 (9/4 to 9/11 is eight days). The physician order also indicated to decrease Prednisone to 20 mg by mouth daily for seven days, indicating specific dates from 9/12 to 9/19 (9/12 to 9/19 is eight days). Review of Resident 1's medication administration record (MAR), for the month of August and September, indicated Resident 1 received 30mg of prednisone from 8/16/24 until 9/9/24. Review of Resident 1's September MAR indicated two prednisone orders. One order for prednisone 30 mg to be given at 9:00 a.m. and a second order for prednisone 25 mg to be given at 10:00 a.m. Resident 1 received 55 mg of prednisone for 6 days, from 9/4/24 through 9/9/24. Resident 1's September MAR also indicated no prednisone was administered to Resident 1 on 9/11/24. During an interview and concurrent record review with licensed vocational nurse A (LVN A) on 9/4/24 at 1:30 p.m., she reviewed Resident 1's September MAR and stated she administered medications to Resident 1 on 9/6/24. When asked what dosage of prednisone was administered to Resident 1 on 9/6/24, LVN A stated she initialed 30 mg of prednisone administered at 9:00 a.m. and 25 mg of prednisone administered at 10:00 a.m. LVN further stated she does not recall administering 55 mg of prednisone to Resident 1 on 9/6/24 and stated she should have questioned the physician orders for two different prednisone dosages. When LVN A was asked what dosage of prednisone was administered to Resident 1 on 9/11/24, she stated there was no evidence of prednisone being administered on 9/11/24 on Resident 1's MAR. During an interview and concurrent record review with the director of nursing (DON) on 9/4/24 at 3:25 p.m., she reviewed Resident 1's physician orders for prednisone. The DON stated the physician orders on 9/3/24 indicated a gradual tapering of the prednisone dosage by 5 mg each week. The DON stated the physician wrote an order to decrease the prednisone from 30 mg to 25 mg on 9/3/24. She further stated the order for 30 mg of prednisone should have been discontinued, but licensed nurses administered both dosages, from 9/4/24 through 9/9/24. The DON confirmed Resident 1's September MAR indicated licensed nurses administered 55 mg of prednisone to Resident 1 for six days, from 9/4/24 through 9/9/24. The DON confirmed that Resident 1 did not receive prednisone on 9/11/24. The DON confirmed the physician orders for prednisone indicated for seven days but she stated the specific dates identified by the physician in the order totaled eight days. The DON stated the licensed nurses should have clarified the orders with Resident 1's physician. Review of the facility's undated facility's policy, Physician Orders, indicated the purpose of the policy is to establish standardized guidelines for receiving, documenting, verifying, and executing physician orders to ensure safe and effective patient care . Orders must be clear, complete, and include all necessary information (e.g., name, date, time, and specific instructions). The policy further indicated, Any ambiguities or concerns must be clarified with the ordering physician before execution.

Based on interview and record review, the facility failed to ensure treatment orders for respiratory [breathing] therapy (RT, treatment that helps individuals optimize their respiratory function, breathe more easily, and live more comfortably) was carried out as ordered for six out of six residents (Residents 3, 5, 6, 7, 8, and 9). The failure had the potential for the residents not attaining their highest practicable physical well-being, such as not being able to attend activities or carry out the activities of daily living (ADLs; such as eating, toileting, dressing, personal hygiene, etc.) due to reduced respiratory functions. Findings: 1a. A review of Resident 5's clinical record indicated she was admitted to the facility with diagnoses including history of COVD-19. Her Minimum Data Set (MDS, a care area assessment and screening tool), dated 11/5/24, indicated she had a BIMS score of 15 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated she had intact cognitive response. A review of Resident 5's RT care plan, dated 5/16/24, indicated, Resident has history of COVID-19 with present of intermittent cough, resident will benefit from daily respiratory service and Resident has and [sic] alteration in respiratory system secondary to SOB [shortness of breath] that contributes to ADL limitations. Resident has high risk for potential development of respiratory distress. A review of Resident 5's clinical record indicated a physician's order, dated 11/15/24, for chest physiotherapy to bilateral anterior [front] and posterior [back] lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day or as tolerated with pre-and post-oxygen saturation check. On 11/20/24, a review of Resident 5's 11/2024 Respiratory Administration Record (RAR, an official document where staff document the RT) indicated the staff did not carry out the RT 5 times per day. It showed the staff only administered respiratory care: - 11/16/24: only 2 times - 11/17/24: only 2 times - 11/19/24: only 3 times During an interview with Resident 5 on 11/20/24 at 2:30 p.m., she stated she had been receiving respiratory treatment 3 times a day. She stated the RT helps her with breathing better and improving her lung functions. During a concurrent interview and record review with the Director of Staff Development (DSD) on 11/20/24 at 3:37 p.m., he reviewed Resident 5's RAR and verified, as per the RAR documentation, the resident only received 2 times of RT on 11/16 and 11/17, and 3 times on 11/19/24. On 11/25/24, further review of Resident 5's 11/2024 RAR indicated she only received RT two times on 11/20, 11/22, and 11/24/24. During another interview with Resident 5 on 11/25/24 at 10:53 a.m., she stated she only received RT 3 times per day. When asked whether she had ever received RT 5 times per day, she stated, No. During a concurrent interview and record review with the Director of Nursing (DON) on 11/25/24 at 2:05 p.m., the DON reviewed Resident 5's 11/2024 RAR and confirmed Resident 5 did not receive RT treatment 5 times a day, as ordered, on 11/16, 11/17, 11/19, 11/20, 11/22, and 11/24/24. 1b. A review of Resident 6's clinical record indicated she was admitted to the facility with diagnoses including respiratory disorders in diseases classified elsewhere. Her 8/14/24 MDS indicated she had a BIMS score of 15, indicating she had intact cognition. Resident 6 had no care plan for RT. A review of her physician's orders indicated an order, dated 11/16/24 for Chest physiotherapy to bilateral anterior and posterior lung segments, 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times per day. A review of Resident 6's 11/2024 RAR indicated her RT treatment was scheduled 5 times daily at 7 a.m., 10 a.m., 1 p.m., 4 p.m., and 7 p.m., but she only received 1 to 3 times per day on the following days: - 11/16/24: 2 times instead of 5 - 11/17/24: 3 times - 11/18/24: 2 times - 11/19/24: 3 times - 11/20/24: 1 time - 11/21/24: 3 times During an interview with Resident 6 on 11/25/24 at 12:42 p.m., she stated RT treatment helped her breathe better; and she only received a RT treatment 2 times per day, once in the morning and once in the afternoon. She clarified that sometimes the staff ran late and administered the afternoon session at 3 p.m., but never after 3 p.m. During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 6's 11/2024 RAR and confirmed Resident 6 did not receive RT treatment 5 times a day, as ordered, on 11/16, 11/17, 11/18, 11/19, 11/20, and 11/21/24. 1c. A review of Resident 3's clinical record indicated she was admitted to the facility with diagnoses including bronchiectasis (a chronic lung disease that causes the airways to widen and thicken, making it difficult to move air in and out of the lungs). Her MDS 11/8/24 MDS indicated she had a BIMS code of 99 indicating the resident could not complete the mental status assessment. A review of Resident 3's care plan for RT, dated 11/19/24, indicated, Resident has an alteration in respiratory system secondary to .BRONCHIECTASIS . that contributes to ADL/functional limitations. Resident has high risk for potential development of cardio-pulmonary [related to heart and lung] symptoms and/or respiratory distress. A review of Resident 3's physician's orders, dated 11/19/24, for Chest physiotherapy to bilateral anterior and posterior lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day. A review of Resident 3's 11/2024 RAR indicated she did not receive 5 times RT treatment on the following days: - 11/19/24: only 2 times - 11/20/24: only 3 times - 11/22/24: zero times received - 11/23/24: only 3 times - 11/24/24: only 3 times During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 3's 11/2024 RAR and confirmed Resident 3 did not receive RT treatment 5 times a day, as ordered, on 11/19, 11/20, 11/22, 11/23, and 11/24/24. 1d. A review of Resident 7's clinical record indicated he was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, an ongoing lung condition caused by damage to the lungs) and asthma. A review of his 9/18/24 MDS indicated he had a BIMS score of 15, indicating he had intact cognition. A review of his care plan for RT, dated 5/6/24, indicated, Resident has an alteration in respiratory system secondary to . CHRONIC OBSTRUCTIVE PULMONARY DISEASE . ASTHMA that contributes to ADL/functional limitations. Resident has high risk for potential development of cardio-pulmonary systems and/or respiratory distress. On 11/2/24, Resident 7 received a physician's order for chest physiotherapy to bilateral anterior and posterior lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day or as tolerated with pre-and post-oxygen saturation check. On 11/25/24, a review of Resident 7's 11/2024 RAR indicated he did not received 5 times treatment on the following days: - 11/8/24: only 4 times - 11/11/24: only 2 times - 11/12/24: only 3 times - 11/16/24: only 3 times - 11/17/24: only 2 times - 11/22/24: only 2 times - 11/23/24: only 2 times - 11/24/24: only 3 times During an interview with Resident 7 on 11/25/24 at 10:50 a.m., when asked how often he received RT treatment, he stated, Two to three times a day. He stated the RT treatment helped him breathe better. During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 7's 11/2024 RAR and confirmed Resident 7 did not receive RT treatment 5 times a day, as ordered, on the above dates. 1e. A review of Resident 8's clinical record indicated he was admitted to the facility with diagnoses including respiratory disorders in diseases classified elsewhere. A review of his RT care plan, dated 10/7/24, indicated the resident had alteration in respiratory system due to respiratory disorders in diseases classified elsewhere and atelectasis [the collapse of a lung or part of a lung, also known as a lobe] that contributes to ADL limitations. Resident has high risk for potential development of respiratory distress. On 11/15/24, Resident 8 received a physician's order for chest physiotherapy to bilateral anterior and posterior lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day or as tolerated with pre-and post-oxygen saturation check. A review of Resident 8's 11/2024 RAR indicated the resident only received 3 times RT treatment on 11/17/24 and 11/23/24. During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 8's 11/2024 RAR and confirmed Resident 8 did not receive RT treatment 5 times a day, as ordered, on 11/17/24 and 11/23/24. 1f. Resident 9 was admitted to the facility with diagnoses including OTHER SPECIFIED SYSTEMS AND SIGNS INVOLVING THE CIRCULATORY [system that delivers nutrients and oxygen to all cells in the body] AND RESPIRATORY SYSTEMS A review of his RT care plan, dated 8/26/24, indicated, Resident has an alteration in respiratory system secondary to OTHER SPECIFIED SYSTEMS AND SIGNS INVOLVING THE CIRCULATORY AND RESPIRATORY SYSTEM that contributes to ADL/functional limitations . A review of Resident 9's physicians orders indicated an order, dated 11/15/24, for chest physiotherapy to bilateral anterior and posterior lung segments. 5 minutes per segment. Chest physiotherapy may include chest percussion and/or huffing/coughing five times a day or as tolerated with pre-and post-oxygen saturation check. A review of Resident 9's 11/2024 RAR indicated he did not receive RT treatment 5 times a day on the following days: - 11/15/24: 4 times only - 11/16/24: 3 times only - 11/17/24: 3 times only - 11/22/24: 3 times only - 11/23/24: 3 times only During a concurrent interview and record review with the DON on 11/25/24 at 2:07 p.m., the DON reviewed Resident 9's 11/2024 RAR and confirmed Resident 9 did not receive RT treatment 5 times a day, as ordered, on 11/15, 11/16, 11/17, 11/22, and 11/23/24. 2. During an interview with the respiratory therapist on 11/25/24 at 11:21 a.m., she explained that many elderly residents need RT due to their many medical conditions that cause reduced respiratory functions. She explained the chest physiotherapy is the procedure that helps breaking the mucous and makes them cough it out, thereby improving their breathing. She stated some nursing staff have received training and been assigned RT duty as part of their responsibilities. When asked whether the residents have received 5 times daily treatment, she stated, It's trick to get five times a day. I can guarantee 3 times a day treatment for those residents assigned to her. As far as documentation on the RAR, she stated, If therapy is completed, they should document after. During a review with the DSD on 11/25/24 at 12:15 p.m., he stated he and four other nursing staff have received training and been assigned resident RT treatment as part of their responsibilities. For documentation on the RAR, he stated the nurses do not have the computer (like the medication nurses) to document after each treatment administered, but the expectation is that they document at the end of their shift. During an interview with the DON on 11/25/24 at 2:40 p.m., the DON stated she did not know the residents not receiving their respiratory treatment as ordered. She also stated the expectation is that the staff carry out the physician's orders, whether it's medication, dietary, physical therapy, or RT, as ordered. As for documentation, the DON stated, They are supposed to document after each service is being done. The facility was requested to provide the policy and procedures related to carrying out the physician's orders on 11/20, 11/21, and 11/25/24. On 11/25/24 at 2:48 p.m., the DON stated she could not find any policies addressing the implementation of the physician's orders besides that for medication orders. A review of the California Title 22 regulations, section 72314(a)(2), indicated, Medications and treatments shall be administered as prescribed.

Based on observation, interview, and record review, the facility failed to ensure appropriate storage of medications in two of four medication rooms when: 1. The medication room that housed the facility's automated dispensing unit (ADU - where medications are stored and electronically tracked) was unlocked when not in use; 2. Two expired medications were identified in the medication refrigerators; and 3. The medication refrigerator temperature in Medication room [ROOM NUMBER] was not consistently monitored twice daily as per the U.S. Centers for Disease Control and Prevention's (CDC) guidelines. The failures had the potential for unauthorized access to dangerous medications; expired medications given to residents; and ineffective medications or loss of drug potency due to unmonitored temperatures. Findings: 1. During a visit to the second floor with Assistant Director of Nursing B (ADON B) on 11/20/24 at 9:30 a.m., an unmarked room was identified unlocked. The ADON B opened the door without using a key. The room housed a large ADU, the facility's main medication supply. A large white bucket was observed in front of the ADU. It contained 5 tablets of clonidine (medication for high blood pressure) 0.1 milligrams. Opposite from the bucket was a large plastic multi-drawer bin/cart that contained multiple intravenous supplies and hydration solutions. The ADON B stated, The door should be locked. A review of the facility's undated policy titled Medication Labeling and Storage indicated, Compartments (nilcuding, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use . 2. During a visit to Station 1 Medication Room with ADON B on 11/20/24 at 9:40 a.m., a bag containing an eye drop solution called latanoprost (medication for glaucoma) 0.005% for Resident 10 was identified inside the medication refrigerator. The yellow sticker outside the bag indicated it was opened on 9/30/24 and expired on 10/28/24. ADON B verified this medication had expired, and stated it should not be in the refrigerator. During a visit to Station 3/4 Medication Room with ADON B on 11/20/24 at 10:01 a.m., an opened multi-dose tuberculin (a protein extract used in a skin test to help diagnose tuberculosis infection) solution vial was identified in the medication refrigerator. The yellow sticker on the vial indicated it was opened on 10/13/24, and expired on 11/13/24. ADON B confirmed the product had expired. A review of the facility's undated policy titled Medication Storage- Refrigerators indicated, Charge nurses or designated employee will be responsible for ensuring medication in refrigerators are not expired. 3. During a visit to Station 1 Medication Room with ADON B on 11/20/24 at 9:40 a.m. , a medication refrigerator was identified. It was observed to contain a round, household-type thermometer and various refrigerated medications such as insulin vials and pens, eye drops, and 13 boxes of flu vaccine. Each box of flu vaccine contained 10 pre-filled single-dose syringes. A review of the November 2024 temperature log with ADON B indicated the staff did not log it 10 times this month, from 11/1 to 11/20/24: 6 times during the NOC (night) shift and 4 times during the day shift. The ADON confirmed this finding and stated the refrigerator should be monitored twice daily. A review of the facility's undated policy titled Medication Storage- Refrigerators indicated the charge nurses/designate employee will check and record refrigerator temperature daily. During an interview with the Director of Nursing on 11/25/24 at 4:28 p.m., she stated medication refrigerator temperature should be monitored and recorded twice daily. A review of the CDC's Vaccine Storage and Handling Toolkit, dated 3/29/24, indicated the following for monitoring of refrigetors containing vaccine: If your TMD [temperature monitoring device] does not read minimum/maximum temperatures, then check and record the current temperature a minimum of two times per workday.

Based on interview, record review, and facility policy review, the facility failed to ensure staff immediately reported an incident of suspected abuse to the Administrator for 1 (Resident #32) of 1 resident reviewed for abuse. Findings included: A facility policy titled, Reporting Abuse to Facility Management, revised in 12/2013, indicated, It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc. [et cetera] to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. The policy specified, 4. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Services, or Charge Nurse. An Admission Record revealed the facility admitted Resident #32 on 10/20/2019. According to the Admission Record, the resident had a medical history that included diagnoses of dysphasia (impaired ability to understand or use spoken language) following cerebral infarction (stroke), schizophrenia, parkinsonism, major depressive disorder, and anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/03/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #32's Care Plan included a focus area, initiated on 06/24/2024, that indicated the resident had a need for activities that were consistent with their abilities and interests. According to the focus area, enjoyable, meaningful activities to the resident included, but were not limited to, visiting with their spouse and talking to their spouse on the cell phone. Resident #32's Progress Notes revealed a Nurse's Note, documented by Licensed Vocational Nurse (LVN) #6 on 10/27/2024 at 7:45 AM, that indicated when LVN #6 entered Resident #32's room to administer medication, the resident was yelling for help. Per the note, when LVN #6 entered the room, LVN #6 heard Resident #32's spouse on the phone very loudly and aggressively telling the resident to shut the [expletive] up. The progress note indicated LVN #6 asked the spouse not to speak to the resident like that under any circumstances, and Resident #32 whispered, thank you as LVN #6 was administering their medications. The note did not indicate whether LVN #6 notified anyone of suspected abuse. During an attempt to contact LVN #6 on 10/31/2024 at 8:52 AM, an automatic recording was received that indicated the wireless customer was unable to be reached. During an interview on 10/30/2024 at 3:53 PM, both the Administrator and Director of Nursing (DON) #16 stated they were not aware of the incident documented in Resident #32's progress notes. During an interview on 10/31/2024 at 11:50 AM, DON #16 said if staff suspected abuse, she expected them to notify the abuse coordinator and the DON, so they could notify the state agency and start an investigation. During an interview on 10/31/2024 at 2:38 PM, the Administrator stated he expected staff to report all suspected abuse to himself or the DON.

Based on interview, record review, facility document review, and facility policy review, the facility failed to resubmit a new Level I Preadmission Screening and Resident Review (PASARR) for 1 (Resident #74) of 4 residents reviewed for PASARR and failed to ensure a PASARR was accurately completed for 1 (Resident #110) of 4 residents reviewed for PASARR. Findings included: An undated facility policy titled, Admission Criteria, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The policy also indicated, 11. The state may choose not to apply the preadmission screening requirement if: a. the individual is admitted directly to the facility from a hospital where he or she received acute inpatient care; b. the individual requires facility services for the condition for which he or she received care in the hospital, and c. the attending physician has certified (prior to admission) that the individual will likely need less than 30 days of care at the facility. 1. An Admission Record revealed the facility admitted Resident #74 on 05/14/2024. According to the Admission Record, the resident had a medical history that included diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2024, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses that included anxiety disorder, depression, and bipolar disorder. Resident #74's care plan, included a focus area initiated on 05/15/2024, that indicated the resident was at risk for psychosocial well-being due to concerns related to anxiety, bipolar disorder, and diagnosis of depression. Interventions directed staff to allow the resident to voice feelings and frustrations; encourage family and friends to visit; to listen attentively; and observe the resident for tearfulness, increased agitation, and decreased participation in care. A State of California - Health and Human Services Agency, Department of Health Care Services letter dated 05/16/2024, revealed the resident had a negative Level I Screening, and the reason was for an exempted hospital discharge. The Department of Health Care Services letter also indicated, If the individual remains in the NF [nursing facility] longer than 30 days, the facility should resubmit a new Level I Screening as a Resident Review on the 31st day. During an interview on 10/31/2024 at 11:54 AM, Director of Nursing (DON) #16 stated a new Level I Screening should have been completed for Resident #74 after 30 days. During an interview on 10/31/2024 at 1:42 PM, the Marketing Director stated that typically the hospital would send out the PASARR electronically and the facility would download it and that someone from the MDS or billing department would conduct a review. The Marketing Director said if there needed to be another review completed, it would be done to make sure it did not go past the 30 days. The Marketing Director said Resident #74 was never brought to his attention. During an interview on 10/31/2024 at 2:21 PM, the Administrator stated the admissions team usually did an audit to see if there was a PASARR and if there were any clinical changes that would warrant a Level II. The Administrator said the admissions team and medical records staff were responsible for catching any errors. For Resident #74, the Administrator said the expectation was that the Level I would be done on the 31st day. 22445 2. An Admission Record revealed the facility admitted Resident #110 on 03/15/2024. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified moderate dementia with other behavioral disturbances (03/15/2024), anxiety disorder (03/15/2024), and unspecified psychosis not due to a substance or known physiological condition (03/15/2024). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2024, revealed the resident had modified independence in cognitive skills for daily decision-making and had short-term and long-term memory problems per the Staff Assessment of Mental Status (SAMS). The MDS indicated the resident had active diagnoses that included anxiety disorder and psychotic disorder. Resident #110's care plan, included a focus area initiated on 05/08/2024, that indicated the resident was at risk for psychosocial well-being concerns related to anxiety. Interventions directed staff to encourage visits from family and friends; listen attentively; and observe for tearfulness, increased agitation, and decreased participation in activities. Resident #110's care plan also included a focus area initiated on 05/17/2024, that indicated the resident was at risk for potential side effects, complications, or adverse reactions related to the ordered use of olanzapine (an antipsychotic medication) that was ordered for psychosis with behavioral disturbances. Interventions directed staff to give the medication as ordered, approach the resident in a calm manner, attempt a gradual dose reduction as indicated, monitor episodes of angry outbursts, observe and report signs of hallucinations, observe for adverse effects of the medications, and observe/record the effectiveness of the medication treatment. A Preadmission Screening and Resident Review (PASRR) [PASARR] Level 1 Screening, dated 03/15/2024 indicated Resident #110 had no serious diagnosed mental disorder that included anxiety disorder and symptoms of psychosis. A State of California- Health and Human Services Agency, Department of Health Care Services letter dated 03/15/2024 revealed the negative Level I Screening for Resident #110 indicated a Level II Mental Health Evaluation was not required. The Department of Health Care Services letter indicated the reason the Level I Screening was negative was due to no mental illness. According to the Department of Health Care Services, if mental illness was suspected, then a Level II Mental Health Evaluation could be conducted to determine if the individual could benefit from specialized mental health services. Social Services Director (SSD) #15 was interviewed on 10/31/2024 at 10:25 AM and stated that anyone could initiate a PASARR. She stated that when a resident was admitted the Director of Nursing (DON) or the nurses on the hall were responsible to make sure the PASARR was accurate. Director of Nursing (DON) #16 was interviewed on 10/31/2024 at 11:54 AM. DON #16 stated the admission team reviewed residents' PASSARs to make sure the PASSARs were accurate. DON #16 stated it was the responsibility of the nursing department to review the PASARR to make sure the diagnoses were accurate and stated that included both her and the MDS nurses. DON #16 reviewed the PASARR for Resident #110 and stated the PASARR was not accurate with the resident's diagnosis of psychosis omitted. The Marketing Director was interviewed on 10/31/2024 at 1:44 PM. The Marketing Director stated that when a resident was admitted , someone from the business office reviewed the PASARR but added he was unsure if that person checked for accuracy of the PASARR. The Marketing Director stated the absence of psychosis on Resident #110's PASARR should have been caught, especially with the psychiatric medications the resident took. The Administrator was interviewed on 10/31/2024 at 2:21 PM. The Administrator stated it was the responsibility of the admission team to review the PASARRs, and if there were inconsistencies, they involved the clinical team. The Administrator stated the medical records staff member audited the charts to make sure a PASARR was present and to make sure there were no clinical changes to warrant a Level II. The Administrator stated that on review by the facility someone should have captured Resident #110's antipsychotic medication and the psychiatric diagnosis.

Based on interview and document review, the facility failed to ensure 1 (room [ROOM NUMBER]) of 62 resident rooms accommodated no more than four residents per room. Findings included: A memorandum dated 11/15/2021, revealed room [ROOM NUMBER] had five beds. During the entrance conference on 10/28/2024 at 9:23 AM, Director of Nursing #16 stated there was one room in the facility, room [ROOM NUMBER], that housed more than four residents. The Maintenance Director was interviewed on 10/31/2024 at 1:18 PM. The Maintenance Director stated the facility had one room that housed more than four residents. The Administrator was interviewed on 10/31/2024 at 2:33 PM. The Administrator stated there had been discussion about the room with five beds. The Administrator stated that yearly the facility received a waiver for the room. The Administrator stated he received no concerns about the room having more than four residents.

Based on observation, interview, record review, and facility policy review the facility failed to follow enhanced barrier precautions (EBP) for 1 (Resident #124) of 5 residents reviewed for wounds. Specifically, during an observation of wound care treatment for a pressure ulcer for Resident #124 staff members failed to wear a gown as part of the appropriate personal protective equipment (PPE). Findings included: The facility undated policy titled, Enhanced Barrier Precautions, indicated, Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. The policy indicated, 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. The policy indicated, 3. Examples 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.); and h. wound care (any skin opening requiring a dressing). The policy also indicated, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. a. wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears. The policy also indicated, 11. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 12. PPE is available outside the resident rooms. An Admission Record revealed the facility admitted Resident #124 on 10/03/2024. According to the Admission Record, the resident had a medical history that included diagnoses of congestive heart failure and need for assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/05/2024, revealed Resident #124 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had one stage I pressure injury and was receiving pressure ulcer/injury care and application of ointments/medications other than to feet. On 10/30/2024 at 9:32 AM, observation was conducted of wound care to Resident #124's pressure ulcer to their coccyx performed by Licensed Vocational Nurse (LVN) #12 and assisted by Infection Control Preventionist (ICP) #13. Both staff wore a surgical mask and gloves, but no gown. On 10/30/2024 at 10:30 AM, ICP #13 stated that based guidance and the facility's EBP policy and procedure, Resident #124 should be on EBP. On 10/30/2024 at 11:01 AM, MDS Nurse #14, who was the previous ICP nurse, said that EBP should be implemented with residents who had drainage ports, indwelling catheters, urostomies, and residents with chronic wounds that required in depth treatments. On 10/31/2024 at 11:55 AM, Director of Nursing #16 stated if a wound was chronic, she expected the ICP to place the resident on EBP. She also said the importance of them being on EBP was to decrease the risk of MDROs.

Based on observation, interview, record review, and facility policy review, the facility failed to obtain treatment orders for a laceration for 1 (Resident #54) of 2 sampled residents reviewed for non-pressure related alteration in skin integrity. Findings included: A facility policy titled, Wound Care, dated 2001, indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The policy indicated, 1. Verify that there is a physician's order for this procedure. The policy also indicated, The following information should be recorded in the resident's medical record: 6. All assessment data (i.e. [id est, which was Latin for, that is], wound bed color, size, drainage, etc. [et cetera, and other similar things]) obtained when inspecting the wound. An Admission Record revealed the facility admitted Resident #54 on 12/17/2019. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified dementia, difficulty in walking, generalized muscle weakness, and unspecified macular degeneration (an eye condition that limited the visual field). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/09/2024, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #54 used a walker for mobility and required setup assistance from staff for transferring from bed to chair or chair to bed, walking 10 feet, and walking 50 feet. The MDS revealed Resident #54 required supervision or touching assistance to walk 150 feet. The MDS indicated Resident #54 had one fall since the previous assessment that resulted in no injury. Resident #54's care plan included a focus area initiated 10/24/2024, that indicated the resident was at risk for falls with or without injury related to a history of falls. Interventions directed staff to encourage and assist with toileting at start of day, to keep call light within reach, keep bed in low position, to keep personal/frequently used items within reach, and to keep the resident within supervised view as much as possible. A nursing Progress Note dated 10/24/2024 at 10:00 PM, revealed that around 7:15 PM, a certified nursing assistant (CNA) notified the licensed vocational nurse (LVN) that Resident #54 was on the floor. The Progress Note indicated that the resident sustained an open cut with active bleeding. The Progress Note indicated the LVN cleaned the wound with normal saline, applied adhesive strips, and covered the wound with a dry dressing. The Progress Note indicated the physician was notified and gave an order to send the resident to the hospital and the resident was transported to the hospital for further treatment. A Progress Note, dated 10/25/2024 at 3:35 AM, revealed the resident returned to the facility at 2:38 AM with no new orders. An interdisciplinary team (IDT) Progress Note dated 10/25/2024 at 7:35 PM, indicated the IDT met to discuss Resident #54's fall. The Progress Note indicated the resident was found on the floor by an LVN with active bleeding from the forehead. The Progress Note revealed the LVN cleaned the wound, applied adhesive strips, notified the physician and the resident's family, and sent the resident to the hospital for further evaluation. The Progress Note indicated the resident returned with no new orders. The Progress Note lacked any evidence of treatment orders for the wound. An Order Summary Report with orders active as of 10/29/2024, did not include orders for the assessment or treatment of the cut on Resident #54's forehead. An observation was made of Resident #54 on 10/28/2024 at 11:20 AM. The resident had a bandage on their left forehead. An observation was made on 10/30/2024 at 8:41 AM of Resident #54 sitting in the hallway in a wheelchair. Three adhesive strips were seen covering a laceration on the resident's left forehead. The area had no redness or drainage. LVN #7 was interviewed on 10/30/2024 at 8:44 AM. LVN #7 stated the area on Resident #54's forehead was due to a fall the resident sustained. LVN #5 was interviewed on 10/30/2024 at 1:15 PM. LVN #5 stated if a resident was sent to the hospital with a laceration and returned to the facility with no orders, she would notify the primary care provider (PCP) to obtain needed orders for treatment. LVN #5 reviewed the orders for Resident #54 and confirmed there were no treatment orders for the resident's adhesive strips or dressing that were observed in place on 10/28/2024 and there should have been. LVN #5 stated that without orders to treat the wound, the wound could become infected. Director of Nursing (DON) #16 was interviewed on 10/31/2024 at 11:01 AM. DON #16 stated that when a treatment was initiated after a fall, she expected the nurse to write an order for the treatment. The Administrator was interviewed on 10/31/2024 at 2:27 PM. The Administrator stated he expected the facility policy for wound care to be followed. The Administrator stated he expected orders to have been written for Resident #54's wound care.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (15) had adequate supervision to prevent an accident and injuries when the facility failed to assist the resident to the bathroom and as a result, the resident fell and sustained periorbital ecchymosis (discoloration of the skin) to the upper cheeks, a forehead laceration (a deep cut or tear in the skin), a nasal bridge laceration, and a right nasal bone fracture (a break in a bone). This deficiency resulted in a fall and injuries to the resident. Findings: Resident 15's clinical record was reviewed and indicated he was admitted with [DIAGNOSES REDACTED]. Resident 15's Fall Risk Assessment, dated 3/10/16, indicated he needed assistance with toileting and was at risk for falls. His therapy notes dated 3/12/16, 3/15/16, 3/23/16 at 2:20 p.m., 3/23/16 at 4:58 p.m., 3/24/16, and 3/25/16, indicated Resident 15 had impulsive behavior. Resident 15's admission Bowel and Bladder Assessment, dated 3/13/16, indicated he needed assistance when walking to the bathroom, transferring to the toilet, managing clothing, and wiping himself after using the toilet. He was confused and needed physical prompting during toilet use. He was also a candidate for a prompted voiding program, habit, toilet or bladder training. A physician order, with a start date of 3/13/16 and an end date of 3/27/16, indicated Resident 15 should have been placed on bladder and bowel training every two hours for 14 days. The hours Resident 15 was scheduled to be taken to the toilet were midnight, 2 a.m., 4 a.m., 6 a.m., 8 a.m., 10 a.m., 12 p.m., 2 p.m., 4 p.m., 6 p.m., 8 p.m., and 10 p.m. Resident 15's bowel and bladder retraining care plan, dated 3/13/16, indicated the nursing staff should take Resident 15 to the toilet and encourage voiding as much as possible. The nursing department should also instruct the certified nurse assistants (CNAs) regarding toileting schedules and documentation. The admission Minimum Data Set (MDS, an assessment tool) for Resident 15, dated 3/17/16, indicated he needed extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person physical assist during toilet use. He was not steady and could only stabilize himself with staff assistance when moving on and off the toilet. He also had both short and long term memory problems. The Occupational Therapy (OT) note, dated 3/25/16, indicated during toileting Resident 15 needed minimum assistance with pulling down his pants and minimum to moderate assistance with pulling up his pants after toilet use. The progress note, dated 3/26/16, indicated Resident 15 was found in the bathroom with his face on the floor. He had lacerations on the bridge of his nose, scalp, and forehead. He stated he got out of his bed to use the restroom and the last thing he remembered was attempting to wipe himself after using the toilet. He speculated he fell when he lost his balance. His walker (assistive device) was found in the restroom. There was no documentation indicating Resident 15 had a behavior of refusing to ask for assistance when going to the bathroom prior to the 3/26/16 fall. There was no documentation indicating Resident 15 was assisted to the bathroom during his scheduled bowel and bladder retraining on 3/26/16, at 12 p.m. The hospital notes, dated 3/26/16, indicated Resident 15 had blunt head trauma with periorbital ecchymosis to his upper cheeks, a forehead laceration of 4 centimeters (cm, unit of length), a nasal bridge laceration of 5 cm, and a right nasal bone fracture. During an observation on 4/1/16, at 8:15 a.m., Resident 15 had a bluish discoloration on his face and a row of stitches on his forehead and nasal bridge. During an observation on 4/6/16, at 7:45 a.m., a walker was at Resident 15's bedside within his reach. During an observation later the same day at 9:30 a.m., Resident 15's room was out of the line of sight from the nurses station. A male resident's room was in front of the nurses station. During an interview and a concurrent record review with the therapy director (TD), on 4/6/16, at 8 a.m., she stated Resident 15 should not have been independent when toileting. The TD stated as of 3/25/16, the OT note indicated Resident 15 needed standby assistance for pericare after toileting which meant a staff member needed to be next to him. During an interview with the director of nurses (DON), on 4/6/16, at 8:45 a.m., he confirmed the incident report for the fall indicated Resident 15 fell on [DATE], at 12:10 p.m. During a subsequent interview at 9:45 a.m., he stated Resident 15 took off his tab alarm (a pull-string attached to an alarm clipped to the resident's clothing that will alarm if the resident attempts to stand up) at the time of the fall. The DON stated it was the first time Resident 15 took off his tab alarm. The DON also stated Resident 15 was not placed in a room in front of the nurses station because the room was occupied by two other residents who were at high risk for falls. He confirmed the two other residents' fall risk assessment scores were lower than Resident 15's fall risk assessment scores. The DON stated the facility cannot just yank the two other residents out of their rooms because they were there before Resident 15 was admitted to the facility. There was no documentation of any attempt to move Resident 15 closer to the nurses station for supervision. During an interview with licensed vocational nurse L (LVN L), on 4/6/16, at 9:36 a.m., she stated she was the nurse who performed the admission Bowel and Bladder Assessment, dated 3/13/16, and the physical prompting during toilet use for Resident 15, meaning the resident needed someone to talk to him and tell him what to do during toilet use. During an interview with LVN F, on 4/6/16, at 10:15 a.m., he stated he was at the nurses station when Resident 15 fell . LVN F stated a therapist who was walking by heard Resident 15 calling from the room. He stated he rushed to the room and found Resident 15 in the bathroom with his face on the floor. He stated Resident 15 should not have been independent when going to the bathroom because he was a fall risk. During an interview with the MDS coordinator (MDSC), on 4/6/16, at 12:15 p.m., she stated Resident 15 was the only resident on the unit on a bowel and bladder retraining program. The facility's 12/2007 policy,Falls and Fall Risk, Managing, indicated the facility should identify the interventions related to the residents' specific risks and causes, based on previous evaluations and current data, try to prevent the residents from falling and try to minimize complications from falling. The facility should also prioritize approaches to managing falls and fall risks for all residents.