Every finding on record at VI at la Jolla Village

Based on observation, interview, and record review, the facility failed to obtained written consent for the use of a bed/chair sensor alarm (a device that detects movement or pressure changes to alert staff for residents at risk of falling) [Resident 51] and for the use of an antipsychotropic medication (treats mental health illnesses such psychosis and schizophrenia) [Resident 1] for two of seven residents reviewed for Resident Rights. This failure had the potential for residents and their responsible parties (RP-a designated person chosen by the resident to represent them in medical and financial decisions), to be uninformed of the risk versus the benefits, for the recommended treatment.1. Resident 51 was admitted to the facility 7/25/2025, after multiple falls at home per the facility's admission Record. Resident 51 had an RP listed on the admission Record. An observation was conducted of Resident 51 in her room on 8/25/25 at 11:06 A.M. Two staff were in the room, assisting the resident to a wheelchair. A sensor alarm was observed attached to the wheelchair. Resident 51's medical record was reviewed on 8/26/25. The physician's order contained no documentation for the use of a sensor alarm. According to the nurses note dated 8/24/25 at 10:05 A.M., Licensed Nurse 1 (LN 1) documented Resident 51's family attempted to get the resident up from bed and the sensor alarm sounded. There was no documented evidence in the electronic or paper medical record that the RP for Resident 51 had consented to the use of a sensor alarm. An Interview and record review was conducted with the Director of Nursing (DON) on 8/26/25 at 12:15 P.M. The DON stated Resident 51 had three previous falls at her assisted living facility and was admitted for a higher level of care. The DON stated Resident 51 was found to have a fracture of the left elbow and left hip, and the fractures appeared old and were believed to be caused by the previous falls. The DON stated because of the risk for falls, Resident 51 was moved to a room closer to the nurse's station and sensor alarms were implemented. The DON reviewed Resident 51's electronic medical record, along with the paper medical record. The DON stated she could not locate any documentation the RP had consented to the sensor alarm, and there should have been written consent. The DON stated there was no documentation from nursing staff that nurses were monitoring the alarm, to ensure it was working. An interview was conducted with LN 1 on 8/27/25 at 9:45 A.M. LN 1 stated before a sensor alarm could be implemented, LNs needed to ensure there was a physician's order and written consent from the resident or RP. LN 1 stated sensor alarms could be considered a restraint, so residents and families needed to understand what they were being used for and why. LN 1 stated once the sensor alarm was implemented, staff needed to monitor it to ensure it was working every shift. According to the facility's policy, titled Resident Rights, undated, .You have the right to.be informed in advance by the physician.of the risk and benefits of proposed care, of treatment and treatment alternatives.be informed, in advance of the care to be furnished. Findings: 2. A review of Resident 1's Face Sheet record indicated the resident was admitted on [DATE] with diagnoses including major depressive disorder (also known as depression). Resident 1 had physician's orders for the following psychotropic medications: -bupropion hydrochloride (HCI) tablet extended release 24 hr.(hour) (generic for Wellbutrin XL, a medication to treat depression) 150 milligram (mg) 1 tablet by mouth once a day: Special Instructions: dx:(diagnosis) depression AEB (as evidenced by) decreased motivation and self-isolation, Start date 6/30/25. -escitalopram oxalate tablet; (generic for Lexapro, a medication to treat depression) 10 milligrams (mg) 1 by mouth once a day: Special Instructions: dx: Depression AEB feeling helpless, hopelessness and disinterested, Start date 6/30/25. A review of Resident 1's EMAR (electronic medical administration record) indicated Resident 1 was administered first dose of bupropion HCI 150 mg tab and first dose of escitalopram 10 mg on 7/1/25. On 8/27/2025 11 A.M., Reviewed informed consents titled Informed Consent- Anti-Depressant Medication Therapy for bupropion and escitalopram, dated by physician on 7/3/25, no date when signed by Resident 1 or Responsible Party. On 8/27/2025 11:06 A.M., an interview and review of Resident 1's clinical record was conducted with the Director of Nursing (DON). The DON stated she was not able to provide evidence that Resident 1's informed consent for psychotropic medication was obtained earlier than 7/3/25. The DON stated informed consent needed to be obtained before starting the psychotropic medications, acknowledged they did not follow their process for Resident 1 and should have. Per facility policy titled Behavioral Management-Psychotropic/Antipsychotic Drugs, revised 10/2023, indicated . 3. Psychotropic medications are not prescribed or administered without the informed consent of the resident and/or the responsible agent.

Based on interview and record review, the facility failed to ensure non-pharmacological interventions (NPI) were done related to the use of an antidepressant (medication used to treat depression) for one of five residents (Resident 1) reviewed for unnecessary medications.This failure had the potential for Resident 1 to receive unnecessary medications, or more medication than necessary to treat depression (feelings of sadness, hopelessness, and loss of interest in activities).Findings:A review of Resident 1's Face Sheet record indicated the resident was admitted on [DATE] with diagnoses including major depressive disorder (also known as depression). A review of Resident 1's physician's orders indicated the following psychotropic medications:-bupropion hydrochloride tablet extended release 24 hr. (hour); (generic for Wellbutrin XL, a medication to treat depression) 150 milligrams (mg) 1 tablet by mouth, once a day: Special Instructions: dx:(diagnosis) depression AEB (as evidenced by) decreased motivation and self-isolation, Start date 6/30/25.-escitalopram oxalate tablet; (generic for Lexapro, a medication to treat depression) 10 milligrams (mg) 1 tablet by mouth once a day: Special Instructions: dx: Depression AEB feeling helpless, hopelessness and disinterested, Start date 6/30/25.A review of Resident 1's MAR (medication administration record) for 8/1/25-8/26/25 indicated the resident did not exhibit depression behaviors [decreased motivation and self-isolation] for bupropion and [feeling helpless, hopelessness and disinterested] for escitalopram, with no evidence of NPI implemented.A review of Resident 1's care plan for Psychotropic Drug use, dated 7/8/25, indicated .Assess for underlying cause for depressive disorder; Lifestyles: Offer and encourage resident to attend programs of choice.provide 1:1 visit, group activities, provide daily verbal reminders of activities.On 8/27/2025 at 11:06 A.M., an interview and review of Resident 1's clinical record was conducted with the Director of Nursing (DON). The DON acknowledged there were no documented evidence that non-pharmacological interventions were provided prior to use of the psychotropic medications. The DON stated Resident 1 should have orders for NPI such as encouragement to attend activities if self-isolating. The DON stated Resident 1 had a care plan for depression which included NPI's. The DON stated since there was no order from Resident 1's physician to provide NPI to the resident, NPI were not provided to Resident 1. Per facility policy titled Behavioral Management-Psychotropic/Antipsychotic Drugs, revised 10/2023, indicated .4. A resident receiving psychotropic medication is reviewed for implementation of behavior interventions to reduce/eliminate the medication usage.6. Behavioral management interventions may be utilized either as directed by a healthcare provider with prescriptive authority or as part of an interdisciplinary plan of care.

Based on observation, interview and record review, the facility failed to provide an activity program to meet the interests of one of one residents reviewed for activities (Resident 3). As a result, Resident 3 was at risk for psychosocial isolation and boredom. Findings:Resident 3 was admitted to the facility on [DATE] with diagnoses to include dementia (loss of memory, language, problem solving and other thinking abilities), per the Resident Face Sheet.An observation and interview was conducted on 8/25/25 at 9:49 A.M. with Resident 3 and his private duty caregiver (PCG 1). Resident 3 was in bed, asleep. PCG 1 stated he was with the Resident 3 five days a week to ensure he was safe and getting good care from the facility. PCG 1 stated Resident 3 was from the Memory Care unit due to his dementia, and he normally was very engaged in activities there. PCG 1 stated since Resident 3 had been on the skilled nursing unit, the Life Enrichment staff dropped off a paper with a list of activities for the day, but they usually left the paper on the bed, or with him, and did not discuss opportunities for Resident 3 to participate or discuss Resident 3's interests. Per PCG 1, He mostly just sits here. He needs engagement to keep his mind busy.An observation and interview was conducted on 8/26/25 at 11:38 A.M. with Resident 3 and PCG 1. Resident 3 was sitting on the side of the bed and did not respond to questions asked. The television was off, and no books or magazines were visible on the bedside table. PCG 1 stated the Life Enrichment staff had dropped off the paper with the days' activities, but the staff had not reviewed the offerings or encouraged Resident 3 to attend. PCG 1 stated Resident 3 liked the music programs best, although he had not gone recently. PCG 1 stated Resident 3 used to be a high-level executive at a technology company, so he liked to be busy helping people. PCG 1 stated Resident 3 liked to doodle things on paper, or help with folding or filing things. Per PCG 1, if Resident 3 went to an activity with an art project, he just sat in the back of the room and did not engage with the group unless individually provided with materials and encouraged to stay on task. PCG 1 stated, It's not worth taking him to a different floor for something that he doesn't enjoy doing. Nobody takes him, they expect the caregiver to bring him to the activity. I am willing to do that, but if he isn't going to participate in the activity, maybe they should be finding him something more appropriate to do instead. An interview was conducted on 8/26/25 at 11:15 A.M. with Lifestyle Assistant (LA) 1. LA 1 stated most of the activities were conducted on this floor of the nursing facility since more residents participated there versus on the other floors. LA 1 stated Resident 3 was well known to her, and he liked to participate in trivia, sing alongs, and travel videos. LA 1 stated if they did not have a program scheduled which Resident 3 would enjoy, the Lifestyles staff would do room visits with more appropriate activities. LA 1 stated room visits should occur several times a week if he did not attend group activities. Per LA 1, the caregivers should be bringing Resident 3 to any groups he might enjoy. LA 1 stated there was a Tuesday Trivia activity later the same day, and Resident 3 should attend as he usually enjoyed trivia. An observation and interview was conducted with Resident 3 and PCG 2 on 8/26/25 at 3 P.M. PCG 2 was walking with Resident 3 in the hallway. PCG 2 stated she was a caregiver for Resident 3 four days a week, for six hours each day. PCG 2 stated she had not been told to bring Resident 3 to the Tuesday Trivia program. PCG 2 stated it was difficult to get Resident 3 to go to another floor for activities due to his dementia, and he needed to stay busy. PCG 2 stated she was not aware the caregivers were supposed to take residents to the activity programs, and she assumed the facility staff would inform her of activities appropriate for Resident 3. An interview was conducted with Certified Nursing Assistant (CNA) 11 on 8/26/25 at 4:30 P.M. CNA 11 stated the PCGs primary responsibility was to keep the residents safe and to provide companionship. CNA 11 stated it was the facility CNA's responsibility to identify activities which might be interesting to the residents, and assist them in attending the program as needed. CNA 11 stated the PCG could also assist, but it was not their job to do so. CNA 11 stated, That's what a care plan is for. It informs facility staff of the care needs and interests of the resident. On 8/27/25, a record review was conducted. Resident 3's Brief Interview for Mental Status (BIMS) score was 0, indicating severe cognition impairment. The Activity Staff assessment of daily activity preferences was blank. Sections on education level and past occupations were blank. Preferred program frequency was listed as Daily, watches golf. Has PDA [PCG] who encourages to go to group programs. Leisure Interest checked were walking/wheeling outdoors and watching TV, music, reading and helping others were not checked. Resident 3's care plan for Activities, dated 8/1/25, indicated the facility would escort Resident 1 to activities as needed, and would inform Resident 1 of upcoming events with daily verbal reminders of the day's programs that might be of interest, including providing an escort to programs of choice. In addition, the care plan indicated Activity staff would provide materials for independent use, such as books, magazines or puzzles. The care plan indicated staff would provide one to one visits three times weekly, and monitor for level of participation in preferred activities. The Activity Participation Log was reviewed for June, July and August 2025. Room visits were checked daily, with Conversation and TV Viewing listed as the primary interventions during the room visits in June. In July, room visits were checked daily, with Visitors and TV Viewing as the primary interventions. In August, room visits were checked daily, with TV Viewing listed as the primary intervention. The Notes section for Activities team discussions was blank. An interview was conducted on 8/27/25 at 9:30 A.M. with LA 2 outside of Resident 3's room. LA 2 stated he had just dropped off the daily list of activities for Resident 3. LA 2 stated he had dropped off the papers but did not review the activities to identify programs that Resident 3 might enjoy. LA 2 stated Resident 3 liked music programs, where he sang along and appeared to enjoy himself. LA 2 stated the Lifestyles staff discussed patterns of engagement, and would document involvement or lack of involvement on the comment section of their documentation. LA 2 stated then the Lifestyles staff could discuss any changes as a team to make decisions about residents. LA 2 stated PCGs should bring residents to any activities they feel they may enjoy participating in. A concurrent interview and record review was conducted on 8/27/25 at 2 P.M. with Lifestyles Manager (LM) 1. LM 1 stated many of the group activities were conducted on the third floor since more people participated on that floor than on others. LM 1 stated the PCGs should be bringing the residents to the activities they enjoy, and the CNAs could assist them as needed. LM 1 stated the LA's should review the daily activities and use their knowledge of the residents to recommend specific activities to meet their needs. LM 1 reviewed the care plan for Resident 3 and stated, I do not see music on his Activity Log. I am aware he likes to listen to music, that should be documented, and we should make sure he attends any music programs. We should have updated the care plan after the team discussed his interests and current status. I don't remember discussing those specifics, and none of the documents include music. LM 1 stated she did not consider a check box indicating a room visit had been conducted was adequate engagement from Activities staff, and they should elaborate more in the comment section. An interview was conducted on 8/28/25 at 2:30 with the Administrator (Admin). The Admin stated she expected Activity staff to individually assess resident's interests and assist them (with the CNAs) to the activity programs. The Admin stated the goal of the activities provided was to meet the various interests of the residents. Per an undated facility policy, titled Daily Programming, It is the policy of this care center to provide an ongoing program of activities designed to meet.the interests and the physical, mental, and psychosocial well-being of each resident.The Activity Director/staff will: Identify each resident's interests and needs.Involve each resident in an ongoing program of activities that is designed to appeal to his or her interests. Per an undated facility program procedure, titled Independent Leisure Pursuits, It is the policy of this care facility to provide recreational and cognitively stimulating program.One to One Setting.Initiate the one to one discussion by explaining the topic to the resident which is relevant to the day's historical events. Offer any variety of programs per the resident's specific desires for each day.Highlight the information reviewed and each resident's contributions to the discussion. Per an undated facility policy, titled Individual & Room Visit Programs, .The in-room activity programs will directly reflect the residents' assessed individualized activity interests.Maintain a record of residents receiving room visits. Include a summary of this information into the Resident progress records.

Based on interview and record review the facility did not ensure medications were documented according to professional standards of practice for two of five Resident (8,36) sampled residents reviewed for pharmacy services when:1. Documentation of controlled medication (drugs with high abuse potential) was not documented the same time as it was administered to Resident 36.2. Controlled medication prescribed to Resident 8 could not be accounted for when a controlled medication was wasted without a second nurse signature.Findings:1. A review of Resident 36's clinical record indicated the resident was admitted on [DATE].On 8/26/25 at 11:08 A.M., an interview and review of Resident 36's clinical record with Licensed Nurse (LN) 2 was conducted. A review of Resident 36's physician order for Tramadol (controlled medication used to alleviate pain) 50 mg, take half a tablet by mouth every eight hours as needed for pain. A review of July 2025 CDR (controlled drug record, an inventory sheet that keeps record of the usage of controlled medications) and EMAR (electronic medical administration record) did not have the same administration times. LN 2 acknowledged CDR had tramadol administration for July 22,2025, time as 3:40 P.M., and documented on the EMAR at 8:25 P.M. LN 2 stated when a controlled medication was given it should be documented on the CDR and the EMAR at the same time. 2. On 8/26/25 at 11:31 A.M., an interview and review of Resident 8's clinical record was conducted with LN 2. LN 2 stated the process for controlled medication disposal are to have two nurses waste together and then they both sign off. LN 2 stated the CDR needed to have two nurse signatures, the CDR in the binder were the only place it's documented as far as she was aware. A review of July 2025 CDR for Resident 8's Tramadol 50mg tablets was reviewed with LN 2. LN 2 stated on 7/27/25, 7/28, and 7/29 the nurse did not get countersignature for the wasted 1/2 tab of tramadol and said the record was supposed to have two nurse signatures.On 8/26/25 at 2:25 P.M., an interview and review of Resident 36's and Resident 8's clinical record was conducted with the Director of Nursing (DON). The DON stated her expectation was for the nurse to sign out on MAR and CDR at the same time they administered the medication. The DON stated two nurses needed sign off all wasted controlled medications. The DON acknowledged missing witness signatures for Resident 8's tramadol on 7/27,7/28, and 7/29. The DON stated there needed to be two nurse signatures for controlled substance waste. Per facility policy and procedure titled Medication Administration, revised November 2016 indicated, .E. Charting doses administered-General Principles-(general principles apply to both paper and/or electronic MARs.1. Each dose administered to a resident shall be properly recorded in the resident's medical record.Per facility policy and procedure titled Disposal of Medication, revised 11/2016, indicated, .B. Single wasted controlled drug may be destroyed by two licensed nurses (in any combination) on count sheet or on back of med sheet.

Based on interview and record review, the facility failed to ensure one of five sampled resident (Resident 31) were free of unnecessary medications when Resident 31 received anticoagulant (blood thinner) medications without monitoring for signs and symptoms of side effects.This deficiency had the potential to cause harm due to lack of monitoring for negative side effects of anticoagulant therapy, including excessive bleeding or bruising.Findings: A review of Resident 31's admission record indicated the resident was admitted on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart muscle cannot pump blood effectively) and atrial fibrillation (A-Fib, condition where the heart beats out of rhythm).A review of Resident 31's physician's order, dated 7/30/25, for Eliquis (apixaban, an anticoagulant) 5 milligrams (mg) take 1 tablet by mouth BID (twice a day) for A-Fib.A review or Resident 31's care plan dated 8/8/25, indicated, Approach: Observe for signs of active bleeding (nosebleeds, bleeding gums.blood in urine, blood in stools, elevated temp, pain in joints, abdominal pain. On 8/27/2025 at 10:35 A.M., an interview and review of Resident 31's clinical record was conducted with the Director of Nursing (DON). The DON stated the drug (Eliquis) can increase risk of bleeding, monitoring is important to make sure there were no signs and symptoms of internal bleeding like bleeding gums, blood in stool. The DON stated monitoring for bleeding needs to be documented every shift. The DON verified monitoring for bleeding was in the care plan but there was no monitoring for signs and symptoms of bleeding for Resident 31 and there should have been. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Eliquis (apixaban), dated 4/17/25, retrieved from DailyMed, indicated, .Increased Risk of Hemorrhage [bleeding]. can cause serious, potentially fatal A review of facility policy titled Medication/Treatment Management Protocol-SN, revised October 2023, did not address high risk medication monitoring for adverse consequences.

Based on observation, interview, and record review the facility did not ensure medication storage cabinet was free from an expired medication.This failure had the potential for medication to have reduced effectiveness and/or medication misuse.Findings: On 8/25/25 at 2:44 P.M., an observation and interview was conducted with a Licensed Nurse (LN) 1 during a medication storage room tour on the third floor. An expired medication bottle labeled Sodium Chloride (salt) Tablets with an expiration date 6/2025 was stored with unexpired medications in the same cabinet. LN 1 acknowledged the medication expired on 6/2025 and should have been discarded. On 8/25/25 at 2:53 P.M., an observation and interview was conducted with Assistant Director of Nursing (ADON) during a medication storage room tour on the third floor. The ADON acknowledged Sodium Chloride bottle was expired on 6/2025. The ADON stated medication cabinet should be checked monthly for expired medications. The ADON stated she would discard the medication. The ADON stated her expectation was for all expired medication to be discarded. Per facility policy and procedures titled Medication /Treatment Management Protocol-SN revised 10/2023 did not indicate a policy for checking or discarding expired medications.

Based on observation, interview, and record review the facility failed to protect one (Resident 1) of four Residents' PHI (protected health information) when Resident 1 was sent out to the emergency room with wrong resident information and documents.As a result, HIPPA (Health Insurance Portability and Accountability Act- a U.S. federal law protecting sensitive patient health information from disclosure without the patient's consent or knowledge) was violated and allowed unconsented disclosure of another resident's PHI. Findings:Review of complaint intake indicated .[Name of SNF] sent a patient to .emergency department with the paperwork of another resident. The correct patient was Resident 1 and he arrived with another patient's chart and medical information, this patient whose chart was brought in with the wrong patient was Resident 2 .Review of facility's Face Sheet for Resident 1indicated that he was admitted on [DATE] with diagnoses that included: Metabolic Encephalopathy (a condition where brain dysfunction occurs due to issues with the body's metabolism), Heart Failure (a condition where the heart can't pump enough blood and oxygen to meet the body's needs), Chronic Kidney Disease (a condition where the kidneys are damaged and can't filter blood effectively), and Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it hard to breathe).Review of facility's Face Sheet for Resident 2 indicated he was admitted on [DATE] for diagnoses which included: Alzheimer's Disease (a progressive brain disorder that gradually impairs thinking, memory, and behavior), Dementia (a condition characterized by a progressive decline in cognitive functions, such as memory, thinking, language, judgment, and behavior), Chronic Obstructive Pulmonary Disease, Hearing Loss, and Legal Blindness (a severe visual impairment that meets specific medical criteria, as defined by law).On 8/12/25 at 9:50 A.M., a concurrent interview with the Director of Nursing (DON) and record review of Progress Note by a Licensed Nurse (LN 1) was conducted. Record review indicated, .Resident (1) was sent out at around 03:55 [A.M.] via 911 to [Name of Hospital].wife notified at 04:20 [A.M.]., MD informed and made aware via text message about Resident 1's recent fall. The DON stated there was no documentation that LN 1 verified the identity of the resident and the documents given to the paramedics, or that a report was given to paramedics prior to discharge.On 8/12/25 at 10:15 A.M., an interview was conducted with LN 2. LN 2 stated that her process for sending an emergent resident to the ER were as follows, .Call physician to get a telephone order if resident is stable, if unstable then call 911. Print out paper work including CCD (a list of essential information used when discharging resident), medication list, and recent vital signs (resident's temperature, pulse respiration). When giving report to paramedics, make sure it is the correct resident by checking resident's identity (ID) band against the paperwork with paramedic.If the resident is alert, ask the resident their name. LN 2 stated that if paperwork of another resident was sent in error, she would call hospital and tell them that she sent the wrong paperwork, and would ask them to shred the incorrect paperwork, and then fax them the correct documents. LN 2 stated she would report to the physician, the DON, and the family that there may have been a HIPAA violation for the incorrect resident.On 8/12/25 at 10:30 A.M., an interview with LN 3 was conducted. LN 3 stated that her process for sending a resident to the ER were as follows: .Call physician to let them know resident needs to go to the emergency room, get a telephone order. If the resident is unstable, call 911. Print out paperwork to go with the resident including face sheet, POLST (Physician Orders for Life-Sustaining Treatment-medical order form that documents a patient's preferences for end-of-life care), recent labs, and notice of transfer forms. When giving the report to paramedics she would double-check if it was the the right resident by looking at the resident's ID band or picture in computer, or ask their name if the resident was alert. After the resident's identity was verified, she would review paperwork with paramedics. LN 3 stated that if paperwork of another resident was sent in error, she would call hospital and tell them that she sent the wrong paperwork, and ask the hospital to shred the paperwork. LN 3 stated she would fax them the correct paperwork. LN 3 stated she would report to her supervisors, the administrator (ADM), and inform the family of the resident whose information was mistakenly sent, to let them know that there may have been a HIPPA violation.On 8/12/25 at 11:15 A.M. a concurrent interview with the DON and record review of two other residents (3 and 4) who were transferred to the hospital was conducted. The DON stated there was no documentation that Resident 3's identity was verified, and transfer documentation was reviewed with paramedics. The DON stated there was no documentation that Resident 4's identity was verified and transfer documentation reviewed with paramedics. The DON stated the expectation was that the nurse should check the identity of the resident being discharged while giving report to the paramedics. The DON stated two acceptable ways to check the resident's identity were: by observing their ID band or asking their name if they are alert. The DON stated the importance of checking a resident's identity is to ensure that the resident is the correct resident and their paperwork is the correct paperwork to ensure the right plan of care for the resident.On 8/12/25 at 11:30 A.M., an interview was conducted with Resident 2. Resident 2 was alert and oriented x 1-2, but hard of hearing. Resident 2 was observed in his wheelchair watching tv. Resident 2 stated that he had been told this morning by the DON, that his information was sent to the hospital with another resident on 7/13/25. Resident 1 stated the DON told him about it this morning. The DON stated that she called Resident 2's son prior to interview but could only leave a message.On 8/12/25 at 12 P.M., a phone interview was conducted with LN 1. LN 1 stated that Resident 1 was sent to the emergency room after a fall. LN 1 stated she had an orientee with her, and the orientee printed the necessary paperwork including Face sheet, history and physical, CCD, and vital signs. LN 1 stated when the paramedics came, she gave them a report. LN 1 stated that Resident 1 was alert so they asked him his name to confirm his identity. LN 1 stated the mistake she made was not reviewing the paperwork with the paramedics. LN 1 stated she handed the paperwork to the paramedics, and they left. LN 1 stated the ER called when they arrived because of the mistaken paperwork. LN 1 stated that she faxed the correct paperwork to the emergency room but never reported it to her supervisors. LN 1 stated the expectation was she should have verified the identity of the resident by looking at the resident's wrist band or asking them their name while reviewing the paperwork with the paramedics. LN 1 stated she should have reported to her supervisors that there was a possible HIPPA violation. LN 1 stated she should have also called the family of Resident 2 to inform them of the possible breach of their family member's PHI.Review of the undated facility policy and procedure titled HIPAA Notice of Privacy Practices indicated .We are required by federal and state laws to maintain the privacy of your PHI (protected health information).We will obtain a written authorization from you before we use or disclose your PHI.We may use or disclose your PHI to provide you with or assist in your treatment, care, and services.We may also disclose your PHI to individuals who will be involved in your care if you leave the community.We will provide you with written notification (either mail or email) in the event of a security breach involving your PHI. The notification will describe what happened, the types of information involved, the steps that we are taking to deal with the situation, what you should do to protect yourself against any harmful consequences, and contacts for obtaining further information.

Based on interview and record review, the facility failed to administer medications to the correct resident for one of two sampled residents (1). This failure placed Resident 1 at an increased risk of low blood pressure. Findings: Per the facility's Resident Face Sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses to include heart failure, atrial fibrillation (abnormal heart rhythm). On 5/7/25 at 9:40 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, on 4/25/25 Licensed Nurse (LN) 2 administered propranolol (a medication to treat heart problems and high blood pressure) and losartan (a medication to treat high blood pressure) to the wrong resident (Resident 1). The DON further stated, the error occurred because LN 2 thought Resident 1 was a different resident, and gave him the other resident's medications by mistake. LN 2 was not available for interview. Per the facility's Physician Order Report, dated 5/7/25, Resident 1 did not have any orders for propranolol or losartan. Per the facility's Resident Progress Notes, there was a note on 4/25/25 at 5:31 P.M., by LN 2, which indicated that LN 2 realized she gave Resident 1 the wrong medication when she gave him losartan and propranolol. The note further indicated that Resident 1's blood pressure at the time of administration was 92/55 (a low blood pressure reading). A review of the facility's policy and procedure, revised October 2023, was conducted. The policy indicated, . Administration of Medications/Treatments . 4. The resident's identity is confirmed prior to administering the medications/treatments .

Based on interview and record review, the facility failed to report an allegation of neglect (a type of abuse that involves failing to provide care and services to a resident) for one of one resident (Resident 1) within the 24-hour timeframe to the State Survey Agency (SA, where the state law provides for jurisdiction in long term care facilities) of the reported incident. This failure resulted in the delay of facility's abuse investigation and potentially expose Resident 1 and other residents for further neglect. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of multiple fractures (broken bones) of the pelvis (a bone that connects the upper body to the lower body) and dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) per facility's admission record. On 10/5/23 at 1:52 P.M., an interview was conducted with the Administrator (ADMIN). The ADMIN stated two certified nursing assistant students (SCNA 1 and SCNA 2) reported witnessing the neglect of Resident 1 by certified nursing assistant (CNA 1) on 9/25/23. On 10/5/23 at 2:07 P.M., an interview was conducted with SCNA 1. SCNA 1 stated she and SCNA 2 began shadowing CNA 1 during the morning shift on 9/25/23 at 8:00 A.M. SCNA 1 stated CNA 1 was assigned to care for Resident 1. SCNA 1 stated Resident 1 was incontinent (inability to control the expression of urine and feces from the body). SCNA 1 stated CNA 1 did not check Resident 1's brief (adult diaper) until 2:00 P.M. SCNA 1 stated she observed blood on the leg openings of the brief. SCNA 1 stated the brief contained urine, and a mixture of dry and fresh bowel movement. SCNA 1 stated Resident 1 started to cry when CNA 1 started to clean Resident 1's groin with a wipe. On 10/5/23 at 2:20 P.M., an interview was conducted with SCNA 2. SCNA 2 stated on 9/25/23 at 2:00 P.M. was the first time CNA 1 assessed and changed Resident 1's brief during the morning shift. SCNA 2 stated Resident 1 started to cry and make noises when he was being cleaned. SCNA 2 stated CNA 1 started to mimic (copy or impersonate) Resident 1's crying in front of SCNA 1, SCNA 2 and Resident 1. SCNA 2 stated she and SCNA 1 notified their clinical instructor (CI) immediately following the incident at 2:30 P.M. on 9/25/23. On 10/5/23 at 3:34 P.M., an interview was conducted with the director of nursing (DON). The DON stated the CI informed them of the SCNA's report on the morning of 9/26/23. The DON stated the abuse allegation was not reported to the SA and local law enforcement within the required 24 hour time period. A review of Resident 1's progress note, dated 9/29/23 at 6:15 P.M., indicated a report was made to the SA on 9/29/23, three days after the incident happened. A review of the facility's fax of the Report of Suspected Dependent Adult/Elder Abuse form regarding Resident 1's allegation to the State Survey Agency and the Ombudsman (advocate for residents in long term care facilities) was completed on 9/29/23, and faxed on 9/29/23 at 5:02 P.M. A review of the facility policy titled, Elder Abuse Protocol, Reporting Suspected, revised December 2017, indicated, Purpose: this protocol outlines the process for reporting suspected elder abuse in care venues . Reporting Responsibilities . 2. The state required report is submitted within required reporting guidelines to the responsible state agency .

Based on observation, interview, and record review, the facility failed to ensure resident-centered care plans were developed for six residents when: 1. Four residents had symptoms of vomiting and/or diarrhea (Resident 2, Resident 3, Resident 4 and Resident 5); 2. Two residents had fall incidents (Resident 1 and Resident 6); 3. A resident ' s bladder incontinence was not addressed (Resident 1) These failures could potentially affect these residents in the care areas that were not care planned. These included proper attention and assessment for dehydration and infection control for Resident 2, Resident 3, Resident 4 and Resident 5; avoiding further falls for Resident 6; preventing injury from further falls for Resident 1; and interventions to address bladder incontinence for Resident 1. Findings: 1. Resident 2 was readmitted to the facility on [DATE] with the diagnoses including diabetes mellitus (too much sugar circulating in the blood) with diabetic kidney disease (a complication of diabetes causing damage to kidneys) according to the facility ' s Resident Face Sheet. An interview was conducted with CNA 3 on 9/21/23, at 11:25 A.M. CNA 3 stated Resident 2 had a cart outside the room with personal protective equipment (PPE- medical supplies to maintain infection control) for protection. CNA 3 stated Resident 2 had gastrointestinal (GI-stomach and intestine) problems. CNA 3 stated a gown, gloves and face mask were needed upon entering Resident 2 ' s room because Resident 2 could be contagious. During an interview and concurrent record review on 9/21/23, at 12:07 P.M. with LN 2, LN 2 stated Resident 2 had projectile (sudden and forceful) vomiting on 9/18/23 and 9/19/23. Upon review of Resident 2 ' s care plan, LN 2 stated there was no care plan regarding Resident 2 ' s vomiting. Resident 3 was admitted to the facility on [DATE] with diagnoses including unspecified protein-calorie malnutrition (reduced nutrients in the body) according to the facility ' s Resident Face Sheet. During an interview and concurrent record review on 9/21/23, at 12:17 P.M. with LN 2, LN 2 stated Resident 3 ' s wife reported that Resident 3 had vomiting on 9/18/23. Upon review of Resident 3 ' s care plan, LN 2 stated there was no care plan regarding Resident 3 ' s vomiting. Resident 4 was admitted to the facility on [DATE] with the diagnoses including dysphagia (difficulty in swallowing) following nontraumatic intracerebral hemorrhage (bleeding inside the brain) according to the facility ' s Resident Face Sheet. During an interview and concurrent record review on 9/21/23, at 12:24 P.M. with LN 2, LN 2 stated Resident 4 had vomiting on 9/18/23 and three episodes of loose bowel movement on 9/19/23. Upon review of Resident 4 ' s care plan, LN 2 stated there was no care plan regarding Resident 4 ' s vomiting and loose bowel movements. Resident 5 was admitted to the facility on [DATE] with the diagnoses including unspecified protein-calorie malnutrition (reduced nutrients in the body) according to the facility ' s Resident Face Sheet. During an interview and concurrent record review on 9/21/23, at 12:07 P.M. with LN 2, LN 2 stated Resident 5 had diarrhea (loose, watery stools) twice on 9/19/23. Upon review of Resident 5 ' s care plan, LN 2 stated there was no care plan regarding Resident 5 ' s diarrhea. LN 2 stated care planning residents ' conditions were important because it was the specific care and intended goal for the resident. LN 2 further stated residents with vomiting and diarrhea were at risk for fluid imbalance, malnutrition, and dehydration. 2. Resident 1 was admitted to the facility on [DATE] with the diagnoses including fracture of right ischium (lower and back sides of the hip bone) and history of falling according to the facility ' s Resident Face Sheet. During a review of Resident 1 ' s progress notes (PN) dated 9/10/23, the PN indicated Resident 1 was found sitting on the floor next to his bed. The PN indicated Resident 1 stated he slipped off the bed as he tried to get up. Upon review of Resident 1 ' s care plan, there was no care plan regarding Resident 1 ' s fall incident on 9/10/23. Resident 6 was readmitted to the facility on [DATE] with the diagnoses including nondisplaced fracture (bone cracks or breaks retaining proper alignment) of right clavicle (collar bone) and repeated falls according to the facility ' s Resident Face Sheet. An interview and concurrent record review was conducted with LN 3 on 9/21/23, at 1:42 P.M. During a review of Resident 6 ' s clinical record titled, Event-Falls, dated 8/10/23, LN 3 stated Resident 6 fell in the room, attempting to toilet herself. LN 3 further stated Resident 6 ' s progress notes dated 8/19/23 at 1:06 A.M., indicated Resident 6 had an unwitnessed fall and was found lying on the right side on the floor. Upon review of Resident 6 ' s care plans, LN 3 stated there were no care plans addressing the fall incidents on 8/10/23 and 8/19/23. LN 3 stated there should be a care plan with new interventions for residents who fall, especially if the resident had frequent fall incidents. 3. During an interview and concurrent record review on 9/21/23, at 10:39 A.M. with the Minimum Data Set (MDS- tool that measures health status of residents) nurse, the MDS nurse stated section H of the MDS indicated Resident 1 was occasionally incontinent of bladder (loss of bladder control). The MDS nurse stated if a resident was triggered for incontinence, she would add an intervention in the care plan. The MDS nurse stated if there was no incontinent care plan, she would create a care plan after interviewing the resident to identify the usual time he or she used the bathroom. The MDS nurse further stated interventions such as toileting before meals, after meals, before bedtime, upon rising and offering toileting at night if awake. The MDS nurse stated Resident 1 was taking a diuretic (water pills) and needed prompting to use the bathroom. The MDS nurse stated there was no care plan for Resident 1 to address the urinary incontinence and if these interventions were created it may have prevented Resident 1 from falling. During a review of the facility ' s policy and procedure (P&P) titled, Care Plan Protocol, dated November 2011, the P&P indicated, .A care plan is started upon initiation of service by the Registered Nurse (RN), with continuing evaluation and service modifications based on the patient ' s needs .The patient ' s health needs, plans and goals are considered by the coordinating nurse on an ongoing basis . A review of the facility ' s P&P titled, Incontinence Management (UIM) Protocol, Urinary, dated October 2017 was conducted. The P&P indicated, .UI (urinary incontinence) may be associated with changes in skin integrity .urinary tract infections (UTI), falls and fractures .UI requires that a resident who is bladder incontinent receives appropriate treatment and services to prevent UTIs and to restore as much normal bladder function as possible .

Based on interview and record review, the facility failed to provide the needed care for one of three residents (Resident 46) when Resident 46's thoracentesis (procedure to drain fluid out of the lungs) incision site was not monitored. This failure had the potential for nursing staff to not identify any deterioration on Resident 46's incision site which could result in delay of treatment. Findings: A review of Resident 46's face sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD, kidney failure), congestive heart failure (CHF, failure of the heart to pump blood). A review of Resident 46's physician order dated 8/17/23, indicated, Resident 46 had a thoracentesis on 8/28/23 at 12:40 P.M. A concurrent interview and record review were conducted with licensed nurse (LN 12) on 9/1/23 at 3:45 P.M. LN 12 stated there was no documentation Resident 46's thoracentesis incision site was assessed and monitored. LN 12 further stated Resident 46's thoracentesis site should have been observed for change in condition every shift. An interview conducted with the director of nursing (DON) on 9/1/23 at 3:55 P.M. The DON stated nursing staff should monitor incision sites and document the monitoring to ensure the resident was receiving the care appropriately. Review of the facility's policy titled Resident Care - Documentation dated 10/2022 indicated, . Skin integrity events are documented in the event and in the MatrixCare Wound Management Module, until healed.

Based on observation, interview and record review, the facility failed to ensure that 1 of 29 medication opportunities was administered per standard of practice when Resident 11's Lidocaine patch (medication for pain) was administered without date and time. Findings: A review of Resident 11's History and Physical dated 7/20/2023 indicated, Resident 11 was admitted to the facility for diagnosis that included Syncope (fainting), back pain and sciatica (pain, tingling in the leg), and hand osteoarthritis (degeneration of joint cartilage). On 09/01/23 at 9:09 A.M., an observation was conducted during Licensed Nurse (LN) 1's medication pass with Resident 11. Resident 11 was administered with a Lidocaine Patch 4%. The lidocaine patch was cut into half and was placed on his left wrist and right wrist, and both patches did not have date and time. A review of Physician 1's order indicated Lidocaine [OTC] adhesive patch, medicated; 4%; amt (amount): 1 patch; topical .back pain . on in AM off in PM . On 9/1/2023 at 9:30 A.M., an interview was conducted with LN 1. LN stated Resident 11 refused to have the Lidocaine patch on his back and requested to have it cut into half and placed on his bilateral wrist. LN 1 stated she called Physician 1 and obtained the order for Lidocaine patch to be applied on Resident 11's bilateral wrist. LN 1 stated she entered the medication order and forgot to put the date and time on the lidocaine patch. LN 1 further stated, it was important to put the date and time to indicate when it was administered in order for the next shift nurse to know when it should be removed. On 9/1/2023 at 10:35 A.M., an interview was conducted with the Director of Nursing (DON). Per DON, the transdermal patch should have a date and time. A review of facility's policy titled Medication/Treatment Management Protocol last revised December 2017 did not indicate specific guidelines on Lidocaine Transdermal patch.

Based on observation, interview and record review, the facility failed to ensure proper storage of medications were followed when: 1. 1 of 2 medication rooms (Medication Room # 1) stored 2 expired residents' medications. 2. 1 of 12 sampled residents (Resident 155) had an unattended medication in Resident 155's bedside table. As a result, using expired medications had the potential to affect the medications' action and effectivity. In addition, leaving medications unattended could result in other residents ingesting another resident's medications which could affect the resident's health and safety. Findings: On 8/31/23 at 4:06 P.M., a concurrent observation and interview were conducted in the Second Floor Medication Room (Medication Room # 1) with Licensed Nurse (LN) 2. In the refrigerator, a compounded medication Pantoprazole (medication that reduces the amount of acid your stomach makes) 2MG/ML 400ML SUSP with expiration date of 8/29/2023 was observed. LN 2 stated Pantoprazole medication had an expiration date of 8/29/2023 and was considered expired. In the medication storage closet, Lactulose Solution (medication for constipation), USP 10g/15 mL with expiration date of 6/2023 was observed. LN 2 stated, the Lactulose Solution had an expiration date of 6/2023, and was considered an expired medication. On 9/1/2023 at 10:35 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was everyone's responsibility including myself to ensure that there were no expired medications stored in the medication room. The DON stated expired medications should be discarded per policy. On 9/1/2023 at 2:23 P.M., an interview was conducted with Pharmacy Consultant (PC). Per PC, she would inspect the medication rooms and perform spot check for expired medications. The PC stated it was important to make sure that expired medications were not stored in the medication room to prevent potential administration to residents. Per PC, expired medications have less active medication ingredients. The PC further stated it was important for residents to be administered with unexpired medication to receive the medication's active ingredients. A review of facility's policy and procedure titled Medication/Management Protocol - SN, revised December 2017, was conducted. The policy did not provide guidance regarding the process for expired medications. 45909 2. Review of Resident 155's medication order dated 8/19/23, indicated, Resident 155 was to receive methenamine mandelate (generic name of a drug) 1 gram (gm, unit of measurement) 1 tablet; oral diagnosis: urinary tract infection (UTI, bladder infection) prevention, twice a day; 9:00 A.M.; 5:00 P.M. During a concurrent observation and interview with Resident 155 on 8/29/23 at 10:37 A.M. inside Resident 155's room. A pink pill was observed inside a medicine cup laying on top of Resident 155's bedside table. Resident 155 stated, the licensed nurse left the mediation for her to take to prevent UTI. Resident 155 further stated she will take the medication whenever she wanted to. A follow up observation and interview were conducted with licensed nurse (LN 2) on 8/29/23 at 11:54 A.M. inside Resident 155's room. LN 2 stated the pink pill was Resident 155's medication for UTI prevention. LN 2 further stated, she should have waited for Resident 155 to take the medication by mouth before leaving the room to ensure the resident had the right dose, the right medication at the right time. On 9/1/23 at 3:45 P.M., an interview was conducted with the director of nursing (DON). The DON stated when LNs administer medications, LNs should stay with the resident to ensure the right mediation, the right dose, the right route, and the right time were observed. Review of facility's policy on Medication/Treatment Management Protocol dated 12/2017, indicated . Confirming the resident is taking the medication as directed. Observing the resident while the medication is taken.

Based on observation, interview and record review the facility failed to ensure the facility's policy and procedure for infection control were implemented for 2 of 12 residents (Resident 10 and Resident 46) when: 1. Resident 10's breakfast meal tray, that had been placed on the resident's bedside table, was brought back to kitchen and meal items were re-stored back in respective storage (food warmer and refrigerator). 2.Resident 46's used nasal cannula (tubing to deliver oxygen) was not stored in a bag. These failures could result in the spread of infection and cross contamination that could affect the 48 residents in the facility, the facility staff, as well as the visitors. Findings: 1. A review of Resident 10's undated Facesheet indicated that Resident 10 was admitted on [DATE] for diagnoses that included hypertension (high blood pressure), visual hallucination (seeing non-existent objects), and anxiety (feeling of fear). On 8/30/2023 at 8 A.M., an observation was conducted in Resident 10's room with Certified Nursing Assistant (CNA) 1. CNA 1 brought to Resident 10's room the breakfast meal tray and placed it on Resident 10's bedside table. Resident 10 was observed lying in bed with eyes closed and refused to eat breakfast. On 8/30/2023 at 8:07 A.M., an observation was conducted with CNA 1 and Server 1. CNA 1 brought Resident 10's breakfast meal tray from Resident 10's room to the 2nd floor's satellite kitchen. Server 1 received Resident 10's breakfast meal tray from CNA 1, brought the breakfast meal tray inside the kitchen, placed the tray on a silver table, then placed the content of the meal tray on their respective areas in the kitchen. Server 1 placed the cold beverage inside the refrigerator and placed the plate of food inside the food warmer. On 8/30/2023 at 8:12 A.M., an interview was conducted with Server 1. Per Server 1, CNA 1 brought back to the kitchen Resident 10's breakfast meal tray to keep warm food warm, and cold items cold to be served later. Server 1 further stated the food from the breakfast tray will be re-served later when Resident 10 is ready to eat breakfast. Server 1 was not aware that the breakfast meal tray has been placed on the bedside table of Resident 10. Per Server 1, the process was to discard the food that entered the resident room. On 8/30/2023 at 8:27 A.M., an interview was conducted with CNA 1. CNA 1 stated, Resident 10 was not ready to eat breakfast. CNA 1 stated, I brought Resident 10's breakfast meal tray back to the kitchen to keep it warm. CNA 1 stated the food will be re-served when Resident 10 was ready to eat breakfast. CNA 1 further stated Resident 10's breakfast meal tray has entered the resident room, and should not be placed back in the food cart with other clean breakfast meal trays. On 8/30/2023 at 10:18 A.M., an interview was conducted with Infection Preventionist (IP). The IP stated, anything that touched the surface of the resident room was considered contaminated and should not enter the clean area of the kitchen. On 8/31/2023 at 11:32 P.M., an interview was conducted with Dining Supervisor (DS). The DS stated meal tray that entered the resident's room or touched anything in the resident's room should not be brought back to the kitchen to be warmed. Per DS, meal trays from resident room were considered contaminated and should not re-enter the kitchen to prevent the spread of infection or the contamination. DS further stated, we have a process that indicated food tray that entered the patient's room and touched the patient's surface area should not re-enter the kitchen. On 8/31/2023 at 3:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated food tray or anything that comes in the resident's room and touched the resident room's surface should not be brought back to the kitchen. Per the DON, anything that touched any surface of a resident's room could potentially contaminate food in the kitchen. The importance was to prevent the spread of contamination and infection. A review of the facility's undated process titled Tray delivered to resident rooms but refused/held for later service indicated 3. If tray is deposited bedside and touches any surface in the resident's room or has entered the room, tray may not be brought back to the pantry. 4. Notify Dietary Staff if tray has been brought to the room and request for a new tray. 45909 2. During an observation of Resident 46 on 8/29/23 at 9:26 A.M., Resident 46's nasal cannula was observed wrapped around his portable oxygen on his wheelchair. A concurrent observation and interview were conducted with licensed nurse (LN 2) on 8/30/23 at 9:01 A.M. inside Resident 46's room. Resident 46's nasal cannula was wrapped around his portable oxygen on his wheelchair. LN 2 stated Resident 46 used the nasal cannula while he was in the hallway. LN 2 further stated the used nasal cannula should have been stored inside a clean bag to prevent cross contamination. During an interview with the Infection Preventionist (IP) on 8/31/23 at 3:15 P.M., the IP stated used nasal cannula should be placed inside a clean transparent bag to prevent exposure of the nasal cannula from contamination. Review of the facility's policy, Respiratory Therapy - Infection Control dated 12/2017 indicated, Keep oxygen cannula and tubing in a plastic bag when not in use.

Based on interview and record review, the facility failed to ensure mandatory annual abuse training was completed for one of one certified nursing assistants (CNA 5), reviewed for abuse. This failure had the potential to place residents at risk for abuse and potential psychosocial harm. Findings: On 4/8/21, an unannounced visit was conducted in response to an allegation of staff to resident abuse, which took place on 3/25/21. On 4/8/21, a record review was conducted of CNA 5's employee file and annual training. CNA 5 was hired on 5/31/17. CNA 5's last abuse training, titled Elder Justice Act Policy and Reporting Procedures, was completed on 2/27/20. On 4/8/21 at 1:15 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON reviewed documentation of CNA 5's training since hire. The DON stated CNA 5's last abuse training was the end of February 2020, which was over a year ago. The DON stated staff get a computer generated reminder when their annual training was due. The DON stated the Director of Staff Development (DSD) was responsible for ensuring all mandatory training was completed. The DON stated CNA 5's mandatory abuse training was overlooked. The DSD was unavailable for an interview. On 4/8/21 at 1:29 A.M., an interview was conducted with CNA 6. CNA 6 stated abuse training was required every year and was mandatory. CNA 6 stated abuse training was important as a reminder to recognize signs of abuse and the reporting requirements. On 4/8/21 at 1:50 P.M., an interview was conducted with the Administrator (ADM). The ADM stated abuse was part of every employee's annual learning plan. The ADM stated there was no evidence CNA 5 completed her abuse training requirements for 2021. According to the facility's policy, titled Abuse/Neglect Prevention Protocol, dated March 2018, .Orientation and Training of Employees: 1. Consistent with the training requirements outlined in 42 CFR 483.95, new and existing staff .are all trained on an annual basis . Dementia management and resident abuse prevention .

Based on interview, and record review, the facility failed to develop written care plans for three residents (1, 2 and 3), who had a potentially infectious episode of vomiting and diarrhea. This failure had the potential to negatively impact the care of the residents. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Face Sheet. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Face Sheet. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/7/20 at 10:10 [NAME]M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the original onset of nausea, vomiting and diarrhea occurred in the facility on 12/20/19. The ADON stated Resident 1, 2 and 3 were affected. Isolation precautions were implemented. Resident 1, 2 and 3's symptoms subsided within 48 hours. On 1/8/20 at 1:20 P.M., a record review was conducted with the Director of Nursing (DON). The DON could not locate written care plans that included the 12/20/19 change of condition for Residents 1, 2, and 3. On 1/8/20 at 1:45 P.M., an interview was conducted with the ADON. The ADON stated she had not developed written care plans for the episode of diarrhea and vomiting for Residents 1, 2 and 3. The ADON stated it was important to write a care plan for a change of condition because it guided staff to provide the correct care for residents. The facility's policy titled Care Plans, dated , includes, . The facility did not provide a policy on the Development and Implementation of a Comprehensive Care Plan.

Based on interview and record review the facility failed to consistently use the pain scale when assessing resident pain. The facility also failed to ensure pain medication was administered based on the resident's pain assessment. As a result, residents pain may not have been well controlled. Findings: 1. On 11/5/19 at 10:24 [NAME]M. Resident 18 complained of pain, she said she wanted her pain pill. The medication nurse, RN 1 was outside her room and stated Resident 18 received her pain pill an hour ago, and she was about to go in to reassess Resident 18's pain. RN 1 stated Resident 18 was confused. On 11/8/19 at 11:21 [NAME]M. Resident 18 clinical record was reviewed. Resident 18's MAR for the 11/5/18, related to morning dose of [MEDICATION NAME] (narcotic pain medication) had RN 1's initials, instead of Resident 18's numerical assessment of pain, for both the pre and post administration pain assessment. According to Resident 18's clinical record, Resident 18 had a physician's order dated 3/8/19 for [MEDICATION NAME], 325 mg, 2 tablets, by mouth every 6 hours as needed for mild (1-3/10) pain. On 10/27/19, and 10/29/19, Resident 18 complained and was assessed for 10/10 pain. On 10/31/19, Resident 18 complained and was assessed for 8/10 pain. On all 3 occasions Resident 18 was medicated with the [MEDICATION NAME] for mild pain. 2. Resident 28's clinical record was reviewed on 11/7/19. Resident 28 was being assessed for pain every shift. The MAR for (MONTH) 26th to (MONTH) 8th, indicated Resident 28's pain was X, every day every shift with the exception of the evening and night shift 11/7/19, Resident 28's pain was assessed as 0. Resident 28 had a physician's order dated 10/17/19, for [MEDICATION NAME] (narcotic-like pain reliever) 50 mg, 1 tablet, once a day, as needed for pain. On 10/28/19 at 12:34 [NAME]M., Resident 28 received a dose for generalized pain. The pre and post pain assessment documentation on the MAR indicated [REDACTED] The DON was interviewed on 11/7/19 at 8:37 [NAME]M. The DON stated there was no physician's order for pain medication for severe pain of 7-10. She was not comfortable getting narcotic pain MEDICATION ORDERS FOR [REDACTED]. The facility provided their Pain Management Protocol, last revised (MONTH) (YEAR). Ongoing Pain Assessments Pain Evaluation Every Shift for [DIAGNOSES REDACTED]. 2. The asking of the question is documented on the eMAR (electronic medication administration record) and the pain lever=l is documented. 2.1. If the level is zero, the question will continue to be asked every shift. 2.2. If the resident has a pain score of one or greater, a MatrixCare CDS Focused Observation for pain or Pain AD assessment will be initiated and pain management interventions carried out as per protocol. Acute Pain/Anticipatory Pain 1. For residents experiencing acute pain (e.g., post-procedure, post-surgery, post-fall) reassessments are completed before each dose of [MEDICATION NAME] is administered and at least 1 hour after it is administered. This continues for as long as the acute pain exists and is being treated Pain Rating Scale Utilization 1. During the pain assessment process utilize the most appropriate tool for the resident, incorporating cognitive status as well as resident preference in deciding which scale to use. 2. The scale that is to be used with the resident should be documented on the residents care plan so all staff can utilize the same scale. 2.1. Pain Scales available for use on the medication care are the: Wong-Baker FACES Pain Rating Scale; Pain Numeric Rating Scale; and Verbal Descriptor Scale.

Based on observation, interview, and record review, the facility failed to fully implement their abuse/neglect prevention protocol when an employee accused of mistreatment towards Resident 1, was not removed from all resident contact while the facility did their investigation. This failure had the potential to put other residents at risk for mistreatment. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses, which included fracture of right femur (broken hip), unsteadiness on feet, muscle weakness, and history of falling per the facility's Resident Face Sheet. During an interview with the administrator (admin) on 3/22/19 at 12:45 P.M., the admin stated Resident 1 reported CNA 2 had taken her to the bathroom on the evening of 3/16/19 and did not return to assist the resident from the bathroom. The admin stated their investigation found that the CNA had forgotten to return to the resident and had gone on his lunch break. The admin further stated the CNA was no longer employed at the facility. According to a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 3/9/19, the resident's Brief Interview for Mental Status indicated a score of 15 (on a scale of 0-15, with 15 being the most cognitively intact). During an interview with Resident 1 on 3/22/19 at 1:03 P.M., the resident stated certified nursing assistant (CNA) 2 helped her up to the bathroom in the evening on 3/16/19, and told her he would be back but did not return. Resident 1 stated, I waited so long, I got myself onto the wheelchair, thinking I would see him go by. The resident stated someone heard her calling and helped her out of the bathroom. The resident stated, It made me anxious because I was stuck in there. It's terrible when you can't help yourself. During an interview on 3/22/19 at 1:19 P.M., licensed nurse (LN) 3 stated she had just returned from her lunch break when she found Resident 1 yelling, which was out of character from her previous pleasant demeanor. Resident 1 reported to LN 3 that CNA 2 had taken her to the bathroom and left her there for about 20 minutes. The resident was upset and concerned about being left and stuck in the bathroom. During an interview on 3/22/19 at 1:37 P.M., CNA 4 stated Resident 1 could stand by herself and was independent in most activities of daily living, but needed assistance to and from the bathroom. CNA 4 stated when she assisted Resident 1 she would wait outside the door of the bathroom until the resident was ready for assistance. CNA 4 stated sometimes she might leave the room briefly, but always returned within five minutes or less. CNA 4 stated when she had a lunch break she always reported to other CNAs to cover for her residents while she was on her break. During a telephone interview with CNA 5 on 3/22/19 at 3:24 P.M., CNA 5 stated on 3/16/19 she was watching over the dining room when she heard Resident 1 calling for help. She went to the room and saw Resident 1 in her wheelchair halfway out of the bathroom doorway. CNA 5 stated Resident 1 had desperation in her voice when she was calling for help. CNA 5 stated the resident told her the CNA got her into the bathroom and was going to come back but he never did. CNA 5 stated she got Resident 1 settled into bed and returned to her assignment in the dining room. CNA 5 stated once she was done in the dining room she reported the incident to the LN. CNA 5 could not recall to which LN she reported the incident. During a telephone interview with LN 3 on 6/12/19 at 5:45 P.M., LN 3 stated CNA 2 was not sent home on 3/16/19 after the incident, but was moved to work with residents in a different hallway. During a telephone interview with the DON on 6/20/19 at 11:50 [NAME]M., the DON stated CNA 2 should have been suspended when the allegation was made on 3/16/19. The DON stated it was their policy to send the CNA home until the investigation was completed. The DON further stated they would not know all the details until an allegation was investigated and they did not want anyone interacting with residents until it was confirmed that the allegation did not occur. According to a review of the facility's policy titled, Abuse/Neglect Prevention Protocol, dated 6/11, .Protection of Residents: .4. Employees of the community who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the Administrator or designee. Employees accused of possible mistreatment shall not complete the shift and will be placed on suspension until the investigation is complete .

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS - an assessment tool) assessments were correctly coded for two of 12 sampled residents (7 and 8). Inaccurate coding of the MDS had the potential to affect the care provided to these residents. Findings: 1. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Face Sheet. On 10/12/17 at 9:15 A.M., Resident 7 was observed sitting up in his wheelchair in the activity room watching TV. At 2:42 P.M., the resident was lying in bed under the covers with his eyes closed and his mouth open. A review of Resident 7's physician orders, dated 8/10/17, indicated the resident was to be admitted to hospice. A review of Resident 7's MDS assessment, dated 8/17/17 was conducted. In this assessment, Section J: Health Conditions, indicated Resident 7 had a life expectancy less than 6 months. In Section O: Special Treatments, Procedures, and Programs, this assessment did not indicate Resident 7 received hospice care. A concurrent interview and record review was conducted with the MDS nurse on 10/13/17 at 8:37 A.M The MDS nurse acknowledged Resident 7's MDS should have indicated he received hospice care. The MDS nurse stated it was important for the MDS assessments to be accurate to ensure the staff knew what care the resident received. The MDS nurse stated an inaccurate assessment had the potential to affect care for the resident. An interview was conducted with the Director of Nursing (DON) on 10/13/17 at 11:12 A.M The DON stated the MDS assessment was a form of communication and was important to provide an accurate reflection of a resident's care. A review of the RAI (Resident Assessment Instrument) version 3.0 Manual, dated 10/15, indicated, .Item O0100, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity, and quality of life . Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation (to relieve or lessen without curing) and management of terminal illness and related conditions . 2. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. pacemaker does not work properly) per the facility's Resident Face Sheet. On 10/12/17 at 12:10 P.M., Resident 8 was observed lying on her right side in bed, under covers with her eyes closed. At 2:40 P.M., the resident was sitting up in her bed with three stuffed animals on her lap. Resident 8's care plan, dated 5/22/17, indicated the resident was on hospice care. A review of Resident 8's physician orders, dated 10/3/17, indicated, .Continue with hospice care . A review of Resident 8's MDS assessment, dated 8/29/17 was conducted. In this assessment, Section J: Health Conditions, indicated Resident 8 had a life expectancy less than 6 months. In Section O: Special Treatments, Procedures, and Programs, this assessment did not indicate Resident 8 received hospice care. A concurrent interview and record review was conducted with the MDS nurse on 10/13/17 at 8:37 A.M The MDS nurse acknowledged Resident 8's MDS should have indicated she received hospice care. The MDS nurse stated it was important for the MDS assessments to be accurate to ensure the staff knew what care the resident received. The MDS nurse stated an inaccurate assessment had the potential to affect care for the resident. An interview was conducted with the DON on 10/13/17 at 11:12 A.M The DON stated the MDS assessment was a form of communication and was important to provide an accurate reflection of a resident's care. A review of the RAI (Resident Assessment Instrument) version 3.0 Manual, dated 10/15, indicated, .Item O0100, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity, and quality of life . Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation (to relieve or lessen without curing) and management of terminal illness and related conditions .

Based on interview and record review, the facility failed to ensure the plan of care for safe transfers was followed when the CNA performed a single assist transfer for 1 sampled resident (1), when the resident required a 2 person assist. As a result, Resident 1 was at risk for injury from an unsafe transfer. Findings: Resident 1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Sheet. In an interview with the Executive Director (ED 1) on 4/18/17 at 12:38 P.M., ED 1 stated Resident 1 was observed with an injury to her lower left leg on 4/11/17 at 8 A.M ED 1 further stated the facility conducted an investigation and determined CNA 1 transferred Resident 1 from a wheelchair to bed without assistance from another staff member. ED 1 added, Resident 1 was non-verbal throughout this admission. ED 1 stated both CNA 1 and CNA 2 were interviewed during the facility investigation, and added, CNA 2 allowed her to view a text message on his phone from CNA 1. ED 1 stated the text message was a request from CNA 1 to CNA 2 asking him to cover for me, and tell management he assisted CNA 1 with a resident transfer. Resident 1's clinical record was reviewed on 4/18/17. There was a physician's orders [REDACTED]. CNA 1 was interviewed via telephone on 5/11/17 at 12:45 P.M CNA 1 stated she was assigned to care for Resident 1 on 4/9/17 during the evening shift. CNA 1 stated she asked CNA 2 to help her transfer Resident 1 from her wheelchair to bed, using the sit to stand lift, on 4/9/17 at 8 P.M., and the transfer was conducted safely. CNA 2 was interviewed via telephone on 5/12/17 at 4:39 P.M CNA 2 stated he worked the evening shift on 4/9/17, and was never approached by CNA 1 to help transfer Resident 1 from wheelchair to bed. CNA 2 further stated CNA 1 communicated with him via a text message, A couple days later, on my day off, CNA 1 sent me a text message which read, I need you to cover for me and tell management you helped me with a transfer for Resident 1. CNA 2 added, When they (management) questioned me, I told the truth. Per the facility policy titled No Lift Transfers, dated June 2012, Two staff members present whenever a lift is being used.