Every finding on record at Willow Creek Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (CP-a a detailed approach to care customized to an individual resident's needs) was developed and implemented for one of three sampled residents (Resident 1) when Resident 1 did not have a patient centered care plan for his anticoagulant medication (refers to class of medication that are used to prevent clot extension and formation) with an invention to monitor Resident 1's current, increased or new bruising.This failure resulted in Resident 1's expanded bruising to go unnoticed and had the potential to result in internal bleedingFindings:During a concurrent observation and interview on 8/19/26 at 8:29 a.m. with Resident 1 in Resident 1's room, Resident 1 was sitting up in his bed with a blanket pulled up to his chest. Resident 1 stated he had some bruising on his groin area. Resident 1 stated he thinks the bruising may be from his anticoagulant medication. Resident 1 stated he bruised easily.During a review of Resident 1's admission Record (AR- a document containing resident profile information), dated 8/19/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (AFIB-irregular heartbeat).During a review of Resident 1's Minimum Data Set (MDS- a federally mandated process for clinical assessment of all residents of long term care nursing facilities) dated 8/14/26, the MDS indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life, a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment) score of 11. The MDS section GG Functional Abilities indicated, partial/moderate assistance - helper does less than half the effort, with toileting, dressing, putting on/taking off footwear, and personal hygiene.During a concurrent observation and interview on 8/19/26 at 10:32 a.m. with the RN in Resident 1's room, Resident 1's bruising was measured. Resident 1 stated his bruises have never been measured before. The RN stated she describes the bruising as discoloration. The RN stated there was discoloration, light and dark purple, to the left flank (side) that measured 10.5 inches by 6 inches, to the right flank that measured 11.5 inches by 6.5 inches, and to the groin area that measured 3 inches by 3.5 inches.During an interview on 8/19/26 @ 10:44 a.m. with the RN, the RN stated she was made aware of the discoloration to Resident 1's bilateral (both) flanks on 8/17/26. The RN stated Resident 1 had some discoloration in his groin area upon admission. The RN stated Resident 1 was on an anticoagulant medication which puts Resident 1 at an increased risk for bleeding and bruising. The RN stated resident care plans for anticoagulant medication should have included monitoring and measuring of the discoloration. The RN stated not having a care plan that provides guidance on Resident 1's anticoagulant medication could put him at risk for internal bleeding and bruising to go unnoticed.During a concurrent interview and record review on 8/19/26 @ 2:10 p.m. with the Director of Nursing (DON), Resident 1's Care Plan Report dated 8/19/26 and Medication Review Report dated 8/7/26 were reviewed. The Care Plan Report indicated, a generic care plan for Resident 1's anticoagulant medication. The Medication Review Report indication Resident 1 was prescribed .apixaban [anticoagulant medication] 5 milligrams [unit of measure] Give 1 tablet.every morning and at bedtime for AFIB.start date 8/8/26. The DON stated Resident 1's care plan was generic and should be more comprehensive and patient specific to use of an anticoagulant medication. The DON stated it is important care plans are updated and patient specific because the care plan notates the residents diagnoses and risks which guides staff caring for the residents. The DON stated Resident 1's care plan should have had interventions and monitoring for Resident 1's bruising. The DON stated Resident 1 not having a comprehensive resident centered care plan for his anticoagulant medication, Resident 1 would be at risk for side effects like internal bleeding and bruising to go unnoticed which could lead to hospitalization and poor patient outcome.During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the policy interpretation and implementation indicated .7. The comprehensive, person-centered care plan: .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change .

Based on observation, interview, and record review, the facility failed to implement the facility's policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating for one of three sampled residents (Resident 1) when Resident 1's bilateral (both) flank (side) bruising of unknown origin was not investigated to rule out abuse.This failure resulted in a delayed investigation of an injury of unknown origin and had the potential to place Resident 1 at risk for further danger, physical and psychosocial harm, and or trauma.Findings:During a concurrent observation and interview on 8/19/26 at 8:29 a.m. with Resident 1 in Resident 1's room, Resident 1 was sitting up in his bed with a blanket pulled up to his chest. Resident 1 stated he had some bruising on his groin area. Resident 1 stated he thinks the bruising may be from his anticoagulant medication. Resident 1 stated he bruised easily.During a review of Resident 1's admission Record (AR- a document containing resident profile information), dated 8/19/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat).During a review of Resident 1's Minimum Data Set (MDS- a federally mandated process for clinical assessment of all residents of long term care nursing facilities) dated 8/14/26, the MDS indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life, a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment) score of 11. The MDS section GG Functional Abilities indicated, partial/moderate assistance - helper does less than half the effort, with toileting, dressing, putting on/taking off footwear, and personal hygiene.During an interview on 8/19/26 at 9:57 a.m. with the certified nursing assistant (CNA), the CNA stated Resident 1 had bruising on his groin and sides. The CNA stated that she does not care for Resident 1 regularly. The CNA stated the bruising on Resident 1 was reported to the registered nurse (RN) who stated she was already aware. The CNA stated it is important to report injuries because they should be investigated to rule out abuse and protect the residents. The CNA stated not reporting the injury of unknown source does not follow [facility name] abuse policy.During a concurrent observation and interview on 8/19/26 at 10:32 a.m. with the RN in Resident 1's room, Resident 1's bruising was measured. The RN stated she describes the bruising as discoloration. The RN stated there was discoloration, light and dark purple, to the left flank (side) that measured 10.5 inches by 6 inches, to the right flank that measured 11.5 inches by 6.5 inches, and to the groin area that measured 3 inches by 3.5 inches.During an interview on 8/19/26 @ 10:44 a.m. with the RN, the RN stated she was made aware of the discoloration to Resident 1's bilateral (both) flanks on 8/17/26. The RN stated Resident 1 had some discoloration in his groin area upon admission. The RN stated Resident 1 was on an anticoagulant medication which puts Resident 1 at an increased risk for bleeding and bruising. The RN stated the discoloration on Resident 1 could be an injury of unknown origin and should have investigated and reported. The RN stated it is important to report injuries of unknown origin because it needs to be investigated to ensure that it is not abuse and our job is to protect the residents. The RN stated by not investigating the discoloration the facility was not following it's own abuse and reporting policy.During a concurrent interview and record review on 8/19/26 @ 2:10 p.m. with the DON, Resident 1's Progress Notes (PR) dated 8/16/26 and 8/17/26 were reviewed. The PR indicated, on 8/16/26 at 11:44 p.m. Resident 1's caregiver reported concern of bruising to Resident 1's pelvic (hip and groin) area. The DON stated she was made aware of the reported bruising on 8/19/26. The DON stated she should have been notified immediately. The DON stated Resident 1 had bruising upon admission, but new bruising should be reported and investigated. The DON stated the bruising to the bilateral flanks would be considered an injury of unknown origin. The DON stated all injuries of unknown origin should have an investigation completed so a root cause could be identified. The DON stated by not reporting the new bruising the facility was not following its Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy. The DON stated it is important to report any suspect abuse, including injuries of unknown origin, to ensure that the incident is investigated and to protect the residents. The DON stated by not investigating the incident the resident could have been at risk for continued abuse if abuse was cause of the bleeding. The DON stated that the abuse coordinator was at conference and was not in the facility at the time of the reporting. During a review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated September 2022, the P&P indicated .All reports of resident abuse (including injuries of unknown origin).are reported to local, state and federal agencies.and thoroughly investigated by facility management.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to provide a safe and sanitary environment for seven of 16 sampled residents (Residents 2, 3, 4, 5, 6, 7, and 8) when:1. Certified Nursing Assistant (CNA) 1 did not discard soiled linens from Resident 2 who was on contact isolation (the practice of separating infected patients from others to prevent the spread of infections transmitted through direct or indirect contact) due to shingles (a painful rash illness caused by the varicella-zoster virus) to a designated isolation barrel (storage unit designed to contain infectious materials and waste) in the soiled utility room on 5/13/26 instead CNA 1 tossed Resident 2's soiled linens into a non-isolation red bin in the soiled utility room on 5/13/26. 2. Laundry Staff (LS) 1 left the blue barrel containing overflowing clean linens inside the dirty area of the laundry room on 5/13/26. These failures had the potential to cause cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) to other residents which could lead to a spread of infection (the invasion and growth of germs in the body), potentially causing health complications, and a facility outbreak (a sudden increase or clustering of disease cases beyond what's normally expected in a specific time, place, or population, often involving common exposure).3. The facility did not report suspected cases of scabies to Fresno County Department of Health (FCDH) and California Department of Health (CDPH) for Residents 3, 4, 5, 6, and 7 when the dermatologist (a medical doctor who specializes in diagnosing, treating, and preventing conditions and diseases that affect the skin, hair, and nails) clinically diagnosed Residents 3, 4, 5, 6, and 7 with suspected scabies on 5/6/26 and 5/7/26, and Resident 8 was assessed by wound doctor on 4/13/26 with suspicious scabies.This failure had resulted in not reporting suspected cases of scabies to local health department and CDPH and had the potential for transmitting and spreading the infection.4. Contact isolation was not initiated for Residents 3, 4, 5, 6, and 7 when symptoms of rash developed. This failure resulted in delay implementation of precautionary measures in mitigating (refers to actions taken to lessen the severity of an outbreak or reduce the probability of disease transmission) the scabies outbreak at the facility and had the potential to cause cross contamination to other residents which could lead to a spread of infection and increasing cases of facility infectious disease outbreak. Findings:1. During an observation on 5/13/26 at 10:49 a.m. in Resident 2's room, a contact isolation sign was posted on the door, one black container with no label was by the door inside the room. CNA 1 and another staff were observed wearing yellow gown and gloves. During an interview on 5/13/26 at 10:55 a.m. with CNA 1, CNA 1 stated he went to soiled utility room and threw a plastic bag containing Resident 2's dirty linen into a bin located in Station 3's soiled utility room. CNA 1 stated he was the CNA assigned for Resident 2. CNA 1 stated Resident 2's bed sheet was changed due to presence of large amount of crusted skin, CNA 2 stated it looked like skin was from his wound. CNA 1 stated Resident 2 also had fluid filled like blisters (a bubble of fluid under the skin) on the side of his head. CNA 1 stated Resident 2 was on contact isolation due to scabies. CNA 1 stated the black container inside Resident 2's room was for trash and used Personal Protective Equipment (PPE -refers to specialized clothing and gear worn by healthcare workers, patients, and visitors to create a barrier that prevents the spread of germs, infectious materials, and dangerous bodily fluids).During a concurrent observation and interview on 5/13/26 at 10:57 a.m. with CNA 1, inside Station 3's soiled utility room, CNA 1 pointed to a red bin and three gray barrels. CNA 1 validated he tossed Resident 2's dirty linens in the red bin. CNA 1 stated the two gray barrels were for resident trash and used PPE. CNA 1 stated there was only one bin for soiled linens in the soiled utility room and there was no designated bin for items from a contact isolation room. During a concurrent observation and interview on 5/13/26 at 11:00 a.m. with CNA 2, inside the soiled utility room, CNA 2 was holding a clear plastic bag containing used PPE and disposed of it into a gray barrel. CNA 2 stated there was no available isolation barrel for dirty soiled linens and laundry for residents on contact isolation in the soiled utility room. CNA 2 stated Station 3 had a scabies outbreak. CNA 2 stated there were residents with scabies in her group assignment. During a concurrent observation and interview on 5/13/26 at 11:10 a.m. with Laundry Staff (LS) 1, inside the soiled utility room, LS 1 was pushing the red bin containing bags of dirty soiled linens. LS 1 stated the red bin was for non-isolation residents only and she did not see a bin for isolation residents inside Station 3's soiled utility room. LS 1 stated there should be two bins, one for isolation and the other one was for non-isolation resident laundry. LS 1 stated laundry staff were responsible in picking up the bins for dirty soiled linens. LS 1stated she washes separately the dirty soiled linens, towels, and personal clothing of isolation residents from non-isolation residents. LS 1 stated the only way to identify dirty soiled linens and laundry for isolation residents, was if they were placed in a designated barrel with an isolation label on top of the lid. During a concurrent observation and interview on 5/13/26 at 11:23 a.m. with the Housekeeping and Laundry Supervisor (HLS), inside the soiled utility room, HLS validated there was no designated barrel for dirty soiled linens and laundry for residents on contact isolation. HLS 1 stated there should be a separate barrel for isolation and should be available to prevent cross-contamination and spread of infection.During an interview on 5/13/26 at 11:31 a.m. with CNA 3, CNA 3 stated CNA 2 was orienting her on the floor, and they were assigned in Station 3. CNA 3 stated she was informed that there is scabies outbreak at Station 3. CNA 3 stated they were assigned to rooms on contact isolation due to scabies. CNA 3 stated there were no isolation barrels for dirty soiled linens and laundry in each isolation room and she only saw a black trash container in isolation rooms. CNA 3 stated she did not see an isolation barrel inside the soiled utility room. CNA 3 stated dirty soiled linens and laundry from isolation rooms should be separated from non-isolation rooms in preventing the spread of infection. During an interview on 5/13/26 at 1:30 p.m. with CNA 1, CNA 1 stated it was his first time to provide care for residents on contact isolation. CNA 1 stated the instruction he received from nurses and CNAs was to dispose resident's soiled and dirty linens and laundry to a red bin located inside the soiled utility room and only use double bag for wet soiled linens and laundry. CNA 1 stated he had not seen a separate bin for isolation inside the soiled utility room. CNA 1 stated he was not aware that Resident 2 had shingles and no scabies. CNA 1 stated dirty soiled linens of residents on contact isolation should be separated the soiled linen should not be mixed, to prevent cross-contamination and to stop the spread of infection. CNA 1 stated the facility has a scabies outbreak in Station 3. During an interview on 5/13/26 at 1:58 p.m. with RN 1, RN 1 stated she's been helping the Infection Preventionist (IP) in providing in-services and training for infection control. RN 1 stated dirty soiled linens should be bagged and airtight while inside residents' room for all residents on contact isolation rooms. RN 1 stated CNAs should use a single bag and use double bag for heavy soiled and wet linens. RN 1 stated the facility does not use a designated container for dirty and soiled linens and laundry for each isolation room. RN 1stated there should be a separate labeled container for dirty and soiled linens and laundry for contact isolation rooms inside the soiled utility room. RN 1 stated the facility process was for laundry staff to pick up the labeled isolation bin containing dirty soiled linen and laundry inside the soiled utility room to prevent the spread of infection. RN 1 stated she started providing in-services today (5/13/26) to nursing staff about infection control: safe handling of soiled linen from isolation rooms.During a review of Resident 2's Order Summary Report (OSR),' ordered date 5/10/26. The OSR indicated, .Strict single room isolation: Contact precautions related to presence of shingles .During an interview on 5/13/26 at 2:50 p.m. with CNA 2, CNA 2 stated the red bin inside Station 3's soiled utility room was for non-isolation rooms' dirty and soiled linens only and should not be used for isolation rooms. CNA 2 stated if there was no isolation bin available, CNAs should notify the licensed nurses and wait until isolation bin was provided. CNA 2 stated isolation rooms' dirty soiled linens should be separated from non-isolation rooms and should be available to prevent cross contamination and spread of infection like scabies. During an interview on 5/13/26 at 3:31 p.m. with the IP, the IP stated the facility's scabies outbreak was contained in Station 3 and had two cases of shingles. The IP stated it was her expectation for nursing staff to follow the facility protocol for contact isolation. The IP stated the CNAs should verify with the licensed nurses the type of isolation precautions needed and wear appropriate PPE. The IP stated staff should remove PPE prior to leaving the isolation room. The IP stated the dirty soiled linen and laundry should be bagged up, airtight and disposed to the proper labeled barrel, which should indicate isolation in the soiled utility room. The IP stated isolation rooms' dirty soiled linens and laundry should be separated and handled separately from non-isolation rooms to prevent cross contamination and spread of infection. During an interview on 5/14/26 at 1:40 p.m. with the IP, the IP stated she started placing a label on isolation barrel on Monday (5/11/26) when one confirmed positive scabies was received. The IP stated isolation barrels should be labeled and stated, I didn't see a label on it before. The IP stated a label should be placed on the isolation barrel when suspected scabies were identified. The IP stated it was important that isolation barrels have a label for staff to identify where to properly dispose of the dirty and soiled linens and laundry. The IP stated laundry staff could not identify where to place contact isolation rooms dirty soiled linen if it was not properly labeled. The IP stated this could increase the risk of laundry staff exposure and transmit the infection to other staff and residents.During an interview on 5/14/26 at 1:45 p.m. with the IP, the IP stated there were two new residents identified and diagnosed by the physician with suspected scabies today (5/14/26). The IP stated the total number of scabies cases including confirmed, suspected, and exposure with symptoms was 18. During an interview on 5/14/26 at 2:37 p.m. with the HLS, the HLS stated contact isolation barrels were put in on Monday (5/11/26) by the IP. The HLS stated a designated labeled barrel for contact isolation should be stored and available in the soiled utility room for nursing staff to identify the correct barrel to place the dirty items. The HLS stated isolation's dirty soiled lines and laundry should be double bagged and labeled and should only be discarded to a labeled isolation barrel to prevent cross contamination and spread of infection. The HLS stated if mixed with non-isolation soiled linens, there was no way for the laundry staff to identify, and it would be laundry together with the non-isolation. The HLS stated the laundry staff will be exposed to infection. The HLS stated they were using a different process of laundry for isolation and non-isolation: one time wash for non-isolation and two washes for isolation.During an interview on 5/14/26 at 3:05 p.m. with Assistant Director of Nursing (ADON) 3, ADON 3 stated the facility's protocol and training for soiled linens and laundry from isolation rooms should be disposed to a designated labeled barrel, separate from non-isolation rooms, and should not be mixed to prevent the risk of cross contamination and spread infection.During an interview on 5/14/26 at 3:35 p.m. with the Director of Nursing (DON), the DON stated it was her expectation for nursing staff to follow the facility's protocol for contact isolation. The DON stated soiled linens and laundry from isolation rooms should be bagged and disposed in labeled isolation barrel strictly for isolation located in the soiled utility room. The DON stated there was a risk of cross contamination and spread of highly transmissible infection.During a review of facility's policy and procedures (P&P) titled, Isolation-Categories of Transmission-Based Precaution, dated 9/2022, the P&P indicated, Transmission-based precautions are initiated when resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of infection; or has a laboratory confirmed infection; and is at risk of transmitting infection to other residents.Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected.1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.During a review of a professional reference titled, Appendix D - Linen and Laundry Management, dated 3/19/24, retrieved from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html, the professional reference indicated, .Place soiled linen into a clearly labeled, leak-proof container (e.g., bag, bucket) in the patient care area. Do not transport soiled linen by hand outside the specific patient care area from where it was removed. 2. During a concurrent observation and interview on 5/13/26 at 11:16 a.m. with LS 1, inside the laundry room, LS 1 placed the red bin containing dirty soiled linens and laundry beside the blue barrel containing overflowing linens. LS 1 stated she was at the dirty side of the laundry room and was pointing at a blue barrel containing overflowing linen. LS 1 then stated they were washed, it's clean and pointed to the other side of the laundry room. LS 1 stated the blue barrel containing clean linens should not be left at the dirty side of the laundry room. During an interview on 5/14/26 at 2:37 p.m. with the HLS, the HLS stated the dirty area of the laundry room is where the washer and dryer located, the clean side was on the other side of the laundry area. The HLS stated the laundry room has a clean and dirty area. The HLS validated that the blue barrel containing overflowing linens were clean and should not be overflowing. The HLS stated the clean barrel should be covered and not left beside the dirty soiled linens (red bin) and isolation barrels at the dirty side of the laundry room. The HLS stated there should be no clean linens in the dirty area. The HLS stated it was her expectation for the laundry staff to follow the facility's P&P for proper and safe handling and processing of laundry. The HLS stated LS 1 should unload the clean linens from the dryer, placed in a clean covered barrel, and transport immediately to the clean area. The HLS stated clean linens should be stored in the clean side and dirty soiled linens on the dirty side to prevent cross contamination.During an interview on 5/14/26 at 1:45 p.m. with the IP, the IP stated the laundry room has a separate area for clean linens and dirty linens. The IP stated clean linens should not be left or stored in the dirty area to prevent the risk of cross contamination.During an interview on 5/14/26 at 3:35 p.m. with the DON, the DON stated clean lines should be placed to the clean side of the laundry room. The DON stated LS 1 should not leave the barrel containing linens beside the dirty bins and isolation barrel in the dirty side of the laundry room. The DON stated clean barrels should not be overflowing and should be covered. The DON stated laundry staff should unload clean linens from the dryer and transport immediately to the clean area to prevent cross contamination from the dirty linens. During a review of facility's P&P titled, Laundry Handling & Processing Policy, dated 2/1/25, the P&P indicated, Healthcare Services Group, Inc. (HCSG) is committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices. Laundry in a health care facility may include bed sheets, blankets, towels, personal clothing, patient apparel, gowns, and other linens. Standard precautions are effective in reducing the risk of disease transmission to the residents, patients, and staff. The control measures described in this section of the guideline are based on principles of hygiene, common sense, and Centers for Disease Control (CDC) guidance as they pertain to laundry services utilized by healthcare facilities. Employees should collect soiled linens from resident/patient rooms throughout the day. Soiled linens and laundry should be handled with minimum agitation in a manner that reduces the possibility of contamination of air, surfaces, and persons. The workflow of laundry processes should be designed in a way that prevents cross-contamination. Receiving areas for soiled linens should be clearly separated from the clean linen area. Clean linens should be sorted, packaged, transported, and stored in a manner that prevents the risk of contamination by dust, debris, or other soiled items. Clean linen should not be stacked higher than the rim.During a review of a professional reference titled, Appendix D - Linen and Laundry Management, dated 3/19/24, retrieved from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html, the professional reference indicated, . Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Have a separation between the soiled linen and clean linen storage areas. 3. During a concurrent interview and record review on 5/14/26 at 11:08 a.m. with ADON 2, Resident 3's SBAR (Situation Background Appearance Review and Notify) Communication Form dated 4/21/26 and 5/7/26, and Admission/readmission Evaluation assessment dated [DATE], were reviewed. The SBAR dated 4/21/26 indicated, .generalized rash with scattered lesions (any abnormal change in the structure of an organ or tissue due to injury, disease, or infection), complaint of itching to trunk, [bilateral upper extremities] / [bilateral lower extremities]. [Doctor ] arrives at the facility to complete skin assessment. New order: referral to dermatology. The SBAR dated 5/7/26 indicated, .suspected scabies.noted with rash to upper back and chest.dermatologist determine suspected scabies.start [brand name topical cream]- ivermectin (a broad-spectrum anti-parasitic medication used primarily to treat infections caused by parasitic worms and specific skin conditions) . strict isolation. The Admission/readmission Evaluation assessment dated [DATE] indicated, .noted rash to upper mid back, redness and raise bumps. resident returning back to facility from hospital sent out on 4/5/26 .received new order from NP (Nurse Practitioner) for hydrocortisone cream (used to treat redness, swelling, itching, and discomfort of various skin conditions) for 14 days then [as needed] for rash to mid back. ADON 2 stated Resident 3 was seen and evaluated by the physician on 4/21/26 due to generalized rashes and ordered referral to dermatologist for consult. ADON 2 stated Resident 3's physician did not indicate suspected scabies. ADON 2 stated Resident 3 was seen and evaluated by dermatologist on 5/6/26 and was diagnosed on [DATE] with suspected scabies. ADON 2 stated Resident 3's skin scraping was done at the dermatologist office and revealed positive for scabies. ADON 2 stated Resident 3 was readmitted from acute care hospital on 4/12/26 with rash to mid back and was treated with hydrocortisone cream for 14 days.During a concurrent interview and record review on 5/14/26 at 11:50 a.m. with the Treatment Nurse (TN), Resident 8's wound doctor's assessment, dated 4/13/26, was reviewed. The wound doctor's assessment indicated, suspicious scabies. The TN stated she assisted wound doctor weekly on Mondays for his wound rounds. During a concurrent interview and record review on 5/14/26 at 2:00 p.m. with the IP, scabies outbreak line listing was reviewed. The line listing indicated, .onset date, location, description of symptoms. The IP stated the onset date of symptoms were the dates when Residents 3, 4, 5, 6, and 7 went to dermatologist to evaluate their rashes, and not when the actual symptoms of rash started. The IP stated Residents 3, 4, and 5 were evaluated and clinically diagnosed by the dermatologist with suspected scabies on 5/6/26. Residents 6, and 7 were evaluated and clinically diagnosed by the dermatologist with suspected scabies on 5/5/26. The IP stated Resident 3 returned to the dermatologist on 5/7/26 for skin scraping to rule out scabies. The IP stated Resident 3's skin scraping for scabies was positive result was received on 5/11/26. The IP stated she reported one confirmed case of scabies and clinically diagnosed suspected scabies to FCDH and CDPH on 5/12/26. The IP sated she did not report the suspected scabies when clinically diagnosed on [DATE] and 5/6/26 by the dermatologist and she waited for a confirmed case for reporting. The IP stated she did not know if suspected scabies should be reported to the health department. The IP stated she needed to check and update the line listing to reflect the actual onset date of symptoms.During a concurrent interview and record review on 5/14/26 at 2:30 p.m. with the IP, Residents 3, 4, 5, 6, and 7's SBAR Communication Form were reviewed. Resident 3's SBAR dated 5/7/26, indicated, .suspected scabies. strict isolation. Resident 4's SBAR dated 5/6/26, indicated, .possible scabies.resident went out to dermatologist appointment came back after skin scraping with diagnosis of possible scabies . Resident 5's SBAR dated 5/7/26, indicated, .noted with possible scabies abdominal area and chest.dermatologist determined suspected scabies. start .strict isolation. Resident 6's SBAR dated 5/8/26, indicated, .dermatologist assistant called to change diagnosis from atopic dermatitis to suspected scabies . Resident 7's SBAR dated 5/8/26, indicated, gave diagnosis of suspected and need to start treatment.noted with rash to entire body, was diagnosed first with atopic dermatitis, changed diagnosis to suspected scabies . During an interview on 5/14/26 at 3:35 p.m. with the DON, the DON stated the facility must report confirmed and suspected cases of scabies to FCDH and CDPH. The DON stated the facility started reporting the scabies outbreak when one confirmed case via skin scraping was received on 5/11/26. The DON stated suspected scabies which were clinically diagnosed by the dermatologist on 5/5/26 and 5/6/26 should be reported to FCDH and CDPH.During a review of facility's scabies outbreak line listing, undated, the line listing indicated Resident 3's onset symptom of rash was on 4/12/26, Resident 4' onset symptoms of rash and itching was on 4/17/26, Residents 5, 6, and 7's onset symptoms of rashes were on 4/21/26.During a review of a professional reference titled, Detecting and Controlling Outbreaks, undated, retrieved from https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/SNF_DetectAndControlOutbreaks.aspx, the professional reference indicated, .SNF (Skilled Nursing Facility) infection preventionists should have policies and procedures in place for what to do as soon as an outbreak is suspected. SNF must report suspected or confirmed outbreaks and unusual infectious disease occurrences to their LHD (Local Health Department) and CDPH. 4. During a concurrent interview and record review on 5/14/26 at 2:00 p.m. with the IP, scabies outbreak line listing was reviewed. The line listing indicated, .onset date, location, description of symptoms. The IP stated the onset date of symptoms were the dates when Residents 3, 4, 5, 6, and 7 went to dermatologist to evaluate their rashes, and not when the actual symptoms of rash started. The IP stated Residents 3, 4, and 5 were evaluated and clinically diagnosed by the dermatologist with suspected scabies on 5/6/26. Residents 6, and 7 were evaluated and clinically diagnosed by the dermatologist with suspected scabies on 5/5/26. The IP stated Resident 3 returned to the dermatologist on 5/7/26 for skin scraping to rule out scabies. The IP stated Resident 3's skin scraping for scabies positive result was received on 5/11/26. The IP stated Residents 3, 4, 5, 6, and 7's symptom of rash developed prior to visits to the dermatologist on 5/5/26 and 5/6/26. The IP stated she needed to check and update the line listing to reflect the actual onset date of symptoms. The IP stated Residents 3, 4, 5, 6, and 7 reside in Station 3. The IP stated contact isolation started when Residents 3, 4, 5, 6, and 7 were clinically diagnosed by the dermatologist with suspected scabies and not on actual onset of their symptoms. The IP stated Residents 3, 4, 5, 6, and 7 should be placed on contact isolation when symptoms of rash developed to prevent the spread of infection.During an interview on 5/14/26 at 3:35 p.m. with the DON, the DON stated contact isolation should be implemented when suspected or confirmed of being infected with microorganisms (tiny living organisms that are too small to be seen with the naked eye) to prevent transmission of infection. The DON stated onset of symptoms means when the residents developed their symptoms and not when seen by the dermatologist. The DON stated contact isolation is important to be initiated when suspecting of a highly transmissible infection (a disease or germ that is extremely capable of being passed on or spread from one person, animal, or environment to another).During a review of facility's updated scabies outbreak line listing, undated, the line listing indicated Resident 3's onset symptom of rash was on 4/12/26, Resident 4' onset symptoms of rash and itching was on 4/17/26, Residents 5, 6, and 7's onset symptoms of rashes were on 4/21/26.During a review of Resident 3, 4, 5, 6, and 7's isolation precautions care plan report dated 5/7/26 and 5/8/26. Residents 3, 4, and 5's care plan indicated, Isolation Precautions: Resident requires strict isolation with contact precaution related to suspected scabies.Date Initiated 5/7/26. Residents 6 and 7's care plan indicated, Isolation Precautions: Resident requires strict isolation with contact precaution related to suspected scabies.Date Initiated 5/8/26.During a review of facility's policy and procedures (P&P) titled, Isolation-Categories of Transmission-Based Precaution, dated 9/2022, the P&P indicated, Transmission-based precautions are initiated when resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of infection; or has a laboratory confirmed infection; and is at risk of transmitting infection to other residents.Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected.1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.

Based on interviews and record review, the facility failed to safeguard and protect residents' personal belongings from admission to discharge at the facility for one of three sampled residents (Resident 1) when Resident 1's personal belongings were not returned on 4/23/26 at discharge. This failure resulted in Resident 1's personal items missing at the time of discharge and for Resident 1's go without her personal belongings necessary to perform her activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, personal hygiene, mobility, and toileting a person performs daily to care for themselves).Findings:During an interview on 5/13/26 at 2:23 p.m. with the Director of Nursing (DON), the DON stated social services were responsible for grievances (a complaint, either oral or written, expressing dissatisfaction with service delivery or the quality of care furnished) related to residents' missing personal belongings when searching the facility was not successful.During an interview on 5/13/26 at 2:59 p.m. with Social Services Director (SSD) 1, SSD 1 stated she remembered giving Resident 1's gray storage bin (containing Resident 1's personal belongings) to a female individual. SSD 1 stated she, handed it to her and said thank you. SSD 1 stated she cannot recall the name of the person she handed in the gray storage bin and did not know the date. SSD 1 stated she did not document and check Resident 1's inventory list prior to giving the gray storage bin. SSD 1 stated she received a call from a family member or a caregiver stating items were missing. SSD 1 stated she informed the family member or caregiver that the facility would look for Resident 1's missing personal belongings. SSD 1 stated there was no grievance filed for Resident 1's missing personal belongings. SSD 1 stated it was the facility's protocol to check the inventory list prior to giving personal belongings to the residents and families to ensure all residents' belongings were documented and accounted for. SSD 1 stated the facility's protocol for residents' missing items when not found after searching was to report a list of missing items to the Administrator (ADM) for review and approval for replacement or reimbursement. SSD 1 stated she should have followed up and updated the family of Resident 1. SSD 1 stated a residents' personal belongings were important to them and missing items should be addressed immediately.During an interview on 5/13/26 at 3:30 p.m. with SSD 3, SSD 3 stated he was responsible for the facility residents' property theft and loss. SSD 3 stated the facility has a process for residents' missing personal belongings and it should be followed by all staff. SSD 3 stated it was the facility's protocol to search for a residents' missing personal belongings on the day they were reported missing by resident, family and staff. SSD 3 stated if a residents' missing items were not successful found, he would then review the residents' inventory record, complete a missing item form and submit to the ADM for review and approval for replacement or reimbursement. SSD 3 stated the ADM's approval takes two to three days. SSD 3 stated he did not receive a report about Resident 1's missing personal belongings. SSD 3 stated Resident 1's family should not have to wait for almost a month to resolve the issue of missing personal belongings. SSD 3 stated a residents' personal belonging should be protected from loss or theft because it is a resident right to have their belongings.During an interview on 5/14/26 at 9:32 a.m. with the ADM, the ADM stated he was not aware that there were missing items from Resident 1's personal belongings. The ADM stated the facility has a process for residents missing personal belongings. The ADM stated the staff will search first for the missing items, if unable to find, the facility will replace or reimburse the missing items immediately. During an interview on 5/14/26 at 9:35 a.m. with the DON, the DON stated it was her expectation for all staff to follow and comply with the facility's process for a resident missing personal belongings, even when the items are reported missing on weekends. The DON stated the nursing staff should identify and complete an inventory list of residents' personal belongings on admission. The DON stated if family reported a missing item from a resident's personal belongings inventory list, nursing staff should look and search right away, if unable to find nursing staff should report to SSD. The SSD will notify the ADM of the need for replacement or reimbursement. The DON stated the process for resident's missing items should take five days to replace or reimburse. The DON stated SSD should call the family to give an update and the plan for resolution regarding missing items. The DON stated a resident's personal belongings should be protected from loss or theft. The DON stated it is a resident right to have their belongings, it's their property. During an interview on 5/14/26 at 11:37 a.m. with the Intermediate Care Facility (ICF-a specialized residential group home) Administrator (ADM), the ICFADM stated Resident 1 was their resident. The ICFADM stated she brought and picked up Resident 1's personal belongings from the facility. The ICFADM stated she completed an inventory list of all Resident 1's personal belongings from admission to the facility with the facility staff. The ICFADM stated she received a call from Assistant Director of Nursing (ADON) 3 that they found two bags of Resident 1's personal belongings yesterday (5/13/26). The ICFADM stated she picked up Resident1's personal belongings on 4/23/26 and yesterday (5/13/26). The ICFADM stated there were remaining items that were still missing. During a concurrent interview and record review on 5/14/26 at 3:05 p.m. with ADON 3, Resident 1's handwritten inventory list dated 5/13/26 was reviewed. The inventory list includes Resident 1's cardigans, slippers, pajama sets, soiled pant, undergarments, socks, capris, blouses and shirts. ADON 3 stated she made an inventory list based on Resident 1's personal belongings found yesterday (5/13/26) and does not include her wheelchair. ADON 3 stated she called the ICFADM yesterday (5/13/26) to pick up two bags containing Resident 1's personal belongings. ADON 3 stated she did not compare what was listed on previously written inventory list dated 4/23/26. ADON 3 stated she was not sure if all Resident 1's personal belongings were accounted for. ADON 3 stated Resident 1's family and caregivers should not wait for about three weeks for the facility to look for Resident 1's personal belongings. ADON 3 stated Resident 1's missing items should be looked for right away and reported to SSD immediately. ADON 3 stated SSD was responsible for escalating Resident 1's missing belongings to the ADM and following up. ADON 3 stated residents had the right to get back all their personal belongings because it's their property. During a review of handwritten inventory list for Resident 1, dated and signed by Registered Nurse (RN) on 4/23/26 at discharge, indicated wheelchair with footrest had no check mark, which indicated not received by ICFADM.During a review of Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/14/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis of Cerebral Palsy (a brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/18/26, the MDS section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 7 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), indicating Resident 1 with severe cognitive impairment.During a review of facility's In-Service Sign-In Sheet titled, Process of Belonging Handling after Sent to emergency room and admitted , dated 5/8/26, indicated, 1. Nurse gives the inventory list of the send out residents. 2. The CNA will reconcile the belongings with the Inventory List Any missing items. Label them with Name and room number and attach the copy of the Inventory List. 4. The bags will be given to SSD Monday to Friday . 5. On the Weekends - Keep the bags in the Utility Room. 6. SSD will follow up on Monday. During a review of facility's policy and procedures (P&P) titled, Resident Rights dated 8/2009, the P&P indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to; a. Be informed about what rights and responsibilities he or she has; e. Voice grievances and have the facility respond to those grievances. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 7. Inquiries concerning resident' rights should be referred to the Social Servers Director.During a review of a professional reference titled, Know Your Rights . As a Long-Term Care Resident, undated, retrieved from https://ombudsman.ablelaw.org/resources/know-your-rights-as-a-long-term-care-resident/, the professional reference indicated, If you live in a nursing home or residential care facility, you have the same rights as you would if you still lived in your own home. As a consumer of long-term care, you are entitled to a safe and healthy home, and the safekeeping of your belongings. You also have the right to be treated with dignity and consideration at all times.

Based on interview and record review, the facility failed to ensure nursing staff immediately notified the physician for physical and mental health change of condition for one of three residents, Resident 1, when on 4/8/25 Registered Nurse (RN) 1 did not recognize the physical and mental health decline of Resident 1 brought to her attention by Resident 1's daughter who was at the bedside. RN 1 did not provide the necessary medical notification for the altered mental status of Resident 1, symptoms included inability to swallow medications which prompted RN 1 to perform an oral sweep with her fingers, Resident 1's inability to verbally respond, refused breakfast, lunch and dinner which were all changes to Resident 1's baseline condition. RN 1 did not provide a full accurate description and assessment to the physician when the physician was notified of Resident 1's change of condition.These failures resulted in further decline of Resident 1's clinical status until the evening of 4/8/25 when RN 2 notified the physician of the decline, an emergency transport was ordered to transfer Resident 1 to the nearest general acute care hospital (GACH A) emergency department where Resident 1 was diagnosed with intracranial hemorrhage (brain bleed a type of stroke), coma, and required immediate intubation (someone who has a breathing tube placed through their mouth or nose into their windpipe to keep the airway open, support breathing) for life support. Resident 1 was then transferred to GACH B for a higher level of care to support the care of the evolving brain bleed and then passed away on 4/16/25 at 4:29 a.m.During a review of Resident 1's admission Record (document containing resident demographic information and medical diagnoses) dated 12/17/25, the admission record indicated Resident 1 was admitted to the facility on [DATE] for physical and occupation rehabilitation due to recent motor vehicle accident. Resident 1's diagnosis included but not limited to idiopathic peripheral autonomic neuropathy (nerve damage affecting automatic body functions such as heart rate and digestion), diabetes mellitus II (a chronic metabolic disease where the body either does not produce enough insulin or does not use insulin effectively) constipation (a condition in which there is difficulty in emptying the bowels and possibly causing hard stools), hypertension (high blood pressure), and muscle weakness (a general lack of strength), multiple fractures of ribs, left side, fracture of right lower leg, neuromuscular dysfunction of bladder (nerve damage disrupts normal bladder control, causing issues with storing or emptying urine), hypothyroidism (does not produce enough essential hormones, causing your body's functions to slow down), atrial fibrillation (an irregular and often very rapid heart rhythm) and muscle spasms (a sudden, involuntary, and often painful contraction of one or more muscles).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/31/2025, the MDS, indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 1 was cognitively intact.During a review of Resident 1's Admission/re-admission Summary Note dated 3/28/25 at 4:40 p.m., the Admission/re-admission Summary Note indicated, .Resident was admitted from [GACH A] due to frontal car collision. resident is alert and oriented [person, place, time], able to make her needs known.During a review of Resident 1's Nurses Notes dated 3/28/25 at 3:52 p.m., the Nurses Notes indicated, .writer received report from RN at [GACH A], per report resident full code (when a patient wants all possible life-saving measures taken), Glasgow Coma Scale 15 (GCS - score of 15 means a person has a fully normal level of consciousness: they are awake, alert, oriented, and responsive, with no neurological deficits, representing the highest possible score on the scale).Physical examination: General: Awake and alert, cooperative, no distress.Pain.currently well controlled Oxycodone (pain reliever used to treat moderate to severe pain) HCL oral tablet 5 (milligrams-mg units of measurement).dosage must be closely managed to prevent neurologic/cognitive problems.During a review of Resident 1's Weekly Summary Notes (WSN), dated 4/3/25 at 6:18 p.m., the WSN indicated, .Basic Activities of Daily Living (ADL)/mobility:. Bed mobility: limited supervision.transfer: limited assistance.Dressing: limited assistance. [Resident 1] ate 75% on average for meals. Alert: yes.oriented: person place time situation.During a review of Resident 1's Physicians Progress Note, dated 4/7/25 at 1:35 p.m., the Physicians Progress Note indicated, .Chief complaint: Mobility and [Activities of Daily Living] dysfunction secondary to right ankle fracture.now with improving endurance and safety.no falls, vital signs stable, no new issues reported. Participating well in therapy.During a review of Resident 1's Physical Therapy Treatment Encounter Notes (PTTEN), dated 4/7/25 and 4/8/25, the Physical Therapy Treatment Encounter Notes, indicated date of service 4/7/25. Resident 1 required moderate cueing for body mechanics and education on importance otherwise engaged. Resident 1 fatigues easily and requires prolonged rest between sets and interventions as session progresses. PTTEN indicated Resident 1was agreeable to therapy. PTTEN indicated Resident 1 instructed to stand and to transfer from bed to wheelchair minimum assistance required minimum cueing for hand/foot sequencing. PTTEN indicated Resident 1 instructed in and completed multiple stand pivot transfer with minimum assistance using parallel bars in order to facilitate safe transfers. PTTEN indicated date of service 4/8/25, Resident 1 encountered semi-Fowlers, daughter at bedside. PTTEN indicated [Resident 1] and daughter stating that they don't feel (Resident 1) can do therapy today as she's having a lot of bowel movements as she was given a suppository.During an interview on 12/17/25 at 8:45 a.m., with Resident 1's daughter (RD), RD stated she came to visit her mother on the morning of 4/8/25 approximately a little after 10 a.m. and her mother was not her normal self. RD stated her mother was usually excited to see her and have a conversation with her as well as being eager for her therapy sessions. RD stated her mother was working to get back home as soon as possible, but on this particular day, her mother did not want to talk at all and told her she had an excruciating headache. RD stated her mother refused therapy that morning and refused to eat due to her headache. RD stated her mother fell asleep around lunch time and the daughter stayed with her at bedside until Registered Nurse (RN) 1 came into her mother's room on that day before 2 p.m. to give her mother her scheduled sodium medication. RD expressed her concerns about her mother, but RN 1 did not seem at all concerned and continued to attempt at waking up my mother. RD stated her mother was barely awake when RN 1 gave her medication. RN 1 tried to get her mother to drink soda from a straw, but her mother was not able to drink. RD stated she again expressed her concerns to RN 1, but RN 1 stated that because Resident 1 had responded to her commands she was fine. RD stated once RN 1 realized her mother was not swallowing the pill, RN 1 stuck her hand in her mother's mouth to find the pill, but she could not find it. RD stated RN 1 left the room unconcerned about the changes in her mother's condition. RD stated her mother went back to sleep. RD stated she called the administrator to voice her concerns about her mother's current change in condition and interaction with RN 1. During an interview on 12/17/25 at 10:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he does not recall working with Resident 1. LVN 1 stated it was communicated to him by other nursing staff that Resident 1 was sent out for further evaluation to the local hospital and did not return back to the facility. LVN 1 stated that when there is a change of conditions for a resident, the nursing staff is expected to document in the Situation, Background, Assessment and Recommendation (SBAR), change in condition (CIC) and progress nursing (PN) notes, the assessment conducted, communication provided to the responsible party, the primary physician and recommendations made. LVN 1 stated a change of condition can include any of following: change in baseline that could include mental status, physical status, behavioral status; meal consumption and medication administration. LVN 1 stated licensed nurses are trained to document the change of condition accurately and notify the appropriate personnel as indicated in our nursing job descriptions. LVN 1 stated by notifying and providing a complete clinical description of the resident the physician will provide a plan of care specific for that resident. LVN 1 stated an inaccurate resident clinical assessment that is communicated to a physician would be unsafe and potentially harm the resident.During an interview on 12/18/25 at 8:15 a.m., with the certified nursing assistant (CNA) 1, CNA 1 stated she had previously cared for Resident 1 and the resident required extensive to moderate assistance with her activities of daily living (ADL) and set up assistance with eating. CNA 1 stated if a resident change of condition could include going from a high energy to a low energy, refusing meals, refusing care or having behaviors and it should all be reported to the charge nurse immediately. CNA 1 stated Resident 1 was usually wide awake, up in her wheelchair and able to communicate to staff about any issues, concerns, wants, needs and pain. I do not recall this resident being sleepy or groggy while caring for her, she was very alert and able to use the call light for assistance.During a concurrent interview and record review on 12/18/25 at 9 a.m., with the Assistant Director of Nurses (ADON) 1, the facility's document titled PN for Resident 1, dated 4/8/25 at 12:16 p.m. was reviewed. The PN indicated, .[ADON] was notified by charge nurse to accompany to residents' room to take a look at resident. Resident [1] had eyes closed and was responsive. Resident [1] was asked by [RN 1] to squeeze [RN 1's] hands 4 times. Resident responded with 4 squeezes. Resident nodded her head with yes and no questions answered appropriately. ADON 1 stated RN 1 asked her to help check on Resident 1 with her since Resident 1's daughter was concerned because her mother was so sleepy. ADON 1 stated I only made visual observations as [RN 1] assessed [Resident 1] .I never checked on [Resident 1] physically myself. ADON 1 stated the daughter was concerned about her mother's well-being since it was a change from her norm. ADON 1 stated she is a licensed vocational nurse and her scope of practice only allows her to collect data and not assess, so she observed RN 1 assessment of Resident 1. During a concurrent interview and record review on 12/18/25 at 9:10 a.m., with the ADON 1, the facility's document titled PN for Resident 1, dated 4/8/25 at 3:50 p.m. was reviewed. The PN indicated, .Writer tried waking up [Resident 1] and she was able to nod her head yes and no and open her mouth. She took her medicine and sucked on it. Writer wore a glove felt in her mouth until resident swallowed her medication. ADON 1 stated that is not normal practice to place a gloved hand in a resident's mouth unless you are doing a mouth sweep for someone who is unconscious or choking. ADON 1 stated we have never taught that in this facility so I do not understand where [RN 1] would have learned that from.During a concurrent interview and record review on 12/18/25 at 9:15 a.m., with the ADON 1, the facility's document titled Situation, Background, Assessment and Recommendation (SBAR) for Resident 1, dated 4/8/25 at 3:31 p.m. was reviewed. ADON 1 stated documentation on the SBAR did not have the full documented assessment for Resident 1. The SBAR did not indicate Resident 1 had difficulty swallowing requiring a mouth sweep with a gloved hand by RN 1, changes in resident verbal baseline responses and meal refusals. ADON stated the full assessment was not communicated to the primary physician for clinical recommendations appropriate for Resident 1. ADON 1 stated by not providing an accurate description of Resident 1's current condition, the physician only made recommendations based on the information provided by RN 1.During a review of the facility's document titled Documentation Survey Report, for Resident 1, printed on 12/18/25, the Documentation Survey Report indicated, Resident Refused her breakfast, lunch and dinner meals for 4/8/25. The Documentation Survey Report indicated, on 4/6/25, Resident 1 ate 26-50 % for breakfast, 76-100% for lunch and 51-75% for dinner and on 4/7/25, Resident 1 ate 26%-50% for breakfast and lunch and 51-75% for dinner.During an interview on 12/18/25 at 9:30 a.m., with the Medical Director (MD) for the facility, the MD stated it is the expectation for licensed nurses to provide physicians with a full and accurate description of a resident's assessment and their current condition. The MD stated based on Resident 1's SBAR records versus what was documented in the nurse's progress notes, the full assessment was not accurately communicated to the primary physician for Resident 1. The MD stated it is important and expected for all aspects of the assessment including changes in vital signs, verbal responses, difficulty with arousal, changes in appetite, and medication refusals to be communicated to all primary physicians. The MD stated physicians depend on information provided by the nursing staff in order to make the necessary recommendations and decisions for a plan of care, evaluation and treatment. During a concurrent interview and record review on 12/18/25 at 10 a.m., with RN 1, the facility's document titled PN for Resident 1, dated 4/8/25 at 3:50 p.m. was reviewed. The PN indicated, .Writer tried waking up [Resident 1] and she was able to nod her head yes and no and open her mouth. She took her medicine and sucked on it. Writer wore a glove felt in her mouth until resident swallowed her medication. RN 1 stated CNA staff failed to communicate to her that Resident 1 had refused breakfast and lunch. RN 1 stated it is her normal practice to place a gloved hand in a resident mouth as she was taught this in nursing school. RN 1 stated Resident 1 pockets (holding medication or food in their cheek instead of swallowing) medication but could not identify anywhere in the medical record that this was documented as a previous concern. RN 1 stated Resident 1 was sucking on her medication, and she had not swallowed it. RN 1 was concerned Resident 1 would choke on the medication so she made the decision to place a gloved hand into Resident 1's mouth to verify Resident 1 had swallowed her medication. RN 1 stated based on her documented progress notes, Resident 1's inability to swallow was a change in the resident baseline condition which should have been communicated to the primary physician and reflected on the SBAR.During a concurrent interview and record review on 12/18/25 at 10:22 a.m., with RN 1, the facility's document titled Situation, Background, Assessment and Recommendation (SBAR) for Resident 1, dated 4/8/25 at 3:31 p.m. was reviewed. RN 1 stated the SBAR did not indicate on the summary detail that a full assessment was reported at 3:26 p.m. to the primary physician for the change of condition signs and symptoms. RN 1 stated she did not notify the primary physician regarding concerns of choking or pocketing medications during assessment, or that she placed a gloved hand in Resident 1's mouth. RN 1 stated she did not communicate Resident 1's meal refusals, to the primary physician, and should have. RN 1 stated the primary physician makes their recommendations based on the information she provides them for residents. RN 1 stated it is the expectation of all licensed nurses to chart accurately and completely. RN 1 stated based on the nursing facility's job description she signed, all documentation, and communication should be precise and accurately depicting what was assessed by the nursing staff. RN 1 stated on 4/8/25 this did not occur.During an interview on 12/18/25 at 10:47 a.m., with the Director of Nursing (DON), the DON stated in reviewing the documentation the action of RN 1 placing a gloved hand into Resident 1's mouth is not standard of practice. The DON stated RN 1 should have initially asked and documented permission for Resident 1 to open her mouth and to check for medication if she had concerns Resident 1 did not swallow the medication. The DON stated there should have been documentation why a gloved hand was placed inside Resident 1's mouth. The DON stated Resident 1 had two missed meals, breakfast and lunch which should have been reported to the licensed charge nurse. The DON stated it is the expectation of the facility that all meal refusals are communicated to the charge nurse. The DON stated RN 1's SBAR did not reflect that she had communicated the complete clinical assessment to the primary physician. The DON stated based on the information provided and reviewed by the primary physician, the physician could not make the appropriate plan of care and treatment for Resident 1 which could have potentially included transporting Resident 1 to a GACH.During a review of the facility's document titled Situation, Background, Assessment and Recommendation (SBAR) for Resident 1 dated 4/8/25 at 7:34 p.m., the SBAR indicated, . [Resident 1] lethargic during [morning] shift. Report of difficulty swallowing medications. Lab results show critically low potassium level. Order obtained for potassium supplement. Resident difficult to arouse or give response from just before dinner served to after dinner time. Became responsive to sternal rub only. [Vital signs] unchanged except oxygen saturation which ranged from 88-91% on room air. Notified provider of level of consciousness and vital signs. Order obtained to send resident to [general] acute hospital for evaluation. During a concurrent interview and record review on 1/5/26 at 11:55 a.m., with the DON, the facility's document titled, Standards of Practice in Nursing for removal of meds from a patient mouth if patient in unable to swallow, dated 1/5/26 at 11:48 a.m. was reviewed. The DON stated the nursing standard of practice involved removing the medication if safely possible and then withholding the dose. The document also indicated the healthcare provider should be notified immediately based on the assessment that a resident is unable to swallow the medication and the nurse had to retrieve the medication or assess for the medication in the mouth. The DON stated this did not occur with RN 1. The DON stated RN 1, failed to provide full and accurate assessment to the primary physician on the day of the 4/8/25. The DON stated the primary physician did not have documented knowledge of the swallowing difficulties Resident 1 was experiencing at the time of notification from RN 1.During an interview on 1/5/26 at 12:25 p.m., with RN 2, RN 2 stated she recalled she was the PM nurse for Resident 1 on 4/8/25. RN 2 stated when she had previously cared for Resident 1, Resident 1 was alert, oriented, able to voice her requests with more than yes or no answers, feed herself with tray assistance and required limited to extensive assistance depending on the ADL. RN 2 stated on 4/8/25, RN 1 indicated Resident 1 was lethargic and required extra work in order for her to swallow her medications on her shift. RN 2 stated at no time did RN 1 state that Resident 1 required a finger sweep of the mouth because she was pocketing medications or was at risk for choking during her shift. RN 2 stated it is not a normal standard of practice in the facility for a nurse to place a gloved hand in any resident's mouth to make sure they swallow their medications. RN 2 stated when it comes to a full neurological assessment, that would include vital signs, checking pupils, assessing range of motion and strength, assessing gait balance, sensation as well as level of consciousness. RN 2 stated assessment findings should have been reported in detail to the primary physician overseeing the resident. RN 2 stated after her assessment of Resident 1 she called the primary physician to report Resident 1's change in condition and Resident 1 was sent to GACH A.During an interview on 1/5/26 at 12:35 p.m., with the Physical Therapist (PT)1, PT 1 stated she was Resident 1's primary therapist during her stay. PT 1 stated Resident 1 was working hard and making progress in multiple aspects as she was eager to go back home with her daughter. PT 1 stated normally Resident 1 was very vocal, spoke in complete sentences, was out of bed in her wheelchair often and was fully aware of her condition, status and environment. PT 1 stated Resident 1 was a very motivated individual.During an interview on 1/5/26 at 12:40 p.m., with the DON, the DON stated Resident 1's baseline included Resident 1 being able to speak in complete sentences, including voicing concerns of pain. The DON stated Resident 1 was able to eat independently with tray set up and prior to 4/8/25, Resident 1 did not have any documented incidents of pocketing medications or food in the medical record. The DON stated Resident 1 was showing progress in occupation and physical therapy notation. The DON stated Resident 1 had acute changes from her baseline. The DON stated RN 1 failed to communicate all information from initial assessment to the primary physician and failed to conduct and document a full neurological assessment that would have included assessing mental status and level of consciousness, pupillary response, motor strength, sensation and gait. During a review of Resident 1's Electronic Medication Administration Record (EMAR), dated 4/8/25 at 2 p.m., the EMAR indicated, . Sodium Chloride Oral (oral medication or supplement containing the chemical compound for salt that functions as an electrolyte replenisher) tablet 1 gram (gm- unit of measurement) . administered by Registered Nurse (RN) 1.During a review of the facilities document titled Nurses Notes for Resident 1 dated 4/8/25 at 8:30 p.m., the Nurses Notes indicated, .Ambulance transported [Resident 1] . to [GACH A] for [Altered Mental Status] .During a review of Resident 1's Emergency Department Provider Notes (GACH A), dated 4/8/25 at 9:17 p.m., the Emergency Department Provider Notes indicated .Patient [arrived to Emergency Department at 8:48 pm] with Altered mental status from [Skilled care facility], staff said [last seen normal] at 2 p.m., decreasing mental status all day, [Emergency Medical Services] found her [Glasgow Coma Scale] of 3 (a score of 3 on the Glasgow Coma Scale, the lowest possible, indicating a patient is in the deepest coma, completely unresponsive).per daughter, patient has been altered since 10 am . [Computer Tomography (medical imaging technique using X-rays and a computer to create detailed cross-sectional slices of the body to diagnose illness, injury, or plan treatments)] of head performed at 9:05 pm .intraparenchymal hemorrhage (bleeding that occurs directly within the brain's functional tissue).intubation (someone who has a breathing tube placed through their mouth or nose into their windpipe to keep the airway open, support breathing) conducted at 9:15 pm.transfer to (GACH B) intubated due to intracranial bleed and Neuro consult.During a review of Resident 1's Emergency Department (ED) Disposition (GACH B), dated 4/8/25 at 11:54 p.m., the ED disposition indicated, . 81 [year old] [female] prior medical history of atrial fibrillation, hypertension, diabetes mellitus present to [offsite hospital] from skilled nursing facility for [Altered mental status] patient has Glasgow Coma Scale of 3 (a score of 3 on the Glasgow Coma Scale, the lowest possible, indicating a patient is in the deepest coma, completely unresponsive). on scene [last known well] was [2 pm], imaging at [offsite hospital] shows a large right sided temporal parietal [intraparenchymal hemorrhage (bleeding that occurs directly within the brain's functional tissue)] . Case and imagining [discussed with] attending, this is a devastating brain bleed, surgical interventions for any meaningful recovery very unlikely.During a review of Resident 1's Expiration Discharge summary, dated [DATE], the Expiration Discharge Summary indicated, .81 [year old] .arrived to [GACH B] on 4/8[2025] as a transfer from [GACH A] for higher level of care after having been found to have a large right side intraparenchymal hemorrhage (bleeding that occurs directly within the brain's functional tissue) in the right temporoparietal region (bleeding that occurs in the area of the brain or skull involving both the temporal and parietal bones or lobes) greater than 1 centimeter (cm-unit of measurement) of leftward midline shift. Reportedly had gradual decline in her exam throughout the day on 4/8/25, last seen awake/talking [at] 2pm. Found by nursing staff in evening as [Glasgow Coma Scale] of 3. Intubated (someone who has a breathing tube placed through their mouth or nose into their windpipe to keep the airway open, support breathing) at sending facility [GACH A]. Found to have hemorrhage leading to transfer. Family opting to transition to comfort measures. admitted to Neurocritical unit for ongoing supportive care.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised dated 2/2021, the P&P indicated, .the nurse will notify the resident 's attending physician or physician on call when there has been a .significant change in the resident 's physical/emotional/mention condition .refusal of treatment.A significant change of condition is a major decline or improvement in the resident 's status that : . will not normally resolve itself without intervention by staff or by implement standard disease related clinical interventions. impact more than once area of the residents health status. ultimately is based on the judgment of the clinical staff .prior to notifying the physician or healthcare provider, the nurse will make detailed observations, gather relevant and pertinent information for the provider. the nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status .During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, revised dated 8/2022, the P&P indicated, .Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting changes of condition consistent with their scope of practice and responsibilities.During a review of the facility's Job description titled, Registered Nurse (RN), signed by RN 1 dated 10/17/22, the job description indicated, .consult with the resident, his/her family, and the residents physician in planning the residents care, treatment.Review nurses notes to ensure that they are informative and description of the nursing care being provided, that they reflect the residents response to the care, and that such care is provided in accordance with the resident wishes. Notify the resident's attending physician and next of kin when there is a change in the resident's condition. evaluate each residents physical and emotional status. report problem areas.demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. knowledgeable of nursing and medical practices and procedures.During a review of a professional reference titled, Change in Mental Status, dated [DATE], retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441973, the professional reference indicated .Altered mental status is a common presentation. It is important to recognize the early signs of altered mental status, identify the underlying cause, and to provide the appropriate care to reduce patient morbidity and mortality. Changes in consciousness can be categorized into changes of arousal, the content of consciousness, or a combination of both. Arousal includes wakefulness and/or alertness and can be described as hypoactivity or hyperactivity, while changes in the content of consciousness can lead to changes in self-awareness, expression, language, and emotions. When eliciting a history from a patient who presents for altered mental status, it is important to obtain information both from the patient and from collateral sources (e.g., parents, children, friends, emergency management services, bystanders, the patient's primary physician). This information can provide more insight regarding the chronicity of the change, precipitating factors, exacerbating or relieving factors, and recent as well as chronic medical history. When performing a physical exam, start with a primary survey (assessing the patient's airway, spontaneous respirations, pulses and heart rate, the level of consciousness). Make sure to expose the patient and check their back and extremities for signs of trauma. or infection. Then, perform a secondary survey, with careful attention to the pupillary and neurologic exam. Patients with a change in mental status are best managed by an interprofessional team that includes a neurologist, internist, psychiatrist, a radiologist, and an emergency department physician. Because there are numerous causes of mental status changes, a thorough history is necessary. While the patient is being worked up, the patient with acute mental status changes needs to be monitored by a nurse. The nursing staff should update the team about changes in the condition of the patient. Close communication should be made with the other healthcare professionals so that no serious cause of mental status changes is missed.During a review of a professional reference titled, Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety, dated September 2009, retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC2757754, the professional reference indicated . Clear and complete communication between health care providers is a prerequisite for safe patient management.Communication between healthcare workers accounts for the major part of the information flow in healthcare and growing evidence indicates that errors in communication impact on patient safety.nurse competency and preparedness are key components of nurse-physician communication about patient issues.There is evidence that clear communication is associated with improved quality of care and patient outcomes.During a review of a professional reference titled, Golden hour management in the patient with intraparenchymal cerebral hemorrhage: an Italian intersociety document, dated May 9,2025, retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC12065239/ the professional reference indicated . Spontaneous intracerebral hemorrhage (ICH- bleeding inside the skull without trauma) accounts for 9-27% of all strokes (medical emergency where blood flow to part of the brain is cut off )worldwide and is associated with high mortality (death, especially on a large scale) and disability. The main causes include vascular malformations (abnormality of blood vessels), small- and large-vessel angiopathies (disease affecting the blood vessels), and coagulation disorders (conditions that affect the blood's clotting activities). Mortality rates reach approximately 40% in 1 month and 54% in 1 year, largely influenced by early management decisions. Rapid intervention, particularly within the first hour, is crucial. Early intervention within

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice to prevent pressure ulcers (PU- a localized injury to the skin and underlying tissues) for one of four residents (Resident 1) when licensed nurses assessed Resident 1 upon admission on [DATE] and were aware of the Resident 1's high risk for pressure ulcers and did not implement effective interventions to prevent pressure ulcers such as changes for size, dimension, weekly description. Resident 1 was assessed to have a stage 2 (a partial-thickness skin injury that involves damage to the epidermis (outer layer of skin) and extends into the dermis (middle layer of skin) pressure ulcer on 5/5/25 and nurses did not implement interventions to prevent wound progression.Resident 1 was diagnosed by a wound specialist physician with an unstageable (a type of pressure injury where the depth of the wound cannot be determined because it is covered by slough or eschar. Slough is yellow, gray, or green dead tissue, while eschar is a hard, black or brown crust that covers the wound.) pressure ulcer on 6/9/25 and required wound vacuum (wound vac-medical device that uses suction to promote wound healing) for healing. These failures resulted in an avoidable Stage 2 pressure ulcer to left buttocks and shearing (a type of skin damage that occurs when tissue layers are pulled in opposite directions, causing them to separate) to the right buttocks that progressed to two avoidable Stage 4 (a severe form of pressure injury that involves full-thickness tissue loss, exposing bone, tendon, or muscle) pressure ulcers (left and right buttocks), suffering, pain and loss of mobility. Resident 1 stated because of the pressure ulcers he acquired, he did not feel the facility acted promptly in providing the care he needed to improve, which caused him to limit his rehabilitation because he was concerned about his wounds. Resident 1 made the decision to be discharged home on 8/8/25 with wound care and wound a vac because he was not accepted at another facility due to his wounds. Resident 1 experienced psychosocial harm when he felt hopeless in his recovery and did not feel the facility addressed his psychosocial needs and quality of care. During a review of Resident 1's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted from the general acute care hospital to the facility on 5/2/25. Resident 1 has a history that includes but not limited to cervical vertebral fracture with surgical intervention(a break in one or more of the seven vertebrae (bones) that make up the neck that required a surgical procedure to repair and stabilize structure), impaired/decrease mobility (a limitation in the independent and purposeful movement of the body or one or more extremities), idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic bodily functions, such as heart rate, blood pressure, digestion, and bladder function), ankylosing spondylitis (a chronic inflammatory disease that primarily affects the spine), cirrhosis of the liver (disease characterized by the formation of scar tissue (fibrosis) that replaces healthy liver cells), muscle weakness (a decreased ability of muscles to generate force or contract effectively), and neuromuscular dysfunction of the bladder (nerve damage to the brain, spinal cord, or peripheral nerves disrupts the coordination between the nerves and muscles needed to store and empty urine).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (the process of acquiring knowledge and understanding through thought, experience, and the senses) and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating no cognitive impairment.During an interview and observation on 8/4/25 at 3:45 p.m., with Resident 1, Resident 1 was observed up in his wheelchair with a wound vac attached along the side of the wheelchair, Staff wheeled Resident 1 to a private area at his request for the interview. Resident 1 stated he was not comfortable discussing his care with the facility staff around because he stated he had concerns with the care he received. Resident 1 stated, he came into the facility with hopes of rehabilitating. Resident 1 stated he wanted to go home after he improved with physical therapy but stated that it did not occur in the facility because he was concerned about his wounds which he felt interfered with his physical therapy. Resident 1 stated, the facility delayed treating his wounds to his buttocks which caused him to lose hope for his recovery and interfered with his physical therapy and rehabilitation. Resident 1 stated, he mentally, physically and emotionally has declined since his arrival into the facility. Resident 1 stated the care he received did not meet his expectations for care and rehabilitation. Resident 1 stated, he came into the facility without any wounds and now has plans to discharge home with two wounds to his buttocks and a wound vac (medical device that uses suction to promote wound healing) in place. Resident 1 felt the facility should have taken actions once his wounds were initially identified to prevent them from getting worse and to work on healing them. Resident 1 stated he was told he could not go to another facility for rehabilitation because other facilities denied him due to his wounds. Resident 1 stated his wounds had limited his ability to receive further physical therapy. Resident 1 stated I came here for therapy the wounds have affect me enough where I can't do therapy to get better. I will refuse therapy because of my wounds, yes, they will give me pain medications, but I don't feel like going. I came to do therapy, I didn't come here to get wounds. Resident 1 stated he had a meeting with the facility leadership regarding his concerns, and he was told things would get better but remained the same.During a review of Resident 1's electronic medical record admission Summary Note, dated 5/2/25, the admission Summary Note indicated Resident 1 did not have any open skin areas to his buttocks.During a concurrent interview and record review on 9/24/25 at 10:30 a.m., with the Director of Nurses (DON), Resident 1's electronic medical record, Skin/Wound Note, dated 5/5/25, and IDT (IDT-a collaborative group of healthcare professionals and other relevant individuals who work together to plan, coordinate, and deliver care for a patient or resident) Note dated 5/16/25 were reviewed. The Skin/Wound Note on 5/5/25 indicated, . Primary medical provider reassessed skin and noted stage 2 PU to left buttocks. The DON stated, the IDT Note dated 5/16/25 indicated the wound was present on admission but that was not accurate. The DON stated the wound was observed three days post admission. The DON stated there were no facility records indicating it was identified on admission. The DON stated that the pressure ulcer found on 5/5/25 on Resident 1's left buttocks was a facility acquired. The DON stated Resident 1 had the standard interventions implemented on admission for all residents which included baseline labs and turning and repositioning. The DON stated wound treatment for Resident 1's left buttock started on 5/5/25 and was measured on 5/5/25 as 2 cm x 2 cm (centimeters (cm)a unit of measurement) the wound was measured on 5/16/25 and 5/22/25 with the same measurements. The DON stated the next measurement was not until 6/9/25 when the wound specialist completed an assessment and Resident 1's left buttock wound measured 4.5 cm x 3 cm and a second wound on the right buttock measuring 5 cm x 3 cm was identified. The DON stated the treatment nurse should follow professional standards for wound care and should have been documenting any changes for size, dimension, and description every week and as needed during daily treatments for Resident 1. The DON stated, because Resident 1 had a specific insurance group she did not initiate a wound consultation with a facility wound specialist until 6/9/25.During a concurrent interview and record review on 9/24/25 at 11:30 a.m., with the licensed vocation nurse (LVN 1), Resident 1's electronic medical record, Skin & Wound Evaluation, dated 5/5/25,5/16/25,5/22/25 and 6/9/25 were reviewed. The Skin & Wound Evaluation on 5/5/25 indicated, .stage 2 PU to left buttocks 2cm x 2cm. on 5/16/25 .stage 2 PU to left buttocks 2cmx2cm. on 5/22/25 .stage 2 PU to left buttocks 2cmx2cm. on 6/9/25 .left buttocks PU unstageable 4.5x3cm and right buttocks shearing 5cmx3cmx0.1cm. LVN 1 stated she is the facility treatment nurse and her roles and responsibilities include measuring residents' wounds weekly in order to identify if wounds are healing and treatment is appropriate. LVN 1 stated Resident 1's wound measurements were not conducted from 5/23/25 to 6/9/25 per professional standards that the facility follows. LVN 1 stated it would have been difficult to determine if Resident 1's wound was healing without an accurate assessment and measurement. LVN 1 stated she did not measure Resident 1's wounds weekly and missed it. LVN 1 stated from the measurement taken on 5/22/25 to wound specialist assessment on 6/9/25 new shearing was found on Resident 1. LVN 1 stated on 6/6/25 during assessment with Resident 1's primary care provider identified a second wound, and it was not measured. LVN 1 stated no staff documented any measurement changes from 5/23/25 to 6/9/25. LVN 1 stated it was not until the facility wound specialist assessed Resident 1 that additional wound measurements were conducted. LVN 1 stated the wound specialist assessed Resident 1 as having an unstageable PU to left buttock and a shearing to the right buttock. LVN 1 stated she is not wound certified but was trained by a previous wound nurse. LVN 1 stated in her new role as a treatment nurse she did not realize she missed the measurements for Resident 1. LVN 1 stated it is important to relay detailed information concerning wounds to a resident's primary care physician or wound specialists to identify further needs for each resident, this did not occur for this Resident 1 and his wounds worsened.During a concurrent interview and record review on 9/24/25 at 1:50 p.m., with the licensed vocation nurse (LVN) 2, Resident 1's electronic medical record, admission Summary Note, dated 5/2/25, was reviewed. LVN 2 was the admitting nurse for Resident 1. The admission Summary Note indicated, LVN 2 completed a full body assessment of Resident 1 on 5/2/25. LVN 2 stated he documented two surgical sites (chest and neck) on Resident 1. LVN 2 stated there was no visible skin breakdown to Resident 1's buttocks. LVN 2 stated that he is knowledgeable in wound care and is certified from an wound care certification program and would be able to identify the presence of pressure ulcers or injuries. LVN 2 stated, Resident 1's Braden scale (used to predict a patient's risk for developing pressure injuries: 19-23 No Risk, 15-18 Mild Risk, 13-14 Moderate Risk, 10-12 High Risk, and 9 or less Severe Risk) score was 17 which indicated resident was at mild risk for skin breakdown. LVN 2 stated, standard interventions used for Resident 1 included turning and repositioning every two hours, and baseline labs.During a concurrent interview and record review on 9/24/25 at 2:03 p.m., with the licensed vocation nurse (LVN) 3, Resident 1's electronic medical record, Skin & Wound Evaluation, dated 5/5/25,5/16/25,5/22/25 and 6/9/25 was reviewed. LVN 3 stated she was not aware that Resident 1 was admitted with any pressure ulcers. LVN 3 stated during the weeks of 5/26/25 to 6/7/25 she worked two times on the floor as the fill in treatment nurse and, there was no instruction indicating she was required to or that it was necessary to measure Resident 1 wounds. LVN 3 stated, she was not aware that the usual wound specialist was not overseeing the wound care for Resident 1 per the facilities (professional) standards. LVN 3 stated she assumed that all wounds were measured and accounted for every Monday by the full-time treatment nurse. LVN 3 stated she did not measure Resident 1 wounds on the days she covered for the full-time treatment nurse. LVN 3 stated because she used her naked eye to assess Resident 1's wounds she believed there was not a change of condition. LVN 3 stated wounds require measurement and detail explanation of appearance, to communicate to physicians. LVN 3 stated, since Resident 1 developed two different pressure ulcers at the facility, she would consider the standard interventions that were put into place inadequate and insufficient based on the needs of Resident 1. LVN 3 stated it is the responsibility of staff to assess skin.During an interview on 9/24/25 at 2:25 p.m., with the DON. The DON stated Resident 1's skin was assessed for the first time on 6/9/25 by the wound specialist. The DON stated Resident 1 wound assessments included two separate PUs to left and right buttocks The DON stated Resident 1's wound to the left buttock was 4.5cmx3cm and newly identified wound to the right buttock measured 5cmx3cmx0.1cm. The DON stated both wounds identified on 6/9/25 were facility acquired pressure ulcers. The DON stated, the treatment nurse failed to follow professional standards for wound care. The DON stated the required weekly assessments included gathering information to identify wound stages, drainage, and measurement of wounds which are used to communicate to the physician. The DON stated it is the expectation of the facility that professional standards of care for wounds are followed by staff. The DON stated that when wounds develop at the facility it means the interventions put into place were not sufficient. The DON stated that the facility failed to maintain the skin integrity of Resident 1 during his length of stay and limited his ability to receive physical therapy. The DON stated Resident 1 had expressed his concerns to her about his wounds interfering with his rehabilitation.During a review of Resident 1's electronic medical record Physical Therapy Missed Visit Details, dated 8/5/25, was reviewed. The Physical Therapy Missed Visit Details indicated, Resident 1 refused treatment because he was more concerned about his wounds at this time and doesn't wish to partake in physical therapy. During a review of the facilities job description manual titled, Treatment Nurse dated Feb. 2024, the job description indicated, . provide primary care to the resident under the medical direction and supervision of the residents attending physician, the DON or the Medical Director of the facility, with an emphasis on treatment and therapy of skin disorders .make written and oral reports/recommendations to the attending physician, Medical Director, or the DON concerning the status and care of the residents .work with the interdisciplinary care plan team in developing comprehensive assessment and care plan for assigned residents . provide written and/or oral status reports of residents that you are treating .evaluate and implement recommendations .identify, manage and treat specific skin disorders . provide assessment and diagnosis services to the resident .ensure that residents with decubitus ulcers (localized areas of skin damage that occur due to prolonged pressure on the body) receive appropriate prophylaxis (any measure taken to prevent disease, rather than treat it once it has occurred) and treatment daily, inspection, turning and activity .During a review of the facility policy and procedure (P&P) titled, Wound Care dated [DATE], the policy and procedure indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. review the residents care plan to assess for any special needs of the resident.obtain equipment and supplies necessary.documentation in residents medical record.type of wound.date and time wound care provided.any change.all assessment data obtained when inspecting wound. problems or complaints by the resident.report other information in accordance with facility policy and professional standards of practice.During a review of the facility policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol dated April 2018, the policy and procedure indicated, .The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length and depth, presence of exudates (fluid that leaks from blood vessels into surrounding tissues or cavities, rich in protein, cells, and solid materials) and necrotic tissue (dead or dying tissue).the staff.will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or poor-healing wounds.the physician will help identify factors contributing or predisposing resident to skin breakdown.the physician will order pertinent wound treatments, including pressure reducing surfaces, wounds cleaning and debridement (the removal of damaged tissue) approaches, dressings and application of topical agents (a medication or substance applied to a specific area of the body's surface, such as the skin) .when wounds are not healing as anticipated or new wounds develop. current approaches should be reviewed for whether they remain pertinent to the resident medical conditions, are affected by factors influencing wound development or healing and the impact of specific treatment choices.During a review of a professional reference titled, Pressure Ulcer, dated January 2024, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK553107/ the professional reference indicated . Examine the following in a patient with a PI (a localized area of skin and/or underlying tissue damage that develops when prolonged pressure or shear forces exceed the tissue's tolerance): Ulcer history, including etiology (the study of the cause or origin of a disease or abnormal condition) , duration, and previous treatment, Staging by thoroughly examining the depth of the wound, which this activity will cover in detail under staging, Size of the affected area, Sinus tracts (an abnormal, tube-like passage that connects an infected area to the surface of the skin), undermining (the lifting and separation of skin and underlying tissues), and tunneling (creating or traversing a passage), The presence of drainage, The presence of necrotic tissue. When evaluating the wound characteristics, it is also important to keep risk assessment instruments in mind to reduce the risk of a PI incidence. The primary goal is to prevent pressure injury. This goal requires an interprofessional team, including primary care providers, wound care specialists, surgeons, specialty-trained wound nurses, physical therapists, and nurse aides. Nurses provide care, monitor patients, and notify the team of issues. Nurse aides are often responsible for turning and repositioning patients.The patient should be kept pain-free by giving analgesics (medications that relieve pain) . They should try to increase physical activity, which a nurse's aide, medical assistant, or rehab nurse can facilitate. Frequent follow-ups are an absolute necessity, and a team approach to patient education and pressure injury management involving the wound care nurse and wound care clinician lead to the best results.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when on 4/23/25 to 5/12/25 ertapenem sodium (antibiotic medication used to treat bacterial infections) medication was not administered via intravenous (IV- Into or within a vein) as prescribed for one of six residents (Resident 1) and no side effects were monitored during the administration of the IV antibiotic medication while in the facility. These failures resulted in Resident 1 not receiving antibiotics as prescribed by the provider and had the potential to contribute to his transfer to a general acute care hospital (GACH) on 5/11/25 and 5/13/25. Findings: During a review of Resident 1 ' s admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/28/25, the admission record indicated, Resident 1 was admitted from the hospital to the facility on 4/22/25. The admission Record indicated Resident 1 has a history that includes but not limited to sepsis (life-threatening response to infection) Chronic Kidney Disease II ( your kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood), muscle weakness (a lack of muscle strength), type II diabetes mellitus (A disease in which glucose levels in the blood are higher than normal because the body does not make enough insulin or use it the way it should), gout (a disease in which defective metabolism of uric acid), history of urinary tract infections (an infection in any part of the urinary system) and morbid obesity (a severe form of obesity characterized by a body mass index [BMI] of 40 or higher, or a BMI of 35 or higher with obesity-related health complications) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment 4/26/25, Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 12 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had moderate cognitive impairment. During a concurrent interview and record review on 6/4/25 at 4:20 p.m., with the Registered Nurse (RN) 1, Resident 1 ' s Progress notes, dated 4/22/25 to 5/13/25 was reviewed. RN 1 stated Resident 1 was admitted to the facility on [DATE] from the general acute care hospital (GACH) for sepsis (life-threatening response to infection) and required intravenous (IV- Into or within a vein) antibiotic medication. RN 1 stated Resident 1 was alert and oriented to person, place, time and location upon admission. RN 1 stated because Resident 1 had sepsis and was receiving IV medication, Resident 1 should have been continuously monitored for changes in his vital signs, level of cognition and mental status by nursing staff and it should have been documented daily. During a concurrent interview and record review on 6/4/25 at 4:25 p.m., with RN 1, Resident 1 ' s Electronic Medication Administration Record (EMAR), dated 4/22/25 to 5/13/25 was reviewed. RN 1 stated the EMAR indicated Resident 1 missed two doses of ertapenem sodium (antibiotic medication used to treat bacterial infections) on 4/26/25 and 5/3/25 at the prescribed time of 6 p.m. RN 1 stated ten of the administered antibiotic doses given on 4/23/24 at 7:40 p.m., 4/24/25 at 9:57 p.m., 5/2/25 at 7:10 p.m., 5/4/25 at 8:47 p.m., 5/5/25 at 8:48 p.m., 5/6/25 at 10:08 p.m., 5/7/25 at 9:42 p.m., 5/8/25 at 8:00 p.m.,5/11/25 at 7:25 p.m., and 5/12/25 at 7:55 p.m. were given to Resident 1 over an hour past the prescribed time. RN 1 stated the missed doses and late administration over an hour are considered medication errors and should have been reported to the Director of Nurses, primary care physician and responsible party at the time it occurred. RN 1 stated she did not see any documentation indicating this occurred. RN 1 stated when a dose of any scheduled medication is missed or given late, it is considered a change of condition according to the facility policy and procedures and the resident should be placed under observation for side effects or further changes of condition. RN 1 stated the missed or late doses should have been documented in Resident 1 ' s chart along with Resident 1 ' s vital signs and current condition. RN 1 stated it is important for medication to be given according to physician orders; this will ensure the medication will be effective. RN 1 stated this was especially true for Resident 1 due to the bacteria present that was causing his sepsis. RN 1 stated an audit should have been conducted by the DON every 24 hours to identify missed medication or late doses, but no documentation indicating a change of condition was reported and no further communication was provided to primary care physician or responsible party. RN 1 stated we monitor side effect indicated on the EMAR, but Resident 1 did not have documentation for side effects. During a concurrent interview and record review on 6/4/25 at 4:45 p.m., with RN 1 , the facility policy and procedure (P&P) titled, Administering Medication dated, April 2019 was reviewed. The P&P indicated all medication should be provided as ordered and any medication errors should be documented and reported. RN 1 stated facility nursing staff who have missed doses or gave Resident 1 late doses of IV antibiotic medication did not follow guidelines indicated in the policy. RN 1 stated no audit was conducted indicating education was provided to nursing staff concerning missed and late doses. During a concurrent interview and record review on 6/4/25 at 4:54 p.m., with Registered Nurse (RN) 2, Resident 1 ' s Electronic Medication Administration Record (EMAR), dated 4/22/25 to 5/13/25 was reviewed. RN 2 stated Resident 1 antibiotic medication should have been given at the scheduled time of 6 p.m. RN 2 stated per documentation on in the EMAR, Resident 1 missed two doses of antibiotics on 4/26/25 and 5/3/25. RN 2 stated there were ten antibiotics doses on 4/23/24, 4/24/25, 5/2/25, 5/4/25, 5/5/25, 5/6/25, 5/7/25, 5/8/25,5/11/25, and 5/12/25 that were given over an hour past the prescribed time. RN 2 stated Resident 1 was taking the antibiotic due to sepsis. RN 2 stated she did not know what sepsis was. RN 2 stated Resident 1 ' s missed doses and late doses of antibiotic would be considered medication errors. RN 2 stated she was not able to locate documentation or communication made concerning the missed and late doses of Resident 1's antibiotic to the primary care provider, responsible party and director of nurses. RN 2 stated each missed dose and late dose provided to Resident 1 would have been considered a change of condition for Resident 1. RN 2 stated Resident 1 should have been administered antibiotics from 4/23/25 to 5/16/25. RN 2 stated notification on facility ' s electronic medical record system would have notified nurses of medication being missed or late. RN 2 stated it is expected that all medications would be provided on time as ordered by the physician. During a concurrent interview and record review on 6/4/25 at 5:15 p.m., with RN 2, Resident 1 ' s Progress notes, dated 4/22/25 to 5/13/25 was reviewed. RN 2 stated there was no documentation in Resident 1 ' s chart for missed and late antibiotic IV doses. RN 2 stated audits are conducted for missed documentation by the DON or RN supervisor daily. RN 2 stated she cannot locate any notes that were written for any missed antibiotic doses. RN 2 stated providing antibiotic IV medication was important for Resident 1 to manage the infection in the body and maintain therapeutic medication levels in the blood. RN 2 stated due to missing the doses and doses being late, this could have contributed to his hospitalization of Resident 1, since Resident 1 was already septic and had an infection. RN 2 stated all nurses failed to follow the change of condition protocols and the facility P&P for medication administration. During a concurrent interview and record review on 6/4/25 at 5:35 p.m., with the Director of Nurses (DON), Resident 1 ' s Progress notes and electronic medication administration record, dated 4/22/25 to 5/13/25 were reviewed. The DON stated Resident 1 was admitted on [DATE] for sepsis with orders of antibiotic IV therapy [brand name for ertapenem sodium] 1 gram (gm-units of measurements) to be provided every 24 hours until 5/16/25. The DON stated the facility Registered Nurses were responsible for providing IV antibiotic medication and would assist the Licensed Vocational Nurses who were overseeing the care of Resident 1. The DON stated it was the responsibility of all staff to ensure doses were being provided per primary care provider orders and that they were given on time. The DON stated Resident 1 stayed in facility from 4/22/25 to 5/13/25 and on 5/13/25 he had delusions, hallucinations, seizure like activity and involuntary shaking. The DON stated Resident 1 ' s primary care provider was in the facility and assessed Resident 1. The DON stated the responsible party was notified and Resident 1 was sent to the general acute care hospital (GACH) for further evaluation. The DON stated during Resident 1 ' s length of stay, he missed two doses of antibiotics on 4/26/25 and 5/3/25. The DON stated ten of the received doses on 4/23/24,4/24/25, 5/2/25,5/4/25, 5/5/25, 5/6/25, 5/7/25,5/8/25,5/11/25, and 5/12/25 were more than an hour past due the prescribed time in Resident 1 ' s orders. The DON stated changes of condition assessments should have been conducted because medication errors would be considered a change of condition. The DON stated, I do not see any communication being made by nursing staff regarding missed or late doses. DON stated it would have been important to communicate the medication errors to the primary care physician to determine if adjustments were required in dosages for the resident to maintain therapeutic medication level. The DON stated the medication errors were a lack of continuity of care and it had potential outcomes that include the worsening of an infection as well as being detrimental to overall health for Resident 1. During a concurrent interview and record review on 6/4/25 at 5:35 p.m., with the DON, the facility ' s [pharmacy name] Proof of Delivery dated 4/23/25 to 5/12/25 and Medication Disposition Record, dated 5/16/25 was reviewed. The DON stated [pharmacy name] Proof of Delivery indicated facility received 23 doses of ertapenem sodium antibiotic for Resident 1 from 4/23/25 to 5/12/25. The DON stated the Medication Disposition Record indicated three doses were disposed of once Resident 1 was discharged to GACH. The DON stated this would confirm that resident missed two doses of antibiotic medication during his stay at the facility and one since admitted to the GACH. During a concurrent interview and record review on 6/5/25 at 1:02 p.m., with the DON, the facilities Electronic medical record/Electronic treatment Record/IV Medication Administration Record Audit (medication audit) dated 4/23/25 to 5/13/25 was reviewed. The DON stated the Electronic medical record/Electronic treatment Record/IV Medication Administration Record Audit indicated, name of resident affected by missing information, what nurse missed the documentation, and type of missing information. The DON stated the medication audit did not include specifics as far as missing medication doses, late medication, etc. The DON stated audits go to her office and she or the assistant director of nurses (ADON) will follow up. The DON stated there is no documentation she could present that follow up of missed medication dose for Resident 1 had occurred. During an interview on 6/5/25 at 1:20 p.m., with the DON, the DON stated there were no side effects indicated in the electronic medical record for the IV medication that was administered to the resident. The DON stated antibiotic stewardship is to ensure antibiotics are used properly for the appropriate diagnosis with the appropriate monitoring that includes side effects. The DON stated it is important to monitor the side effects for primary care physicians to address concerns and adjust dosage or change medication as needed based on side effects. During a review of the facility policy and procedure (P&P) titled, Administering Medications dated April 2019, the policy and procedure indicated, .Medications are administered in a safe and timely manner, and as prescribed . medications are administered in accordance with prescriber orders, including any required time frame .medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staff training . medications are administered within (1) hour of their prescribed time . if a dosage is believe to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber to discuss concerns .the individual administering the medication records in the residents medical record: the date and time the medication was administered . the signature and title of the person administering the drug . During a review of the facility policy and procedure (P&P) titled, Change in Resident Condition or Status dated February 2021, the policy and procedure indicated, .The nurse will notify the resident attending physician or physician on call when . significant change in the resident physical/emotional/mental condition . need to alter the resident medical treatment significantly . need to transfer the resident to a hospital .a significant change of condition is a major decline or improvement in the resident status that will not normally resolve itself without interventions by staff or by implement standard disease related clinical interventions . requires interdisciplinary review and /or revision to the care plan and ultimately is based on the judgment of the clinical staff .regardless of the resident current mental and physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatment . the nurse will record in the resident ' s medical record information relative to the changes . During a review of professional reference from the National Library of Medicine titled, Nursing Rights of Medication Administration, dated September 2023, the professional reference indicated .Nurses have a unique role and responsibility in medication administration . It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ' five rights ' or ' five R ' s ' of medication administration . sequence include: . ' Right patient ' – ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed . ' Right drug ' – ensuring that the medication to be administered is identical to the drug name that was prescribed . ' Right Route ' – Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration . ' Right time ' – administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level . ' Right dose ' – Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error .

Based on observation , interview and record review, the facility failed to recognize and appropriately act on a change in condition for one of three sampled residents, Resident 1, when staff were provided a list of medications on Resident 1's admission on 1/30/25 that included insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) and did not inform the physician. Nursing staff were aware of the diagnosis of diabetes (a disease that occurs when sugar in the blood is too high) and did not closely monitor symptoms of hyperglycemia (high blood sugar), nausea and malaise (general feeling of discomfort) and did not inform the physician of high blood glucose (sugar) measurements. These failures resulted in Resident 1 not being managed appropriately for diabetes, to not receive needed insulin medication to control high blood glucose, experienced several days of feeling unwell, nauseous and malaise and required emergently being transferred to an acute care hospital on 2/10/25. During admission, Resident 1 was diagnosed with uncontrolled hyperglycemia, Diabetic Ketoacidosis (DKA- a complication of diabetes in which acids build up in the blood to levels that can be life-threatening) and sepsis (body's extreme response to an infection a life-threatening medical emergency) he was hospitalized for nine days and was discharged back to the facility on [DATE]. Findings: During a review of Resident 1's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/19/25, the admission record indicated, Resident 1 was admitted from the hospital to the facility on [DATE]. The Admission Record indicated Resident 1 has a history that includes but not limited to muscle wasting and atrophy ( is the wasting or thinning of your muscle mass leading to muscle weakness), Crohn's Disease (an inflammatory bowel disease that causes chronic inflammation of the GI tract), Chronic Kidney Disease III ( your kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood), Muscle Weakness (a lack of muscle strength), and diabetes type II (high levels of sugar in the blood) chronic pain syndrome (persistent pain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had no cognitive impairment. During a concurrent observation and interview on 4/22/25 at 2:22 p.m., with Resident 1 in his room, Resident 1 was resting in bed comfortably, dressed appropriate for the season and doing better since his last hospitalization . Resident 1 stated on his first admission to the facility from 1/30/25 to 2/10/25 he did not receive his insulin medication. Resident 1 stated the facility did not provide him with his insulin and he had to go to the hospital due to his diabetes being too high . Residents 1 stated his daughter-in-law gave the facility admission nurse his home medication list when he was admitted on [DATE] and Resident 1 did not understand why the facility would not follow what his doctor had previously prescribed. Resident 1 stated he felt ill days prior to being sent out to the hospital on 2/10/25 and it wasn't until he was sent to the hospital that he was told at the hospital his sugar was high . During a record review of Resident 1's Diabetes Care Plan, dated 2/1/25, the Diabetes Care Plan indicated, .Resident has a diagnosis of diabetes and is at risk for complications on hypo(low)/hyperglycemia (low blood sugar) . administer medications as ordered . diet as ordered . educate on the signs and symptoms of hypo/hyperglycemia and to report promptly . interventions to manage hypo/hyperglycemia episodes as indicated . monitor for signs of hypo/hyperglycemia . During a concurrent interview and record review on 4/22/25 at 2:43 p.m., with License Vocational Nurse (LVN) 1, Resident 1's electronic medical records, Admission/Readmission Evaluation/Assessment and Home Medications, dated 1/30/25 were reviewed. LVN 1 stated, he was aware the family provided the admission nurse with a list of home medications for Resident 1, and the expected normal process was to document order verification for all medications. The admission nurse did not do that for Resident 1. LVN 1 stated telephone communication to the primary care providers should have included the medications that were continued as well as discontinued to clarify the appropriate medications, dosages and frequency to continue while Resident 1 was in the facility. LVN 1 stated that since appropriate communication did not occur, Resident 1 did not receive medication needed to manage his diabetes which placed Resident 1's health and well-being in danger and possibly caused his hospitalization . During a concurrent interview and record review on 5/7/2025 at 9:14 a.m., with the Director of Nurses (DON), Resident 1's electronic medical records, Admission/Readmission Evaluation/Assessment and Home Medications, dated 1/30/25 were reviewed. The DON stated the home medication list provided by family indicated Resident 1 was on insulin (medication used to turn food into energy and mange blood sugar levels) prior to admission and the admission nursing staff did not clearly identify or clarify what medications listed on the home medication list were to be continued or discontinued in her summary note documentation. The DON stated that her expectations are for nursing staff to contact the primary care physician or nurse practitioner and verify all medications listed on provided medication list in order to identify each individual medication and document. During a concurrent interview and record review on 5/7/2025 at 9:22 a.m., with the DON, Resident 1's electronic medical record, Blood Sugar Summary and Order Summary Report, dated 1/30/25 to 2/9/25 were reviewed. The DON confirmed that Resident 1's blood sugar ranged from 79 milligrams per deciliter (mg/dl-unit of measurement) to 389 mg/dl. The DON stated normal blood sugar ranges from 70mg/dl to 110 mg/dl for diabetic residents. The DON stated Resident 1's doctors' orders dated 1/30/25 to 2/9/25 indicated to Notify MD if blood sugar is less than 70 and/or greater than 400. The DON stated the physicians should have been notified regardless, because of the range. The DON stated there was no indication that nursing staff notified the primary care provider of blood sugar ranges prior to Resident 1 being sent to the hospital. During a concurrent interview and record review on 5/7/2025 at 9:30 a.m., with the DON, Resident 1's electronic medical records, Home Medications dated 1/30/25 and Order Summary Report, dated January 2025 and February 2025 were reviewed. The DON stated home medications provided by the family should have been clarified and listed individually with date and time of acknowledgment to verify which medications were to be continued in the facility. The DON stated the Home Medication list has markings with unknown origin and no signatures, dates or times documented on sheet. The DON stated it is not clear what medications were verified for Resident 1. The DON stated that because of the missed insulin order for Resident 1, it was a potential factor that could have caused Resident 1 to be admitted for DKA and his hospital admission. During a concurrent interview and record review on 5/7/25 at 10:25 a.m., with Registered Nurse (RN) 1, Resident 1's electronic medical records, Admission/Readmission Evaluation/Assessment and Home Medications, dated 1/30/25 were reviewed. RN 1 stated insulin was indicated on home medications list and should have been continued or clarified by primary care provider. RN 1 stated she is unsure if clarification was obtained by the primary care provider with the admission nurse. RN 1 stated nursing staff should have documented in detail what medications were discussed with the primary care provider during admission evaluation/assessment to verify if any home medications would be continued. RN 1 stated Resident 1 was not on any insulin during his time at the facility from 1/30/25 to 2/10/25 but was receiving blood sugar checks three times a day. During a concurrent interview and record review on 5/7/25 at 10:30 a.m., with RN 1, Blood Sugar Summary, dated 1/30/25 to 2/9/25 were reviewed. RN 1 stated a baseline blood sugar ranges from 70-100 mg/dl and if they are diabetic anything less than 200 is best. RN 1 stated Resident 1's ranges from 79-389 mg/dl which are not within normal ranges and should have been communicated with the primary care provider. RN 1 stated the blood sugar ranges that were documented for Resident 1 should have prompted staff to place Resident 1 under change of condition protocol, due to abnormal blood sugar ranges, this did not occur. RN 1 stated due to the lack of insulin and failure to follow up on communication with primary care providers concerning Resident 1's abnormal blood sugars, these items could have potentially caused Resident 1's admission to the general acute care hospital (GACH) for DKA. During a concurrent interview and record review on 5/12/25 at 1:30 p.m., with the Registered Dietitian (RD), Resident 1's electronic medical records, Admission/Readmission/Evaluation/Assessment, dated 1/30/25 were reviewed. The Admission/Readmission/Evaluation/Assessment, indicated Resident 1 was placed on a regular diet without restrictions. The RD stated he is to evaluate all residents within seven days of admission to determine adequate nutritional needs are met with diet. The RD stated Resident 1 was admitted on [DATE] to 2/10/25 and he did not complete an assessment for Resident 1. During a concurrent interview and record review on 5/12/25 at 2:22 p.m., with the Assistant Director of Nurses (ADON), Resident 1's electronic medical records, Blood Sugar Summary, dated 1/30/25 to 2/9/25 were reviewed. The ADON stated baseline blood sugar ranges from 70-100 mg/dl and 70-120 mg/dl for diabetics. Resident 1 had blood sugar ranges from 79-389 mg/dl which should have been documented as out of range and should have been communicated to primary care providers. The ADON stated there is no documentation indicating any nursing staff communicated blood sugar ranges for Resident 1 to primary care provider. The ADON stated that by not communicating blood sugars, the patient can have uncontrolled blood sugars that can cause further harm to the resident if not treated on time. The ADON stated the abnormal blood sugar ranges should have triggered nursing staff to place resident under a change of condition charting. The ADON stated nursing staff did not indicate a change of condition for Resident 1. The ADON stated the facility was monitoring Resident 1's blood sugars but not communicating them to the primary provider. The ADON stated facility staff did not provide Resident 1 with his insulin and Resident home insulin orders were not clarified upon admission. The ADON stated the facility potentially caused the DKA by not providing the insulin to Resident 1. The ADON stated failure to document precise information caused confusion in medication orders which caused residents to not have his insulin. During a record review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Communication Form, dated 2/10/25, the SBAR Communication Form indicated, . The change in condition, symptoms or signs observed and evaluated is/are: Abnormal vital signs .Nausea/Vomiting . started on 2/10/25 .Vital signs (reflect essential body functions) .Blood Pressure (the pressure of the blood in the circulatory system) 60/37 (normal ranges for 60 + age group is 133-139/68-69 ) . pulse (the regular movement of blood through your body that is caused by the beating of your heart) 118 (normal ranges 60-100 beats per minute- units of measurement) .Respirations (the process of breathing) 19 (normal ranges 12-18 breaths per minute- units of measurement) .Temperature (the degree of hotness or coldness of an object) 97.8 (normal ranges 97-99 Degree Fahrenheit- units of measurement) .Summarize .observation and evaluation .writer went in to the resident room to give routine meds. Writer notified by the CNA (certified nursing assistant) that residents BP (Blood Pressure) had been low. Upon initial assessment, the resident complained of nausea and feeling weak. Writer took blood pressure manually and got a reading on 62/34. During this time the resident had green emesis (vomiting) .daughter in law was notified and wanted to send resident to acute care. Doctor agreed and emergency medical services was called at [9:42 a.m.] . Resident taken by gurney During an interview on 5/19/25 at 3:30 p.m., with the DON, the DON stated, change of condition assessments should be conducted when there are abnormal changes in the resident's condition. The DON stated facility staff failed to accurately identify, verify or document in Resident 1's chart any communication made to primary care providers regarding his insulin, the home medication list or blood sugar readings while being cared for in the facility. The DON's expectations are for detailed events to be documented for each resident to indicate what was discussed, what medications should be continued as well as discontinued as well as indicating any communications made for blood sugars being monitored since staff were taking blood sugars, but no one communicated them. The DON stated there is no record of medication reconciliation between two nurses for Resident 1 as indicated in the facility's policy and procedures titled, Reconciliation of Medications on admitted d July 2017. The DON stated for Resident 1 who was diabetic, not on insulin and getting finger blood sugar checks three times a day, she would have expected the staff to address the change of condition with the MD. The DON stated that a diabetic resident with no insulin administration, abnormal blood sugar ranges required MD notification to make sure the MD is aware of the resident's condition and to give the MD an opportunity to adjust the residents' plan of care. The DON stated potentially that the lack of insulin could have contributed to his admission to the acute care hospital. During a record review of Resident 1's Emergency Department (ED) Provider Notes, dated 2/10/25, the ED Provider Notes indicated, Resident 1 .presented to the emergency department for vomiting and diarrhea. He was severely hypotensive (low blood pressure) but improved with IV (intravenous - a medical technique that administers fluids, medications and nutrients directly into a person's vein) fluids. He is severely acidotic (when acid builds up in your body) and has hyperkalemia (high levels of potassium in the body) . During a record review of Resident 1's General Acute Care Hospital Assessment and Plan for admitted d on 2/11/25, the Assessment and Plan indicated, . [Resident 1] was being admitted for sepsis and Diabetic Ketoacidosis (DKA- a complication of diabetes in which acids build up in the blood to levels that can be life-threatening) . The patient presented with nausea, vomiting, and diarrhea that has been ongoing for couple days. The skilled nursing facility staff reported subjective fever, productive cough and dysuria (painful or uncomfortable sensation experienced during urination) . He was found to be hypotensive at the skilled nursing facility, so he was transferred .in the emergency department (ER) . white blood count (WBC- a test that measures the number of white blood cells in your body) 27.4 (normal ranges 4.5-11.0) . potassium(It helps your nerves to function and muscles to contract) 6.9 (normal ranges-3.6-5.2) .bicarb (a byproduct of your body's metabolism) 12 (normal ranges 22-29), Glucose (sugar level in blood) was 496 During a review of the facility policy and procedure (P&P) titled, Diabetes- Clinical Protocol dated March 2025, the P&P indicated, .For resident with confirmed diabetes, the nurse will assess and document/report the following during the initial assessment . history of medication management . all other current medications . resident blood sugar history over 48 hours . where insulin is indicated, simplified treatment regiments are preferred .the staff will identify and report issues that may affect, or be affected by, a patients diabetes and diabetes management .hyperglycemia . staff will notify the practitioner as soon as possible . During a review of the facility policy and procedure (P&P) titled, Change in Resident Condition or Status dated February 2021, the policy and procedure indicated, .The nurse will notify the resident attending physician or physician on call when . significant change in the resident physical/emotional/mental condition . need to alter the resident medical treatment significantly . need to transfer the resident to a hospital .a significant change of condition is a major decline or improvement in the resident status that will not normally resolve itself without interventions by staff or by implement standard disease related clinical interventions . requires interdisciplinary review and /or revision to the care plan and ultimately is based on the judgment of the clinical staff .regardless of the resident current mental and physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatment . the nurse will record in the resident's medical record information relative to the changes . During a review of the facility policy and procedure (P&P) titled, Reconciliation of Medications on admitted d July 2017, the policy and procedure indicated, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility . Gather the information needed to reconcile the medications list . all prescription and supplement information obtained from the resident/family during the medication . Medication reconciliation is the process of comparing pre-discharge medications to the post discharge medications by creating an accurate list of both prescription and over the counter mediations that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care . if a medication history has not been obtained from the resident or family, complete this first. Information for the medication history should include prescription medications, including those taken only as needed . dose, route, frequency, and last dose taken for all items .document the medications discrepancies on the medication reconciliation form If the discrepancy was resolved, document how the discrepancy was resolved . During a review of professional reference from the American Diabetes Association (ADA) titled, Standards of Medical Care in Diabetes, dated January 2024, the professional reference indicated .Insulin therapy remains essential for individuals with type 1 diabetes and is often necessary for individuals with type 2 diabetes when glycemic goals are not met with oral agents. Insulin is the most effective agent in lowering blood glucose and reducing the risk of diabetes-related complications when used appropriately .continuous glucose monitoring are essential components of effective diabetes management, allowing for timely adjustments in therapy and prevention of hypoglycemia and hyperglycemia . During a review of professional reference from the Academy of Nutrition and Dietetics titled, Nutrition intervention and monitoring in long-term care settings for individuals with diabetes, dated September 2018, the professional reference indicated .In long-term care and skilled nursing facilities, individualized nutrition therapy is critical for optimizing glycemic control, maintaining nutrition status, and improving quality of life in resident with diabetes. Liberalized diets and consistent carbohydrate meal planning are recommended to enhance adherence and satisfaction while preventing complications .

Based on observation, interview and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. The facility had a large clear plastic container with red gelatinous (jelly like substance) without any labels to identify product in container, open date or expiration date was in the kitchen refrigerator. 2. The facility had a large, opened container of mayonnaise without open date or expiration date was in the kitchen refrigerator. 3. The cook did not take the temperature of the tray of cauliflower taken out of the oven during the lunch tray line service. 4. The facility failed to store food in Resident 146's room in a safe manner. These failures had the potential for exposure of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) of residents' food, staff lunch bags and cups resulting in food-borne illness (stomach illness acquired from ingesting contaminated food). Findings: 1. During a concurrent observation and interview on [DATE] at 7:30 a.m. with the Dietary Manager (DM), in one of two refrigerators, red gelatinous (jelly like substance) without any labels to identify product in container, open date or expiration date was in the kitchen refrigerator. The DM stated, the container should have been labeled identifying what was in the container and when it was opened and when it expired to prevent the residents from being served expired foods which could lead to food born illness. 2. During a concurrent observation and interview on [DATE] at 7:35 a.m. with the DM, in one of two refrigerators, a large, opened container of mayonnaise without open date or expiration date was in the refrigerator. The DM stated the mayonnaise should have had the opened date and the expiration date on the container. 3. During a concurrent observation and interview on [DATE] at 11:30 a.m. with the DM in the kitchen, the cook did take the temperature of the pan of cauliflower during the lunch tray line service. The DM stated, the cook should have checked the temperature of the cauliflower prior to serving to the residents to prevent food born illness from undercooked food. During a concurrent interview and record review on [DATE] at 2:41 p.m. with the Registered Dietitian (RD), the facility's policy and procedure (P&P) titled, Food and Storage dated ,d+[DATE] was reviewed. The P&P indicated, . All food .shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Date and rotate items; first in first out .discard food past the use-by or expiration date . must be stored in containers that have tight fitting lids . The RD stated all food should be handled following the food and safety codes to help prevent residents from food borne illness. During a review of California Code of Regulations (CCR), Title 22 Security, Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, Chapter 8.5 - Intermediate Care Facilities/Developmentally Disabled-Habilitative, Article 3 - Services Section 76888 - Food and Nutrition Services-Food Storage dated, [DATE], the CCR indicated, . All readily perishable foods or beverages shall be maintained at temperatures of 7 C (45 F) or below, or at 60 C (140 F) or above . except during necessary periods of preparation and service . Keep hot food hot-at or above 140 F. Place cooked food in chafing dishes, preheated steam tables, warming trays, and/or slow cookers . 47888 4. During a concurrent observation and interview on [DATE] at 9:20 a.m., with Resident 146 in her room, Resident 146 had an undated, not labeled bowl with cooked, perishable (food that is likely to decay, spoil, or become unsafe to eat if not kept refrigerated or frozen) cabbage and onions on her bedside table. Resident 146 stated the food had been brought in by a family member the day before. Resident 146 stated the cabbage and onions had been by her bedside since her family member brought it in. During a review of Resident 146's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated [DATE], the MDS assessment indicated Resident 146's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15 (a score of ,d+[DATE] indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), ,d+[DATE] indicates moderately impaired, and ,d+[DATE] indicates severe impairment). The BIMS assessment indicated Resident 146 was cognitively intact. During a review of Resident 146's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the Admission Record indicated, Resident 146 was admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness (harder to perform everyday tasks and movements), unspecified fracture of the left pubis (break in the pelvis), history of falling and vitamin D deficiency (vitamin D plays is critical for maintaining strong bones, teeth, and muscles). During an interview on [DATE] at 3:45 p.m., with the Assistant Director of Nursing (ADON), the ADON stated perishable or cooked food needed to be thrown away right after consumption. The ADON stated Resident 146 could have gotten sick from bacterial grown due to the food being left out. The ADON stated that would have caused vomiting and diarrhea for the resident. The ADON said Resident 146 could have been hospitalized from this potential sickness. During an interview on [DATE] at 4:37 p.m., with the Registered Dietician (RD), the RD stated a cooked or perishable food needed to be consumed within two hours of arriving at the facility. The RD stated that the cabbage and onions could have had bacterial growth because of the length of time being left out not refrigerated. The RD could have gotten gastrointestinal [stomach] distress [problems] that would have resulted in foodborne illness [food poisoning]'.The RD stated the facility did not follow the policy and procedure (P&P) Food for Residents from Outside Sources. During an interview on [DATE] at 1:59 p.m., with the Director of Nursing (DON), the DON stated the food on Resident 146's bedside table should not be there. The DON stated the food was old, perishable and could have been spoiled [bad]. The DON stated availability of that food put the resident at risk for gastrointestinal issues and she could have gotten sick. The DON stated from her sickness she ultimately could have required a hospitalization . The DON stated the P&P Food for Residents from Outside Sources was not followed by staff members. During an interview on [DATE] at 3:26 p.m., Certified Nursing Assistant (CNA) 8, CNA 8 stated food should not be at the bedside from the day before. CNA 8 stated Resident 146 could have gotten sick from eating that food because it could have been bad. During a review of facility's P&P titled, Food for Residents from Outside Sources, dated [DATE], the P&P indicated, . staff will monitor the intake of outside foods to support effectiveness of this intervention . prepared food brought in for the resident must be consumed within one hour after removal from temperature control to minimize risk of foodborne illness. Unused food will be disposed of immediately thereafter .

Based on observation, interview and record review the facility failed to provide a homelike environment for eight of 16 sampled residents (Residents 8,43, 62, 72, 95, 104, 108, and 110), when resident rooms had missing thresh holds (a strip of wood, metal, or stone forming the bottom of a doorway and crossed in entering a house or room), holes in the walls were not repaired, wall paper was torn and missing, blood stains and scuff marks were on the walls, strong urine odor, and curtains with blood stains were left hanging. Thes failures had the potential to cause emotional harm and frustration to the residents. Findings: During a review of Resident 8's Admission Record (AR), dated 4/14/25, the AR indicated Resident 8 was admitted from an acute care hospital on 7/17/24 with the following diagnosis, . history of falling, abnormality of gate, macular degeneration (age related disease that affects the center of the eye that can cause blurry, distorted or darkened center of vision), fracture of right humerus (long bone of the upper arm),fracture of right femur (long bone of upper leg), Diabetes Mellitus (DM-chronic condition in which the body cannot regulate blood sugar), and Polymyalgia rheumatica (a disorder causing muscle pain and stiffness) . During a review of Resident 8's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 8's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status on a scale of 0 to 15 [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 3 out of 15 which indicated Resident 8 had severe cognitive deficit. During a review of Resident 104's AR, dated 4/4/25, the AR indicated Resident 104 was admitted from an acute care hospital on 7/24/23 with the following diagnosis, . muscle weakness, history of falls, major depressive disorder (a serious mental illness that involves persistent feelings of sadness and loss of interest in activities), hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone, a crucial hormone for regulating metabolism, energy levels, and body temperature), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time) . During a review of Resident 104's MDS assessment dated [DATE], the MDS assessment indicated Resident 104's BIMS score was 7 out of 15 which indicated Resident 104 had severe cognitive deficit. During an interview on 4/1/25 at 9:20 a.m. with Resident 104, Resident 104 stated, . this room always smells like pee, even after it has been cleaned . During a concurrent observation and interview on 4/1/25 at 9:24 a.m. with Certified Nursing Assistant (CNA) 2 and the Infection Prevention Nurse (IP), outside of Resident 8 and Resident 104's room, a urine odor was smelled outside of the room. The IP stated, the urine smell did not provide a home like environment for Resident 8 or Resident 104. CNA 2 stated the smell was coming from the urine-soaked pants that were hanging in the bathroom. CNA 2 stated, Resident 104 does not want the facility to wash her clothes, the pants were hung in the bathroom to dry. The IP stated the pants should have been placed in a plastic bag, so the smell of urine did not permeate the room. During a review of Resident 72's AR, dated 4/4/25, the AR indicated Resident 72 was admitted from an acute care hospital on 7/12/24 with the following diagnosis, . chronic respiratory failure, muscle weakness, Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills), Dementia (brain disease that cause a decline in thinking, memory, and reasoning abilities), repeated falls, and heart failure . During a review of Resident 72's MDS assessment dated [DATE], the MDS assessment indicated Resident 72's BIMS score was 5 out of 15 which indicated Resident 72 had severe cognitive deficit. During a review of Resident 95's AR, dated 4/4/25, the AR indicated Resident 95 was admitted from an acute care hospital on 9/5/24 with the following diagnosis, . muscle weakness, chronic respiratory failure, dysphasia (a language disorder that affects the ability to produce and understand spoken language, cerebral infarction (a blood vessel stops blood flow to part of the brain), and history of falling . During a review of Resident 95's MDS assessment dated [DATE], the MDS assessment indicated Resident 95's BIMS score was 12 out of 15 which indicated Resident 95 had moderate cognitive deficit. During a concurrent observation and interview on 4/3/24 at 10:15 a.m. with Resident 72's and Resident 95's room, the walls had scuff marks from the beds and other equipment rubbing against the walls, an electrical outlet was dangling from a black cord coming out of hole in the wall approximately two inches (unit of measure) by 3 inches. Resident 72 and Resident 95's room did not have the threshold covering in the bathroom. Resident 95 stated, he did not know he could ask to have the outlet repaired and he had thought about the outlet catching on fire. During an interview on 4/3/24 at 10:30 a.m. with the Director of Maintenance (DM), the DM stated, the electrical socket hanging from the wall needed to be repaired immediately as it could cause a fire in the residents room. The DM stated the missing threshold was a tripping hazard for the residents and staff, and the dirty and torn wall paper was not a homelike environment for the residents in the room. During a review of Resident 43's AR, dated 4/4/25, the AR indicated Resident 43 was admitted from an acute care hospital on 10/13/20 with the following diagnosis, . legal blindness, post traumatic stress disorder, major depressive disorder, and chronic pain . During a review of Resident 43's MDS assessment dated [DATE], the MDS assessment indicated Resident 43's BIMS score was 15 out of 15 which indicated Resident 43 had no cognitive deficit. During a review of Resident 62's AR, dated 4/4/25, the AR indicated Resident 62 was admitted from an acute care hospital on 6/7/22 with the following diagnosis, .traumatic brain injury, repeated falls, chronic pain, heart failure, and major depressive disorder . During a review of Resident 62's MDS assessment dated [DATE], the MDS assessment indicated Resident 62's BIMS score was 3 out of 15 which indicated Resident 62 had severe cognitive deficit. During a concurrent observation and interview on 4/4/25 at 11:00 p.m. in Resident 43's and Resident 62's room with the DM, the wall behind Resident 43's bed was dented in with an approximate 5 inch by 2-inch hole in the wall. The wall behind Resident 62's bed had a large dent from the top of the headboard to the bottom of the wall. The DM stated, the wall should have been repaired when it was damaged, the residents should not have to have dents and holes in their walls. During a review of Resident 108's AR, dated 4/4/25, the AR indicated Resident 62 was admitted from an acute care hospital on 6/7/22 with the following diagnosis, .traumatic brain injury, repeated falls, chronic pain, heart failure, and major depressive disorder . During a review of Resident 108's MDS assessment dated [DATE], the MDS assessment indicated Resident 108's BIMS score was 15 out of 15 which indicated Resident 108 had no cognitive deficit. During a concurrent observation and interview on 4/5/25 at 3:10 p.m. with Resident 108, in Resident 108's room, next to Resident 108's bed had blood splatter stains on the wall and on the privacy curtain. Resident 108, the bathroom threshold was missing, the wall behind the television had white plaster on the blue wall, the wall paper was peeling and missing and the bottom of the walls had scuff marks and areas that were not painted. Resident 108 stated, she felt as if no-one listened to her complaints, she had asked the housekeeper to have her curtain with the blood changed or cleaned, she had asked if the blood stains on the wall could be cleaned, and she was told it would be done as soon as possible but it was never done. Resident 108 stated, . I feel so frustrated, I feel as if no one listens to me and I do not have any family to help me talk to the higher ups, I feel as if no one cares . During an interview on 4/5/25 at 3:25 p.m. with the House Keeping Manager (HM), the HM stated, Resident 108 should not have had to ask to have her curtain changed or the blood cleaned off her wall. The HM stated blood is an infection issue, and it is not a home like environment for the resident. The HM stated Resident 108 room was not cleaned to her expectations. During a review of the facility's policy and procedure (P&P), titled, Homelike Environment dated 2/2021, the P&P indicated, . The facility staff and management maximizes . homelike setting . clean, sanitary and orderly environment . in good condition .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for four of 24 sampled residents (Resident 17, 110, 203, 404) when: 1.Resident 110's care plan was not updated after droplet isolation (precaution taken for patients with known or suspected to be infected with pathogens transmitted by respiratory droplets that are generate by a patient who is coughing, sneezing or talking) was discontinued. This failure had the potential for Resident 110 to not receive person-centered care to meet his medical and nursing care needs. 2. Resident 17 was ordered and administered divalproex (medication used to treat seizure and prevent migraine headache) medication since 10/19/24 and did not have a care plan for the use of medication and diagnosis. This failure placed Resident 17 at risk of not meeting his care needs. 3. Resident 203 did not have specific care plan interventions developed for his use of the pain reliving medication oxycodone (a drug used to relieve moderate to severe pain). This failure had the potential to cause Resident 203 to experience unmonitored side effects of the medication such as decreased respiratory rate, constipation (inability to pass stools), nausea, and vomiting. 4. The facility did not implement a person-centered care plan for Resident 404, who required oxygen therapy, and this was not addressed in the smoking care plan. This failure of implementing an individualized care plan for Resident 1 had the potential to place Resident 404's safety at risk and her specific needs not being met. Findings: 2. During a concurrent observation and interview on 4/1/25 at 3:02 p.m. with Resident 110 in the resident's room, two residents were assigned to the room. Resident 110 wore a yellow mask as she sat on her bed. Resident 110 was alert, oriented to person, place, date, time and was able to understand and answer questions. Resident 110 stated she wore the yellow mask to prevent from catching germs from others. Resident 110 stated her roommate was out of the building for dialysis. During a review of Resident 110's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/4/25, the AR indicated Resident 110 admitted to the facility on [DATE] with diagnoses: Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe) and influenza (flu-a contagious respiratory infection of the nose, throat and lungs potentially causing mild to severe illness, and sometimes death). During a review of Resident 110's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/11/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 110 had no cognitive impairment. During a review of Resident 110's Care Plan Report, dated 4/1/25, the Care Plan indicated Isolation Precautions: Resident requires strict single room droplet isolation precautions due to influenza until 2/7/25. During an interview on 4/3/25 at 10:09 a.m. with Certified Nurse Assistant (CNA) 4, CNA 4 stated care plans were managed by the licensed nurse (LN) and provided staff with information to provide resident care. CNA 4 stated the risk of not following the care plan may result in not meeting the resident's needs. During a concurrent interview and record review on 4/3/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 110's care plan was reviewed. The care plan indicated the resident was on droplet precautions and should be in a single room. LVN 4 stated the care plan should provide staff with a baseline plan of care (a preliminary care plan developed within 48 hours of a resident's admission to a nursing home, outlining the initial care and services needed) that identified person-centered care needs. LVN 4 stated Resident 110's care plan should include actions staff should take to ensure individualized care was provided by the facility. LVN 4 stated the care plan should be updated when staff receive feedback from the resident, family or other staff to improve the resident's response to care. LVN 4 stated the care plan should include a start and stop date to ensure appropriate care was provided. LVN 4 stated Resident 110 was not on droplet precautions and was not in a room by herself. LVN 4 stated that care plan did not have an end date and should have been updated. LVN 4 stated the licensed nurses, and the Assistant Director of Nursing (ADON) managed the care plans. During a concurrent interview and record review on 4/3/25 at 10:11 a.m. with the Director of Nursing (DON), Resident 110's care plan dated 4/3/25 was reviewed. The care plan indicated, Isolation Precautions: Resident requires strict single room droplet isolation precautions due to influenza until 2/7/25. The DON stated the care plan should be updated, revised, changed weekly, and quarterly to ensure the care plan was current and updated. The DON stated the care plan should include the focus (the actual problem), potential goals and interventions. The DON stated a long-term care plan would include 90 days stop date and a short-term care plan stop date would depend on the issue. The DON stated if a care plan was not updated it would not accurately reflect the condition of the resident or their person-centered care needs. The DON stated the droplet precaution and need for a single room ended 2/7/25 and should have been removed from the active care plan. During a review of Job Description: LVN LPN dated 11/2018, the Care Plan and Assessment Functions indicated Review care plans daily to ensure that appropriate care is being rendered. Inform the Nurse Supervisor of any changes that need to be made on the care plan. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs . During a review of the Job Description: Director of Nursing, not dated, the general purpose indicated the DON is a registered nurse who oversees and supervises the care of all the residents .Essential Duties .develop and implement nursing policies and procedures and ensure compliance .Coordinate MDS and care planning .Supervisory Requirements -the DON is responsible for supervising and managing the Assistant DON, and entire nursing staff either directly or indirectly . During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the policy interpretation and implementation indicated .7. The comprehensive, person-centered care plan: .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change . During a review of professional reference review retrieved from https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, the professional reference review indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making . Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation . During a review of professional reference review retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/ the National Library of Medicine.org titled, Nursing Process, dated 4/10/23, the professional reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid (having two or more medical conditions or diseases present in the same person at the same time) conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition . 40641 2. During an observation on 4/1/25 at 9:10 a.m. in Resident 17 ' s room, Resident 17 was observed lying in bed, eyes closed, floor mat on one side of the bed. Resident 17 ' s eyes opened when questions asked but did not answer. During a review of Resident 17 ' s Admission Record (document with resident demographic and medical diagnosis information), dated 4/3/25, the AR indicated Resident 17 was admitted in the facility on 7/11/25 and readmitted on [DATE] with diagnoses which included Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, rigidity, and slow, imprecise movements), respiratory disorder and dementia (a progressive state of decline in mental abilities). During a review of Resident 17's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 17's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 17 had no cognitive deficit. During a review of Resident 17 ' s Order Summary Report [OSR], undated, the OSR, indicated .Divalproex Sodium [medication used to treat certain types of seizures-a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) . Give 1 tablet by mouth one time a day for migraine, headache . During a concurrent interview and record review on 4/4/25 at 9:10 a.m. with Minimum Data Set Nurse (MDSN), Resident 17 ' s OSR was reviewed. The MDSN stated Resident 17 ' s divalproex was ordered on 10/19/24 for migraine headache. The MDSN stated she did not find a care plan for divalproex medication and migraine headache. The MDSN stated there should have been a care plan for medication and diagnosis of migraine headache to care for Resident 17 ' s needs. The MDSN stated a residents care plan was important in order to direct nursing staff to care for residents. The MDSN stated it was the responsibility of all licensed nurses to ensure a care plan was initiated for new medications and diagnosis. During an interview on 4/4/25 at 2:05 p.m. with Assistant Director of Nursing (ADON) 1, she stated charge nurses and DON are responsible to make sure care plan was completed. ADON 1 stated, I am not sure when to complete comprehensive care plan, but it should be completed right away. ADON 1 stated care plan was necessary to direct staff on how to care for residents. During an interview on 4/4/25 at 3:30 p.m. with Director of Nursing (DON), the DON stated MDSN was responsible in completing comprehensive care plan while charge nurses are responsible for initiating a care plan. The DON stated the expectation in completing a comprehensive care plan was within seven days and no more than 21 days. The DON stated care plan are necessary for nursing staff to care for residents. During a review of facility ' s policy and procedure(P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/22. The P&P indicated, . The comprehensive, person-centered care plan is developed within seven (7) days . and no more than 21 days after admission . describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided . any specialized services to be provided . reflects currently recognized standards of practice for problem areas and conditions . 51620 3. During a review of Resident 203's Admission Record(AR), dated 4/3/25, the AR indicated, Resident 203 was admitted to the facility on [DATE] with the following diagnoses: fracture of thoracic vertebrae (a break in one or more of the bones in the mid-back region), spinal stenosis (a condition where the space surrounding the spinal cord, becomes narrowed), ileostomy (a surgical procedure that creates an opening in the abdomen to divert waste from the small intestine), pseudoarthrosis (a condition where a broken bone fails to heal properly ). During an interview on 4/1/25 at 3:19 p.m. with Resident 203, Resident 203 stated he takes the pain medication oxycodone for his back pain. During a concurrent interview and record review on 4/3/25 at 4:42 p.m. with Licensed Vocational Nurse (LVN) 6, Resident 203 ' s Order Summary Report (OSR), dated 4/3/25 and Care Plan, dated 4/3/25, were reviewed. The OSR indicated, . [oxycodone] Oral Tablet [extended release] 12 hours . give 1 tablet by mouth every 12 hours for pain to lower back . LVN 6 stated Resident 203 ' s oxycodone should have a care plan. LVN 6 reviewed Resident 203 ' s Care Plan and stated no interventions were listed for Resident 203 ' s oxycodone use. LVN 6 stated oxycodone was a very strong pain reliever, and it needed to be care planned because it could cause side effects like a lowered respiratory rate and possible overdose. During an interview on 4/4/25 at 3:57 p.m. with the Director of Nursing (DON), the DON stated Resident 203 should have had his oxycodone appropriately care planed. The DON stated care planning proper interventions for the oxycodone was required because oxycodone was a high-risk medication and it had the potential to cause respiratory depression, constipation, and even an overdose. During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, comprehensive Person-Centered, dated 3/22, the P&P indicated, . The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes, b. describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being . 47888 4. During a concurrent observation and interview on 4/1/25 at 3:54 p.m., with Resident 404, in Resident 404 ' s room, Resident 404 was lying in bed with a nasal cannula (a simple medical device used to deliver oxygen to the nose) in her nostrils receiving 2L (liters- unit of measurement) ' s of oxygen therapy. Resident 404 stated she received continuous oxygen therapy, but also smoked at the facility. During a review of Resident 404's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/4/25, the Admission Record indicated, Resident 404 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- an ongoing lung condition caused by damage to the lungs that makes it hard to breathe), muscle weakness, displaced fracture of base of neck of left femur (broken thigh bone) and respiratory (breathing) disorders in diseases classified elsewhere. During a review of Resident 404 ' s Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 3/25/25, the MDS assessment indicated Resident 404's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS assessment indicated Resident 404 was cognitively intact. During a review of Resident 404 ' s Order Summary Report (OSR), dated 4/1/25, the OSR indicated, .O2 [oxygen] 2 LPM [Liters per minute- unit of measurement] via nasal cannula . to keep O2 saturation [how well your blood is carrying oxygen] above 90% every 2 hours as needed for COPD . During a review of Resident 404 ' s Care Plan, dated 3/21/25, the Care plan indicated, Focus: Smoking- Resident is a smoker and is at-risk for smoking related injury as evidenced by requires supervision when smoking . Goal: Will continue to demonstrate safe smoking . Intervention/Tasks: Assess ability to smoke safely . Provide education on positive benefits related to smoking cessation . respect residents wishes about smoking within facility guidelines . smoking apron as indicated . supervision provided while resident is smoking . During a concurrent interview and record review on 4/4/25 at 10:42 a.m., with Certified Nursing Assistant (CNA) 10, Resident 404 ' s care plan was reviewed. Resident 404 care plan did include interventions for her oxygen in the smoking interventions. CNA 10 stated she needed to know what to do with the residents oxygen before she goes to smoke. CNA 10 stated this instruction should be within the care plan for the Resident 404 ' s safety. CNA 10 stated CNA ' s are responsible for reading and implementing the care plans. During a concurrent interview and record review on 4/4/25 at 11:33 a.m., with the Respiratory Therapist (RT), Resident 404 ' s care plan was reviewed. The RT stated the oxygen was not care planned for in regard to her smoking. The RT stated a staff member might not know what do with the oxygen before smoking because it is not outlined in the care plan. The RT stated this was a safety issue for the resident and it could hinder her health. During a concurrent interview and record review on 4/4/25 at 2:22 p.m., with the Director of Nursing (DON), Resident 404 ' s care plan was reviewed. The DON stated care plans develop a plan of care for an identified or potential problem and create an intervention for it. The DON stated all staff were to follow the care plan to manage the residents issue. The DON stated Resident 404 ' s smoking care plan was not person centered, or individualized because it did not acknowledge her wearing oxygen and what interventions should take place to keep her safe while she smoked. The DON stated because the care plan did not reference the oxygen therapy, Resident 404 could have been injured. The DON stated, smoking with oxygen could have potentially caused fire and harm. The DON stated the facility did not follow the policy and procedure P&P Care Plans, Comprehensive Person-Centered. During a concurrent interview and record review on 4/4/25 at 5:03 p.m., with the Assistant Director of Nursing (DON), Resident 404 ' s care plan was reviewed. The ADON stated care plans provide daily guidance for the residents care. The ADON stated there was nothing in the smoking care plan that referenced the oxygen Resident 404 was wearing. The ADON stated the resident could suffer burning or blowing up. During a concurrent interview and record review on 4/4/25 at 5:26 p.m., with Licensed Vocational Nurse (LVN) 11, Resident 404 ' s care plan was reviewed. LVN 11 stated she was Resident 404 ' s current nurse. LVN 11 stated care plans were important because they let us know everything going on with the resident. LVN 11 stated that Resident 404 ' s was not individualized and person centered. LVN 11 stated Resident 404 could blow up and catch on fire. During a review of the facilities P&P Care plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, . a comprehensive person centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident . the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . the comprehensive, person-centered care plan: . reflects currently recognized standards of practice for problem areas and conditions . care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the residents problem areas and their causes, and relevant clinical decision making . when possible interventions address the underlying source of the problem not just symptoms or triggers . During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse ' s decision-making . Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer ' s health or the situation . During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition .

Based on observation, interview and record review, the facility failed to follow their policy and procedure Food-Related Garbage and Refuse Disposal for one of three outside trash bins, when one of the trash bins was uncovered, and a large amount of plastic and debris was noted on the ground behind the trash bin. This failure had the potential to attracts animals, insects and pests which could lead to infestations, unsanitary conditions, and the spread of disease. Findings: During an observation on 4/4/25 at 2:59 p.m., three of three trash bins were uncovered with paper and plastic bags littering the ground surrounding the bins. During an interview on 4/1/25 at 2:30 p.m. with the Certified Dietary Manager (CDM), the CDM stated, the trash bins should be closed at all times and there should not be trash on the ground or around the trash bins. The CDM stated, the open trash bin and trash on the ground around the trash bins could attract rats and bugs. During an interview on 4/2/25 at 2:45 p.m. with the Registered Dietitian (RD), the RD stated, the trash bins should always be closed, and there should never be trash on the ground to prevent an infestation of pests. During an interview on 7/24/24 at 2:22 p.m. with the Director of Maintenance (DM), the DM stated, the lid of the trash should not have been open and there should never be trash on the ground around the trash bins. The DM stated trash around the trash bin can attract animals and insects which could cause infestation. During a review of the facilities policy and procedure titled, Food Related Garbage and Refuse Disposal dated 10/2017, indicated, .Food Related Garbage and Refuse Disposal indicated . 1. All food waste shall be kept in containers . garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . outside dumpsters will be kept closed ad free of surrounding litter .

Based on observation, interview and record review, the facility failed to maintain professional standards of quality for seven of 32 sampled residents (36, 90, 97, 110, 138, 253 and 405) when: 1. Resident 405 had medication in a medicine cup on her bedside table (serves as a surface for food trays and can hold personal items such as phones, laptops, or books) without a self-administration of medications assessment completed, nor nursing staff present. This failure had the potential to put Resident 405 ' s and other facility residents, safety at risk and her specific needs not being met. 2. Resident 90 ' s Oxygen (O2) order was incomplete and did not specify how many liters (L- a unit of measurement) of O2 she was to receive per minute. This failure had the potential to result in Resident 90 to not receive the required amount of oxygen for her needs. 3. The facility failed to follow their Oxygen Administration Policy for one of five sampled residents (Resident 110) when the Oxygen in Use sign was not posted outside or inside the resident ' s room who received physician ordered oxygen therapy. This failure had the potential to place residents at risk for fire if a visitor or resident decided to smoke where oxygen was being administered. 4. Licensed Vocational Nurse (LVN) 7 administered insulin (medication used to diabetes) to Resident 36 and Resident 138 and did not follow professional standard of practice with insulin pen administration. 5. Resident 97 ' s handheld nebulizer machine tubing unlabeled and unprotected, and hanging on the back of bedside table touching the floor. 6. Resident 253 did not have a physician order for enhanced barrier precautions (EBP - wearing gowns and gloves during certain high-contact care activities for residents who are at risk of having or spreading germs that are hard to treat). These failures placed Resident 36, Resident 97, Resident 253 and Resident 138 at risk of infection which could result in a serious health condition. Findings: 1. During a concurrent observation and interview on 4/2/25 at 4:55 p.m., with Resident 405, in Resident 405 ' s room, Resident 405 was by herself and there was one orange pill (medications) sitting on her bedside table while she was lying in bed. Resident 405 stated the medication had been there awhile and she thought it was for her blood pressure. Resident 405 stated the nurse left to get her an applesauce to swallow the pill easier and never came back. During a review of Resident 405's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/4/25, the Admission Record indicated, Resident 405 was admitted to the facility on [DATE] with a diagnosis of hypertension (high blood pressure- the force of your blood pushing against your artery walls is consistently too high, potentially damaging your blood vessels and organs over time), malignant neoplasm (cancer) of unspecified female breast, cerebral infarction (a stroke, happens when a part of the brain doesn't get enough blood and oxygen, causing brain cells to die) and generalized muscle weakness. During a review of Resident 405 ' s Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/20/25, the MDS assessment indicated Resident 405's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview). The BIMS assessment indicated Resident 405 was cognitively intact. During a review of Resident 405 ' s Medication Administration Record (MAR), dated 4/1/25 to 4/4/25, the MAR indicated, . Hydralazine oral tablet 100 mg (milligram- unit of measurement) . Give 1 tablet by mouth three times a day for hypertension .Start date: 3/26/25 . Administration: . 4/3/25 at 1 p.m., [Medication not administered] . 4/3/25 at 6 p.m. Blood Pressure 158/61 . May crush all crushable medications and mix with applesauce for better tolerance . During an interview on 4/3/25 at 3:28 p.m., with Registered Nurse (RN) 2, RN 2 stated she was responsible for Resident 405 ' s care. RN 2 stated medication should never be left on the bedside table without a nurse in the room. RN 2 stated it was not safe for the medication to be there and another confused resident could have taken it. During an interview on 4/3/25 at 3:44 p.m., with the Assistant Director of Nursing (ADON), the ADON stated RN 3 was the nurse responsible for having left the medication on Resident 405 ' s bedside table. The ADON stated the medication was Hydralazine, a blood pressure medication and was due at 1 p.m. The ADON stated Resident 405 would be able to self-administer medications if a self-administration assessment was done and it was not. The ADON stated this was a medication error for not giving the medication at the appropriate time per the physician order. The ADON stated another resident could have entered the room and took the medication because it was left unattended. The ADON stated if another resident had taken the medication, they could have gotten hypotensive (drop in blood pressure). The ADON stated Resident 405 could have gotten hypertensive (rise in blood pressure) due to the missed dose due to her underlying diagnosis and not taking the medication as prescribed. The ADON stated the facility did not follow the policy and procedure (P&P) Administering Medications. During a concurrent interview and record review on 4/4/25 at 1 p.m., with the Director of Nursing (DON), Resident 405 ' s Electronic Medical Record (EMR), dated 4/4/25 was reviewed. The DON stated the expectation would be for RN 3 to administer the medications according to the physician ' s order and she did not. The DON stated medication should have not been left at Resident 405 ' s bedside. The DON stated Resident 405 does not have a self-administration assessment completed and would not be able to take medications without the nurse present. The DON stated Resident 405 ' s blood pressure would not be managed because the scheduled blood pressure medication was not given. The DON stated these potential implications for leaving the medication on the bedside table would have put Resident 405 ' s safety at risk. The DON stated the facility did not follow the P&P Administering Medications. On 04/04/25 at 2:12 p.m., the facilities medication self-administration assessment policy and procedure was requested, but was not received. During an interview on 4/4/25 at 3:57 p.m., with RN 3, RN 3 stated she was Resident 405 ' s nurse and she left the medication on her bedside table. RN 3 stated she left the medication with the resident to go and get her pudding to put her pill in, she got distracted and never went back. RN 3 stated by leaving the medication unattended another resident could have taken it, or the resident could have taken it later and been too much. RN 3 stated this was a safety issue for Resident 405 and could have resulted in a hospitalization due to not receiving her medication per the physician order. During a review of the facility ' s P&P titled, Administering Medications, dated April 2019, the P&P indicated, . medications are administered in a safe and timely manner and as prescribed . 4. Medications are administered in accordance with prescriber orders, including in the required time frame . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely . During a review of the Joint Commssion.org Professional Reference titled, Medication Security- Bedside Medications/Self Administration, dated 10/25/21, (found at https://www.jointcommission.org/standards/standard-faqs/nursing-care-center/medication-management-mm/000002190/#:~:text=The%20Joint%20Commission%20standards%20do,01.) the reference indicated, . organizations must ensure the medications are secure- meaning protected from unauthorized access, tampering, theft, or diversion . Conducting a risk assessment is a helpful way of identifying risks associated with various options under consideration for securing medication. A proactive risk assessment examines a process in detail including sequencing of events, actual and potential risks, and failure or points of vulnerability. The risk assessment prioritizes, through a logical process, areas for improvement based on the actual or potential impact (that is, criticality) of care, treatment, or services provided . 51620 2. During a review of Resident 90's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/3/25, the AR indicated, Resident 90 was admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease, (COPD- a long-term disease that makes it hard to breathe), congestive heart failure (CHF - a condition where the heart is not pumping blood as well as it should be), and acute respiratory failure with hypoxia (when a person ' s lungs are not working well enough to get enough oxygen into the blood). During an observation on 4/1/2025 at 8:56 a.m. in Resident 90 ' s room, Resident 90 had O2 via nasal canula (a small flexible tube that delivers oxygen through a person ' s nose). The flow meter (a device that shows how much oxygen is flowing through the tube) was set to two liters per minute. During a concurrent interview and record review on 4/3/25 at 11:41 a.m. with the Respiratory Therapist (RT), Resident 90 ' s Order Summary Report (OSR), dated 4/3/25 was reviewed. The OSR did not have the specific oxygen rate on Resident 90 ' s O2 order. The RT stated Resident 90 received oxygen and breathing treatments as part of her therapy. The RT stated Resident 90 had a history of COPD and CHF. The RT stated he does an assessment and then starts the oxygen if warranted. The RT stated Resident 90 came over from the acute care hospital with orders for oxygen at two liters per minute (LPM). The RT stated Resident 90 was placed on three LPM on admission due to her labored breathing and fatigue with the transfer. The RT stated Resident 90 ' s O2 order should have specified the O2 delivery rate in order to properly deliver the amount of O2 Resident 90 required. The RT stated if a nurse or RT was unfamiliar with her O2 delivery rate, Resident 90 could have retained carbon dioxide (a waste product produced by the lungs which can cause harm if not expelled from the body) since she had COPD. During an interview on 4/4/25 at 11:41 a.m. with Registered Nurse (RN) 1, RN 1 stated nurses and RTs should have noticed the oxygen therapy order was incomplete and contacted the doctor to clarify orders. RN 1 stated incomplete O2 orders could have caused Resident 90 to receive more or less O2 than she needed, and it could be harmful to her health. During an interview on 4/4/2025 at 3:47 p.m. with the Director of Nursing (DON), the DON stated Resident 90 ' s oxygen order should have indicated the rate of delivery since her admission on 3/13/25. The DON stated nurses should have called the doctor to clarify the order once they noticed it was not specific. During a review of the facility ' s policy and procedure (P&P) titled, Oxygen Administration, dated October 2010, the P&P stated .verify that there is a physician order for this procedure. Review the physician ' s order or facility protocol for oxygen administration . During a review of the facility ' s P&P titled, Medication and Treatment Orders, dated July 2016, the P&P indicated, . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe medication in this state . 9. Orders for medication must include: . c. dosage and frequency of administration . 51223 3.During a concurrent observation and interview on 4/1/25 at 3:02 p.m. with Resident 110 in the resident ' s room, Oxygen in Use/No Smoking signs were not posted outside or inside of the resident ' s room. Resident 110 was sitting on the edge of the bed next to an oxygen concentrator (an oxygen concentrator continuously purifies the air around you (atmospheric air) to deliver 90% to 95% pure oxygen) with a flow rate set at two liters (L-a measurement of how much oxygen you're getting through the cannula.) Resident 110 was alert, oriented to person, place, date, time and was able to understand and answer questions. Resident 110 stated the physician ordered continuous oxygen use. During a review of Resident 110 ' s Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/4/25, the AR indicated Resident 110 admitted to the facility on [DATE] with diagnoses: Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), Acute Respiratory Failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), and asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe). During a review of Resident 110 ' s Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/11/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 110 had no cognitive impairment. During a concurrent observation and interview on 4/3/25 at 4:12 p.m. with Licensed Vocational Nurse (LVN) 1 at Resident 110 ' s room and at nurses ' station two, the Oxygen in Use/No Smoking sign was not posted on Resident 110 ' s doorway or in the resident ' s room. LVN 1 stated Resident 110 had physician ordered oxygen and there should have been an Oxygen in Use/No Smoking sign on the door. LVN 1 stated the risk of not having proper signage on the door could result in a fire if a resident or visitor tried to smoke in the facility in the presence of oxygen. During a concurrent interview and record review on 4/4/25 at 10:11 a.m. with Director of Nursing (DON) in the DON office, Resident 110 ' s Order Summary dated 2/3/25 and a photo taken 4/1/25 at 8:13 a.m. of Resident 110 ' s doorway was reviewed. The Order Summary indicated; the physician ordered continuous oxygen at 2 LPM (liters per minute). The photo indicated the facility did not post an Oxygen in Use/No Smoking sign on the doorway. The DON stated the Oxygen in Use/No Smoking sign should have been on the doorway and in the room to indicate the resident was using oxygen. The DON stated the Licensed Nurse and Respiratory Therapists were responsible to ensure the signage was properly displayed. The DON stated the facility did not follow their policy. The DON stated there would be a potential risk of fire if someone were to smoke in the presence of oxygen. During a review of the Job Description: LPN LVN, dated 11/2018, administrative functions indicated ensure all nursing service personnel comply with the procedures set forth in the Nursing Service Procedures Manuals . Interpret the department ' s policies and procedures to personnel, residents, visitors and government agencies as required . Nursing Care Functions indicated .Implement and maintain established nursing objectives and standards .Ensure that direct nursing care be provided by licensed nurse .qualified to perform the procedure .Administer professional services .as required .Safety and Sanitation monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies. Ensure that established departmental policies and procedures .are followed by your assigned nursing personnel .Ensure that your unit ' s resident care rooms, treatment rooms, etc., are maintained in a clean, safe, and sanitary manner. During a review of the Job Description: Director of Nursing, not dated, the general purpose indicated the DON is a registered nurse who oversees and supervises the care of all the residents . Essential Duties .develop and implement nursing policies and procedures and ensure compliance .Supervisory Requirements-the DON is responsible for supervising and managing the Assistant DON, and entire nursing staff either directly or indirectly . During a review of the facility ' s policy and procedure titled, Oxygen Administration, dated 10/2010, the Steps in the Procedure indicated .The purpose of this procedure is to provide guidelines for safe oxygen administration .2. Place an ' Oxygen in Use ' sign on the outside of the room entrance door. Close the door. 3. Place an ' Oxygen in Use ' sign in a designated place on or over the resident ' s bed . During a review of American Health Care Association & National Center For Assisted Living Professional Reference titled, Simplifying Oxygen Signage Requirements, published 3/4/25, (found at https://www.ahcancal.org/News-and-Communications/Blog/Pages/Simplifying-Oxygen-Signage-Requirements-.aspx) the reference indicated, a facility that allows smoking must provide precautionary signage wherever supplemental oxygen is in use, including the aisles and walkways leading to such areas .the signage must be readable from a distance of five feet away . 40641 4.During a review of Resident 36 ' s Admission Record, (AR) dated 4/3/25, the AR indicated Resident 36 was readmitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), muscle weakness and depression (persistent feeling of sadness and loss of interest). During a review of Resident 36's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 36's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale,0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) indicating Resident 37 had no cognitive deficit. During a review of Resident 36 ' s Order Listing Report, undated, the Order Listing Report indicated, . [brand name insulin] Auto cover Pen Needle . (Insulin Pen Needle) . [brand name insulin] Pen [medication used to treat diabetes] . During an observation on 4/2/25 at 11:38 a.m. with Licensed Vocation Nurse (LVN) 7 in Station 2 front end, LVN 7 prepared Resident 36 ' s medication including insulin pen. LVN 7 attached insulin needle to insulin pen and did not wipe the pen tip with alcohol pad. LVN 7 administered Resident 36 ' s insulin, removed insulin needle, placed insulin pen cap and did not wipe insulin pen tip before replacing the insulin cap. During a review of Resident 138 ' s AR, dated 4/3/25, the AR indicated Resident 138 was admitted to the facility on [DATE] with diagnoses which included multiple fractures (break in the bone), diabetes and weakness. During a review of Resident 138 ' s MDS assessment dated [DATE], indicated Resident 138 ' s BIMS assessment score was 15 out of 15 indicating Resident 138 had no cognitive deficit. During a review of Resident 138 ' s Order Listing Report, undated, the Order Listing Report indicated, . [brand name] Solution [treat diabetes]100 unit/ML (milliliter-unit of measure) Inject as per sliding scale . During an observation on 4/2/25 at 12:16 p.m. with LVN 7 in Station 2, LVN 7 prepared Resident 138 ' s insulin. LVN 7 did not wipe insulin pen tip with alcohol pad prior to attaching insulin needle. LVN 7 administered Resident 38 ' s insulin, removed insulin pen needle, did not wipe insulin pen tip with alcohol wipe and replaced insulin cap. During an interview with LVN 7 on 4/4/25 at 3:59 p.m. LVN 7 stated she administered insulin to Residents ' 36 and 138. LVN 7 stated she did not wipe the insulin pen tip with alcohol wipe prior to attaching insulin needles and after she administered insulin and removed the insulin needles. LVN 7 stated, I should have wiped the insulin pen tip with alcohol wipe before I attached the needle and after I removed the needle, but I did not. LVN 7 stated not wiping the insulin tip with alcohol wipe was an infection control issue which could cause infection not only to injection site which could lead to more serious health condition. During an interview on 4/4/25 at 1:55 p.m. with Assistant Director of Nursing (ADON) 1, ADON 1 stated the facility practice for insulin pen administration was, .wipe insulin pen tip with alcohol wipe before attaching the needle, administer the insulin then clean insulin tip again with alcohol wipe then put the lid on . ADON 1 stated not cleaning the insulin pen tip is an infection control issue which could lead to serious health issues. During an interview on 4/4/25 at 3:25 p.m. with the Director of Nursing (DON), the DON stated, Licensed Nurses just had their skills check on medication administration recently and I was expecting more from them . The DON stated LVN 7 should have made sure she wiped the insulin pen tip with alcohol wipe before she attached the insulin pen needle and after she removed the insulin pen needle before placing the insulin pen cover. The DON stated it was the expected professional practice when preparing insulin pen. The DON stated it was an infection control issue which could result to serious health issues for residents receiving insulin. During a review of facility ' s policy and procedure (P&P) titled Insulin Administration, dated 9/14, the P&P indicated, .The type of insulin, dosage requirements, strength, and method of administration must be verified before administration . Pens - containing insulin cartridges deliver insulin subcutaneously through a needle . Disinfect the top of the vial with an alcohol wipe . 5.During a review of Resident 97 ' s AR, dated 4/3/25, the AR indicated Resident 97 was readmitted to the facility on [DATE] with diagnoses which included respiratory failure (lungs cannot adequately oxygenate the blood), muscle weakness and dementia. During a review of Resident 97 ' s MDS assessment dated [DATE], indicated Resident 97 ' s BIMS assessment score was 13 out of 15 indicating Resident 97 had no cognitive deficit. During a concurrent observation and interview on 4/1/25 at 8:59 a.m. in Resident 97 ' s room, Resident 97 was lying in bed, covered with blanket and watching television. Anebulizer machine (a machine used to change medication from a liquid to a mist so you can inhale it into your lung) was observed on top of bedside table, nebulizer tubing (plastic tubes used from the machine to the resident) were not labeled and were hanging at the back of bedside table. Resident 97 stated he did not remember how long he had been in the facility. Resident 97 stated he did not remember using oxygen or medicine using a nebulizer machine. During a concurrent observation and interview on 4/1/25 at 12:36 p.m. in Resident 97 ' s room with Assitant Director of Nursing (ADON) 2, ADON 2 stated The tubing is on the floor, it not labeled and not placed in a privacy bag. ADON 2 stated licensed nurses are responsible in making sure nebulizer tubing is changed every seven days, labeled and placed in a privacy bag. ADON 2 stated CNAs are also responsible in making sure nebulizer tubing are not touching the floor and placed in a privacy bag. ADON 2 stated Respiratory Therapist (RT) are also responsible in making sure nebulizer tubing are dated and not touching the floor. ADON 2 stated labeling nebulizer tubing with dates was important to ensure the tubing are not too old for patient use because bacteria could gather in the tubing causing infection when placed in resident nostrils. During an interview on 4/4/25 at 1:57 p.m. with ADON 1, she stated oxygen and nebulizer tubing are changed weekly and labeled with date to ensure tubing are not used over a week. ADON 1 stated bacteria could get in the oxygen and nebulizer tubing causing respiratory infection or other health issues to residents. During an interview on 4/4/25 at 3:18 p.m. with the Director of Nursing (DON), the DON stated the practice was to change oxygen and nebulizer tubing every seven days and labeled with date and name of resident. The DON stated tubing should also be placed in a privacy bag when not in use to prevent resident from getting sick. The DON stated the oxygen and nebulizer tubing when used goes in the nasal cannula and or mouth straight in the lungs which could cause serious health issues if tubing were not replaced and kept in a privacy bag. The DON stated her expectation was for nursing to staff to ensure oxygen and nebulizer tubing labeled and placed in a privacy bag. During a review of facility policy and procedure titled, Respiratory Therapy- Prevention of Infection, dated 11/11, the P&P indicated, .7. Change the oxygen cannulas and tubing every seven (7) days, or as needed . Infection Control Consideration Related to Medication Nebulizers/Continuous Aerosol: .Store the circuit in plastic bag, marked with date and resident ' s name, between uses . Discard the administration set-up every seven (7) days . 51593 6. During an interview on 4/1/25 at 9:26 a.m. with Resident 253, Resident 253 stated, I have a wound on my bottom. Resident 253 stated, The skin is broken from laying on my bathroom floor at home for 16 hours. During a review of Resident 253 ' s OSR dated 4/4/25, the OSR indicated, Cleanse stage 2 (pressure wounds classified in stages with the least damage stage 1, to wounds which deepen all the way down to the bone, stage 4) to right buttock . The OSR indicated, [Enhanced Barrier Precautions] (EBP - wearing gowns and gloves during certain high-contact care activities for residents who are at risk of having or spreading germs that are hard to treat).: Resident requires enhanced barrier precautions during high contact care activities due to the presence of: chronic wound .Order Date: 4/2/25. During a concurrent interview and record review on 4/3/25 at 10:54 a.m. with (Infection Preventionist (IP), Resident 253 ' s Admission/ Re-admission Summary Note dated 3/29/25 was reviewed. The Admission/ Re-admission Summary Note indicated Resident 253 had an open wound to the right hip and buttock. The IP stated, For any open areas on the skin, contact the doctor and request an order for EBP. The IP stated, The need for EBP came to my attention when I did a chart review yesterday morning. The IP stated, This resident should have been placed on EBP upon admission. The IP stated, If the admissions nurse doesn ' t catch skin issues, I will follow up. The IP stated, Admissions nurse can put in an order for EBP. The IP stated, There is a potential for cross contamination to other residents and for the resident to be further exposed to other residents and staff. During an interview on 4/4/25 at 3:09 p.m. with the Director of Nursing (DON), the DON stated, Admission assessment includes skin assessment. The DON stated, Whatever if found on the skin assessment, admission nurse will put in the orders and the physician will confirm. The DON stated, Expectation for EBP orders is that if a resident has open wounds, EBP is implemented upon admission. The DON stated, It ' s important to identify residents who need to be on precautions to avoid the spread of any infection. The DON stated, Admission nurse communicates with the IP nurse. During a review of the Registered Nurse (RN) job description, dated February 2024, the RN job description indicated, Admit .residents as required. The RN job description indicated, Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident as necessary. The RN job description indicated, Assist the .Infection Control Coordinator in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks in which there is potential exposure to blood/ bodily fluids are properly identified and recorded. During a review of the IP job description, undated, the IP job description indicated, Help review potential resident admissions . The IP job description indicated, Monitor and ensure that all nursing services personnel follow established infection prevention and control practices .when caring for residents. During a review of the facility ' s P&P titled, Enhanced Barrier Precautions dated February 2025, indicated, EBPs are indicated .for residents with wounds .wounds generally include chronic wounds (i.e. pressure ulcers .)

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with current accepted professional principles for three of 20 sampled residents (Resident 29, Resident 33 and Resident 79) when: 1. Resident 79 ' s brand name eye medication used to relieve dryness or pain in the mouth or throat solution was without an open date (date it was opened and first used) and Resident 29 ' s brand name insulin (medication used to control high blood sugar) was without an open date. This failure had the potential for Resident 79 and Resident 29 to receive expired medication and could have resulted in uncontrolled blood sugar, and eye irritation. 2. Resident 33 ' s lorazepam (medication used to control anxiety [a feeling of fear, dread, and uneasiness]) did not have a complete legible medication label. This failure had the potential to result in Resident 33 to be administered an incorrect dose of medication. 3. An unattended medication cart was observed in the hallway near nurse ' s station two with a set of keys and a clear, plastic cup containing five unidentified, loose pills sitting on top. This failure had the potential for residents and visitors to ingest unidentified medication of unknown potency which could lead to overdosing, under dosing, allergic reaction, or death. Findings: 1. During a concurrent observation and interview on [DATE], at 9:56 a.m., with Assistant Director of Nursing (ADON) 1 and the Director of Staff Development (DSD) at nurse ' s station two medication cart, Resident 79 ' s open bottle of [brand name eye medication] was observed without an open date. ADON 1 stated, [brand name eye medication] is not dated with an open date. ADON 1 stated, Medication should have an open date. ADON 1 stated, The medication should be discarded. The DSD stated, Licensed nurses are to check the dates on medications in the carts every shift. During a review of Resident 79 ' s Admission Record (AR) dated [DATE], the AR indicated, Resident 79 was admitted to the facility on [DATE] with a diagnosis of mild protein malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients). During a review of Resident 79 ' s Order Summary Report (OSR) dated [DATE], the OSR indicated, [brand name]/ Throat Solution (Artificial Saliva) .Order Date: [DATE]. During a concurrent observation and interview on [DATE], at 2:04 p.m., with Licensed Vocational Nurse (LVN) 1 at nurse ' s station two medication cart, Resident 29 ' s [brand name] insulin pen was observed with a label indicating Date Opened . [lined area underneath that was blank] . Discard Date: [DATE]. LVN 1 stated whoever opened the medication should have put the open date. LVN 1 stated, You can only assume the open date based on the discard date. LVN 1 stated, Insulin should have a discard date of 28 days. During a review of Resident 29 ' s AR dated [DATE], the AR indicated, Resident 29 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (disease that occurs when your blood sugar is too high). During a review of Resident 29 ' s OSR dated [DATE], the OSR indicated, Insulin Glargine . Subcutaneous (layer of tissue beneath the skin ' s upper layers) Solution .Order Date: [DATE]. During an interview on [DATE] at 3:09 p.m. with the Director of Nursing (DON), the DON stated, If a medication is opened, it should have an open date and a discard date. During a review of the LVN job description, dated [DATE], the LVN job description indicated, Review medication cards for completeness of information . The LVN job description indicated, Dispose of . drugs as required, and in accordance with established procedures. During a review of the DON job description, dated February 2024, the DON job description indicated, Develop and implement nursing policies and procedures and ensure compliance. During a review of the facility ' s policy and procedure (P&P) titled, Medication Labeling and Storage, undated, indicated, Multidose vials that have been opened or accessed . are dated and discarded within 28 days . 2. During a concurrent observation and interview on [DATE], at 2:32 p.m., with Registered Nurse (RN) 1 at nurse ' s station one medication cart, Resident 33 ' s lorazempam was observed without a legible medication label. RN 1 stated, The label is not legible. RN 1 stated, The label should be legible, and a new medication should be ordered. During a review of Resident 33 ' s AR dated [DATE], the AR indicated, Resident 33 was admitted to the facility on [DATE] with a diagnosis of anxiety. During a review of Resident 33 ' s OSR dated [DATE], the OSR indicated, lorazpam .Order Date: [DATE]. During an interview on [DATE] at 3:09 p.m. with the DON, the DON stated medication labels should include, Prescription number, doctor ' s name, date filled, expiration date, name of medication with the order, and resident ' s identifying information. The DON stated, The medication label should be legible. The DON stated, The nurse should call the pharmacy as soon as they notice they can ' t see the label to get a replacement. During a review of the LVN job description, dated [DATE], the LVN job description indicated, Verify the identity of the resident before administering the medication . The LVN job description indicated, Order prescribed medications . as necessary . The LVN job description indicated, Dispose of drugs . as required . During a review of the RN job description, dated February 2024, the RN job description indicated, Ensure that all RNs and LVNs on your shift comply with written procedures for . storage . of medications . The RN job description indicated, Monitor medication passes . to ensure that medications are being administered as ordered . During a review of the DON job description, dated February 2024, the DON job description indicated, Develop and implement nursing policies and procedures and ensure compliance. During a review of the facility ' s P&P titled, Medication Labeling and Storage, undated, indicated, .The medication label includes, at a minimum: medication name, prescribed, dose, strength, expiration date when applicable, resident ' s name, route of administration, and appropriate instructions and precautions .If medication containers have missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. 3. During a concurrent observation an interview on [DATE], at 10:52 a.m., with Licensed Vocational Nurse (LVN) 2 in the hallway near nurse ' s station two, there was an unattended medication cart. The medication cart had a set of keys and a clear, plastic cup containing five unidentified, loose pills sitting on top. LVN 2 was observed to be at the nurse ' s station on the phone, with his back turned to the medication cart. LVN 2 stated, Keys and medication should not have been left unattended. During an interview on [DATE] at 2:52 p.m. with LVN 2, LVN 2 stated, I should have taken the keys and medications with me or put it in the cart and locked it while my back was turned. LVN 2 stated, A resident could grab the keys or medications. LVN 2 stated, If a resident takes unknown medications, they could have adverse reactions that could lead to death. During an interview on [DATE] at 3:09 p.m. with the Director of Nurse (DON), the DON stated, Medications and keys should not be left on the cart, that is unacceptable. The DON stated, Anyone can walk away with the keys and cause a security issue. The DON stated, If a resident takes unknown medications, they could have adverse reactions. During a review of the LVN job description, dated [DATE], the LVN job description indicated, .Implement and maintain established nursing objectives and standards . During a review of the DON job description, the DON job description indicated, Develop and implement nursing policies and procedures and ensure compliance. The DON job description indicated, .Responsible for ensuring resident safety . During a review of the facility ' s P&P titled, Medication Labeling and Storage, undated, indicated, .Compartments (including but not limited to . carts .) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others .

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for six of 19 sampled residents (Residents' 36, 74, 115, 138, 361 and 554) when: 1.Resident 74 urinary catheter (flexible tube inserted into bladder to drain urine) bag was not covered and was visible to residents and visitors to see. 2. Registered Nurse (RN)1 and Licensed Vocational Nurse (LVN) 9 checked Resident 115 and Resident 361's blood pressure (B/P- measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) and did not provide privacy. 3. Licensed Vocation Nurse (LVN) 7 checked Resident 554's blood sugar (amount of sugar in the blood) and did not provide privacy. 4. Licensed Vocation Nurse (LVN) 7 administered insulin to Resident 36 and Resident 138 and did not provide privacy. These failures had the potential to violate Residents' 36, 74, 115, 138, 361 and 554 respect and dignity during direct resident care which could potentially impact residents' well-being leading to vulnerability, decreased dignity, anxiety, stress, and depression. Findings: 1.During a review of Resident 74's Admission Record [AR-a document with personal identifiable and medical information], dated 4/3/25, the AR indicated Resident 74 was admitted to the facility on [DATE] with diagnoses which included Pressure ulcer (localized skin and soft tissue injury caused by prolonged pressure) of sacral bone (tail bone), and muscle weakness. During a concurrent observation and interview on 4/2/25 at 4:55 p.m. in station 1 cart 1 with Licensed Vocational Nurse (LVN) 8 in Resident 74's room, Resident 74 was lying in bed with a urinary catheter bag hanging on the bed frame uncovered, facing the door. The urinary bag was visible and easily seen when entering the room and the bag was filled with yellow urine. Resident 74's family was at bedside visiting. Resident 74 stated she needed the urinary catheter because she was not able to void (urinate). LVN 8 stated she is from staffing agency, and it was her first time in station 1. LVN 8 stated it was Resident 74's right and dignity issue to not have urinary catheter bag exposed and for everyone walking by to see. LVN 8 stated urinary catheter bags should be placed in a privacy bag all the time. During an interview on 4/2/25 at 5:22 p.m. with Certified Nurse Assistant (CNA) 9, CNA 9 stated urinary catheter should be in a privacy bag and not exposed for everyone to see. CNA 9 stated it is a dignity issue and resident rights to not have their urinary catheter bag exposed. CNA 9 stated urinary catheter bag should be placed in a privacy bag and not touching the floor. During an interview on 4/3/25 at 11:15 a.m. with the Infection Preventionist (IP), the IP stated, Urinary catheter bag should be clipped on the bed rails and covered with privacy bag for dignity issue. The IP stated nursing staff are responsible in making sure urinary catheter bag are kept in privacy bag. During an interview on 4/4/25 at 2:15 p.m. with Assistant Director of Nursing (ADON) 1, ADON 1 stated nursing staff are responsible in making sure urinary catheter bags of residents are kept in a privacy bag and not touching the floor. ADON 1 stated, We do not want other residents or visitors being able to see bag full of urine. During an interview on 4/4/25 at 3:40 p.m. with the Director of Nursing (DON), the DON stated urinary catheter bags should always be in a privacy bag. The DON stated residents and visitors are walking by and did not want urinary catheter bags to be exposed for everyone walking by to see. The DON stated it was a dignity issue and resident right to their privacy. During a review of facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 8/22, the P&P indicated, . Ensure the catheter remains secured wit a securement device to reduce friction and movement at insertion site . Check the resident frequently to be sure he or she is not lying on the catheter . Position the drainage bag lower than the bladder at all times . During a review of facility's policy and procedure titled, Dignity, dated 2/21, the policy and procedure indicated, .1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs . 6. Residents' private space and property are respected at all times . Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . helping the resident to keep urinary catheter bags covered . 2. During a concurrent observation and interview on 4/3/25 at 4:54 p.m. with Licensed Vocation Nurse (LVN) 9 in Resident 115's room, Resident 115 was in semi sitting position in bed and LVN 9 checked Resident 115's B/P and did not close the privacy curtain between A and B bed or the door. Visitors and residents walking by and could see LVN 9 checking Resident 115's blood pressure (B/P- measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) from the hallway. LVN 9 stated she did not provide Resident 115's privacy when she checked her B/P, she should have closed the privacy curtain but she did not. LVN 9 stated, The roommate was also in the room and was looking at us while I was checking [Resident 115's] blood pressure. During a review of Resident 115's Admission Report, dated 4/3/25 indicated Resident 115 was readmitted to the facility on [DATE] with diagnoses which included heart failure (heart can't pump enough blood to meet the body's needs), anemia and diabetes. During a concurrent observation and interview on 4/3/25 at 1:36 p.m. with Registered Nurse (RN) 1 in Resident 361'a room, Resident 361 was sitting up in her wheelchair next to the window facing the door and inside the room was a family member of Resident 361's roommate. Resident 361's roommate had a visitor. Resident 361 room had a privacy curtain between A and B bed and it was not drawn. RN 1 approached Resident 361 and checked Resident 361's B/P and did not provide privacy. RN 1 stated she did not provide privacy to Resident 361 when she checked Resident 361' B/P and she should have. RN 1 stated it was a dignity issue and resident had the right to their privacy. During a review of Resident 361's Admission Report, dated 4/3/25, the AR indicated Resident 361 was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), osteoporosis (weak and brittle bone) and weakness. During a review of Resident 361's Order Summary Report, undated, the OSR indicated, .Amlodipine [used to treat high blood pressure] Give one tablet by mouth one time a day for [hypertension] hold if SBP [systolic blood pressure-force of blood pushing against the artery walls when the heart beats] is less than 100 . During an interview on 4/4/25 at 2:05 p.m. with the Assistant Director of Nursing (ADON) 1, ADON 1 stated nursing staff are expected to provide resident privacy when checking blood pressure. ADON 1 stated blood pressure can not be checked in the hallway or dining room, nursing staff should have to bring resident in their rooms and provide privacy. ADON 1 stated nursing staff had to either closed the privacy curtain or the door. ADON 1 stated, It is a dignity issue. During a review of facility's policy and procedure titled, Dignity, dated 2/21, the policy and procedure indicated, .1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs . 6. Residents' private space and property are respected at all times . Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . helping the resident to keep urinary catheter bags covered . 3. During a review of Resident 554's Admission Report, dated 4/3/25, the AR indicated, Resident 554 was admitted to the facility on [DATE] with diagnoses which included diabetes, dysphagia (difficulty swallowing foods or liquids), and hypertension (high blood pressure). During a review of Resident 554's Order Summary Report, undated, the OSR indicated, . [medication used to treat high blood sugar] Injection Solution . Inject as per sliding scale (dose of medication based on your blood sugar level just before your meal) . During a concurrent observation and interview on 4/2/25 at 12:34 p.m. with LVN 7 in Resident 554's room, LVN 7 entered Resident 554's room and checked Resident 554's fingerstick (A procedure in which a finger is pricked with a lancet) blood sugar. LVN 7 did not close the door to provide Resident 554 privacy. LVN 7 stated she should have provided Resident 554 privacy when she her blood sugar. LVN 7 stated it was a dignity issue and resident right to have privacy. During a concurrent observation and interview on 4/4/25 at 1:58 p.m. with ADON 1, she stated LVN 7 should have provided privacy to Resident 554 and Resident 138 when she checked their blood sugar. ADON 1 stated the expectation was to provide privacy when checking blood sugar of residents. During a review of facility's policy and procedure titled, Dignity, dated 2/21, the policy and procedure indicated, .1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs . 6. Residents' private space and property are respected at all times . Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . helping the resident to keep urinary catheter bags covered . 4. During a review of Resident 36's Admission Report, dated 4/3/25, the AR indicated, Resident 36 was readmitted to the facility on [DATE] with diagnoses which included diabetes, muscle weakness and anemia (condition that develops when blood produces a lower-than-normal amount of healthy red blood cells). During a review of Resident 36's Order Summary Report, undated, the OSR indicated, .[insulin medication used to treat high blood sugar] . Inject as per sliding scale . During a concurrent observation and interview on 4/2/25 at 11:33 a.m. with LVN 7 outside of Resident 36's room, LVN 7 prepared Resident 36 medications and entered Resident 36's room. LVN 7 administered Resident 36 insulin and did not close the door. LVN 7 stated she should have closed the door before she administered Resident 36's insulin because there are visitors and residents walking by and could see inside Resident 36's room. LVN 7 stated it was a dignity issue and resident right for their privacy. During a review of Resident 138's Admission Report, dated 4/3/25, the AR indicated, Resident 138 was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar in the blood), weakness, and multiple fractures (break in bones) of ribs. During a review of Resident 138's Order Summary Report, undated, the OSR indicated, . [insulin medication used to treat high blood sugar] . Inject as per sliding scale .before meals and at bedtime . During a concurrent observation and interview on 4/2/25 at 12:08 p.m. with LVN 7 in Station 2 hallway. LVN 7 entered Resident 138's room, administered insulin and did not close the door. LVN 7 stated she should have closed the door before she administered Resident 138's insulin. LVN 7 stated visitors and residents walking by could see Resident 138's bed which was closest to the door. During an interview on 4/4/5 at 2:15 p.m. with Assistant Director of Nursing (ADON) 1, she stated it was the practice in the facility to ensure residents are provided with privacy during medication administration like checking blood sugar, checking B/P and administering insulin to residents. ADON 1 stated it was a dignity issue, there are visitors and residents can walk by and see. During an interview on 4/4/25 at 3:45 p.m. with the Director of Nursing (DON), DON stated her expectation, and the facility protocol was for licensed nursing to provide privacy to residents when checking blood pressure, blood sugar and administering insulin. The DON stated it was resident rights to have their privacy respected and dignity issue. The DON stated there are staff, visitors and residents walking by and could see what direct care was being done to residents. The DON stated, licensed nurses just had their skills check on medication administration recently, I was expecting more from them. During a review of facility's policy and procedure titled, Dignity, dated 2/21, the policy and procedure indicated, .1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs . 6. Residents' private space and property are respected at all times . Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . helping the resident to keep urinary catheter bags covered .

Based on observation, interview and record review, the facility failed to report a alleged abuse incident to the California Department of Public Health (CDPH) when two of six sampled residents (Resident 30 and Resident110) were involved in a resident-to-resident altercation without serious injury. This failure resulted in the facility not reporting the alleged violation involving resident to resident abuse within the required timeframe and had the potential for additional allegations of abuse to go unreported. Findings: During a concurrent observation and interview on 4/1/25 at 3:02 p.m. with Resident 110 in the resident ' s room, Resident 110 was sitting on the edge of her bed facing the window. Resident 110 had six 1.5-inch adhesive strips (small bandages made of breathable material used as an alternative to stitches to help close small cuts and wounds) applied to her left hand. Resident 110 was alert, oriented to person, place, date and time, understood and answered questions appropriately. Resident 110 stated a resident threw a piece of metal towards her and it hit her hand resulting in a skin tear. Resident 110 stated the incident was reported to the police. During a review of Resident 110 ' s Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/4/25, the AR indicated Resident 110 admitted to the facility on [DATE] with diagnoses: Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe) and influenza (flu-a contagious respiratory infection of the nose, throat and lungs potentially causing mild to severe illness, and sometimes death). During a review of Resident 110 ' s Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/11/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 110 had no cognitive impairment. During a review of Resident 30 ' s Progress Notes dated 3/25/25 at 7:32 a.m., the nurse ' s note indicated the writer contacted all appropriate agencies relating the altercation, Ombudsman (someone who acts as a neutral and independent point of contact for resolving complaints or concerns), local police department, the ADM and the resident ' s representative. During an interview on 4/3/25 at 10:09 a.m. with Certified Nurse Assistant (CNA) 4, CNA 4 stated when a resident-to-resident altercation occurs the staff would intervene, remove both residents from the situation to de-escalate the situation. CNA 4 stated she would alert the licensed nurse of a resident-to-resident altercation for resident assessment and potential treatment. CNA 4 stated the licensed nurse (LN), or administrator (ADM) would report the alleged abuse to the appropriate agencies. During an interview on 4/3/25 11:25 a.m. with the Administrator (ADM), the ADM stated the facility reported the resident-to-resident altercation to the Ombudsman and police. The ADM stated the facility did not need to report the incident to CDPH because Resident 30 had dementia. During a concurrent interview and record review on 4/3/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 110 and Resident 30 ' s electronic medical records (EMR) were reviewed. Resident 110 ' s EMR indicated Resident 110 sustained left hand skin tear on 3/25/25 from an alleged resident-to resident altercation. LVN 1 stated Resident 110 ' s roommate was Resident 30 and was re-roomed. Resident 30 ' s EMR indicated Resident 30 room was changed immediately after the alleged resident-to-resident incident. LVN 1 stated when resident-to-resident altercation occurs the staff should separate the individuals, assess the residents for injury, provide each resident with treatment as necessary, notify the physician and the resident representative, and document their incident and findings. LVN 1 stated the licensed nurse (LN) would notify outside agencies of allegations of abuse, if resident to staff altercation the LN would also notify the administrator (ADM), and resident-to-resident incidents the LN would notify local law enforcement. LVN stated altercation incidents should be reported the appropriate agencies due to the involvement of physical contact. During a review of Resident 30 ' s Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 4/4/25, the AR indicated Resident 30 admitted to the facility on [DATE] with diagnoses: idiopathic peripheral autonomic neuropathy (nerve damage in the nerves outside the brain and spinal cord affecting the autonomic nervous system (which controls involuntary functions), where the underlying cause is unknown), personal history of TIA (transient ischemic attack-a temporary disruption of blood flow to the brain that causes stroke-like symptoms) without residual deficits, anxiety disorder, dementia (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 30 ' s Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/10/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 10 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 30 had moderate cognitive impairment. During an interview on 4/4/25 at 10:11 a.m. with the Director of Nursing (DON), the DON stated when a resident-to-resident altercation occurs the facility would separate the residents to prevent further injury, notify the DON, ADM, and the supervisor. The DON stated the ADM was the facility ' s abuse coordinator (facility staff who initiates investigation of the allegation, responsible for maintaining communication with the resident or responsible party of the status of the investigation, ensures individuals involved in the allegation are protected from retaliation) appropriate agencies to report. The DON stated the aggressor had dementia so the facility would report to the Ombudsman and local law enforcement. The DON stated non-dementia related abuse would be reported to CDPH. During a concurrent interview and record review on 4/4/25 at 11:19 a.m. with the Administrator (ADM) in the ADM office, an Assembly [NAME] (AB)-1417 (2023) dated 2/2024 and Resident-to Resident Altercations policy and procedure (P&P), dated 9/2022 were reviewed. AB-1417 (2023) Mandated Reporting System for Elder & Dependent Adult Abuse & Neglect in LTC (Long Term Care) Facilities indicated the mandated reporter observes, has knowledge of, or reasonable suspect abuse or neglect in a long-term care facility, resident with dementia (caused by a resident diagnosed with dementia with no serious bodily injury) within 24 hours (preferably ASAP) SOC-341 (Report of Suspected Dependent Adult/Elder Abuse) to: LTC Ombudsman, Law Enforcement. Abuse of an elder .can include: (1) Physical abuse .with resulting physical harm .NOTE: Facilities may have additional reporting requirements under state and federal law . The Resident-to-Resident Altercations P&P ' s Policy Interpretation and Implementation indicated, 3. Occurrences of such incidents are promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating .4. If two residents are involved in an altercation, staff .j. report incidents, findings, and corrective measures to appropriate agencies as outline in Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating. The ADM stated when a resident-to-resident altercation occurs, the facility followed the AB 1417 state guidance for mandated reporters which stated if one of the resident ' s has dementia and no serious bodily injury occurred, the facility would report the incident to the Ombudsman and local law enforcement. During a concurrent interview and record review on 4/4/25 at 2:01 p.m. with the ADM in the ADM office, All Facilities Letter (AFL) 24-09 dated 2/28/24, and 42 CFR (Code of Federal Regulations) 483.12 dated 4/2/25 were reviewed. AFL 24-09 indicated the revised process outlines requirements for reporting incidents of known, suspected or alleged abuse committed by residents diagnosed with dementia .For incidents involving resident-on-resident abuse that did not result in bodily harm where the alleged abuser is a resident diagnosed with dementia, facilities are required to notify the ombudsman and local law enforcement in writing within 24 hours. For incidents resulting in physical harm, facilities are required to notify local law enforcement immediately or as soon as possible, but no later than two hours after the incident occurred. Facilities are further required to provide written notice of the incident to, the appropriate state agency, the ombudsman, and local law enforcement. 42 CFR 483.12(C)(1) indicated Ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse ., or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency .) in accordance with State law through established procedures. The ADM stated the AFL revised the reporting requirements for resident-to resident abuse when one of residents had a diagnosis dementia, so the facility reported the incident to the ombudsman and local law enforcement. The ADM stated 42 CFR 483.12 (C) (1) indicated .if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures and the facility followed the guidance in accordance with State law through established procedures. During a review of the facility documents dated 3/25/25, the fax indicated the facility successfully reported the altercation between two residents to the local police department and the Ombudsman to include: the completed SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) and face sheet for Resident 30 and Resident 110. During a review of Facility Reported Event dated 3/25/25, the describe incident indicated At approximately 10:40 a.m. Resident 30 allegedly threw a rod at her roommate (Resident 110) who was sitting on her bed receiving a breathing treatment. Upon skin assessment, Resident 110 sustained skin tear to left hand. Resident 30 also allegedly shoved a clipboard and hit Resident 110 on her right shoulder. No injuries were noted to the right shoulder at the time of assessment. Resident 30 was noted to be very confused with episodes of yelling at the time of incident. Residents were immediately separated; Resident 30 was moved from room .to room . Respective attending physicians and RP and/or family for both residents were notified of incidents. Skin tear to Resident 110 ' s left hand was treated according to physician orders. Skin tear was superficial, no signs and symptoms of infection noted at this time. Resident 30 is a long-term resident, admitted on [DATE] with BIMS score of 10 (moderately impaired) and diagnose of idiopathic peripheral autonomic neuropathy, chronic pancreatitis, personal history of TIA (transient ischemic attack), paroxysmal atrial fibrillation, CKD (chronic kidney disease), essential HTN (hypertension), anxiety disorder, age-related osteoporosis, heart failure, HLD (hyperlipidemia), dementia, unspecified psychosis. The 5 Day Follow Up indicated the full investigation was completed and the interdisciplinary team determined the root cause of [Resident 30 ' s] behavior is related to increased confusion at the time of assessment related to active ear infection and folliculitis which were being treated with antibiotic therapy as well as new roommate as of 3/21/25. [Resident 30] has a history manifested behavioral issues (i.e. yelling out, spiting, repeating calling out of ' help me God, ' digging out and throwing feces, making false accusations, turning over bedside table), but this is the first incident that involved physical aggression with another resident . During a review of Job Description: Administrator (ADM), dated 12/2018, the General Purpose indicated, .the purpose of your job positions is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. The Essential Duties indicated .responsible for the overall operational functioning of the facility .Monitors industry regulations, laws, compliance updates and makes changes appropriately .Ensure that all facility personnel, residents, visitors, etc., follow established safety regulations . During a review of Job Description: Director of Nursing (DON), dated 2/2024, the General Purpose indicated, .The DON is a registered nurse who oversees and supervises the care of all residents . The Essential Duties indicated, .implement nursing policies and procedures and ensure compliance. Responsible for ensuring resident safety .Responsible for keeping current on any regulation changes and disseminating this information appropriately . During a review of the facility ' s policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 9/2022, the Policy Statement, indicated All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) . The Policy Interpretation and Implementation indicated .The administrator or the individual making the allegations immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .3. Immediately is defined as: b. within two hours of an allegation involving abuse . During a review of the facility ' s policy and procedure titled, Resident-to-Resident Altercations, dated 9/2022, the Policy Interpretation and Implementation indicated, 3. Occurrences of such incidents are promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating .4. If two residents are involved in an altercation, staff .j. report incidents, findings, and corrective measures to appropriate agencies as outline in Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating .

Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs of residents) accurately reflected resident's health and functional status of one of four sampled residents (Resident 17) when Resident 17's use of anxiety medication and diagnoses of migraine was not accurately coded on the MDS assessment. This failure had the potential to result in Resident 17's care needs not met. Findings: During a review of Resident 17's Admission Record (document with resident demographic and medical diagnosis information), dated 4/3/25, the AR indicated Resident 17 was admitted in the facility on 7/11/25 and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, rigidity, and slow, imprecise movements), respiratory disorder and dementia (a progressive state of decline in mental abilities). During a review of Resident 17's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 17's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 14 out of 15 (0-15 scale, 0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) indicating Resident 17 had no cognitive deficit. During a review of Resident 17's Order Summary Report, undated, the Order Summary Report, indicated .Divalproex Sodium (medication used to treat certain types of seizures-a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) . Give 1 tablet by mouth one time a day for migraine, headache . LORazepam (medication used to treat anxiety disorders) Oral Tablet . order date: 11/14/24 . During a concurrent interview and record review on 4/4/25 at 9:10 a.m. with Minimum Data Set Nurse (MDSN), Resident 17's quarterly MDS assessment dated [DATE], section N (medications) was reviewed by MDSN. The MDSN stated Resident 17 has an order for antianxiety medication and should have been coded in MDS but was not coded. The MDSN stated Resident 17's diagnosis of migraine headache should have been coded in the MDS assessment but was not coded. The MDSN stated she should have reviewed Resident 17's list of medications and diagnosis for an accurate and complete MDS assessment. During a concurrent interview and record review on 4/4/25 at 10:50 a.m. with the Assistant Director of Nursing (ADON) 2, Resident 17's medication orders were reviewed. ADON 2 stated Resident 17's antianxiety medication was ordered on 11/14/24 when admitted to hospice care. ADON 2 stated Resident 17's medication for migraine headache was ordered on 10/19/24. ADON stated she did not find a diagnosis of migraine headache in Resident 17's record. ADON 2 stated it was the MDS responsibility to ensure diagnosis are reviewed and accurately coded in MDS assessments. During an interview on 4/4/25 at 3:05 p.m. with the Administrator (ADM), the ADM stated his expectation was for MDSN to gather all information including medications and diagnosis to accurately code in MDS. The ADM stated MDSN should have made sure and reviewed Resident 17's records to accurately code in MDS assessment. During an interview on 4/4/25 at 3:35 p.m. with the Director of Nursing (DON), the DON stated her expectation was, .[MDSN] to ensure resident MDS assessments are accurate when completing MDS . The DON stated the MDSN is responsible in making sure resident medications and diagnosis are reviewed and coded in the MDS assessments. During a review of professional guideline titled, Long Term Care Facility Resident Assessment Instrument version 1.18.11 Manual (RAI- core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) dated 10/23, indicated, . Physician-documented diagnoses . that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments . Medical record sources for physician diagnoses include progress notes . Review documentation from other health care settings where resident may have received any of these medications . Code all high-risk drug class medications .

Based on observation, interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR- The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a admission level screening and if necessary a level ll evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed accurately for one of four sampled residents (Resident 17) when Resident 17 was admitted for hospice care on 11/14/24 and an updated PASRR was not completed. This failure had the potential for Resident 17 not to receive the necessary and appropriate psychiatric treatment and evaluation in the facility. Findings: During a review of Resident 17's Admission Record [AR], dated 4/3/25, the AR indicated, Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, rigidity, and slow, imprecise movements), hypothyroidism (thyroid gland does not produce enough thyroid hormone) and dementia (a progressive state of decline in mental abilities). During an observation on 4/1/25 at 9:25 a.m. in Resident 17's room, Resident 17 was lying in bed, bed in low position, floor mat on one side of the bed. Resident 17's eyes opened when spoken to but did not answer questions when asked. During a concurrent interview and record review on 4/4/25 at 10:15 a.m. with Minimum Data Set Nurse (MDSN), Resident 17's PASRR dated 8/15/24 was reviewed. The MDSN stated the PASRR was completed in the facility when Resident 17 was readmitted to the facility on [DATE]. The MDSN stated Resident 17 was admitted to hospice care on 11/14/24 and a PASRR assessment should have been completed. The MDSN stated it is the practice of the facility to complete PASRR annually, change of condition and when admitted to hospice. The MDSN stated it was the responsibility of MDS to ensure assessment was completed. The MDSN stated Resident 17 did not have PASRR assessment completed when admitted for hospice care, which is considered a change in condition. The MDSN stated Resident 17's last PASRR assessment was dated 8/15/24. The MDSN stated there should have been a PASRR assessment completed when Resident 17 was admitted for hospice care but there was none. During an interview on 4/4/25 at 2:59 p.m. with the Administrator (ADM), the ADM stated his expectation was for the MDSN to do her job and complete a PASRR assessment when needed. The ADM stated it was the responsibility of MDSN to make sure a PASRR assessment was completed for any changes in condition per the facility policy. During an interview on 4/4/25 at 3:35 p.m. with the Director of Nursing (DON), the DON stated the MDSN was responsible in making sure a PASRR assessment was completed for Resident 17's change of condition. During a review of facility's document titled, Tool Tip Legend, undated, the document indicated, . The screening type Resident Review (RR) is selected for an individual who: (1) Experience a Significant Change in Condition for the same stay .

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for one of three sampled residents (Resident 253) when Resident 253 did not have a care plan for oxygen (O2) andmedication ciprofloxacin (antibiotic medication used to treat bacterial infections in different parts of the body). This failure resulted in no baseline care plan to address the use of ciprofloxcin and had the potential for Resident 253 to not have her oxygen needs met. Findings: During a concurrent observation and interview on 4/1/25 at 9:26 a.m. with Resident 253 in her room, Resident 253 was observed to be on oxygen (O2) at 3 liters(measurement) per minute (LPM) via nasal cannula (NC-tube used to administer via the nose). Resident 253 stated, I haven ' t always had oxygen; just since my hospitalization . During a review of Resident 253 ' s Admission Record (AR) dated 4/3/25, the AR indicated, Resident 253 was admitted to the facility on [DATE] with diagnoses which included fracture (break or crack in a bone) of first lumbar (lower region of the spine) vertebra (one of the small, individual bones of the spine) and bronchiectasis (a condition that occurs when the tubes that carry air in and out of the lungs gets damaged, causing them to widen and become loose and scarred). During a review of Resident 253 ' s Order Summary Report (OSR) dated 4/4/25, the OSR indicated, Ciprofloxacin (antibiotic medication used to treat bacterial infections in different parts of the body) [hydrochloride] Oral Tablet 500 mg (milligrams unit of measurement) . Order Date: 3/29/25. During an interview on 4/3/25 at 10:54 p.m. with the Infection Preventionist (IP), the IP stated, There should have been .a care plan for O2. The IP stated, If giving O2, you would get an order, do a care plan, and a nurse ' s note. The IP stated, If a resident is on antibiotics, it should be care planned. The IP stated, It is important to have an action plan for the resident, so we know what to watch for. During an interview on 4/3/26 at 2:56 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Use of O2 should have a care plan. LVN 3 stated, If a resident is on antibiotics, there needs to be a care plan. LVN 3 stated, The care plan should be initiated after reviewing the order for antibiotics. During an interview on 4/4/25 at 3:09 p.m. with the Director of Nursing (DON), the DON stated there should be a care plan for O2 use. The DON stated, Care plans are important to make sure we are documenting nursing interventions according to the doctor ' s order. The DON stated, Antibiotics should be care planned to document what we are doing for the residents care and the interventions needed. The DON stated, Expectation is, once you put in an order, the nurse should care plan and do nurse ' s notes. The DON stated baseline care plans are initiated within 48 hours of admission. During a review of the facility LVN job description, dated November 2018, n indicated, Review care plans daily to ensure that appropriate care is being rendered .Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs . During a review of the DON job description, dated February 2024, the DON job description indicated, .Develop and implement nursing policies and procedures and ensure compliance . During a review of the facility ' s policy and procedure (P&P) titled, Care Plans - Baseline, dated March 2022, indicated, .A baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident .

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 128) was free from accidents, when Resident 128 was smoking and had ashes fall on her shirt and into her wheelchair. This failure put Resident 128 ' s safety at risk and the ashes had the potential to burn the resident. Findings: During a concurrent observation and interview on 4/2/25 at 11:40 a.m., with Resident 128, Resident 404, Activities Assistant (AA) 2 and AA 1, outside in the atrium designated smoking area of the facility, Resident 128 smoked two cigarettes and dropped ashes on her shirt and between her legs on her wheelchair. AA 2 was sitting on a bench to the right of the resident conversating with both residents and another Activities Assistant (AA 1). Resident 128 brushed the ashes off her body with her hand that had a cigarette in it. Resident 128 was not wearing a smoking apron and stated she was not offered one prior to smoking. During a review of Resident 128's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/4/25, the Admission Record indicated, Resident 128 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (a person ' s heart can't pump enough blood to meet your body's needs, leading to fluid buildup in the lungs and other parts of the body), polyneuropathy (a condition involving damage or malfunction of many peripheral nerves, which are the nerves outside of the brain and spinal cord, often resulting in symptoms like numbness, tingling, and pain) and muscle weakness. During a review of Resident 128 ' s Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/31/25, the MDS assessment indicated Resident 128 ' s Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 128 was cognitively intact. During a review of Resident 128 ' s Smoking Observation/Assessment (SOA), dated 4/2/25 at 12:41 p.m., the SOA indicated, .Smoking Assessment: Resident is a smoker . Type of Smoking Device: Cigarette . Safety: . Smoking adaptive equipment needed: [Checkmark] Smoking Apron . Level of Assistance: . [Checkmark] Supervision Required . IDT Rationale/Concerns: Resident will be supervised to help prevent burns. Offer resident smoking apron .Print name of resident educated: [Resident 128] . During a review of Resident 128 ' s Progress Notes (PN), dated Late Entry 4/2/25, the PN indicated, . Activities staff supervised patient with smoke break at 11:30, activities staff did not observe any ashes falling on patient . Author: [AA 2] . During an interview on 4/3/25 at 1:19 p.m., with AA 2, AA 2 stated she was out there with Resident 128 when she was smoking. AA 2 stated the expectation was to offer a smoking apron (worn over the front of the body to prevent burns in clothing and keep hot ashes from burning the skin) prior to smoking, but her nor AA 1, had not done that. AA 2 stated she was keeping more of an eye now after Resident 128 dropped ashes on herself the previous day. AA 2 stated the resident dropping ashes on herself was an issue because the ashes could be hot and she could have burned her skin or clothes. AA 2 stated Resident 128 ' s safety was put at risk. During an interview on 4/3/25 at 1:41 p.m., with the Activities Director (AD), the AD stated her department oversees smoking activities at the facility. The AD stated the expectation was that residents were observed by activities staff for safe smoking practices, which meant ashes go in the ash tray. The AD stated after the incident Resident 128 was reassessed on 4/2/25 and now offered a smoking apron. During an interview on 4/3/25 at 3:44 p.m., with the Assistant Director of Nursing (ADON), the ADON stated she had been made was aware of Resident 128 dropping ashes on herself while she smoked on 4/2/25. The ADON stated that shouldn ' t happen ever. The ADON stated Resident 128 could burn herself and it was dangerous for the ashes to have fallen on her. The ADON stated a fire could have started because the ashes were not going in an ash tray. The ADON stated Resident 128 should have had a smoking apron on and offered prior to smoking. The ADON stated staff members should have been watching and made sure Resident 128 was smoking safely and they weren ' t. The ADON stated the facilities policy and procedure (P&P) Smoking Policy- Residents was not followed. During an interview on 4/4/25 at 2:06 p.m., with the Director of Nursing (DON), the DON stated Resident 128 should not be dropping ashes on herself and the ashes go in the ash tray. The DON stated the expectation was Resident 128 was free from ashes on her body. The DON stated Resident 128 could have been burned, as the ashes could go through clothes or fall on her skin. The DON stated the ashes could have potentially caused a fire as well. The DON stated the ashes that fell on Resident 128 put her safety at risk. The DON stated Resident 128 should have had a smoking apron offered prior to smoking and she did not. The DON stated the facilities P&P Smoking Policy- Residents was not followed. During a review of the facility ' s P&P titled Smoking Policy- Residents, dated 10/2023, the P&P indicated, .The facility has established and maintains safe resident smoking practices . The staff consults with attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident smoking privileges based on the Safe Smoking Evaluation . The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision . Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member . at all times while smoking .

Based on interview and record review, the facility failed to ensure the physician was notified for a change in condition for one of three residents (Resident 1) when on 5/14/24 Resident 1 was observed to have an acute change in mental status, an abrupt loss of in appetite, weakness, fatigue, and was difficult to arouse. CNA 4 communicated the changes of Resident 1 to the licensed nurse and the license nurse did not assess the resident, did not notify the physician and the Responsible Party (RP-a decisionmaker for the resident) regarding the change in condition. This failure resulted in a delay in physician notification of a change in condition that occurred on 5/14/24 and did not provide the physician the resident assessment to diagnose promptly to treat or transfer Resident 1 to a higher level of care. The delay in physician notification lead to a delay in transferring to a general acute care hospital where Resident 1 ' s CT (computerized tomography x-ray image) scan results were consistent with an acute ischemic stroke (when blood flow to the brain is blocked). The delay in physician notification lead to Resident 1 inability receive medication treatment for a stroke and decline in mental and physical abilities. This led the Responsible Party to place Resident 1 on hospice (care for people who are neat the end of life) and palliative care (care that focuses on providing relief from pain and symptoms of a serious illness). Findings: During a review of Resident 1's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included constipation, hypertension (high blood pressure), and muscle weakness, cardiac murmur (a blowing, whooshing, or rasping sound heard during a heartbeat), overactive bladder (a condition in which the bladder squeezes urine out at the wrong time). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/11/24, the MDS, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 1 was cognitively intact. During a review of Resident 1's MDS assessment, dated 5/11/23, the MDS Section GG (Functional Abilities and Goals) indicated Resident 1 was a partial to moderate assistance (helper does 50% of assistance) with transfer, dressing and bathing. During an interview on 6/4/24 at 1:45 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she worked at the facility for more than two years. CNA 4 stated she took care of Resident 1 on a regular basis and was familiar with her care. CNA 4 stated she remember Resident 1 was her normal talkative self in the chair the morning of 5/14/24. CNA 4 stated in the afternoon of 5/14/24 Resident 1 was weak, less talkative and was out of it after lunch. CNA 4 stated Resident 1 ' s .eyes were stuck to the side . while looking out the window and responded slower to questions. CNA 4 stated she provided care for Resident 1 after lunch and noticed she was not as strong. CNA 4 stated Resident 1 looked tired and did not want to eat lunch on 5/14/24. CNA 4 stated she notified License Vocation Nurse (LVN) 2 regarding Resident 1 ' s condition. CNA 4 stated LVN 2 told her to offer extra fluids to Resident 1. CNA 4 stated when she returned to work on 5/15/24 Resident 1 was not eating, not talkative, not able to drink out of the straw and she was total assistance which indicated she was worse than 5/14/24. CNA 4 stated Resident 1 had eaten 25% of breakfast on 5/14/24 and refused breakfast on 5/15/24. CNA 4 stated it was unusual for Resident 1 to not eat. During an interview on 6/6/24 at 10:36 a.m. with LVN 1, LVN 1 stated she was a float (a work assignment that moves from one section of the healthcare facility to another) nurse and worked for the facility for six years. LVN 1 stated she was assigned to Resident 1 on 5/14/24 for the afternoon (pm) shift. LVN 1 stated she had received report (update) about a change in condition from LVN 2 for Resident 1. LVN 1 stated she was told in report LVN 2 and the Assistance Director of Nursing (ADON) 1 assessed Resident 1 for a change in condition. LVN 1 stated on 5/14/24 during her afternoon shift Resident 1 was tired and difficult to arouse (stay awake) and slow to respond when spoken to. LVN 1 stated when a resident is difficult to arouse it was considered a changed in condition. LVN 1 stated Resident 1 had a change in condition and LVN 2 was responsible to notify the physician on 5/14/24, the RP and revise the care plan (an individualized plan of care that is personalized for a person's health conditions and current treatments needed for their care). LVN 1 stated the facility has a communication form for nurses to monitor for decline in residents when there a change in condition and one was not completed for Resident 1 on 5/14/24. During a review of Progress Notes (PN) dated 5/14/24 at 10:05 p.m., the PN indicated, Writer [received] report from [morning charge nurse] that resident [Resident 1] presented with normal vitals[clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] however difficulty arousing on [morning] shift. ADON aware assess resident .Resident continue to exhibit difficulty arousing on [afternoon] shift .resident consumed less than 25% of dinner meal, intake 220 [milliliters- a unit of measurement for liquids] of fluids . There was no indication in the PN by LVN 1 that the doctor was notified regarding Resident 1 ' s change in condition. During an interview on 6/6/24 at 11:08 a.m. with LVN 2, LVN 2 stated she had been the nurse for Resident 1 for over a year and half. LVN 2 stated Resident 1 could feed herself and was a one-person assistance with showers. LVN 2 stated CNA 4 was familiar with Resident 1 and reported to her Resident 1 did not look like her normal self in the afternoon on 5/14/24. LVN 2 stated, Resident 1 was responding slowly and staring out the window on 5/14/24. LVN 2 stated she believed Resident 1 ' s slow response was from a side effect (unwanted undesirable effects) of an antibiotic. LVN 2 stated she did not notify Resident 1 ' s doctor on 5/14/24. LVN 2 stated Resident 1 ' s condition worsened on 5/15/24 when she responded slower to questions. LVN 2 stated she called the physician, RP, ADON 1, ADON 2 and Director of Nursing (DON) on 5/15/24 (one day after Resident 1 ' s change in condition was noticed). During an interview on 6/6/24 at 12:08 p.m. with the ADON 1, ADON 1 stated she went to assess Resident 1 on 5/15/24 at around 2:30 p.m. ADON 1 stated Resident 1 consumed 50-70% for breakfast and zero percent for dinner on 5/14/24. ADON 1 stated Resident 1 ate zero percent of her breakfast and lunch on 5/15/24. ADON 1 stated on 5/15/24 Resident 1 was not able to drink from a straw which Resident 1 had done before. ADON 1 stated a change of condition for a resident would include an elevated temperature, increased respirations, a change in mental status, a change in eating habits and a change in their ability to perform self-care and an increased demand for oxygen. During an interview on 6/6/24 at 2:05 p.m. with ADON 2, ADON 2 stated nurses were expected to complete a full head to toe assessment and compare the findings to the resident ' s baseline (initial measurement of a residents condition). ADON 2 stated a change of condition for a resident would include an increased pulse, headache, nausea, vomiting, lethargy, change in vital signs, increased oxygen demand, not eating or drinking and difficult to arouse. The ADON 2 stated, all certified nursing assistants were responsible to notify a charge nurse when there was a change in meal consumption. ADON 2 stated charge nurses were responsible to start the process for a change in condition assessment. The ADON 2 stated Resident 1 was lethargic and speaking slowly on 5/14/24 and Resident 1 ' s change in condition should have been assessed. During an interview on 6/6/24 at 2:34 p.m. with the Director of Nursing (DON), the DON stated, a change in condition was when a resident had abnormal vital signs and/or a clinical change from the baseline. The DON stated nurses were to assess residents from head to toe during a change in condition and to complete a situation, background, assessment, and recommendation (SBAR a structured communication framework that help teams share information about the condition of a resident.) The DON stated staff completed change in condition training in March 2024. During an interview on7/15/24 at 3:41 p.m. with the Medical Doctor (MD), the MD stated, when a resident was difficult to arouse or lethargic it was considered a change in condition. The MD stated staff were to notify him or the nurse practitioner. The MD stated each resident was treated differently depending on the family or RP ' s wishes. The MD stated each resident ' s medical care was dependent on the Physician Orders for Life-Sustaining Treatment (a POLST is a physician order that helps give seriously ill patients more control over their end-of-life care) form and medical history. During a review of the facility ' s document titled SBAR Communication Form and Progress Note for RNs/LPN/LVNs (SBAR) for Resident 1, dated 5/15/24, the SBAR indicated .Situation .The change in condition, symptoms, or signs observed and evaluated is/are: Altered Mental Status .This started on 05/15/2024 .Since this started it has gotten: .[box checked] Better .Things that make this condition or symptom better are: IV Hydration (replenishes lost fluids through a tube in a vein) .This condition, symptom, or sign has occurred before: [box checked] Yes .Treatment for last episode .: Changing the [Residents] [Medication] and IV Hydration .Resident/Patient Evaluation .1. Mental Status Evaluation (compared to baseline check all that changes that you observe) .[box checked] Altered level of consciousness .Describe symptoms or signs [blank] .2. Functional Status (capacity an individual can perform activities and tasks) Evaluation (compared to baseline; check all that you observe) . No changes observed .10. Neurological Evaluation .[box checked] Altered level of consciousness .Describe symptoms or signs: [Resident] noted Not responding as Normal .Appearance .Summarize your observations and evaluations: [Resident] was noted with [Altered Mental Status] and is slow to respond. [Resident] was not eating and had to be fed .Review and Notify . Primary Care Physician Notified: Yes .Date 05/15/2024 .Time: 9:20 AM .Interventions .IV (soft flexible tube placed inside the vein) . During review of SNF/NF to Hospital Transfer Form dated 5/15/24, the SNF/NF to Hospital Transfer Form indicated Resident 1 was transferred from the skilled nursing facility to the acute care hospital on 5/15/24 at 4:13 p.m. During a review of Resident 1 ' s General Acute Care Hospital (GACH) H&P Addendum (H&P), dated 5/15/24, the H&P indicated, .CT (computerized tomography x-ray imaging) head shows acute [experienced to a severe or intense degree]or early subacute [ a recent onset or rapid change] infract [stroke] in the right PCA (posterior cerebral artery -one of a pair of arteries that supply oxygenated blood to the back of the brain) .Neurology was consulted. Not a candidate for TPA (tissue plasminogen activator- medication used to dissolve blood clots in stoke patients and must be given with 3 hours of onset of symptoms) since her symptoms started 3 days ago . During a review of Resident 1 ' s General Acute Care Hospital (GACH) Discharge Summary (DS) dated 5/24/24, the DS indicated, .admitted : 5/15/2024 discharge date : 5/24/2024 .Indication for Admission: Chief Complaint Patient presents with Altered Mental Status . [chief complaint of Altered Mental Status for] 3 days .baseline glasgow coma scale 15 (a system to measure how conscious a person is, a score of 15 means you ' re fully awake, responsive and have no problems with thinking ability or memory) .Admission Diagnoses: Acute CVA (cerebrovascular accident) .Active Hospital Problems Diagnosis .(Principal) Acute Ischemic stroke .AMS (altered mental status) .Hemiparesis (one sided muscle weakness) affecting left side .05/17 .Failed swallow evaluation .05/21 .Daughter agreed to meet with Palliative care to discuss goals of care .Disposition .Hospice . During review of Resident 1 ' s facility Discharge Document (DC) dated 6/11/24, the DC indicated .admitted : 2/3/2021 .discharge date [DATE] .Condition on discharge: Guarded .Significant Findings and Events: Long term patient became weak and altered sent to the hospital .Recommendation and Arrangements for Future Care: Per hospital course Prognosis Fair to poor Physician ' s Signature [signed] Date 06-11-2024 . During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status, revised dated 2/202, the P&P indicated, .the nurse will notify the resident ' s attending physician or physician on call when there has been a .significant change in the resident ' s physical/emotional/mention condition .2. A significant change of condition is a major decline or improvement in the resident ' s status .the nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status .

Based on interview and record review, the facility failed to implement its fall risk care plan for one of three sampled residents (Resident 1), when Resident 1, who was assessed as being a high fall risk, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Resident 1 getting out of bed unassisted on 12/22/20. Resident 1 sustained a fall and obtained a left upper leg posterior and left hip femoral neck (bone that connects the hip and the upper thigh bone) impaction fracture (broken bone in the hip) and experienced pain. Resident 1 required a six day hospitalization from [DATE] to 12/28/2020. Findings: During a review of Resident 1's Admission Record (a document with personal and medical information), dated 12/28/2020, the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS assessment of healthcare and functional needs) assessment, dated 10/9/2020, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS assessment of cognitive status) score was 10 of 15 points which indicated Resident 1 had moderate cognitive impairment in decision making during activities of daily living and required cues and supervision. The MDS assessment also indicated Resident 1 required the use of a bed alarm [pressure pad alarm] to monitor resident movement and to alert the staff when movement is detected. During a telephone interview, on 1/20/2021, at 1:34 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was a CNA employed through a Registry/Agency (employees that can be hired out for temporary or long-term work) utilized by the facility as needed for staffing needs. CNA 1 stated she was assigned to work the night shift (11 p.m. to 7 a.m.) on 12/22/2020 and was the CNA assigned for Resident 1. CNA 1 stated on 12/22/2020, Resident 1 was very confused, kept getting up from her bed, had weakness and her gait was unsteady. CNA 1 stated the p.m. shift CNA (2:30 p.m. to 10:30 p.m.) informed her during the change of shift report that Resident 1 was very confused and kept getting up from her bed. CNA 1 stated she was not aware Resident 1 had history of falls, was a high risk for falls and used a pressure pad alarm in the bed. CNA 1 stated nobody mentioned to her that she needed to monitor the resident closely or monitor if her pressure pad alarm was working because she was a high risk for falls. CNA 1 stated she did her first rounds (observe the physical and mental condition of the resident) after getting report from the p.m. shift nurse but did not check for pressure pad alarm placement. CNA 1 stated she could not recall the exact time she saw Resident 1, but it was during her first rounds around 12 a.m. when she checked Resident 1's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). CNA 1 stated, . [Resident 1] gets up all the time that night (12/22/2020). Nobody knew she had an alarm pad. I did not check at the beginning of my shift if she had a bed alarm because I did not know she used a bed alarm. At around [1 a.m. to 1:15 a.m.], I heard somebody screaming in the hallway and I saw her [Resident 1] on the floor. She complained of leg pain, but she always had leg pain before. I saw the [pressure pad alarm] and it was not properly connected. It was connected and plugged to the phone line . [the facility] is always short staffed so it's very scary. They should be giving reports about the resident if they are high risk for falls especially, we are from the registry and we are not familiar with the residents in the facility . CNA 1 stated Resident 1 does not walk fast and if the pressure pad alarm was connected properly and not in the telephone line she could have heard Resident 1 when she attempted to get up on her own unassisted and could have prevented her fall. CNA 1 stated the pressure pad alarm makes a loud sound when resident attempts to move or get up and would prompt her to respond and check on Resident 1. CNA 1 stated the night shift Licensed Nurse (LVN 1) did not inform her (CNA 1) Resident 1 was a high fall risk and had a pressure pad alarm. CNA 1 stated she had worked in different skilled nursing facilities as a CNA for registry/agency staffing, and she was familiar with pressure pad alarms being used as fall intervention for residents at high risk for falls. CNA 1 stated if she knew Resident 1 had a pressure pad alarm she would have checked if it was working and plugged in the alarm box. CNA 1 stated it was important to ensure the pressure pad alarm was connected to the pad alarm box to alert staff if residents tried to get up and could have prevented Resident 1's fall. During a review of the facility document titled, Certified Nursing Assistant Job Description dated 10/2012, the Job Description indicated, . The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors . Ensure that residents who are unable to call for help are checked frequently. Answer resident calls promptly . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or the improvement of services . During a telephone interview, on 1/22/2021, at 10:55 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he started working in the facility in November 2020. LVN 1 stated Resident 1 was alert, forgetful and had confusion. LVN 1 stated Resident 1 required one to two persons assist with ADL's (Activities of daily living a term used in healthcare to refer to people's daily self care activities) and she would try to get up on her own a lot without using the call light. LVN 1 stated Resident 1 had history of falls in the facility and was a very high risk for falls because of her behavior of trying to get up unassisted. LVN 1 stated Resident 1 has a pressure pad alarm that made a loud sound when residents attempted to move or get up from the bed. LVN 1 stated it was very important for the nurses and the CNAs to check the pressure pad alarm if it was properly working especially if a resident is high risk for falls. LVN 1 stated he was not aware if CNA 1 knew Resident 1 used a pressure pad alarm while in bed. LVN 1 stated it was the responsibility of the Licensed Nurses to inform CNAs if a resident was high risk for falls, to check for placement of pressure pad alarms and to ensure the pressure pad alarm was properly working. LVN 1 stated the facility started to utilize staff from registry/agency to meet staffing needs. LVN 1 stated CNAs employed through the registry/agency were not that familiar with the residents in the facility so it was very important to inform registry/agency staff if a resident was a high risk for falls and the interventions to prevent falls. LVN 1 stated she saw Resident 1 on the floor and stated Resident 1's pressure pad alarm was a very important fall prevention intervention to prevent her falling because it would usually make a very loud sound whenever Resident 1 would attempt to move or get up from the bed unassisted. LVN 1 stated the pressure pad alarm was supposed to be plugged in the alarm pad box and not in the telephone line and it was not done. LVN 1 stated if Resident 1's pressure pad alarm was plugged in the alarm pad box, the staff could have heard when Resident 1 tried to get up and walked unassisted from her bed and could have potentially prevented her from fall and injuries. During a review of the facility document titled, Licensed Vocational Nurse Job Description dated 11/2018, the Job Description indicated, The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times . Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility . Meet with your assigned nursing staff, as well as support personnel, in planning the shifts' services, programs and activities . Provide leadership to nursing personnel assigned to your unit/shift . Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status . Ensure that residents who are unable to call for help are checked frequently . Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies . Review care plans daily to ensure that appropriate care is being rendered . Ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment. Ensure that your assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNA's refer to the resident's care plan prior to administering daily care to the resident . During a telephone interview, on 1/25/2021, at 10:28 a.m., with CNA 2, CNA 2 stated she worked as per diem (as needed) in the facility particularly on p.m. shifts. CNA 2 stated she was aware when Resident 1 fell on [DATE]. CNA 2 stated she took care of Resident 1 several times and was familiar with her care. CNA 2 stated, . [Resident 1] is alert . knows me by name, confused at times . Most of the time she would call out and not use the call light. She is a high risk for fall. She's impulsive (doing things or tending to do things suddenly and without careful thought) to a point but slow moving. She is very slow moving and moves very slowly. She needs help before she can get up . She did have a pad alarm . If a resident is a high risk for fall, we checked on them every 15 minutes and check the bed alarm if it is turned on. If the bed alarm was working and plugged correctly, [staff] would know if a resident tried to get up. There would be no reason [Resident 1] can unplug the bed alarm. She couldn't even move when she is in her wheelchair. We had to push her so I don't see how she can unplug her bed alarm on her own . [staff] could hear her bed alarm because it makes a really loud sound . CNA 2 stated Resident 1's room was close to the nurse's station so if her bed alarm was plugged in the alarm pad box and was checked for proper placement, staff could have heard it [loud noise from pad alarm] when Resident 1 got up unassisted and could have prevented her fall. During a telephone interview, on 1/26/2021, at 12:21 p.m., with CNA 3, CNA 3 stated she was familiar with Resident 1's care. CNA 3 stated she was the p.m. shift nurse on 12/21/2020 and gave report to CNA 1 on the night shift. CNA 3 stated, . That day [12/21/2020], [Resident 1] got really agitated. She was trying to get up a lot, multiple times. She was moving a lot. I remember telling [CNA 1] that she was very agitated that time. She will sit on the edge of the bed trying to get up. She is a very high risk for fall . CNA 3 stated Resident 1 had a pressure pad alarm in the bed because she was a very high risk for falls. CNA 3 stated, I remember her bed alarm makes a really loud sound. When a bed alarm is functioning, it flashes a red light in the [pad alarm] box when it's properly connected, and it makes a sound when resident moves or attempts to get up and we would hear it and check on the resident. She is a very high fall risk. She was so weak and confused. The bed alarm is very important for her and it's important for a bed alarm to be properly placed and connected to prevent a fall . CNA 3 stated it was the Licensed Nurse and CNA's responsibility to check at the beginning of the shift and during rounds if the pressure pad alarm is properly placed and connected. During a telephone interview on 1/26/2021, at 1:35 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was alert with periods of confusion. The DON stated CNA 1 was employed through the registry/agency and provided care to Resident 1 on night shift on 12/22/2020. The DON stated Resident 1 had a pressure pad alarm in bed because she was a high risk for falls and had history of falls in the facility. The DON stated Resident 1 had an unwitnessed fall back in 11/2020 with no injuries. The DON stated the pressure pad alarm was ordered by Resident 1's physician (MD) on 4/6/2020. The DON stated Licensed Nurses and CNAs should have known Resident 1 was a high risk for falls and had a pressure pad alarm in the bed. The DON stated CNA 1 should have checked at the beginning of her shift and in between shifts if Resident 1's pressure pad alarm was properly connected and functioning. The DON stated the purpose of a bed alarm was to notify staff when a resident would try to move or get up on their own unassisted to prompt staff to check on the resident. The DON stated, It's important for the bed alarm to be inspected every shift and during their multiple rounds for functioning and if it's properly connected [to the alarm pad box]. That is the expectation for the bed alarm to be functioning and connected so when the resident gets up, the bed alarm will sound and alert the staff so staff can respond and prevent a fall. During a telephone interview on 1/26/2021, at 1:53 p.m., with Resident 1, Resident 1 stated, I did get up on my own. I had a couple of falls last month (December 2020). I experienced some pain in my leg. I broke something and had a fracture. I went to the hospital for a few days. I am receiving pain medications for my fracture . Resident 1 stated she did not know if she has a pressure pad alarm in place or if she used the call light when she needs help. Resident 1 stated, . I don't know what an alarm is or call light. I just get up on my own without calling for help sometimes . During a review of Resident 1's Nursing Notes, dated 3/10/2020, the Nursing Notes indicated, CNA notified nurse that Resident was on the floor @ (at) 4:33 p.m. Writer went to room found Resident on knees at bedside. Staff assisted Resident back to bed. Writer assessed Resident head to toe. No injuries .Resident transferred self from w/c (wheelchair) in hall way to bedside without assistance .Bed alarm in place fall precaution maintained . During a review of Resident 1's Nursing Post Fall Review, dated 3/10/2020, the Post Fall Review indicated, .1. Reason for Assessment Request a. Unwitnessed fall .1) Recent Falls .3. History of Falls within last six months .2. 1 2 times . During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Care Plan, dated 7/16/2020, the Care Plan indicated, . [Resident 1] is at risk for additional falls [related to] . dementia, [CONDITION(S)], seizures, limited mobility, not using the call light and history of fall . Interventions .Pressure Pad Alarm while in bed or wheelchair to alert staff of resident's attempt to rise unassisted or ambulate without assistance . During a review of Resident 1's Fall Risk Observation/assessment dated [DATE], the fall risk assessment indicated, .[name of resident] .Category: High Risk [Fall] .Score: 18.0 .Date 10/20/2020 09:29 [9:29 a.m.] .Scoring .A. Low Risk 0 8 .B. Moderate Risk 9 15 .C. High Risk 16 42 . During a review of Resident 1's Progress Notes, dated 11/15/2020, the Progress Notes indicated, .S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Cont (continue) with current plan of care and report changes . During a review of Resident 1's Progress Notes, dated 12/22/2020, at 2:10 a.m., the Progress Notes indicated, . Acetaminophen (pain medication) tablet 325 milligrams (mg a unit of dry measurement) . give 2 tablets . every 4 hours as needed for mild pain . [Resident 1] complained of mild leg pain . During a review of Resident 1's Progress Notes, dated 12/22/2020, at 3:25 a.m., the progress notes indicated, . [Acetaminophen] administration was ineffective. [Resident 1] states that her pain continues. Follow up pain scale was [3 out 10 pain level] . During a review of Resident 1's Progress Notes, dated 12/22/2020, at 12:26 p.m., the progress notes indicated, . [Resident 1] noted with pain to left upper leg posterior, and left hip [related to] fall earlier in the morning. MD notified and ordered [MEDICATION(S)] (pain medication) 50 mg [every] 6 hours prn (as needed) for moderate pain . MD also ordered x ray to left upper leg and left hip . During a review of Resident 1's Progress Notes, dated 12/22/2020, at 5:39 p.m., the Progress Notes indicated, . Result of x ray done on left hip left femoral neck impaction [fracture] with [CONDITION(S)] (condition in which the bones become brittle and fragile from loss of tissue) acute . Notified [Nurse Practitioner] of [MD] via phone . discuss with family to transfer to [emergency room ] . spoke with daughter via phone . During a review of Resident 1's Progress Notes, dated 12/22/2020, at 7:10 p.m., the Progress Note indicated, . [Resident 1[ transferred to [name of acute care hospital] for further evaluation . due to left femoral neck impaction fracture . During a review of Resident 1's Progress Notes, dated 12/29/2020, the Progress Note indicated, . On 12/22/2020 [at 1 a.m.] . two CNAs informed writer that [Resident 1] had just falls. As writer entered the room, resident was approximately two feet from her bed, lying on the floor. Prior to the fall, CNA had just finished changing resident and writer personally checked resident's bed alarm to ensure it was functioning properly . Writer checked the pad alarm again and it was plugged in to another jack . Resident stated that she was attempting to retrieve a garment from her closet when she tripped on the corner of the wall. Resident stated that she was in a standing position when she fell to the floor . During a review of Resident 1's X ray Results (X ray imaging creates pictures of the inside of your body), dated 12/22/2020, the x ray results indicated, . [Resident 1] . History . Pain in left hip, Pain in left leg . Significant Findings . Left femoral neck impaction fracture most likely acute (present) . During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person Centered dated 12/2018, the P&P indicated, . A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person centered care plan will .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being . e. Include the resident's stated goals upon admission and desired outcomes . g. Incorporate identified problem areas. H. Incorporate risk factors associated with identified problems . 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . During a review of the facility's P&P titled, Falls and Fall Risk, Managing, dated 3/2018, the P&P indicated, . According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor or other lower level . Fall risk factors . d. pain, e. lower extremity weakness . arthritis . balance and gait disorders . Position change alarms will not be used as the . sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident . Staff will respond to alarms in a timely manner . During a review of the facility's P&P titled, Falls Prevention, dated 4/2012, the P&P indicated, .Intervention .Bed .Bed Alarm .Staff Education . Orientation for staff and volunteers about fall prevention efforts and strategies .Interdisciplinary Team Conferences .Formulate interdisciplinary goals addressing safety. Identify specific strategies for fall prevention in the care plan, related to the resident's specific risk factors and condition. Communicate level of risk to staff caring for resident . During a review of the pressure pad alarm's manufacturer's instructions titled, Sensor Pad and Monitor Instructions, undated, the instructions indicated, . Set Up Instructions . 2. Plug the cord end of the sensor pad into the bottom of the . fall monitor. Pinch the cord together and loop it through the strain relief recess on the fall monitor (near plug input). 3. Test the system. Put pressure on the sensor pad to activate the pad and fall monitor. The fall monitor will beep two times to indicate that the sensor pad and fall monitor are in use. The In Use or Status Light will blink when pressure is on the pad. When pressure is removed, the fall monitor will alarm .Make sure the sensor pad is plugged into the fall monitor .

Based on observation, interview and record review, the facility failed to follow established national standards of practice for the prevention of COVID-19 (a serious contagious respiratory (Lung) infection) transmission affecting 89 (Resident 1 through 89) out of 134 residents and 40 staff members when: 1. Seven of Seven staff members, Infection Preventionist (IP- staff member responsible for monitoring infection control process are being followed and implemented to prevent the spread of infections in the facility), Licensed Vocational Nurse (LVN) 1, Housekeeper (HK) 2, Certified Nursing Assistants (CNA 29 and 30) were permitted to work and provide care to residents while exhibiting COVID-19 symptoms, and two CNAs (CNA 1 and CNA2) were permitted to work after obtaining COVID positive test results against Centers for Disease control and Prevention (CDC-federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) standards for healthcare workers. 2. Facility staff did not follow CDC standards for actively screening healthcare workers prior to the start of each shift and permitted Healthcare workers (HCWs) with COVID-19 symptoms to work. 3. Staff in the Red Zone and Yellow Zone did not follow CDC standards to keep resident room doors closed to prevent the spread of COVID-19 virus. 4. Staff in the Yellow Zone were re-using potentially infectious Isolation gowns for one or more residents for an eight-hour shift. 5. The facility did not ensure the IP possessed the infection prevention competencies to oversee the infection prevention program to aide in the prevention and containment of COVID-19 infection outbreak. 6. The facility did not follow CDC recommendation to perform Health Care Personnel (HCP) N95 respirator fit testing (tests the seal between the respirator's facepiece and the HCP face .is a pass/fail test method that uses sense of taste or smell, or reaction to an irritant in order to detect leakage into the respirator facepiece) for all HCP. The cumulative effects of these failures resulted in the transmission of COVID-19 virus to 89 of 134 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, and 89) who were previously COVID-19 negative; 13 of the 89 residents were transferred to a higher level of care at local hospitals to care for their respiratory symptoms; six of the 89 residents died related to their COVID-19 disease; and a total of 70 residents and 41 staff had COVID-19 positive lab results. Because of the serious actual harm to 19 of 89 residents and the serious potential harm to the additional 70 of 89 residents as a result of not following CDC infection control standards to prevent COVID-19 transmission, an Immediate Jeopardy (IJ) situation was called on [DATE] at 3:45 p.m. with the facility Administrator (ADM), Director of Nursing (DON), Business Office Manager and Regional Director of Clinical Services (RDCS) in the area of Code of Federal Regulations (CFR) 483.80 Infection Control. The facility submitted an acceptable IJ Removal Plan on [DATE] to conduct staff COVID screening training and competencies, re-structure the facility screening process, implement staff training and education regarding not returning to work while experiencing COVID-19 symptoms, re-education the IP on her role and perform IP competencies for her position. The components of the IJ Removal Plan were validated through observations, interviews, and record review. The IJ situation was removed on [DATE] at 3:56 p.m., with the ADM, DON and the RDCS. Findings: 1. During an interview with the Administrator (ADM) and Director of Nursing (DON) on [DATE] at 10:45 a.m., the ADM stated prior to the facility's COVID-19 outbreak on [DATE], the facility had been COVID-19 free. The DON stated the outbreak began when Certified Nursing Assistants (CNA) 1, and CNA 30 tested positive for COVID -19 on [DATE]. The DON stated a day later Housekeeper (HKS) 2 tested positive for COVID-19 on ,[DATE]. The DON stated the three staff members had worked with residents on [DATE], [DATE] and [DATE]. The ADM stated a fourth staff member CNA 29, tested positive on [DATE]. The ADM stated CNA 29 was informed she had tested positive on the night of [DATE], did not stay home and return to work on [DATE] for a few hours. The DON stated CNA 29 provided direct resident care to residents the hours she worked. The DON stated CNA 29 received the positive COVID-19 results late on [DATE] and thought it would be okay to returned to work after knowing she was positive for COVID -19. The ADM stated on [DATE] thirteen residents (Resident's 1, 6, 15, 17, 25, 31, 36, 37, 42, 45, 69, 71, and 84) had confirmed COVID-19 positive test results. The ADM stated on [DATE] an additional four staff (CNA 21, 22, 24 and Social Service Director (DSS 1)) also had positive COVID -19 test results. The DON stated on [DATE] an additional eight resident (Residents 56, 19, 27, 20, 35, 40, 38, and 2) and three staff (CNA 27, CNA 25, and CNA 19) had positive COVID-19 test results, making the total of 21 residents and 11 staff that had been contaminated with COVID-19 virus. The DON stated the COVID-19 virus outbreak was occurring on station 1, station 2 and station 3 and they did not know why because the facility was following all infection control standards. During a concurrent interview with the IP 1 and record review on [DATE] at 3:20 p.m., the IP reviewed the facility document titled, LTC (Long term care) Respiratory Surveillance Line List dated, ,[DATE], which indicated LVN 1 had been working on station 2 and station 3 on [DATE]. The Respiratory Surveillance Line List indicated that LVN 1 had been tested for COIVD -19 using a point of care test on [DATE] because she was experiencing COVID-19 signs and symptoms of cough, body aches and headache and LVN 1 tested positive for COVID-19. The Respiratory Surveillance Line List did not indicate the last day LVN 1 had been working in the facility. The IP 1 stated she documented LVN 1's symptom onset date ([DATE]) incorrectly. The IP 1 stated LVN 1's COVID-19 symptoms began on [DATE] but IP 1 did not think LVN 1 had COVID -19, she related the symptoms to LVN 1's potential menstrual symptoms. During an interview on [DATE], at 4:35 p.m., with LVN 1, LVN 1 stated she began experiencing a cough, body aches and headaches after work on the evening of [DATE]. LVN 1 stated, she returned to work on [DATE], at 7 a.m. because her body aches had improved. LVN 1 stated during the front door facility screening process, she did not report the body ache symptoms she had experienced the evening prior to her shift because she was not experiencing pain at the time she was being screened. LVN 1 stated the reason she returned to work on [DATE] was because IP 1 had educated all staff that if they experience COVID-19 symptom and the symptom improve within 24 hours they are permitted to return to work. LVN 1 stated she did not think she had the COVID-19 virus. LVN 1 stated at approximately 9:30 a.m., on [DATE] her body aches returned while she was in the middle of performing a medication administration pass. LVN 1 stated she informed her supervisor (Registered Nurse Supervisor- RNS) that she was experiencing headache and body aches. LVN 1 stated she asked the RNS to allow her to finish what she needed to do (patient care and clinical documentation) and then leave. LVN 1 stated RNS agreed to allow her to stay and finish her task. LVN 1 stated she finished her medication pass around 10 a.m. and completed her resident clinical assessment documentation around noon time. LVN 1 stated she was tested in the facility around noon and tested positive for COVID-19 and went home. During a review of LVN 1's time sheet titled Detail Time Report dated [DATE] indicated LVN 1 began her shift on [DATE] at 7:15 a.m., and ended her shift at 12:31 p.m., Total (hours) 5.27. During an interview on [DATE], at 9:52 a.m., with CNA 1, CNA 1 stated she was tested weekly for COVID-19 by the IP 1 on [DATE] and on [DATE] the IP notified the COVID-19 test results were borderline positive. CNA 1 stated she did not know what that meant, and the IP 1 did provide education on the meaning of borderline positive. CNA 1 stated she was not asked to stay home and reported to work on [DATE]. CNA 1 stated she received a call from the Scheduler (SCH) on [DATE] at 5 a.m. and informed her that she was COVID positive and told her to stay home. CNA 1 stated the SCH told her the COVID-19 test results from [DATE] were positive. During an interview on [DATE], at 10:57 a.m., with the Housekeeper (HK) 2, HK 2 stated that she worked in the COVID unit Red Zone on [DATE], [DATE] and [DATE]. HK 2 stated on [DATE] she was cleaning her last resident rooms when her COVID-19 symptoms began. She stated, It started in my eye. I felt like my eye was going to run. HK 2 stated while she was driving home on [DATE] she started coughing, sneezing, having runny nose and watery right eye. HK 2 stated she worked everywhere station 1, 2 and 3. HK 2 stated on [DATE] and [DATE] she had lost her sense of taste and kept working. HK 2 stated on [DATE] she did not feel well and called her boss the Housekeeping Supervisor (HKS) to call in sick for [DATE]. HK 2 she stated on [DATE] the HKS called her back and informed her that her COVID-19 test from [DATE] had been positive. HK 2 stated she did not report her symptoms on [DATE], [DATE] and [DATE] on her COVID screening form because she did not think she had COVID-19. HK 2 stated she informed her supervisor of her symptoms on [DATE] when HKS informed her that she was positive for COVID-19 from the test dated [DATE]. During an interview on [DATE], at 11:20 a.m., with CNA 2, CNA 2 stated she was tested for COVID -19 on [DATE] by the IP 1. CNA 2 stated she worked on the evening shift of [DATE] and on [DATE] the IP 1 informed her that her COVID test was borderline not positive and not negative and was permitted to continue work with residents. CNA 2 stated on [DATE] the SCH notified her that her COVID-19 test results form [DATE] had been positive. During an interview on [DATE], at 3:46 p.m., with the Director of Staff Development (DSD), the DSD stated she had spoken to LVN 1 after the SCH had informed her that LVN 1 did not feel well. The DSD stated she spoke with LVN 1 and she informed her that she was having body aches. The DSD stated LVN 1 informed her that she began experiencing body aches on the evening of [DATE] and made the decision to report back to work on [DATE] while experiencing COVID-19 symptoms. The DSD stated LVN 1's supervisor had asked LVN 1 to finish her work and then leave for the day. The DSD stated LVN 1's Supervisor (RNS) should have sent LVN 1 home as soon as she informed her of her COVID-19 symptoms, but she did not do that. The DSD stated when an employee feels ill, staff need to immediately report that to the management staff and the staff that is feeling ill needs to go home immediately and should not be allowed to continue to work. During an interview with the Registered Nurse Supervisor (RNS) on [DATE], at 4:10 p.m., the RNS stated she works as a supervisor in the COVID unit Red Zone. RNS stated on [DATE] at around 10 a.m. LVN 1 informed her that she had not being feeling well the day before ([DATE]). The RNS stated LVN 1 had informed her that she had a headache and body aches ([DATE]). RNS stated that LVN 1 informed her that she had revealed the symptoms she had the night before to the screener when she arrived at work. RNS stated LVN 1 requested to be allowed to finish her medication pass. RNS stated, She (LVN 1) was almost done and I wanted to let her finish it. RNS stated she agreed to allow LVN 1 to finish her work and then go home. RNS stated she did not know what time LVN 1 left the facility because she did not check. RNS stated she has not received training on what to do if an employee began to exhibit COVID-19 symptoms at work. RNS stated that she realized that allowing LVN 1 to remain in the facility providing resident care may have spread COVID-19 to others. During an interview on [DATE], at 11:39 am, with IP 1, she stated that she educated the staff that if an employee had a scratchy throat and/or headache and if the employee symptoms improve in 24 hours they were permitted to return to work. IP 1 stated that on [DATE] she had a scratchy throat. On [DATE] she was not feeling well, she had a headache. She called off work and got tested for COVID-19. IP 1 stated on [DATE] she was still not feeling well and again called off work. The IP stated her symptoms improved and on [DATE] she made the decision return to work. IP 1 stated she had not received the COVID-19 test result of [DATE]. IP 1 stated she worked with residents and staff her entire eight-hour shift on [DATE] and when she arrived at her home, she had a voice mail informing that her COVID-19 test dated [DATE] was positive. During a concurrent interview with the IP 1 and record review on [DATE] at 11:48 a.m., the facility document titled, LTC (Long term care) Respiratory Surveillance Line List dated, ,[DATE], was reviewed and indicated IP 1 had worked on [DATE] while experiencing a sore throat. The Respiratory Surveillance Line List indicated that IP 1's onset of symptoms [DATE]. The line list indicated IP 1 had been tested for COIVD -19 on [DATE] with positive test results. IP stated she did not document all the symptoms she was experiencing since [DATE]. IP 1 stated she did not think she had COVID -19, because she related the symptoms to menstrual symptoms. During a concurrent interview with the ADM and record review on [DATE] at 10 a.m. the ADM reviewed the facility document titled, .visitor/staff screening log dated [DATE] indicated IP 1 was screened on [DATE] and indicated she did not have sore throat or headache. The Screening Log indicated, Deny entry (if) YES (response to any COVID-19 symptoms), IP 1 indicated NO symptoms. The Screening log indicated, For questions on guidelines contact IP (1) . During an interview with the HKS on [DATE], at 4:20 p.m., the HKS stated he had three housekeepers test COVID-19 positive. HKS stated, on [DATE] HK 2 informed him while she was working that she was not feeling well, and HK 2 was permitted to continue working. HKS stated on [DATE] HK 2 called off work because she was not feeling well. HKS stated HK 2 asked for the results of her COVID-19 test results of [DATE]. HKS stated he did not know the outcome of the results and would have to ask the IP 1 for the results. HKS stated he contacted HK 1 to inform her that her test of COVID-19 dated [DATE] were positive. During a professional reference review retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on [DATE], titled, Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection dated [DATE] indicated, (Health care personnel) HCP with symptoms of COVID-19 should be exclude from work at least 10 days and up to 20 days have passed since symptoms first appeared .At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved . (prior to returning to work) Consider consultation with infection control experts . If HCP develop fever (T?100.0oF) or symptoms consistent with COVID-19 while at work, they should inform their supervisor and leave the workplace . 2. During an interview on [DATE], at 4:35 p.m., with LVN 1, LVN 1 stated she began experiencing a cough, body aches and headaches after work on the evening of [DATE]. LVN 1 stated, she returned to work on [DATE], at 7 a.m. because her body aches had improved. LVN 1 stated during the front door facility screening process, she did not report the body ache symptoms she had experienced the evening prior to her shift because she was not experiencing pain at the time she was being screened because she did not think she had COVID -19. LVN 1 stated at approximately 9:30 a.m., on [DATE] her body aches returned while she was in the middle of performing a medication administration pass. During an interview on [DATE], at 12:37 p.m., with the SCH, SCH stated that she had been working as the scheduler for last 8 months at the facility. The SCH stated she was the individual that staff reported to when feeling ill. The SCH stated that she was the individual responsible to give staff direction on when they should stay home if staff reported COVID symptoms. The SCH stated that the first line of the screening process would be when staff are calling off ill. The SCH stated she had received and reviewed all staff call off slips. The SCH stated she did not have a protocol or policy to follow for telling staff to stay home when staff reported COVID symptoms, but she would use her judgement. The SCH stated that if an employee called with what could be a COVID symptom, headache, cough, sore throat and the symptoms went away within twenty-four hours without taking any medication, staff was permitted to return to work. The SCH stated, It could be just a little bug. The SCH stated she would not keep someone from returning to work and would not require a negative COVID test when staff called off a backache or a cough. The SCH stated, A backache is not a COVID symptom it is probably a result of their (menstrual pain) and a cough could be from their asthma. During a concurrent interview and record review on [DATE], at 10:25 a.m., two documents titled ABSENCE REPORT, dated [DATE], [DATE], and [DATE] were reviewed with the DSD. The report indicated . (IP 1) . [DATE] . Not feeling well . (CNA 8) . [DATE] .Not feeling well Sore throat . The DSD stated the information would not be enough to describe symptoms. The DSD stated to ensure the screening process was correctly performed someone should have called the staff to collect additional information and provide staff direction on not to return to work. The DSD stated the staff calling in with symptoms should have received a call back by the IP1, DSD, or DON for clarification to determine what symptoms the staff was having but no one did that. During an interview on [DATE], at 10:35, with the DSD, the DSD stated, The person filling out the sick call lists (slips/sheets), needs training immediately .The whole sick call process needs to be fixed .The Staffer is not able and should not diagnose (those calling in) sick calls, only a Doctor can diagnose .The IP would be the one to give advice to the staffer, (regarding when to tell people to stay home). The DSD stated the CDC had information about everything related to COVID and the facility staff had access to information but did not use it. During a concurrent observation and interview on [DATE], at 7:20 a.m., with CNA 10, she was being screened by CNA 30 and was asked to remove her N95 discard it in the trash, use hand sanitizer, and handed her a new N95 to use. CNA 10 stated she was a registry staff that had been working in the Red Zone for the past three days. CNA 10 stated the registry agency she was working with had performed fit testing for the N95 respirator that she was asked to throw away. CNA 10 stated she was not fit tested for the universal N95 respirator the screener provided and requested her to use. During an interview on [DATE], at 7:25 a.m., with CNA 30, CNA 30 stated she was educated by the IP that all staff entering the building was to be given a new N95 respirator and asked to discard the mask they are wearing. CNA 30 stated she did not know that CNA 10 or other registry staff had been fit tested by their agency and were safer wearing the mask they were fit tested for. During a professional reference review retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on [DATE], titled, Preparing for COVID-19 in Nursing Homes dated [DATE] indicated, . nursing homes must remain vigilant for COVID-19 among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death .Reinforce sick leave policies, and remind HCP not to report to work when ill . performing infection surveillance, providing competency-based training of HCP, .Actively screen all HCP at the beginning of their shift for fever and symptoms of COVID-19.Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea . Fever is either measured temperature (greater than) 100.0 (degrees) F or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed (weak immune system), or taking certain medications (e.g., NSAIDs) . If HCP develop fever (100.0-degree F) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace . 3. During a concurrent observation and interview on [DATE], at 10:56 a.m., with CNA 6, Resident rooms doors were observed wide open. CNA 6 stated she worked in the COVID unit Red Zone and the reason residents' doors were left open was because the all residents are at risk for falling. CNA 6 stated she did not know what factors made the residents a risk for falling. During a concurrent observation and interview on [DATE], at 2 p.m., with CNA 5, working on station 1, CNA 5 stated station 1 had the Yellow Zone. CNA 5 stated the doors are kept open if a resident refused to have the doors closed. CNA 5 stated, We have to leave them (doors) open for those residents and for residents that are fall risk, we also leave doors open. During an interview on [DATE], at 5:45 p.m., with the DSD, the DSD stated Red Zone residents' doors are left open for residents who refuse to have their doors closed. The DSD stated, For residents that are at risk for falls doors are kept open. During an observation on [DATE], at 7 p.m., in the Red Zone, residents were in their room with their doors open. During an interview on [DATE], at 1:27 p.m., with CNA 3 in the COVID-19 unit, CNA 3 stated in the COVID -19 Red Zone room doors are left open for residents that are a fall risk and for resident that refuse to have their door closed. During a concurrent observation and interview on [DATE], at 2:43 p.m., DSD, on station 3 (Yellow Zone) room doors were observed left open. The DSD stated doors in the Yellow Zone were kept open because residents were at risk for falls. The DSD stated a risk assessment was not conducted to evaluate the risk to residents when closing the room doors. The DSD stated the facility did not conduct a facility risk assessment that would individually evaluate each COVID -19 positive and suspected for COVID-19 exposed resident's fall risk. The DSD stated it would be important to conduct a facility risk assessment to identify the risk to all other residents by leaving room doors open. During an interview on [DATE], at 11:17 am, with CNA 13, CNA 13 stated that room doors on the yellow PUI zone were always left open. During an interview on [DATE], at 10:35, with the DSD, DSD stated, the doors are open in the red and yellow zones. The DSD stated the hallways in the red zone and yellow zone are the clean areas and there was no need to wear PPE. The DSD stated COVID was a droplet precaution (control interventions used to prevent transmission of pathogens spread through close respiratory or mucous contact with respiratory secretions) and droplets can only travel six feet. During a review of a professional reference retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html titled, Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection dated [DATE], indicated, Establish Reporting within and between Healthcare Facilities and to Public Health Authorities Implement mechanisms and policies that promote situational awareness for facility staff including infection control For patients with COVID-19 or other respiratory infections . patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection . with the door closed . 4. During an observation on [DATE], at 10:45 a.m., Stations 1, 3 and half of Station 2 had potentially contaminated cloth isolation gowns hanging outside of the resident's rooms on hooks labeled Nurse and CNA. During an interview on [DATE], at 2 p.m., with CNA 5, CNA 5 stated station 1 used cloth isolation gowns. CNA 5 stated one gown is used for each resident room and each room had at least two residents. After the cloth gown was used to perform resident care, the cloth gown would be placed on the hooks that were labeled on the outside of the door. During an interview on [DATE], at 2:30 p.m., with CNA 4, CNA 4 stated she had to use cloth potentially contaminated gowns in the yellow zones. CNA 4 stated one gown was provided for each resident room even if there were 2 residents in that room. CNA 4 stated the gowns were hung outside of the resident's door after the gown was used to provide resident care. During a concurrent observation and interview on [DATE], at 2:43 p.m., with the DSD in station 3 (Yellow Zone). Potentially contaminated cloth gowns were observed hanging on the outside of resident's room doors. The DSD stated that each employee who works with the resident was provided with their own gown. The DSD stated the nurses leave their potentially contaminated cloth gown hanging on the door and use it throughout their shift and then put it in the laundry at the end of their shift. During a concurrent observation and interview on [DATE], at 3:00 p.m., with the ADM, DSD, CNA11 and CNA12, thirty rooms had cloth potentially contaminated gowns hanging on the door hooks on the outside of the room doors. During an interview on [DATE] at 3:30 p.m., with the DSD, the DSD stated the facility was using the Centers for Disease Control policy for Personal Protective Equipment for the re-use of the potentially contaminated gowns. Received copy of Centers for Disease Control, (CDC), from DSD [DATE], at 3:45 p.m. During an interview on [DATE] at 3:40 p.m. with the ADM, the ADM stated the gowns could be a potential infection source and the facility should only use cloth gown if the facility was in crisis mode (a strategy of re-use of isolation gowns when supplies are critically short) and the facility was not currently in a gown crisis mode. During a concurrent interview with the DSD and record review, on [DATE], at 3:50 p.m., the DSD reviewed the document titled, Strategies for Optimizing the Supply of Isolation Gowns from the CDC dated [DATE], which indicated, .Extended use of Isolation gowns is only under the Crisis Capacity Strategies .reusable gowns should not be reused before laundering, because reuse poses risk for possible transmission among HCP (healthcare providers), and patients that likely outweigh any potential benefits . gown reuse has the potential to facilitate transmission of organisms . among patients. Repeatedly donning and doffing a contaminated gown may increase risk for health care provider self-contamination. If reuse is considered, gowns should be dedicated to care of individual patients. The DSD stated their cloth gown reuse was wrong. 5. During an interview [DATE], at 10:35 a.m., with the DSD, DSD stated, the IP 1 should have stayed home when she was exhibiting COVID-19 symptoms because IP 1 could have spread COVID throughout the facility by coming into work on [DATE]. During a concurrent interview and record review on [DATE], at 4:40 p.m., with the ADM, The ADM reviewed the document titled, The Screening Record dated ,[DATE] and ,[DATE]. The ADM stated the expectation was for the screener and IP 1 to review and report to the DON any irregularities. The ADM stated another expectation was for the IP 1 to ensure staff had COVID-19 negative results before returning to work. The AMD stated the IP worked on [DATE] while she was exhibiting COVID -19 symptoms and received positive COVID-19 test results on [DATE]. During an interview on [DATE], at 11:39 a.m., with IP 1, IP 1 stated she was the IP 1since August of 2020, (approx. 3months). The IP 1 stated she was currently at home after testing positive for COVID. She stated that on [DATE] she had a scratchy throat and thought her symptoms were from the smoke in the air from the wildfires. On [DATE] she called in sick because she had a headache and thought it was related to her menstrual cycle and was COVID tested . On [DATE] she called off sick again because she had a headache and thought it was from her menstrual cycle. On [DATE] she made the decision to go into work while having a sore throat. Ip 1 stated on 1the evening of [DATE] she received COVID test results, and she was COVID positive. IP 1 stated, she did not think she had COVID. During an interview on [DATE] at 11:39 a.m., with IP 1, she stated the facility did not have a policy for keeping staff home when staff would be experiencing COVID like symptoms. IP 1 stated she was using the education that was given by the previous IP to allow staff to return to work after their COVID like symptoms improved within 24 hours. IP 1 stated that was the education that was taught to her by the previous IP. IP 1 stated she educated staff that they were permitted to return to work if staff had COVID like symptoms that were relieved within 24 hours. IP 1 stated that she did not believe the staff had COVID symptoms because most of the symptoms described by the staff were also related to a woman's menstrual cycle. IP 1 stated the menstrual cycle symptoms could also be associated to the male employees and she did not limit the menstrual symptoms just to women. IP 1 stated she used her own judgment to permit staff to return to work after they had reported COVID like symptoms the day prior. The IP 1 stated she did not go by the CDC return to work HCP recommendations because those symptoms could be related to the menstrual cycle and not COVID. The IP 1 stated she had not read the CDC HCP return to work recommended. the IP 1 she had permitted staff to return to work after staff had reported COVID like symptoms within 24 hours prior to returning to work. The facility's COVID policy was requested and IP 1 stated, I did not know there was a COVID policy. IP 1 stated she took her IP training in August but did not remember going over return to work criteria for healthcare workers. IP 1 stated, If staff have 1 symptom like a dry cough and it resolves in 24 hours, they can come back into work. During a concurrent interview with the DSD and record review on [DATE], at 10:50 p.m., the document titled ABSENCE REPORT, dated [DATE] was reviewed by DSD. The absence report indicated, . (CNA 8) . [DATE] . Not feeling well Sore throat . The DSD stated IP 1 should have called CNA 8 to follow up with the symptoms indicated on the absence report but she did not. The DSD stated the last day CNA 8 worked was on [DATE]. The DSD stated not reviewing absence reports and following up with staff could potentially lead to staff returning to work while symptomatic. 6. During an interview on [DATE], at 7:10 a.m., with Physical Therapist (PT) 1, PT 1 stated that she worked in the Yellow Zone of the facility. PT 1 stated the Yellow Zone houses residents that have been exposed to COVID-19 positive staff or residents and are being ruled out for COVID-19. PT 1 stated she wears her N95 respirator and face shield but she has not (TRUNCATED)

Based on observation, interview and record review the facility failed to ensure residents received treatment and care to attain and maintain their highest practical wellbeing for two of four sampled residents (Resident 83, Resident 95) when: 1. Resident 83's nutritional needs were not accurately and consistently assessed on admission and as needed and effective interventions were not identified and implemented for weight loss. 2. Resident 83's assessment and nursing interventions to address pressure ulcer were not monitored and evaluated for effectiveness. 3.Resident 95's nutritional needs were not accurately and consistently assessed on admission and as needed and effective interventions were not identified and implemented for weight loss. These failures resulted in actual decline in physical wellbeing for Resident 83 and Resident 95. Findings: 1. During an observation in Resident 83's room, on 5/6/19, at 8:15 a.m., Resident 83 was in her room, in bed and sitting upright with her eyes closed. Resident 83's collar and shoulder bones were easily visible and her skin appeared dry and wrinkled. Resident 83's wrist and arms were visibly thin and without muscle mass. An over bed table was observed at the left side of Resident 83 with a breakfast tray. The following uneaten meal items were observed on the meal tray: pancakes with syrup and margarine, oatmeal in a bowl, scrambled eggs, a glass of juice, and a glass of milk. On the meal tray was an empty cup with a dry tea bag and a bowl with a small amount of cottage cheese. Resident 83 opened her eyes and began grimacing (facial expressions of pain) and stated the bed was uncomfortable and her backside was hurting. Resident 83 stated the meal tray was hers but she did not want it. Resident 83's face sheet (a document containing resident profile information) undated, indicated Resident 83 was admitted to the facility on [DATE] for a planned short rehabilitation stay to recover from a surgical repair of a broken hip. Resident 83 was admitted with [DIAGNOSES REDACTED]. of stomach acid into the esophagus). During a review of the clinical record for Resident 83, the Minimum Data Set (MDS) assessment (functional and cognitive abilities assessed), dated 4/5/19, under Section C, Brief Interview for Mental Status (BIMS) score was 10 which indicated Resident 83 was moderately impaired in cognition (memory and judgement). During an interview with Certified Nursing Assistant (CNA) 3, on 5/6/19, at 3:25 p.m., she stated Resident 83 required assistance with the set-up of her meal tray. CNA 3 stated, Resident 83 was able to feed herself with set-up but required staff supervision and constant reminders to eat during her meals. CNA 3 stated, The staff member feeding Resident 83's roommate had to make sure to keep an eye on Resident 83 and to give constant reminders to eat. During a concurrent observation of Resident 83 in her room and interview with CNA 9, on 5/7/19, at 1:15 to 1:30 p.m., Resident 83 was in bed with the head of the bed elevated. Resident 83 was moving her food on her plate from one area to the next without bringing the food to her mouth. The lunch meal consisted of: Macaroni and cheese, stewed tomatoes, Cole slaw, bread roll, peaches, one glass of milk and a cup of hot tea. CNA 9 was in the room feeding Resident 83's roommate for 15 minutes and was not heard providing reminders or encouragement for Resident 83 to eat her meal. Resident 83 stated she was full and did not want to eat more. CNA 9 replied to Resident 83 Okay and continued to feed Resident 83's roommate. CNA 9 did not offer a substitute for the uneaten lunch meal. CNA 9 removed Resident 83's meal tray and stated that Resident 83 usually did not eat her meals. CNA 9 stated he should have offered Resident 83 an alternative food choice. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 11), on 5/7/19, at 2:35 p.m., LVN 11 stated Resident 83 required supervision with meals. LVN 11 stated CNA's assigned to Resident 83 had to make sure to give her reminders to eat and report to the nurse when Resident 83 refused to eat. LN 11 stated she had not received a report from CNA 9 that Resident 83 refused her meals. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated, Resident 83 eats what she wants to eat. She is confused too so I have to talk to the CNA's taking care of her (for meal consumption information). The RD stated Resident 83 liked yogurt, cottage cheese and fruits and hot tea. The RD stated those were options that could be given to Resident 83 if she refused her meal. RD stated she had not observed Resident 83 eat a meal since admission and relied on the CNAs documentation for the meal percentage. The RD stated she continued to monitor the documentation of Resident 83's weights weekly as well as her meal intake. The RD stated Resident 83 was admitted to the facility on [DATE] with a weight of 130.6 lbs. The RD stated Resident 83's current weight on 5/8/19 was 82.7 lbs. (a total of 47.3 lbs. weight loss within nine months from the date of admission of 7/27/18). The RD stated Resident 83 was currently under her ideal body weight of 160 to 130 lbs. The RD stated on admission, Resident 83's weight was 130.6 lbs. The RD stated she reviewed her initial assessment dated [DATE] and Resident 83's weight was at the lower end of Resident 83's Body Weight Range (BWR) of 160 to 130 lbs. and height was 64 inches. The RD stated Resident 83's usual weight was 130 lbs. per Resident 83. The RD stated she identified Resident 83 at nutritional risk due to her inadequate oral intake which would not meet her nutritional needs. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 7/27/18 and 8/27/18, Resident 83's weight dropped from 130.6 lbs. to 119.3 lbs., representing a weight loss of 11.3 lbs or 8.7 percent for one month. The RD stated she calculated Resident 83's meal intake using the CNAs documented meal percentages. The RD stated her calculations were that Resident 83 was eating 71 percent of her meals. The RD stated the weight loss was related to Resident 83's [DIAGNOSES REDACTED]. diff, is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) infection. The RD stated Resident 83 was started on [MEDICATION NAME] (antibiotic medication to treat the infection) 500 mg three times a day times for 10 days. A stool culture to check for [MEDICAL CONDITION] was collected on 8/3/18 and indicated positive for [DIAGNOSES REDACTED]. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated, between 8/27/18 through 9/24/18 Resident 83's weight dropped from 119.3 lbs. to 104.9 lbs., representing a weight loss of 14.4 lbs., a 1 percent loss over one month. The RD stated Resident 83 was sent out to the general acute care hospital (GACH) from 9/9/18 thru 9/18/18 with [DIAGNOSES REDACTED]. The RD reviewed the nutritional assessment dated [DATE] which indicated, Resident 83 was to continue with the current diet of Regular/Liberalized diet, looks visibly thin. The RD stated, Resident is meeting energy needs, the weight loss might have been related to the UTI, and the main goal was to prevent further weight loss. RD stated no new nutritional interventions were implemented at that time. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 9/24/18 through 11/6/18 the weight dropped from 104.9 lbs. to 97.8 lbs., representing a weight loss of 7.1 lbs., or 6.8 percent in 6 weeks. The RD reviewed the nutritional assessment dated [DATE], and stated Resident 83 continued on a Regular/liberalized diet, (new intervention of) House supplement two times a day. No chewing or swallowing problem, eats in her room for all meals and continue to require tray set-up. Intake 59% . (Resident 83) looks visibly thin. The RD note dated 10/3/18, indicated, Saw (Resident 83) food services and visited often and collect food preferences. The RD reviewed her RD notes dated 11/5/18, which indicated, RD saw resident and checked chewing and swallowing problem and collected food preferences. The RD note indicated, (Resident 83) likes cottage cheese and fruits and added as interventions. The RD stated, (Resident 83) was at risk for further weight loss. The RD reviewed the clinical record for her documented Frequent resident visits and interventions and was unable to find documentation of the frequent nutritional visits or interventions. The RD stated, I don't have those. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 11/6/18 through 12/6/18 the weight dropped from 97.8 lbs. to 93.3 lbs., a weight loss of 4.5 lbs. or 4.6 percent. The RD reviewed her RD note dated 11/7/18 and 11/12/18 which indicated, Per clinical meeting resident with soft/loose stools despite diet intake of fiber, resident will benefit from Nutrisource (fiber) packet twice a day to provide additional fiber. Appetite improving consuming 63% of meals, Resident 83 meeting estimated energy needs. The RD stated she was unsure why Resident 83 was continuing to lose weight when she was meeting her estimated nutritional needs. The RD stated she had not observed Resident 83's meal consumption since admission, but relied on the CNA's meal consumption documentation. RD stated she did not implement new nutritional interventions to slow or attempt to stop ongoing weight loss. During a concurrent record review and interview with the RD, on 5/8/19, at 10:43 a.m., the RD stated, between 12/6/18 through 1/8/19 the weight dropped from 93.3 lbs. to 88.7 lbs., representing a weight loss of 4.6 lbs., or 4.9 percent. The RD stated the weight loss was not significant, and no new interventions were added at that time. During a concurrent record review and interview with the RD, on 5/8/19, at 10:44 a.m., the RD stated, between 1/8/19 through 2/4/19 the weight dropped from 88.7 lbs. to 88.4 lbs., representing a weight loss of 0.3 lbs. The RD stated the weight loss was not significant and weight had been stable, but the RD did add one nutritional supplement with breakfast. During a concurrent record review and interview with the RD, on 5/8/19, at 10:46 a.m., the RD stated, between 2/4/19 through 3/4/19, the weight dropped from 88.4 lbs. to 84.6 lbs., representing a weight loss of 3.8 lbs., or 4.3 percent. The RD reviewed the nutritional assessment dated [DATE] which indicated, Continue on Regular/Liberalized . Evaluation/Nutrition plan: (Resident 83) meeting estimated energy needs, previous oral intake was meeting estimated energy needs, main goal to prevent further weight loss. Resident had snacks in between meals. The RD stated Resident 83 was underweight. During a concurrent record review and interview with the RD, on 5/8/19, at 10:47 a.m., the RD stated, between 3/4/19 through 4/15/19, the weight dropped from 84.6 lbs. to 81.3 lbs., representing a weight loss of 3.3 lbs., or 3.9 percent. The RD stated she reviewed the nutritional assessment dated [DATE] and 4/2/19, which indicated, Continue on Regular Liberalized diet . Nutrition History: Has triggered for significant weight loss X (for) 6 months, -(lost) 24.9%, -(lost) 28lbs. comparison weight of -(lost) 8.7lbs, -(lost) 9.3% X 3 months . Resident weight loss continues . During a concurrent record review and interview with the RD, on 5/8/19, at 10:48 a.m., the RD stated between 4/5/19 through 4/29/19, the weight was 82.7 lbs. The RD stated Resident 83's weight loss had stabilized since March, and she did not add new interventions. The RD stated she did not attend any of the interdisciplinary team meeting (IDT) or care plan conferences to communicate Resident 83's ongoing weight loss with the team. The RD stated the IDT would invite her to the meetings but she had not attended the meetings for any of the residents that were losing weight, including Resident 83. RD stated she should have been present in the care conferences and should have discussed the continued weight losses but she had not. The RD stated she did not monitor or validate the CNA's capability to document meal percentages accurately. The RD stated, I assumed that they are calculating it correctly, I relied on the data that was presented to me. The RD stated CNAs were not documenting Resident 83's meal percentages accurately based on the intake documented and the weight loss that had occurred. The RD stated the meal percentages documented by the CNAs did not match or support Resident 83's ongoing weight loss. The RD stated she did not provide in-service education to CNA's on how to accurately document meal percentages. The RD stated, The director of staff development (DSD) does the in-services regarding food percentages and there are postings for the CNA's to follow in regards to the calculations of meals percentages. RD stated she attended Customer at Risk (CAR) meetings every Tuesday morning with the MD, DON, Social Service Director (SSW), and RN supervisor. In the CAR meeting the group discussed recent weight loss, weight changes and new admissions. The RD stated she had not discussed the weight loss of Resident 83 in the meetings. She stated, For some reason, I just missed it (Resident 83's ongoing weight loss). The RD stated she did not remember talking to Resident 83's Responsible Party about the weight loss and did not look at the Provider Orders for Life-Sustaining Treatment (POLST) form. The RD stated she was responsible for the nutrition care plans, evaluating and updating the interventions as needed when nutritional issues were identified. The RD stated she reviewed the care plan interventions but was unable to find documentation where she evaluated and/or revised her nutritional interventions for Resident 83. The RD stated she did not know why Resident 83 was losing weight. The RD stated, I just missed it (the weight loss). During a review of Resident 83's clinical records the Weights and Vitals Summary dated 7/27/18 to 4/26/19 indicated Resident 83's admission weight on 7/27/18 was 130.6 lbs. and on 5/8/19 the weight was 82.7 lbs. There was a total loss of 47.9 lbs. or 36.7 percent weight loss within nine months. During a review of the facility document the, (RD) JOB DESCRIPTION: DIETITIAN dated 5/29/17 indicated . RESPONSIBLITIES and ACCOUNTABILITILITIES .4. Collaborates with the interdisciplinary team to develop nutritional plans of care for the residents/patients. 5. Monitor and evaluate effectiveness of nutritional interventions . 12. Participates in the education and training of center staff . Review of facility document titled HIGH RISK NOTE FORMAT dated (MONTH) 2013 indicated . Pressure Ulcer Review: . 2. Weight and weight history, trend . 4. Current nutritional interventions, if any. Are they accepted and effective? . Significant Weight Loss Review: . 6. Do meal rounds on resident as appropriate, document observations. Anything in the dining situation that should be improved? . 11. In IDT weekly weight meeting, evaluate current weekly weight on resident. If the resident has continued to lose weight, add or change current interventions. 12. Update Care Plan (CP). During a concurrent interview and record review with LN 7, on 5/8/19, at 11:21 a.m., she stated Resident 83 required supervision with eating, set-up with meals and encouragement and prompting while eating. LN 7 stated staff feeding Resident 83's roommate, should have monitored Resident 83 at the same time giving cueing and encouragement to eat. LN 7 stated the CNA's should have reported to the nurse if Resident 83 refused to eat so the nurse could encourage her to eat or offer a food alternative. LN 7 stated she had not received reports of Resident 83 refusing to eat. LN 7 stated she had not observed Resident 83's meal consumption. LN 7 stated she relied on the CNAs documented meal percentages and reports. LN 7 stated Resident 83 liked hot tea, cottage cheese, yogurt and nourishment and those items were available for Resident 83. LN 7 stated the rehabilitative nurse aide (RNA) took Resident 83's weights every week and reported any weight changes to the registered nurse supervisor (RNS). LN 7 stated the RN'S were the nurses responsible for the calculation of percentages of the meals eaten, weight loss or gains and notification to the Medical Doctor (MD) and family. LN 7 stated the RN was the person who would identify resident weight changes (LN 7 was a Licensed Vocational Nurse). LN 7 stated she did not review weights. LN 7 stated the RD recommendations were handled by her or other LNs. LN 7 reviewed the RD nutritional notes for Resident 83 and stated the RD had not given nutritional recommendations for Resident 83. During a concurrent observation and interview with CNA 9, on 5/8/19, at 2 p.m., Resident 83 was lying in bed with a lunch tray at the bedside. The lunch tray contained an empty cup of tea and empty bowl of cottage cheese. There was an uneaten sandwich, uneaten sliced peaches, a full glass of milk and house nourishment. CNA 9 stated Resident 83 ate 25 percent of her lunch based on the eaten cottage cheese and tea. CNA 9 stated Resident 83's appetite varied from okay to poor. CNA 9 stated Resident would eat approximately 25 to 75 percent of her meals. CNA 9 stated Resident 83 ate 75 percent of her breakfast the morning of 5/6/19 (Resident 83 was observed as refusing her breakfast meal on 5/6/19). CNA 9 stated he usually let the nurse know if Resident 83 ate 50 percent or less or if she refused to eat. CNA 9 stated he did not document that Resident 83's refused her breakfast the morning of 5/6/19 because Resident 83 ate what she wanted and documented that she ate 75 percent on 5/6/19. During an interview and record review with the unit manager (UM) on 5/9/19 at 9:24 a.m., UM stated she was aware of Resident 83's poor meal intake. The UM stated the CNA's assigned to Resident 83 were instructed to inform the nurses if Resident 83 refused to eat or the intake was 25 percent or less so the nurse could encourage the resident to eat or offer alternates. The UM stated the charge nurse monitored the meal intake of Resident 83 by checking the meal intake percentages the CNA's documented. The UM stated Resident 83 had an order for [REDACTED]. The UM reviewed the MAR dated 4/2019 through 5/2019 and did not find documentation of a house supplement or protein drinks consumed by Resident 83. The UM stated she did not find documentation of the amount of supplement consumed by Resident 83. During an interview with the UM, on 5/9/19, at 3:12 p.m., the UM stated, Resident 83 did not need to be fed because the resident was able to hold her spoon to feed herself and pick up her cup to drink. The UM stated the resident just needed reminders and cueing. The UM stated during meals CNA's feeding Resident 83's roommate were supposed to give Resident 83 reminders to pick up her spoon and cue Resident 83 to eat her meal. The UM stated, (Resident 83) sometimes will eat, sometimes refused to eat and sometimes she spits out her food. The UM stated meal intakes and supplements were monitored through the CNA's documentation of the meal intakes. The UM stated, When residents refused to eat or the meal intake are 25 percent or less the CNA's let me know and I go and talk to the resident to give encouragement and offer alternate food. The UM stated, I can only talk about myself, I don't know if all the nurses are doing it. The UM reviewed the meal intake of Resident 83 for the last three months and the record had not indicated any meal refusals. The UM stated, I did not understand how (Resident 83) continued to lose weight when meal intake and supplements are charted (documented by CNAs) that she did not refuse any meal or consumed only 25 percent and the supplements charted (documented) also as consumed. The UM stated weights were done by the Rehabilitative Nurse Aide (RNA) every week and every month. The UM stated Resident 83's weight loss was identified six months ago around the end of (MONTH) (YEAR). The intervention was to weigh Resident 83 weekly, monitor her intake and provide more nutritional supplements. The UM stated due to the poor communication between the RD and the nursing department Resident 83's weight loss was not aggressively addressed and could have been prevented. During a concurrent interview and record review with the RNA, on 5/9/19, at 3:56 p.m., the RNA stated weights were done weekly and monthly. Weekly weights were performed on residents who were losing weight. The RNA stated if the scale showed a weight gain or loss of 5 lbs., he called the charge nurse who would confirm the weight. The RNA stated he made copies of the weights and Resident 83's weight loss was documented with copies given to the director of nursing (DON), RD and the RN supervisors. During a review of the facility policy and procedure titled, Weights and Heights, revised date 3/5/19, indicated, .1.2 The Weights Exception Report will be reviewed by a licensed nurse with follow-up as indicated .2.1 Significant weight changes will be reviewed by the licensed nurse for assessment . 3. The Interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight changes . 12. Document all interventions, support of oral intake, resident's response, and notifications (physician, resident representative, dietitian, etc.) . During an interview with the DON, on 5/9/19, at 5:15 p.m., the DON stated they held customer at risk (CAR) meetings every week with the other management staff, including the RD, and discussed weight loss. The DON stated the RD did not discuss Resident 83's weight loss in the meeting. The DON stated the RD was responsible for the weights and for nutritional assessments and notes. The DON stated the RD had not informed the team of the significant ongoing weight loss Resident 83 had experienced. The DON stated, We don't have the (RD weight loss) documentation. The DON stated she did not talk with the resident or the family about the weight loss or go over the wishes indicated in the POLST form for artificial nutrition (the provision of nutrients and liquids through the use of tubes). The DON stated she spoke with Resident 83's primary physician to ask him if he had discussed the option of artificial nutrition with the resident and family and the physician denied speaking to the resident or family member. The DON stated she expected her nurses to do a change of condition assessment when residents were experiencing significant weight changes. The DON stated the nurses did not do that. The DON stated the interdisciplinary team (IDT a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) reviewed changes of conditions every morning, discussed and checked care plans, and made sure family and physicians were notified. The DON stated the unit managers and supervisors were also responsible in following up on weight loss issues and making sure that actions were taken to resolve the issues when the DON was not available. The DON stated the weight loss for Resident 83 was avoidable and could have been prevented if the team would have communicated effectively. During a concurrent observation and interview with CNA 8, on 5/10/19 at 2 p.m., a lunch tray (photo obtained for comparison) came out of a Resident 83's room. On the tray was a plate with partially eaten pot pie with 2 slices of bread, uneaten bowl of fruit, a cup of tea, uneaten container of yogurt, uneaten bowl of peaches, uneaten covered soup and milk that got partially transferred to a plastic cup. CNA 8 stated the lunch meal contained the pot pie with bread, bowl of fruit, soup and milk. CNA 8 stated they (CNAs) calculate the food on the plate as 100%. CNA 8 stated, We only focus on the plate, we don't count the other stuff (other meal items on the tray). CNA 8 stated the meal tray's intake was calculated as 50 percent. CNA 8 stated, We document it as 50% . if the meal intake is low, like 25%, we inform the charge nurse. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with LVN 7, on 5/10/19 at 4:22 p.m., she stated, Nobody taught me how to do meal percentage. I think that is 25 percent (meal consumption) . we just measure the plate (CNA documented meal percentage as 50%). During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with Registered Nurse Supervisor (RNS) 1, on 5/10/19, at 4:32 p.m., she stated, I think that is 50 percent. The plate is half eaten. I just look at it (plate) and calculate it in my head. I don't remember any training on meal intake measurement. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with DON, on 5/10/19, at 5:02 p.m., she stated, I do not recall having any in-service or training for measuring food intake. The staff answers are different which means meal measurement documented were not accurate. During an interview and record review with the DON, on 05/13/19, at 2:03 p.m., the DON reviewed Resident 83's clinical record the Care Plan undated and stated, We did interventions for the nutrition and weight loss, provided care but now looking back we could have added to it. The DON stated, She (RD) should have involved the IDT and considered another interventions and tried to follow the POLST and tried the trial artificial nutrition then, we did not do it and when we addressed it, it was already too late. During a phone interview with Resident 83's Physician, on 5/17/19, at 5:40 p.m., the Physician stated he knew Resident 83 was admitted to the facility for a short term period with the goal to return home. The Physician stated Resident 83 did not achieve her short term goal and was moved to the long term wing. The Physician stated the nurse had called regarding weight loss and he had ordered some blood tests. The Physician stated he did not remember the nurse talking to him about the extent of the weight loss. The Physician stated he was not aware Resident 83 had lost so much weight. The Physician stated he did not speak with the family about a weight loss nor discussed a trial tube feeding because he was not informed of the significant weight loss by the nurse. The Physician stated he was never made aware about the Resident POLST form indicated wishes for a trial of artificial nutrition tube feeding (tube surgically inserted into the stomach to provide nutrition, hydration and medications). The Physician stated it should have been initiated prior to Resident 83 losing a significant amount of weight. During a review of Resident 83's clinical record, the Physician's orders, dated 7/27/18, indicated, [MEDICATION NAME] (depression medication) tablet give 20 (milligrams) mg, give 1 tablet by mouth one time a day .[MEDICATION NAME] (type of antibiotic to treat lung infection) tablet 500 mg 1 tablet daily X (for) 5 days for Pneumonia. [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) Sodium tablet 75 mcg (unit of measurement) 1 tablet by mouth in the morning for [MEDICAL CONDITION] . [MEDICATION NAME] (improves sleep in patients with [MEDICAL CONDITION]) tablet 10 mg. Give 1 tablet every 24 hours as needed for [MEDICAL CONDITION] . The facility policy and procedure titled, Nutrition/Hydration Management dated 3/15/16 indicated. .Staff will consistently observe and monitor patients for changes and implement revisions to the plan of care as needed . 6. Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration . 7. Observe oral intake of meals, supplements and snacks and complete the Meal Monitor Data Collection Sheet when ordered or indicated .9.1 Review advance directives or healthcare instructions to determine appropriateness of new or ongoing recommendations . The facility policy and procedure titled, Nutrition/Hydration Management dated 12/1/06 indicated . Staff will consistently observe and monitor residents for changes and implement revisions to the service plan as needed. Resident will receive care and support to enhance potential or attaining the highest level of nutrition and hydration status and the pleasure of eating . Consult with dietitian may be indicated . 3.1 unplanned weight loss . 3.2 Any stage pressure ulcer . 3.3 skin breakdown 3.4 inadequate oral intake, less than 50% of meals in 72 hours period. 2. During a concurrent observation and interview with Resident 83, on 5/6/19, at 8:15 a.m., Resident 83 was in her room sitting upright in bed on an air loss mattress (special mattress to distribute weight and minimize pressure to bony prominences) and a urinary catheter (a flexible tube inserted into the bladder to drain urine) at the side of her bed, her eyes were closed and sunken. Resident 83 was thin with sunken cheeks and dry wrinkled skin. Resident 83 grimaced and stated the bed was uncomfortable and her backside was hurting. During an interview with Certified Nursing Assistant (CNA) 3, on 5/6/19, at 3:25 p.m., she stated Resident 83 required assistance with turning and repositioning and set-up with meal trays. CNA 3 stated Resident 83 was incontinent of bowel and occasionally had loose stools. CNA 3 stated Resident 83 did not have open areas on her skin with the exception of redness to the lower back. CNA 3 stated the redness on Resident 83's lower back was related to moisture in the skin from the loose stools Resident 83 experienced. CNA 3 stated Resident 83 was bedridden and did not get out of bed. During a concurrent observation and interview with CNA 9, on 5/7/19, at 1:05 p.m., Resident 83 was in bed on her back side and awake. CNA 9 stated Resident 83 had redness to her lower back and was unsure if there were any open areas on Resident 83's skin. CNA 9 stated he did not recall completing a skin check to document Resident 83's skin condition. CNA 9 stated CNA's were required to check residents skin during care and position changes and inform the nurse if the CNA noticed any skin issues or wounds. During a concurrent interview and record review with the Unit Manager (UM) 1, on 5/7/19, at 1:30 p.m., UM 1 stated Resident 83 had a pressure ulcer stage 3 on the coccyx area. UM 1 stated the Stage 3 was reported on 5/6/19 to the nurse in the evening shift. UM 1 stated the treatment nurse and Registered Nurse Supervisor were asked to assess Resident 83's skin breakdown. During a concurrent interview and clinical record review with the UM 1, on 5/7/19, at 2 p.m., she reviewed the document titled BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK dated 3/12/19 and 5/7/19 which indicated, Moisture, degree to which skin is exposed to moisture, rarely moist: skin is usually dry .Activity, degree of physical activity, Chairfast .assisted into wheelchair .Nutrition, usual food intake pattern, Adequate. Wats over ½ of most meals. Eats a total of four servings of protein each day . The UM 1 stated the skin risk assessments were inaccurate because Resident 83 had loose stools and was exposed to moisture from the loose stools. The UM 1 Resident 83 was bedridden and did not get up in a wheelchair. The UM 1 stated Resident 83 was admitted to the facility on [DATE] weighing 130.6 lbs. and now weighted 82.0 lbs. 5/ (TRUNCATED)

Based on observation, interview and record review the facility failed to ensure residents maintained their usual body weight for two of four sampled residents (Residents 83 and 95) when Registered Dietician (RD) did not conduct accurate nutritional assessments, communicate weight loss to interdisciplinary (IDT) team (members of the care team that include nurses, social workers, doctors, therapists and others) and implement effective actions and services to prevent significant weight loss. The RD and nursing staff failed to accurately document and monitor the daily meal consumption for Resident 83 and Resident 95. These failures resulted in Resident 83 experiencing a 47.9 pound (lbs.) weight loss or 36.7 percent weight loss over a period of 9 months. Resident 83 weighed 130 lbs. on admission on 7/27/18 and on 4/19/19 weighed 82 1b. For Resident 95 the failure resulted in a 25.3 lb. weight loss or 21.4 percent weight loss over a period of ten months. Resident 95 weighed 118 lbs. on admission on 7/3/18 and on 4/29/19 weighed 92.7 lbs. Findings: 1. During an observation in Resident 83's room, on 5/6/19, at 8:15 a.m., Resident 83 was in her room, in bed and sitting upright with her eyes closed. Resident 83's collar and shoulder bones were easily visible and her skin appeared dry and wrinkled. Resident 83's wrist and arms were visibly thin and without muscle mass. An over bed table was observed at the left side of Resident 83 with a breakfast tray. The following uneaten meal items were observed on the meal tray: pancakes with syrup and margarine, oatmeal in a bowl, scrambled eggs, a glass of juice, and a glass of milk. On the meal tray was an empty cup with a dry tea bag and a bowl with a small amount of cottage cheese. Resident 83 opened her eyes and began grimacing (facial expressions of pain) and stated the bed was uncomfortable and her backside was hurting. Resident 83 stated the meal tray was hers but she did not want it. Resident 83's face sheet (a document containing resident profile information) undated, indicated Resident 83 was admitted to the facility on [DATE] for a planned short rehabilitation stay to recover from a surgical repair of a broken hip. Resident 83 was admitted with [DIAGNOSES REDACTED]. of stomach acid into the esophagus). During a review of the clinical record for Resident 83, the Minimum Data Set (MDS) assessment (functional and cognitive abilities assessed), dated 4/5/19, under Section C, Brief Interview for Mental Status (BIMS) score was 10 which indicated Resident 83 was moderately impaired in cognition (memory and judgement). During an interview with Certified Nursing Assistant (CNA) 3, on 5/6/19, at 3:25 p.m., she stated Resident 83 required assistance with the set-up of her meal tray. CNA 3 stated, Resident 83 was able to feed herself with set-up but required staff supervision and constant reminders to eat during her meals. CNA 3 stated, The staff member feeding Resident 83's roommate had to make sure to keep an eye on Resident 83 and to give constant reminders to eat. During a concurrent observation of Resident 83 in her room and interview with CNA 9, on 5/7/19, at 1:15 to 1:30 p.m., Resident 83 was in bed with the head of the bed elevated. Resident 83 was moving her food on her plate from one area to the next without bringing the food to her mouth. The lunch meal consisted of: Macaroni and cheese, stewed tomatoes, Cole slaw, bread roll, peaches, one glass of milk and a cup of hot tea. CNA 9 was in the room feeding Resident 83's roommate for 15 minutes and was not heard providing reminders or encouragement for Resident 83 to eat her meal. Resident 83 stated she was full and did not want to eat more. CNA 9 replied to Resident 83 Okay and continued to feed Resident 83's roommate. CNA 9 did not offer a substitute for the uneaten lunch meal. CNA 9 removed Resident 83's meal tray and stated that Resident 83 usually did not eat her meals. CNA 9 stated he should have offered Resident 83 an alternative food choice. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 11), on 5/7/19, at 2:35 p.m., LVN 11 stated Resident 83 required supervision with meals. LVN 11 stated CNA's assigned to Resident 83 had to make sure to give her reminders to eat and report to the nurse when Resident 83 refused to eat. LN 11 stated she had not received a report from CNA 9 that Resident 83 refused her meals. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated, Resident 83 eats what she wants to eat. She is confused too so I have to talk to the CNA's taking care of her (for meal consumption information). The RD stated Resident 83 liked yogurt, cottage cheese and fruits and hot tea. The RD stated those were options that could be given to Resident 83 if she refused her meal. RD stated she had not observed Resident 83 eat a meal since admission and relied on the CNAs documentation for the meal percentage. The RD stated she continued to monitor the documentation of Resident 83's weights weekly as well as her meal intake. The RD stated Resident 83 was admitted to the facility on [DATE] with a weight of 130.6 lbs. The RD stated Resident 83's current weight on 5/8/19 was 82.7 lbs. (a total of 47.3 lbs. weight loss within nine months from the date of admission of 7/27/18). The RD stated Resident 83 was currently under her ideal body weight of 160 to 130 lbs. The RD stated on admission, Resident 83's weight was 130.6 lbs. The RD stated she reviewed her initial assessment dated [DATE] and Resident 83's weight was at the lower end of Resident 83's Body Weight Range (BWR) of 160 to 130 lbs. and height was 64 inches. The RD stated Resident 83's usual weight was 130 lbs. per Resident 83. The RD stated she identified Resident 83 at nutritional risk due to her inadequate oral intake which would not meet her nutritional needs. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 7/27/18 and 8/27/18, Resident 83's weight dropped from 130.6 lbs. to 119.3 lbs., representing a weight loss of 11.3 lbs or 8.7 percent for one month. The RD stated she calculated Resident 83's meal intake using the CNAs documented meal percentages. The RD stated her calculations were that Resident 83 was eating 71 percent of her meals. The RD stated the weight loss was related to Resident 83's [DIAGNOSES REDACTED]. diff, is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) infection. The RD stated Resident 83 was started on [MEDICATION NAME] (antibiotic medication to treat the infection) 500 mg three times a day times for 10 days. A stool culture to check for [MEDICAL CONDITION] was collected on 8/3/18 and indicated positive for [DIAGNOSES REDACTED]. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated, between 8/27/18 through 9/24/18 Resident 83's weight dropped from 119.3 lbs. to 104.9 lbs., representing a weight loss of 14.4 lbs., a 1 percent loss over one month. The RD stated Resident 83 was sent out to the general acute care hospital (GACH) from 9/9/18 thru 9/18/18 with [DIAGNOSES REDACTED]. The RD reviewed the nutritional assessment dated [DATE] which indicated, Resident 83 was to continue with the current diet of Regular/Liberalized diet, looks visibly thin. The RD stated, Resident is meeting energy needs, the weight loss might have been related to the UTI, and the main goal was to prevent further weight loss. RD stated no new nutritional interventions were implemented at that time. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 9/24/18 through 11/6/18 the weight dropped from 104.9 lbs. to 97.8 lbs., representing a weight loss of 7.1 lbs., or 6.8 percent in 6 weeks. The RD reviewed the nutritional assessment dated [DATE], and stated Resident 83 continued on a Regular/liberalized diet, (new intervention of) House supplement two times a day. No chewing or swallowing problem, eats in her room for all meals and continue to require tray set-up. Intake 59% . (Resident 83) looks visibly thin. The RD note dated 10/3/18, indicated, Saw (Resident 83) food services and visited often and collect food preferences. The RD reviewed her RD notes dated 11/5/18, which indicated, RD saw resident and checked chewing and swallowing problem and collected food preferences. The RD note indicated, (Resident 83) likes cottage cheese and fruits and added as interventions. The RD stated, (Resident 83) was at risk for further weight loss. The RD reviewed the clinical record for her documented Frequent resident visits and interventions and was unable to find documentation of the frequent nutritional visits or interventions. The RD stated, I don't have those. During a concurrent record review and interview with the RD, on 5/8/19, at 10:41 a.m., the RD stated between 11/6/18 through 12/6/18 the weight dropped from 97.8 lbs. to 93.3 lbs., a weight loss of 4.5 lbs. or 4.6 percent. The RD reviewed her RD note dated 11/7/18 and 11/12/18 which indicated, Per clinical meeting resident with soft/loose stools despite diet intake of fiber, resident will benefit from Nutrisource (fiber) packet twice a day to provide additional fiber. Appetite improving consuming 63% of meals, Resident 83 meeting estimated energy needs. The RD stated she was unsure why Resident 83 was continuing to lose weight when she was meeting her estimated nutritional needs. The RD stated she had not observed Resident 83's meal consumption since admission, but relied on the CNA's meal consumption documentation. RD stated she did not implement new nutritional interventions to slow or attempt to stop ongoing weight loss. During a concurrent record review and interview with the RD, on 5/8/19, at 10:43 a.m., the RD stated, between 12/6/18 through 1/8/19 the weight dropped from 93.3 lbs. to 88.7 lbs., representing a weight loss of 4.6 lbs., or 4.9 percent. The RD stated the weight loss was not significant, and no new interventions were added at that time. During a concurrent record review and interview with the RD, on 5/8/19, at 10:44 a.m., the RD stated, between 1/8/19 through 2/4/19 the weight dropped from 88.7 lbs. to 88.4 lbs., representing a weight loss of 0.3 lbs. The RD stated the weight loss was not significant and weight had been stable, but the RD did add one nutritional supplement with breakfast. During a concurrent record review and interview with the RD, on 5/8/19, at 10:46 a.m., the RD stated, between 2/4/19 through 3/4/19, the weight dropped from 88.4 lbs. to 84.6 lbs., representing a weight loss of 3.8 lbs., or 4.3 percent. The RD reviewed the nutritional assessment dated [DATE] which indicated, Continue on Regular/Liberalized . Evaluation/Nutrition plan: (Resident 83) meeting estimated energy needs, previous oral intake was meeting estimated energy needs, main goal to prevent further weight loss. Resident had snacks in between meals. The RD stated Resident 83 was underweight. During a concurrent record review and interview with the RD, on 5/8/19, at 10:47 a.m., the RD stated, between 3/4/19 through 4/15/19, the weight dropped from 84.6 lbs. to 81.3 lbs., representing a weight loss of 3.3 lbs., or 3.9 percent. The RD stated she reviewed the nutritional assessment dated [DATE] and 4/2/19, which indicated, Continue on Regular Liberalized diet . Nutrition History: Has triggered for significant weight loss X (for) 6 months, -(lost) 24.9%, -(lost) 28lbs. comparison weight of -(lost) 8.7lbs, -(lost) 9.3% X 3 months . Resident weight loss continues . During a concurrent record review and interview with the RD, on 5/8/19, at 10:48 a.m., the RD stated between 4/5/19 through 4/29/19, the weight was 82.7 lbs. The RD stated Resident 83's weight loss had stabilized since March, and she did not add new interventions. The RD stated she did not attend any of the interdisciplinary team meeting (IDT) or care plan conferences to communicate Resident 83's ongoing weight loss with the team. The RD stated the IDT would invite her to the meetings but she had not attended the meetings for any of the residents that were losing weight, including Resident 83. RD stated she should have been present in the care conferences and should have discussed the continued weight losses but she had not. The RD stated she did not monitor or validate the CNA's capability to document meal percentages accurately. The RD stated, I assumed that they are calculating it correctly, I relied on the data that was presented to me. The RD stated CNAs were not documenting Resident 83's meal percentages accurately based on the intake documented and the weight loss that had occurred. The RD stated the meal percentages documented by the CNAs did not match or support Resident 83's ongoing weight loss. The RD stated she did not provide in-service education to CNA's on how to accurately document meal percentages. The RD stated, The director of staff development (DSD) does the in-services regarding food percentages and there are postings for the CNA's to follow in regards to the calculations of meals percentages. RD stated she attended Customer at Risk (CAR) meetings every Tuesday morning with the MD, DON, Social Service Director (SSW), and RN supervisor. In the CAR meeting the group discussed recent weight loss, weight changes and new admissions. The RD stated she had not discussed the weight loss of Resident 83 in the meetings. She stated, For some reason, I just missed it (Resident 83's ongoing weight loss). The RD stated she did not remember talking to Resident 83's Responsible Party about the weight loss and did not look at the Provider Orders for Life-Sustaining Treatment (POLST) form. The RD stated she was responsible for the nutrition care plans, evaluating and updating the interventions as needed when nutritional issues were identified. The RD stated she reviewed the care plan interventions but was unable to find documentation where she evaluated and/or revised her nutritional interventions for Resident 83. The RD stated she did not know why Resident 83 was losing weight. The RD stated, I just missed it (the weight loss). During a review of Resident 83's clinical records the Weights and Vitals Summary dated 7/27/18 to 4/26/19 indicated Resident 83's admission weight on 7/27/18 was 130.6 lbs. and on 5/8/19 the weight was 82.7 lbs. There was a total loss of 47.9 lbs. or 36.7 percent weight loss within nine months. During a review of the facility document the, (RD) JOB DESCRIPTION: DIETITIAN dated 5/29/17 indicated . RESPONSIBLITIES and ACCOUNTABILITILITIES .4. Collaborates with the interdisciplinary team to develop nutritional plans of care for the residents/patients. 5. Monitor and evaluate effectiveness of nutritional interventions . 12. Participates in the education and training of center staff . Review of facility document titled HIGH RISK NOTE FORMAT dated (MONTH) 2013 indicated . Pressure Ulcer Review: . 2. Weight and weight history, trend . 4. Current nutritional interventions, if any. Are they accepted and effective? . Significant Weight Loss Review: . 6.Do meal rounds on resident as appropriate, document observations. Anything in the dining situation that should be improved? . 11. In IDT weekly weight meeting, evaluate current weekly weight on resident. If the resident has continued to lose weight, add or change current interventions. 12. Update Care Plan (CP). During a concurrent interview and record review with LN 7, on 5/8/19, at 11:21 a.m., she stated Resident 83 required supervision with eating, set-up with meals and encouragement and prompting while eating. LN 7 stated staff feeding Resident 83's roommate, should have monitored Resident 83 at the same time giving cueing and encouragement to eat. LN 7 stated the CNA's should have reported to the nurse if Resident 83 refused to eat so the nurse could encourage her to eat or offer a food alternative. LN 7 stated she had not received reports of Resident 83 refusing to eat. LN 7 stated she had not observed Resident 83's meal consumption. LN 7 stated she relied on the CNAs documented meal percentages and reports. LN 7 stated Resident 83 liked hot tea, cottage cheese, yogurt and nourishment and those items were available for Resident 83. LN 7 stated the rehabilitative nurse aide (RNA) took Resident 83's weights every week and reported any weight changes to the registered nurse supervisor (RNS). LN 7 stated the RN'S were the nurses responsible for the calculation of percentages of the meals eaten, weight loss or gains and notification to the Medical Doctor (MD) and family. LN 7 stated the RN was the person who would identify resident weight changes (LN 7 was a Licensed Vocational Nurse). LN 7 stated she did not review weights. LN 7 stated the RD recommendations were handled by her or other LNs. LN 7 reviewed the RD nutritional notes for Resident 83 and stated the RD had not given nutritional recommendations for Resident 83. During a concurrent observation and interview with CNA 9, on 5/8/19, at 2 p.m., Resident 83 was lying in bed with a lunch tray at the bedside. The lunch tray contained an empty cup of tea and empty bowl of cottage cheese. There was an uneaten sandwich, uneaten sliced peaches, a full glass of milk and house nourishment. CNA 9 stated Resident 83 ate 25 percent of her lunch based on the eaten cottage cheese and tea. CNA 9 stated Resident 83's appetite varied from okay to poor. CNA 9 stated Resident would eat approximately 25 to 75 percent of her meals. CNA 9 stated Resident 83 ate 75 percent of her breakfast the morning of 5/6/19 (Resident 83 was observed as refusing her breakfast meal on 5/6/19). CNA 9 stated he usually let the nurse know if Resident 83 ate 50 percent or less or if she refused to eat. CNA 9 stated he did not document that Resident 83's refused her breakfast the morning of 5/6/19 because Resident 83 ate what she wanted and documented that she ate 75 percent on 5/6/19. During an interview and record review with the unit manager (UM) on 5/9/19 at 9:24 a.m., UM stated she was aware of Resident 83's poor meal intake. The UM stated the CNA's assigned to Resident 83 were instructed to inform the nurses if Resident 83 refused to eat or the intake was 25 percent or less so the nurse could encourage the resident to eat or offer alternates. The UM stated the charge nurse monitored the meal intake of Resident 83 by checking the meal intake percentages the CNA's documented. The UM stated Resident 83 had an order for [REDACTED]. The UM reviewed the MAR dated 4/2019 through 5/2019 and did not find documentation of a house supplement or protein drinks consumed by Resident 83. The UM stated she did not find documentation of the amount of supplement consumed by Resident 83. During an interview with the UM, on 5/9/19, at 3:12 p.m., the UM stated, Resident 83 did not need to be fed because the resident was able to hold her spoon to feed herself and pick up her cup to drink. The UM stated the resident just needed reminders and cueing. The UM stated during meals CNA's feeding Resident 83's roommate were supposed to give Resident 83 reminders to pick up her spoon and cue Resident 83 to eat her meal. The UM stated, (Resident 83) sometimes will eat, sometimes refused to eat and sometimes she spits out her food. The UM stated meal intakes and supplements were monitored through the CNA's documentation of the meal intakes. The UM stated, When residents refused to eat or the meal intake are 25 percent or less the CNA's let me know and I go and talk to the resident to give encouragement and offer alternate food. The UM stated, I can only talk about myself, I don't know if all the nurses are doing it. The UM reviewed the meal intake of Resident 83 for the last three months and the record had not indicated any meal refusals. The UM stated, I did not understand how (Resident 83) continued to lose weight when meal intake and supplements are charted (documented by CNAs) that she did not refuse any meal or consumed only 25 percent and the supplements charted (documented) also as consumed. The UM stated weights were done by the Rehabilitative Nurse Aide (RNA) every week and every month. The UM stated Resident 83's weight loss was identified six months ago around the end of (MONTH) (YEAR). The intervention was to weigh Resident 83 weekly, monitor her intake and provide more nutritional supplements. The UM stated due to the poor communication between the RD and the nursing department Resident 83's weight loss was not aggressively addressed and could have been prevented. During a concurrent interview and record review with the RNA, on 5/9/19, at 3:56 p.m., the RNA stated weights were done weekly and monthly. Weekly weights were performed on residents who were losing weight. The RNA stated if the scale showed a weight gain or loss of 5 lbs., he called the charge nurse who would confirm the weight. The RNA stated he made copies of the weights and Resident 83's weight loss was documented with copies given to the director of nursing (DON), RD and the RN supervisors. During a review of the facility policy and procedure titled, Weights and Heights, revised date 3/5/19, indicated, .1.2 The Weights Exception Report will be reviewed by a licensed nurse with follow-up as indicated .2.1 Significant weight changes will be reviewed by the licensed nurse for assessment . 3. The Interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight changes . 12. Document all interventions, support of oral intake, resident's response, and notifications (physician, resident representative, dietitian, etc.) . During an interview with the DON, on 5/9/19, at 5:15 p.m., the DON stated they held customer at risk (CAR) meetings every week with the other management staff, including the RD, and discussed weight loss. The DON stated the RD did not discuss Resident 83's weight loss in the meeting. The DON stated the RD was responsible for the weights and for nutritional assessments and notes. The DON stated the RD had not informed the team of the significant ongoing weight loss Resident 83 had experienced. The DON stated, We don't have the (RD weight loss) documentation. The DON stated she did not talk with the resident or the family about the weight loss or go over the wishes indicated in the POLST form for artificial nutrition (the provision of nutrients and liquids through the use of tubes). The DON stated she spoke with Resident 83's primary physician to ask him if he had discussed the option of artificial nutrition with the resident and family and the physician denied speaking to the resident or family member. The DON stated she expected her nurses to do a change of condition assessment when residents were experiencing significant weight changes. The DON stated the nurses did not do that. The DON stated the interdisciplinary team (IDT a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) reviewed changes of conditions every morning, discussed and checked care plans, and made sure family and physicians were notified. The DON stated the unit managers and supervisors were also responsible in following up on weight loss issues and making sure that actions were taken to resolve the issues when the DON was not available. The DON stated the weight loss for Resident 83 was avoidable and could have been prevented if the team would have communicated effectively. During a concurrent observation and interview with CNA 8, on 5/10/19 at 2 p.m., a lunch tray (photo obtained for comparison) came out of a Resident 83's room. On the tray was a plate with partially eaten pot pie with 2 slices of bread, uneaten bowl of fruit, a cup of tea, uneaten container of yogurt, uneaten bowl of peaches, uneaten covered soup and milk that got partially transferred to a plastic cup. CNA 8 stated the lunch meal contained the pot pie with bread, bowl of fruit, soup and milk. CNA 8 stated they (CNAs) calculate the food on the plate as 100%. CNA 8 stated, We only focus on the plate, we don't count the other stuff (other meal items on the tray). CNA 8 stated the meal tray's intake was calculated as 50 percent. CNA 8 stated, We document it as 50% . if the meal intake is low, like 25%, we inform the charge nurse. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with LVN 7, on 5/10/19 at 4:22 p.m., she stated, Nobody taught me how to do meal percentage. I think that is 25 percent (meal consumption) . we just measure the plate (CNA documented meal percentage as 50%). During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with Registered Nurse Supervisor (RNS) 1, on 5/10/19, at 4:32 p.m., she stated, I think that is 50 percent. The plate is half eaten. I just look at it (plate) and calculate it in my head. I don't remember any training on meal intake measurement. During a concurrent photo (dated 5/10/19 of Resident 83's uneaten meal on the tray) review and interview with DON, on 5/10/19, at 5:02 p.m., she stated, I do not recall having any in-service or training for measuring food intake. The staff answers are different which means meal measurement documented were not accurate. During an interview and record review with the DON, on 05/13/19, at 2:03 p.m., the DON reviewed Resident 83's clinical record the Care Plan undated and stated, We did interventions for the nutrition and weight loss, provided care but now looking back we could have added to it. The DON stated, She (RD) should have involved the IDT and considered another interventions and tried to follow the POLST and tried the trial artificial nutrition then, we did not do it and when we addressed it, it was already too late. During a phone interview with Resident 83's Physician, on 5/17/19, at 5:40 p.m., the Physician stated he knew Resident 83 was admitted to the facility for a short term period with the goal to return home. The Physician stated Resident 83 did not achieve her short term goal and was moved to the long term wing. The Physician stated the nurse had called regarding weight loss and he had ordered some blood tests. The Physician stated he did not remember the nurse talking to him about the extent of the weight loss. The Physician stated he was not aware Resident 83 had lost so much weight. The Physician stated he did not speak with the family about a weight loss nor discussed a trial tube feeding because he was not informed of the significant weight loss by the nurse. The Physician stated he was never made aware about the Resident POLST form indicated wishes for a trial of artificial nutrition tube feeding (tube surgically inserted into the stomach to provide nutrition, hydration and medications). The Physician stated it should have been initiated prior to Resident 83 losing a significant amount of weight. During a review of Resident 83's clinical record, the Physician's orders, dated 7/27/18, indicated, [MEDICATION NAME] (depression medication) tablet give 20 (milligrams) mg, give 1 tablet by mouth one time a day .[MEDICATION NAME] (type of antibiotic to treat lung infection) tablet 500 mg 1 tablet daily X (for) 5 days for Pneumonia. [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) Sodium tablet 75 mcg (unit of measurement) 1 tablet by mouth in the morning for [MEDICAL CONDITION] . [MEDICATION NAME] (improves sleep in patients with [MEDICAL CONDITION]) tablet 10 mg. Give 1 tablet every 24 hours as needed for [MEDICAL CONDITION] . The facility policy and procedure titled, Nutrition/Hydration Management dated 3/15/16 indicated. .Staff will consistently observe and monitor patients for changes and implement revisions to the plan of care as needed . 6. Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration . 7. Observe oral intake of meals, supplements and snacks and complete the Meal Monitor Data Collection Sheet when ordered or indicated .9.1 Review advance directives or healthcare instructions to determine appropriateness of new or ongoing recommendations . The facility policy and procedure titled, Nutrition/Hydration Management dated 12/1/06 indicated . Staff will consistently observe and monitor residents for changes and implement revisions to the service plan as needed. Resident will receive care and support to enhance potential or attaining the highest level of nutrition and hydration status and the pleasure of eating . Consult with dietitian may be indicated . 3.1 unplanned weight loss . 3.2 Any stage pressure ulcer . 3.3 skin breakdown 3.4 inadequate oral intake, less than 50% of meals in 72 hours period. 2. During a review of the clinical record for Resident 95, the Weights and Vitals Summary dated 5/15/19, indicated Resident 95 was admitted on [DATE] weighing 118.0 lbs. and on 4/29/19 weighed 92.7 lbs. Resident 95 had a weight loss of 25.3 lbs or 21.4 percent in the last ten months (4/29/19). Review of the Weights and Vital Summary report dated 5/15/19, indicated the following weights: (7/3/18) admission weight of 118.0 lbs and height 60 inches. 7/9/18, 116.2 lbs 7/16/18, 114.3 lbs, 7/23/18 111.9 lbs, 7/30/18 111.2 lbs 8/6/2018 112 lbs 9/9/18, 113.9 lbs. 10/5/18, 112.3lbs 11/6/18, 108.7lbs 12/6/18, 111.8 lbs 1/8/19, 106.7 lbs 2/8/19, 103.8 lbs 3/5/19, 91.7 lbs 3/11/19, 91.0 lbs 3/18/19, 89 lbs 3/25/19, 94 lbs. 4/1/19, 92.0 lbs 4/8/19, 91.1 lbs 4/15/19, 92.0 lbs 4/22/19, 91.8 lbs., (weight loss of 26.2 lbs) 4/29/19, 92.7 lbs. (weight loss of 25.3 lbs.) During a concurrent record review and interview with Registered Nurse Supervisor (RNS) 2, on 5/15/19, at 1:31 p.m., she stated Resident 95 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RNS 2 stated Resident 95's admission weight on 7/3/18 was 118 lbs. The RNS 2 stated the weight summary report indicated Resident 95's weight of 112 lbs (a total of 6 lbs. lost) on 8/6/18 date. RNS 2 stated Resident 95 had experiences a weight loss of 5% during the first month of admission from 7/3/18 to 8/6/18. RNS 2 stated she was the person responsible for monitoring resident weight changes and identifying weight concerns timely. RNS 2 sated, This weight loss was not identified by nursing department and it should have been identified. RNS 2 stated since the weight loss went unnoticed Resident 95 did not receive nutritional assessments. The RNS 2 stated Resident 95's physician was not notified of the 5% weight loss. RNS 2 stated, There should have been a nursing assessment, nutritional assessment, physician notification and new care plan interventions (to prevent ongoing weight loss) for the significant weight loss . RNS 2 stated the RD progress note dated 8/9/18 indicated, Resident current body weight is 112 . which reflects a significant weight loss x (for) 1 month of 5% = 6lbs. (pounds - unit of measure for weight) . Continue with P[NAME] (plan of care - no new interventions) as resident is maintaining body weight . RNS 23 stated the RD's progress noted did not reflect that Resident 95 was experiencing weight loss and did not implement interventions to attempt to prevent future weight loss. During a concurrent observation and inte (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 83) remained free from developing pressure ulcers (localized injury to the skin and or underlying flesh usually over a bony area as a result of pressure/friction/shear) when Resident 83 had a known history of recurrent skin breakdown and was not repositioned every two hours and kept clean and dry as per the plan of care to prevent pressure ulcers. Resident 83 was bedridden following a fall that resulted in a [MEDICAL CONDITION], after admission to the facility experienced a significant weight loss and nursing failed to conduct accurate skin risk assessments. This failure resulted in Resident 83 developing a preventable Stage 3 (Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia) pressure ulcer to the coccyx area (tailbone). Findings: During a concurrent observation and interview with Resident 83, on 5/6/19, at 8:15 a.m., Resident 83 was in her room sitting upright in bed on an air loss mattress (special mattress to distribute weight and minimize pressure to bony prominences) and a urinary catheter (a flexible tube inserted into the bladder to drain urine) at the side of her bed, her eyes were closed and sunken. Resident 83 was thin with sunken cheeks and dry wrinkled skin. Resident 83 grimaced and stated the bed was uncomfortable and her backside was hurting. During an interview with Certified Nursing Assistant (CNA) 3, on 5/6/19, at 3:25 p.m., she stated Resident 83 required assistance with turning and repositioning and set-up with meal trays. CNA 3 stated Resident 83 was incontinent of bowel and occasionally had loose stools. CNA 3 stated Resident 83 did not have open areas on her skin with the exception of redness to the lower back. CNA 3 stated the redness on Resident 83's lower back was related to moisture in the skin from the loose stools Resident 83 experienced. CNA 3 stated Resident 83 was bedridden and did not get out of bed. During a concurrent observation and interview with CNA 9, on 5/7/19, at 1:05 p.m., Resident 83 was in bed on her back side and awake. CNA 9 stated Resident 83 had redness to her lower back and was unsure if there were any open areas on Resident 83's skin. CNA 9 stated he did not recall completing a skin check to document Resident 83's skin condition. CNA 9 stated CNA's were required to check residents skin during care and position changes and inform the nurse if the CNA noticed any skin issues or wounds. During a concurrent interview and record review with the Unit Manager (UM) 1, on 5/7/19, at 1:30 p.m., UM 1 stated Resident 83 had a pressure ulcer stage 3 on the coccyx area. UM 1 stated the Stage 3 was reported on 5/6/19 to the nurse in the evening shift. UM 1 stated the treatment nurse and Registered Nurse Supervisor were asked to assess Resident 83's skin breakdown. During a concurrent interview and clinical record review with the UM 1, on 5/7/19, at 2 p.m., she reviewed the document titled BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK dated 3/12/19 and 5/7/19 which indicated, Moisture, degree to which skin is exposed to moisture, rarely moist: skin is usually dry .Activity, degree of physical activity, Chairfast .assisted into wheelchair .Nutrition, usual food intake pattern, Adequate. Wats over ½ of most meals. Eats a total of four servings of protein each day . The UM 1 stated the skin risk assessments were inaccurate because Resident 83 had loose stools and was exposed to moisture from the loose stools. The UM 1 Resident 83 was bedridden and did not get up in a wheelchair. The UM 1 stated Resident 83 was admitted to the facility on [DATE] weighing 130.6 lbs. and now weighted 82.0 lbs. 5/6/19 (total weight loss of 48. 6 lbs. within nine months). The UM stated Resident 83 had experienced significant weight losses during her stay in the facility which compromised the integrity of her skin making Resident 83 a high risk for skin breakdown. The UM 1 stated, the skin risk assessment (BRADEN) was not completed accurately because the BRADEN assessment indicated a score of 18 (Mild risk: total score of 15-18). The UM 1 stated an accurate BRADEN assessment would ensure Resident 83 received interventions to attempt to prevent the development of pressure ulcers. The UM 12 stated, That did not happen. During an interview with Licensed Nurse (LN) 11, on 5/7/19, at 2:50 p.m., LN 11 stated, Resident 83 has a Stage 3 to coccyx area. LN 11 stated Resident 83 was occasionally non-compliant with turning and repositioning in bed. LN 11 stated Resident 83 was incontinent of bowel which caused the redness to her buttocks area. During a concurrent observation and interview with CNA 9, on 5/8/19, at 11 a.m., Resident 83 was in bed on her left side. CNA 9 stated Resident 83 was supposed to be on her right side and not on the left side. CNA 9 stated the position change was scheduled on the facilities turning schedule. CNA 9 stated he was approximately 20 minutes late in turning Resident 83 on her right side. CNA 9 stated the turning and repositioning was due every two hours and as needed. CNA 9 stated Resident 83 sometimes was non-compliant with turning and repositioning and favored to be positioned on her back. CNA 9 stated Resident 83 was incontinent of bowel and had redness to her buttocks area related to her loose stools. During a review of the clinical record for Resident 83, the document titled, Skin Check dated 7/27/18, indicated Resident 83 was admitted to the facility on [DATE] with a Stage 1 (Intact skin with non-blanchable redness over a bony prominence) to the coccyx area. The document indicated Resident 83 had scattered bruises to both upper arms and a surgical incision site to the right hip. During an interview with the Director of Nursing (DON), on 5/8/19, at 2:33 p.m., she stated Resident 83's air loss mattress was put in place on 3/19/19 because of the risk of pressure ulcer development. The DON stated Resident 83 was at risk for skin breakdown and pressure ulcer development because of her poor nutrition, significant weight loss and stool incontinence. During a concurrent observation and interview with Treatment Nurse (TN), on 5/8/19, at 3:35 p.m., TN prepared to measure Resident 83's pressure ulcer and administer the treatment. The pressure ulcer on the coccyx area was partially covered with slough (dead tissue, usually cream or yellow in color) and granulating (healing tissue) red in color on the wound. TN stated the pressure ulcer on Resident 83's coccyx was 1.5 centimeters (cm) in length by 1 cm in width by .1 cm in depth. TN stated she was informed about Resident 83 having a pressure ulcer on 5/6/19. TN stated the last time she saw Resident 83 was on 5/1/19 when Resident 83 received treatment for a Stage 1 pressure ulcer on the coccyx. TN did not give additional information on why Resident 83's newly identified pressure ulcer did not receive treatment for two days after it was identified on 5/6/19. TN stated the new pressure ulcer was a Stage 3. TN stated she did not know why the wound was not seen before it progressed to a Stage 3. TN stated the CNAs give care and should have identified the worsening skin condition earlier and informed her but that did not occur. During a concurrent interview and record review with UM 1, on 5/9/19, at 3:12 p.m., UM 1 reviewed Resident 83's medical record and stated Resident 83 required assistance of two people with turning and repositioning in bed. UM 1 stated Resident 83 was initially admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. UM 1 stated Resident 83 weighed 130.6 pounds (lbs.) on 7/28/18 and was now 82 lbs. UM 1 stated Resident 83 experienced a weight loss of 48.6 lbs. UM 1 stated resident was identified at risk for pressure ulcer due to her incontinence of bowel and her poor meal intake and weight loss. UM 1 stated Resident 83 could not make position changes without staff assistance and did not tolerate being up in a chair. UM 1 stated Resident 83 always remained in bed. UM 1 stated pressure ulcers could develop overnight, and Resident 83's pressure ulcer was an avoidable pressure ulcer because Resident 83 was not turned or repositioned by nursing staff consistently every two hours. UM 1 stated CNA's were supposed to complete skin checks on a weekly basis and document the skin check. UM 1 stated the weekly skin checks were not documented and could not produce documentation of the skin checks.UM 1 stated the skin checks were supposed to help in the identification of skin changes and to address a skin change before the skin status worsened. UM 1 stated the care plan interventions for Resident 83 dated 2/19/19 indicated Evaluate for any localized skin problems .dryness, redness .Observe skin for signs/symptoms of skin breakdown .Encourage resident to consume all fluids of choice during meals, assist resident in turning and repositioning every two hours .Apply barrier cream with each cleansing . UM 1 stated care plan interventions for Resident 83's pressure ulcer risk were revised on 5/8/19, 48 hours after the identification of the Stage 3 pressure ulcer. UM 1 stated the charge nurse were able to modify care plans and interventions when the interventions in place were not effective. UM 1 stated this was not done for Resident 83. UM 1 stated Resident 83 had occasional loose stools that increased her risk for skin breakdown. UM 1 stated there were no interventions to address the possibility for bowel retraining because this was not in the facility policy and procedure. UM 1 stated there were no care planned interventions to address Resident 83's loose stools. During a concurrent interview and record review with LN 7, on 5/9/19, at 3:49 p.m., LN 7 stated Resident 83 required 2-person assistance with turning and repositioning. LN 7 stated Resident 83 had redness to her lower back prior to the Stage 3. LN 7 stated Resident 83 received treatment for a Stage 1 on her coccyx's every shift and CNA's were instructed to make sure Resident 83 was kept clean and dry. LN 7 stated Resident 83's weekly skin assessment was last completed on 5/2/19. The skin assessment indicated there was skin moisture associated [MEDICAL CONDITION] (MASD) on Resident 83's to coccyx area. LN 7 stated a treatment was started to apply the barrier cream every shift for 14 days. During an interview with the Registered Dietician (RD), on 5/10/19, at 11:47 a.m., RD stated Resident 83 was at risk for pressure ulcer development secondary to her weight loss. RD stated the main goal for Resident 83 was to have good oral intake to meet the caloric needs. RD stated Resident 83 was underweight and was not consuming the required caloric amount to prevent weight loss. RD stated she reviewed meal rounds when she did nutrition assessments but did not document all of her encounters concerning Resident 83's poor nutritional intake. RD stated Resident 83 experienced weight loss since her admission to the facility on [DATE]. RD stated residents who experienced weight loss were discussed in the Customer at risk meeting. RD stated she attended to two meetings for Resident 83 and she did not address or discuss the weight loss. RD was unable to explain why she did not discuss or address Resident 83's reduced meal intake and weight loss in the two meetings she attended. RD stated she did not make recommendations for laboratory work up to follow up on Resident 83's weight loss and was unable to explain why she did not make these recommendations. RD stated she was responsible to participate with the interdisciplinary team (IDT) (a group formed by a physician, nurse, social worker and a dietician) to develop nutrition plans of care for the Resident 83. RD stated she could have improved the outcome of Resident 83 if she attended the meeting and actively discuss the weight loss trend of Resident 83. RD stated Resident 83's Physician Orders for Life Sustaining Treatment (POLST) dated 2/23/19, indicated Resident 83's son selected for a trial period of artificial nutrition which included feeding tubes under section C of the POLST form. RD stated she did not discuss the progressive weight loss with Resident 83's son and she did not discuss the wishes selected on the POLST for a trial of artificial nutrition. RD stated the weight loss increased Resident 83's risk for skin breakdown. During an interview with CNA 3, on 5/10/19, at 3:45 p.m., CNA 3 stated she reported the open area to Resident 83's coccyx area, she stated Resident 83 complained of discomfort on her back while she was providing care. CNA 3 stated that was the time she noticed the open area on Resident 83's coccyx (5/6/19). CNA 3 stated Resident 83 did not always accept to be repositioned and was placed on an air mattress to prevent skin breakdown. During a concurrent interview and record review with the DON, on 5/13/19, at 9:55 a.m., the DON reviewed Resident 83's record and stated Resident 83 had care planned interventions to prevent skin breakdown which included turning and repositioning, skin check every week by CNA's, use of therapeutic mattress and gel cushion when up in wheelchair, and application of skin moisturizer to skin. The DON stated if a skin issue was identified, nurses were responsible to notify the physician, obtain treatment order, start a change in condition monitoring for 72 hours and initiate a care plan. The DON stated when Resident 83 was first admitted she had a stage 1 to her coccyx area that healed on 10/25/18. The DON stated Resident 83 developed incontinence associated skin [MEDICAL CONDITION] (IASD) to coccyx area on 1/23/19. The DON reviewed Resident 83's pressure ulcer risk care plan and stated the interventions were not effective to prevent recurrent skin breakdown based on the development of Resident 83's pressure ulcer. The DON stated the charge nurses were responsible for checking the interventions were effective and to revise them when they were not. During a concurrent observation and interview with Resident 83 and CNA 10, on 5/15/19, at 2:32 p.m., CNA 10 stated Resident 83's scheduled turning and repositioning was to occur every hour but sometimes Resident 83 wiggled herself to her back again. During a review of Resident 83's Minimum Data Set (MDS) assessment (an evaluation of cognitive function and care needs) dated 4/5/19, indicated Resident 83 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. During a review of the facility policy and procedure titled SKIN INTEGRITY CARE DELIVERY PR[NAME]ESS dated 6/1/16, indicated .Perform daily observation of the skin. Promote adequate nutrition and hydration .Encourage ambulation and movement .Incontinent of .feces .Evaluate for continence management program .toileting program) . During a review of the facility policy and procedure titled NSG 236 Skin Integrity Management dated 11/28/16, indicated, . 3.3 Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. 3.4 Perform daily monitoring of wounds or dressings for presence of complications or declines and document . 9. Review care plan weekly and revise as indicated . During a review of the facility policy and procedure titled 8.5 Nutrition/Hydration Management dated 12/1/06, indicated . Staff will consistently observe and monitor residents for changes and implement revisions to the service plan as needed. Resident will receive care and support to enhance potential or attaining the highest level of nutrition and hydration status and the pleasure of eating . Consult with dietitian may be indicated . 3.1 unplanned weight loss . 3.2 Any stage pressure ulcer . 3.3 skin breakdown 3.4 inadequate oral intake, less than 50% of meals in 72 hours period .

Based on interview and record review the facility failed to ensure timely assessment and treatment of [REDACTED]. care plan. As a result of this failure, Resident 1 did not benefit from timely recognition and assessment of a decline in physical condition, subsequently developed signs and symptoms of urinary tract infection, was transferred by ambulance to the General Acute Care Hospital (GACH) for treatment where Resident 1 was diagnosed with [REDACTED]. Findings: Review of Resident 1's clinical record titled, Admission Record (a record which contains resident personal information) indicated Resident 1 was [AGE] years old and was readmitted to the Skilled Nursing Facility (SNF) on 11/27/17 from the GACH with [DIAGNOSES REDACTED]. Resident 1's clinical record titled, Minimum Data Set (MDS) (a resident assessment tool that is used to develop a plan of care) dated 12/4/17, indicated a Brief Interview for Mental Status (BIMS) score (a score that is developed by reviewing the resident's status during the prior seven day period) of 14 points out of 15 possible points which indicated Resident 1 was cognitively (pertaining to memory, judgement and reasoning ability) intact. Review of Resident 1's clinical record titled, Physician's History and Physical dated 11/27/17, indicated, History of Present Illness: Transferred back from the MICU (Medical Intensive Care Unit) at (GACH) after being treated for [REDACTED].Patient also had urosepsis .Past Medical History: 1. Recurrent UTIs .Review of Systems . [MEDICAL CONDITION]: No incontinence (involuntary loss of urine from the bladder) .Plan: 76 y/o (year old) female with .urosepsis .2. Will recheck urine and start antibiotics if appropriate. Review of Resident 1's Physician order [REDACTED]. Review of Resident 1's UA result dated 11/30/17, indicated White Blood Cell (WBC, cells that protect the body against infection and increase in numbers during an infection) 6-10 HPF (High Power Field - urine sample was examined under a microscope), reference range (normal range) 0-5 HPF. The UA indicated a WBC count higher than the reference range. The UA indicated the presence of a few bacteria and the reference range indicated there should be no bacteria seen in the urine. The UA indicated the appearance of the urine was slightly cloudy and the reference range indicated the normal appearance of urine should be clear. The UA indicated Leukocyte Esterase (a screening test for WBCs in the urine, a positive result indicates the presence of a UTI) was 1+ (positive) and the reference range indicated the normal result should be negative for Leukocyte Esterase. Review of Resident 1's Progress Notes dated 12/2/17, indicated Called (Medical Doctor - MD) made aware of resident's (Resident 1) concern upon urination, dribbling (incontinence of small amounts of urine from the bladder) with burning sensation. Has DX (diagnosis) Chronic UTI, U/A was done, bacteria few .Remains alert and oriented x 3 (knows who she is, where she is and what day it is). Obtained [MEDICATION NAME] (a medication to relieve dysuria, painful or difficult urination, a symptom of a UTI) 100 MG (milligram) one tablet by mouth x (times) 7 days then reassessed . Review of Resident 1's Physician order [REDACTED]. Review of Resident 1's care plan dated 12/2/17, indicated Resident (Resident 1) claimed dribbling with burning sensation upon urination with HX (history) Chronic UTI. Interventions: Medication as ordered, evaluate response to treatment . Review of Resident 1's urine culture and sensitivity laboratory result dated 12/3/17, indicated > (greater than) 50,000 colonies of Escherichia coli (a bacteria which can cause UTI). Review of http://www.glowm.com/lab indicated, Urine is normally sterile (free of bacteria). However, in the process of collecting the urine, some contamination from skin bacteria is frequent. For that reason, up to 10,000 colonies of bacteria/ml (per milliliter) are considered normal. Greater than 100,000 colonies/ ml represents urinary tract infection. For counts between 10,000 and 100,000, the culture is indeterminate. On 12/15/17 at 10:09 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated she had provided care for Resident 1 during her stay at the SNF. CNA 1 stated Resident 1 had complained of abdominal pain or bladder pain on 12/2/17 or 12/3/17, but she could not remember the exact date or time. CNA 1 stated Resident 1 usually had a big appetite, but on 12/2/17 or 12/3/17 (could not remember the exact date) she refused her breakfast and just ate soup. CNA 1 stated on that same day, Resident 1 appeared pale. Review of facility's Census and Nursing Hours Per Patient Day (NHPPD) dated 12/2/17 and 12/3/17, indicated CNA 1 had provided care for Resident 1 on 12/2/17 and 12/3/17 during the morning shift. Review of Resident 1's clinical record titled ADL (activities of daily living) indicated under meal percentage Resident 1 ate between 50 percent (%) to 100 % of her meals between 11/28/17 and 12/1/17. The meal percentage indicated Resident 1 refused her breakfast, and ate 50 percent of her lunch and 50 percent of her dinner on 12/2/17 and 12/3/17. The meal percentage indicated Resident 1 ate 0% of breakfast, lunch and dinner offered on 12/4/17. The meal percentage indicated Resident 1 refused her breakfast on 12/5/17. On 12/15/17 at 10:37 a.m., during a concurrent interview and record review, Licensed Nurse (LN) 1 stated she was the day shift nurse caring for Resident 1 on 12/4/17. LN 1 stated, She (Resident 1) was not doing well. She refused her morning medications. LN 1 stated in the afternoon on 12/4/17, Resident 1's pulse was fast and her blood pressure (BP) was low. LN 1 stated, She (Resident 1) had a UTI and was placed on [MEDICATION NAME] for dysuria on 12/2/17. LN 1 reviewed Resident 1's Weights and Vitals (vital signs, a record of blood pressure, pulse, temperature and respiratory rate) Summary dated 12/4/17 and noted Resident 1's pulse rate at 10:07 a.m. was 108 beats per minute and Resident 1's blood pressure (B/P) at 3:52 p.m. was 98/51mmHg (millimeters of mercury, a unit measurement of pressure). LN 1 stated, With the pulse (rate) being high and the BP being low, resident (Resident 1) was dehydrated or had a UTI. LN 1 stated on 12/5/17 Resident 1's physician was in the facility and ordered to send Resident 1 out to the GACH because Resident 1 had increased confusion and did not look good. Review of professional reference, Fundamental Nursing Skills and Concepts, Barbara K. Timby, Lippincott, Williams and Wilkins, Philadelphia, c. 2009, indicated the normal range for pulse in adults was 60 to 100 beats per minute and normal blood pressure for adults was 120/80 mmHg. On 12/15/17 at 11:25 a.m., during a concurrent interview and record review, the MD reviewed the Weights and Vitals Summary. The MD stated she was not informed of Resident 1's change in vital signs on 12/4/17 with a low BP and high pulse rate. The MD stated if she was notified of the change in vital signs along with the dysuria and laboratory results she would have sent the resident to the hospital STAT (right away). The MD stated Resident 1's low blood pressure and high pulse rate along with the laboratory results indicated Resident 1 was septic (overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death). On 12/15/17 at 11:59 a.m., during an interview, LN 1 stated Resident 1's high pulse rate and low BP on 12/4/17 in conjunction with the laboratory result was a change of condition (C[NAME]) for Resident 1. LN 1 stated if there was a change of condition for a resident, the following steps should be followed: notify the doctor, notify the family or resident representative (RP), perform a full assessment of the resident, monitor the resident, update the care plan and document the change of condition every shift for 72 hours. LN 1 stated I did not recognize that it was a change of condition right away. I did not do a care plan. There is no documentation that the doctor or the family was notified of the low BP and high pulse (rate). I did not recognize the patient was septic by looking at the pulse, a little faster. I just knew that she was not doing well. Review of Resident 1's clinical record titled, Weights and Vitals Summary indicated Resident 1's pulse was taken at 10:07 a.m. on 12/4/17 and was recorded as 108 beats per minute and blood pressure was taken at 3:52 p.m. and was recorded at 98/51. There was no record of any other pulse or blood pressure checks for Resident 1 on 12/4/17 after 3:52 p.m. On 12/15/17 at 12:51 p.m., during an interview, the Director of Nursing (DON) stated a change in vital signs (B/P, Pulse, Respiration or Temperature) was a C[NAME] if it was outside the resident's usual range for vital signs. The DON stated the following actions were to be done in every C[NAME]: reassess the resident, review laboratory results if available, do a medication regimen review (MRR), notify the MD of C[NAME], notify the family, do alert charting (documentation on C[NAME] signs and symptoms every shift for 72 hours), and develop a care plan. The DON stated No care plan was developed for C[NAME] regarding vital sign change. On 1/26/18 at 11:06 a.m., during a concurrent interview and record review, the DON stated Resident 1 complained of pain on 12/4/17 and received [MEDICATION NAME] HCl (a pain medication) 50 MG at 4:43 p.m. The DON stated Resident 1's clinical record did not indicate the location of the pain experienced by Resident 1. Review of Resident 1's Medication Administration Record [REDACTED]. On 1/26/18 at 11:37 a.m., during an interview, LN 2 stated a C[NAME] is something new/ different that was not there before. LN 2 stated if there was a C[NAME] the nurse should: check the resident's vital signs, call the MD, and call the family and inform them of the C[NAME]. LN 2 stated the nurse should assess the resident and do alert charting every shift for three days, develop a care plan and evaluate the effectiveness of the care plan. On 1/26/18 at 3:18 p.m., during an interview, LN 3 stated dysuria was a C[NAME]. LN 3 stated she assessed Resident 1 on 12/2/17 for complaints of discomfort, dribbling and burning on urination (dysuria). LN 3 stated she called the MD on 12/2/17 and the MD ordered [MEDICATION NAME]. LN 3 stated alert charting should have been done for the C[NAME] every shift for three days by the LNs. LN 3 stated the alert charting should have included vital signs (VS), level of consciousness (alert, confused, or increased confusion), presence of dysuria, color and smell of the urine, abdominal pain, temperature, low BP and elevation of pulse rate. LN 3 stated I do not remember if I did an SBAR (a communication tool to assess and report C[NAME], S - Situation, B - Background, A - Assessment, R - Recommendation). The DON was present during the interview with LN 3. The DON stated there was no SBAR done for Resident 1's symptom of dysuria. Review of facility SBAR Communication Form indicated areas that should be assessed for C[NAME] included, .Vital Signs .Mental status evaluation : decreased level of consciousness, increased confusion .symptoms or signs of [MEDICAL CONDITION] (acute change in mental status including increasing confusion) .Cardiovascular evaluation .resting pulse (greater than) 100 or (less than) 50 .Abdominal/GI Evaluation .decreased appetite/fluid intake .GI/Urine Evaluation .lower abdominal pain or tenderness .new or worsening incontinence .painful urination .urinating more frequently or urgency with or without other urinary symptoms .Pain . On 1/26/18 at 3:33 p.m. during a concurrent interview and record review, the DON stated Resident 1's Progress Notes dated 12/2/17 at 4:45 p.m. indicated Resident 1's dysuria was addressed and an order for [REDACTED]. On 1/26/18 at 4:02 p.m., during an interview and concurrent record review with the DON and LN 3, LN 3 stated Resident 1's change in blood pressure and pulse on 12/4/17 was a change of condition. LN 3 stated Resident 1's clinical record had no documentation regarding the change of condition. LN 3 stated there was no record of MD notification of the change in Resident 1's blood pressure and pulse, no family notification of a change in Resident 1's condition, no assessment of Resident 1's condition and no care plan developed for the change of condition. The DON stated Resident 1's change of condition should have been care planned and the MD should have been notified of Resident 1's change in blood pressure and pulse. The DON stated the MD was not notified of Resident 1's change in blood pressure and pulse and the C[NAME] was not care planned. On 1/26/18 at 5:03 p.m., during an interview, LN 4 stated she worked the p.m. shift on 12/4/17 and was assigned to Resident 1. LN 4 stated, She (Resident 1) was nauseated on 12/4/17 on p.m. shift. LN 4 stated Resident 1 refused her dinner and was a little confused on the evening of 12/4/17. LN 4 stated prior to 12/4/17 Resident 1 knew who she was, where she was and what day it was. LN 4 stated on 12/4/17 Resident 1 didn't know where she was; prior to that she knew where she was. LN 4 stated she did not call the MD regarding the change in Resident 1's mental status. Review of Resident 1's Progress Notes dated 12/4/17 indicated Resident 1 received [MEDICATION NAME] MG TAB RAPDIS (a medication for treatment of [REDACTED]. On 3/6/18 at 8:05 a.m., during an interview, the DON stated there was no written policy on SBAR. The DON stated an SBAR was triggered by a C[NAME]. The DON provided a few examples of C[NAME]; fall, fever, cough, diarrhea, dysuria, consistent change in vital signs, consistent refusal of meals (on consecutive days or refusal of all meals in one day). The DON stated the SBAR should be initiated by the LN and the LN should notify the MD and the resident's family of the C[NAME]. The DON stated when an SBAR is initiated, the LN should continue to monitor and assess the C[NAME] every shift for 72 hours. Review of Resident 1's Progress Notes dated 12/5/17 at 10:30 a.m., indicated patient (Resident 1) alert and oriented to herself, some confusion noted, patient refused her AM medication, waiting for Dr (MD) and her daughter here. Review of Resident 1's clinical record, Weights and Vital Signs Summary dated 12/5/17 at 12:26 p.m. indicated Resident 1's B/P was 105/55 and pulse rate was 116 beats per minute. Review of Resident 1's Progress Notes dated 12/5/17 at 12:44 p.m., indicated Resident noted with increase confusion, weakness, altered mental status, c/o nausea/vomiting, poor PO (by mouth) intake, assessed by MD (name) today .received order send her out to hospital for further eval (evaluation). Review of Resident 1's Progress Note dated 12/5/17 further indicated at 12:45 p.m., Picked up (Resident 1) by (name of ambulance company) ambulance to transfer out to (GACH) daughter at bedside. Review of Resident 1's GACH ED (Emergency Department) record dated 12/5/17 at 3:47 p.m., indicated Chief Complaint: Altered Mental Status, altered mental status since Sunday (12/2/17) .recent dx of uti . The ED physician notes indicated, UA consistent with UTI. Review of Resident 1's GACH clinical record titled, Critical Care Medicine Consult dated 12/5/17 at 4:48 p.m., indicated, Patient remains hypotensive (low blood pressure) .will continue IV (intravenous, injected into a vein) fluids (liters 4 and 5) .Will re-evaluate after her fifth liter .patient's blood glucose (blood sugar) is critically low .patient's blood pressure is currently 92/51 .Clinical Impression: UTI,[MEDICAL CONDITION], suspect urinary source .[MEDICAL CONDITION], [DIAGNOSES REDACTED]. Review of Resident 1's GACH clinical record titled, Critical Care Medicine Consult dated 12/5/17 at 8:10 p.m., indicated Resident 1 was hypotensive and the reasons for the critical care consultation [MEDICAL CONDITION], urosepsis with [MEDICAL CONDITION], altered mental status, and [DIAGNOSES REDACTED] (low blood sugar). PLAN: The patient is on [MEDICATION NAME] (an antibiotic). I ordered [MEDICATION NAME] (an antibiotic) x 1 until the cultures (urine cultures) are back. I also ordered [MEDICATION NAME] (an antifungal). She has yeast in the urine . Review of Resident 1's GACH clinical record UA laboratory results dated [DATE], indicated Color - amber, appearance - hazy, Leukocyte Esterase 1+ (positive), WBC 82 HPF (reference range 0 to 5 HPF), bacteria - occasional, yeast budding -few, and Hyaline cast 79 (reference range: None Seen), Protein 30 mg/dl (milligrams per deciliter, a measurement of protein in the urine) and the reference range indicated there should be no protein in the urine. Review of Resident 1's urine culture results at the GACH dated 12/7/17 at 12:56 p.m., indicated > 100,000 cfu/ml (colony forming unit per milliliter) of [MEDICAL CONDITION][MEDICATION NAME] (a fungal infection). Review of Resident 1's GACH record dated 12/7/17, indicated Discharge/Death Note: Date and time of death 12/7/17 @ (at) 14:09 (2:09 p.m.) hours. Cause of death:[MEDICAL CONDITION] with multi-organ failure due to urinary tract infection. admitting [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (low sodium level in the blood), history of [MEDICAL CONDITION] (irregular heart beat), and acute kidney injury. The facility policy and procedure titled NSG122 Change in Condition: Notification dated 11/28/16, indicated Policy: A Center must immediately inform the patient, consult with patient's physician, and notify, consistent with his/her authority .where there is: A significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) .A need to alter treatment significantly .or to commence a new form of treatment . The facility clinical record form titled Care Path Symptoms of Urinary Tract Infection [MEDICAL CONDITION] dated 2014, indicated Symptoms or Signs of UTI: painful urination, lower abdominal (suprapubic) pain or tenderness, blood in urine, new or worsening urinary urgency, frequency, incontinence. The Care Path indicated if signs and symptoms of UTI were present the nurse should, Take Vital Signs, Temperature, BP, pulse, apical HR (heart rate), Respiration, Oxygen saturation (level of oxygen in the blood), Finger stick glucose (diabetics). Vital Signs Criteria (any met?): Temp (temperature) > 100.5 degrees Fahrenheit, Apical heart rate >100 or < 50, Respiratory rate >28/min or < 10/min, BP <90 or >200 systolic, Oxygen saturation <90 %, Finger stick glucose <70 or > 300, and Resident unable to eat or drink. If Yes (criteria were met), Notify the MD/NP (Nurse Practitioner)/PA (Physician Assistant). The facility policy and procedure titled OPS100 Accidents/Incidents dated 11/28/16, indicated Policy: .staff will use the Risk Management System (RMS) to report, review, and investigate all accidents/incidents which occurred, or allegedly occurred .or allegedly involved, a patient who is receiving services .Purpose: .to define the causative/contributing factors and institute preventive measures to avoid further occurrence .Process: 2. Assessment, Medical Assistance, Documentation: 2.1 Patients: 2.1.1 The nurse will examine the patient. 2.1.2 The nurse will notify the physician .and obtain orders as indicated. 2.1.5 The patient's responsible party/family will be notified of the accident/incident .2.1.6 The nurse will: 2.1.6.2 Document the accident/ incident in the patient's chart; Documentation will include all pertinent information, date, time, place, notifications, and initial and ongoing assessments . Sepsis Symptom Centers for Disease Control titled Basic Information dated 3/1/18, at https://www.cdc.gov/sepsis/basic/index.html, indicated .There is no single symptom [MEDICAL CONDITION]. Symptoms [MEDICAL CONDITION] can include confusion or disorientation, shortness of breath, high heart rate, fever, or shivering, or feeling very cold, extreme pain or discomfort, and clammy or sweaty skin . Review of Professional Reference, Infection Control and Hospital Epidemiology: Development of Minimum Criteria for the Initiation of Antibiotics in Residents of Long-Term-Care: Results of a Consensus Conference dated 2/2001, indicated .UTI .1. For residents who do not have an indwelling catheter (a tube placed into the bladder to drain urine), minimum criteria for initiating antibiotics include acute dysuria alone and one of the following: worsening urgency, frequency .or urinary incontinence.

Based on resident and staff interview, clinical record and administrative document review, the facility failed to ensure Res 1 was free from financial abuse when the Business Office Manager (BOM) had not followed the facility's resident trust fund policy and procedure and gave an unauthorized staff member, the Social Service Director (SSD) $300.00 in cash from Res 1's account. The SSD used the $300.00 to purchase items at a local department store for which Res 1 denied authorization. This failure had the potential to place all residents at risk for misappropriation of resident property. Findings: On 02/20/15 at 12:40 p.m., during an interview, the BOM stated she had worked at the facility for 7 years and understood the process of authorizing funds removed from resident trust accounts. The BOM stated on 10/21/14 she received a request from the SSD for removal of funds from Res 1's trust account. The BOM stated it was, Not very common for (SSD) to request money. When questioned about the facility Policy and Procedures the BOM stated, I knew the policy, . I trusted (SSD) so I just gave her the money. The BOM stated she gave $300.00 in cash to the SSD from Res 1's Trust Account on 10/23/14. The BOM stated she should not have given the money to the SSD. Review of the facility's Policy and Procedure titled, Resident Trust Fund Policy and Procedure, dated 11/01/12 indicated, Authorized Signatures on the Trust Fund Account are as follows: President, Chief Financial Officer, Vice President Operations, Administrator, Director of Nursing, MDS Nurse or Assistant Director of Nursing .The following facility positions CANNOT be signers: all business office staff, social services and activities. On 2/20/15 at 10:25 a.m., during a concurrent interview and clinical record review, the Administrator stated on 02/10/15 Res 1's son arrived for a visit. The son of Res 1 stated he had received the quarterly statement for Resident 1's trust account and questioned the authorization to withdraw $300.00. Res 1's son requested information and receipts regarding the $300.00 withdrawn from Res 1's trust account on 10/21/14. The receipt totaled $299.64 and listed several items purchased from a local department store on 11/06/14. Included in the purchase of items were several types of female underwear, including bikini-type (sub-total $42.56); a purse (sub-total $39.99); personal outer wear for legs (sub-total $8.00); and several blouses (sub-total $105.96), several pajama sets ($69.97) and other miscellaneous items. On 2/20/15 at 1:30 p.m., during an interview, Res 1 stated, . No, I did not authorize her (SSD) to take $300.00 and go shopping . Res 1 stated regarding the items purchased: I would not have worn them (the clothes) to a dog fight! They said I OK'd it .(SSD) tried to get me to change my story. I wonder how many other times she has done this and gotten away with it . Res 1 stated she did not wear underwear but briefs (adult diapers). During interview, Res 1 began to cry and clasp and unclasp her hands. Res 1 stated, I would like to know why she (SSD) did it and if she would do it again? Someone asked me if I would like to talk to a psychiatrist and I said, No, I don't need one. Res 1 stated, (SSD) stole $300.00 from me. I don't want to be questioned about it.That was financial abuse! The clinical record titled, Physician Notification of Change of Resident Condition, indicated on 02/10/15, Resident (Res 1) was upset and emotional this afternoon about her missing belongings ($300.00). She refused to eat dinner at social dining this evening. Res 1 was subsequently placed on closer observation due to the concern of refusing to eat and documented the need to monitor Res 1 for behavioral changes. On 02/20/15 at 1:05 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated that she usually took care of Res 1. CNA 1 stated that Res 1 continued was irritated and upset about the missing $300.00. On 02/20/15 at 3 p.m., during an interview, the Dietary Service Supervisor (DSS) stated on 02/18/15 she was in the hall when she heard Res 1 crying. The DSS stated she then entered the room and asked Res 1 what was wrong. Res 1 stated, (SSD) stole $300.00 from me! I don't want to be questioned about it. I just want it to be left alone. The facility failed to protect Res 1 from misappropriation of resident property when the BOM did not follow the Trust Fund Policy and Procedure and gave $300.00 of Res 1's fund to the SSD who spent the funds at a local department store without Res 1's authorization. As a result of this misappropriation of funds Res 1 exhibited behavioral changes such as wringing of hands, refusal to eat, and refusal to participate in social dining along with episodes of crying about the loss of property.

Based on observation, resident and staff interview, clinical record and administrative document review, the facility failed to ensure 2 of 2 residents (Resident 1 and Resident 2)'s funds were safeguarded from unauthorized use when the Business Office Manager removed resident funds from the residents trust accounts, gave them to the Social Services Director (SSD) who was not approved to remove resident funds. The SSD accessed the resident's trust fund without approval and made unauthorized purchases. This failure had the potential to place all residents at risk for psychological harm, mistrust of staff who cared for them, and misuse of resident funds. Findings: 1. On 02/20/15 at 12:40 p.m., during an interview, the Business Office Manager (BOM) stated she had worked at the facility for 7 years and understood the process of authorizing the release of funds from resident accounts. The BOM stated on 10/21/14 she received a request from the SSD for funds from Res 1 and Res 2's trust accounts. The BOM stated it was, Not very common for (SSD) to request money. When questioned about the facility's Policy and Procedure the BOM stated, I knew the policy, . I trusted (SSD) so I just gave her the money. The BOM stated she gave $300.00 in cash to SSD from Res 1's Trust Account and $250.00 in cash from Res 2's Trust Account on 10/23/14. The BOM stated she should not have given the money to the SSD. Review of the facility's Policy and Procedure titled, Resident Trust fund Policy and Procedure, dated 11/01/2011 indicated, Authorized Signatures on the Trust Fund Account are as follows: President, Chief Financial Officer, Vice President Operations, Administrator, Director of Nursing, Minimum Data Set (MDS) (an assessment tool used to determine mental and physical ability, etc.) Nurse, or Assistant Director of Nursing.the following facility positions CANNOT be signers; all business office staff, social services and activities. Resident 1's MDS assessment dated [DATE] indicated, Res 1's Brief Interview for Mental Status (BIMS) (an assessment tool used to determine the cognitive level of residents) score was 15 of 15, which indicated she was mentally alert and oriented and able to make appropriate decisions regarding her care. On 02/20/15 at 10:25 a.m., during an interview and concurrent document review, the Administrator stated on 02/10/15 Res 1's Family Member (FM) 1 arrived for a visit. FM 1 stated he had received the quarterly statement for Res 1's trust account from the facility. FM 1 identified $300.00 had been removed from Res 1's trust account on 10/21/14. FM 1 requested receipts from the business office staff for the $300.00 removed from the account. The receipt listed several items that had been purchased from a local department store on 11/6/14. The items listed were as follows: Hobo purse, under garments (different kinds and sizes) including a type of Bikini Underwear, Butterfingers candy, child's toy, lip gloss, leggings, and four blouses. On 02/20/15 a review of the department store receipt indicated there were bikini underwear purchased on 11/6/14. 2. Resident 2's MDS assessment dated [DATE] indicated the BIMS score for Res 2, was 5 of 15, which indicated he was severely impaired cognitively. On 02/20/15 at 12:40 p.m., during an interview, the BOM stated the SSD had informed her on 10/21/14 that she needed to withdraw funds from Res 1 and Res 2's trust accounts. On 02/20/15 at 3 p.m. during a concurrent interview and document review, a review of the department store receipt indicated the SSD had purchased a quilt, underwear, socks, musical tapes, and a boom box to play the tapes on. On 4/14/15 at 2:45 p.m., during an interview, the Social Service Assistant (SSA) stated he had spent time with Res 2. The SSA stated Res 2 was alert but not oriented to time or place and did not understand anything that happened. On 4/14/15 at 3 p.m. during a concurrent interview with the MDS coordinator, the MDS coordinator stated Res 2 had a [DIAGNOSES REDACTED]. In review of the receipt of items bought at the department store on 11/6/14, the list included men's underwear of a boxer type. On 4/14/15 at 3:15 p.m., during an concurrent observation and interview with Res 2 in Res 2's room with the SSA, a portable Compact Disc (CD) player sat at the bedside table. Res 2 stated, I don't know. when asked if he had any music to play. When asked if he liked to watch television or listen to music he stated, Sometimes. There were no CD's present in the room when searched by staff. Res 2 had been unable to converse with staff regarding the activities he enjoyed.

Based on observation, resident and staff interview, clinical record and administrative document review, the facility failed to ensure 1 of 21 sampled residents (Resident 4) was adequately supervised when Resident 4 had been left unattended without the safety belt applied, fell and sustained an injury. This failure led to Resident 4's fractured nose, bruises and multiple abrasions. Findings: On 9/28/11 at 1:50 p.m., during the initial tour, Registered Nurse (RN) 1 stated Resident 4 had a fall "yesterday" morning and had a non-displaced nasal (nose) fracture (a broken bone that had not moved from it's normal position), bruising to the left arm, a swollen left thumb and abrasions (a wound causing damage to the skin) to both knees. On 9/28/11 at 1:52 p.m., during a concurrent observation and resident interview, Resident 4 was noted to have several steri-strips (thin adhesive strips used to close small wounds) over the bridge of the nose. The nose bridge had dried blood surrounding the wound that measured 1-2 cms (centimeter). Resident 4 had a purplish blue discoloration to the facial area, swollen eyelid and the area surrounding the left eye. Resident 4 was wearing a removable left wrist splint and had swelling of the left hand. Resident 4 attempted to move her left thumb but was unable to do so fully. Resident 4 stated she could not move her thumb well. The Occupational Therapy Daily Documentation dated 9/28/11 indicated "...(L) (left) hand in removable wrist splint (sic). Thumb bruised and tender..." On 9/29/11 at 8:05 a.m., during an observation, Resident 4 had purplish blue to green discoloration of both sides of the face near the eyes. The left eye had more swelling and discoloration than the right eye. Resident 4 had steri strips in place over the bridge of the nose. On 9/29/11 at 9 a.m., during an interview, RN 1 stated Certified Nursing Assistant (CNA) 1 assisted Resident 4 out of the bathroom on 9/27/11. CNA 1 left Resident 4 sitting outside the bathroom door in a wheelchair while CNA 1 went back into the bathroom. Resident 4 then fell forward out of the wheelchair, face down to the floor and injured her face. RN 1 stated, "blood was gushing" from the resident's face. RN 1 stated she assessed Resident 4 after the fall and Resident 4 complained of right shoulder pain. RN 1 stated the resident's face and knees were on the floor. RN 1 stated Resident 4's seat belt was not in place before the fall. RN 1 stated "(It) should have been in place. That's one of the interventions because she tends to lean forward and already had falls in the facility." RN 1 stated Resident 4 was sent out to the hospital for evaluation. On 9/29/11 at 10:20 a.m., during an interview, CNA 1 stated on 9/27/11 she left Resident 4 by the bathroom door in a wheelchair and went back into the bathroom. Resident 4 then fell out of the wheelchair to the floor. CNA 1 stated, "(The) seatbelt was not locked when I left her. It should have been. (I) knew I must lock the seat belt but I didn't. (I) forgot to do it." The admission "FALL RISK ASSESSMENT" dated 8/5/11, indicated Resident 4 had a score of 16. The fall assessment indicated "... If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented in the care plan." Reassessments were done on the following dates and the recorded scores were as follows: 17 on 8/8/11, 16 on 8/11/11 and 15 on 9/27/11. All three scores indicated a high risk for falls. The current patient care plan on "FALLS" initiated on 8/5/11 indicated Resident 4 was at risk for falls. The care plan indicated Resident 4 had "Falls since 8/8/11." The indicated goal was "The resident/patient will: have no injuries related to Falls..." The "PHYSICIAN'S PROGRESS NOTES" for Resident 4 dated 8/9/11 indicated the resident had a previous fall and safety precautions should be implemented. The physician's orders [REDACTED]." A physician's orders [REDACTED]." The "INTERDISCIPLINARY (IDT) TEAM NOTES," dated 8/12/11 indicated Resident 4 had a fall on 8/11/11 and "...Sustained a bump golf ball size on her forehead and had slight nose bleed... IDT Recommendations... review use of self release belt..." The IDT notes dated 8/22/11 for Resident 4 indicated the self release belt had been effective and the IDT recommended continued use. The current care plan intervention for "FALLS" dated 8/12/11 for Resident 4, indicated, "The staff will...(connect) Self release belt when in w/c (wheelchair) to keep upright position..." The nursing assessment for Resident 4 following the current fall dated 9/27/11 at 9:40 a.m., indicated, "1. injury to nose - with moderate bleed. 2. c/o (complaint of) R (right) shoulder pain 3. Bilat (bilateral - both) knee skin tears." The nurse's note dated 9/27/11 at 10 a.m., indicated "... Resident (4) was sitting on her w/c (wheelchair) in her room... CNA turned to BR (bathroom) and Res (resident) suddenly leaned forward and fell to the floor sustained injury to nose bleeding moderately. Res. was transferred to (hospital name) for further eval (evaluation)..." The patient transfer record for Resident 4 from the facility dated 9/27/11 indicated, "s/p (status [REDACTED]. The Radiology Report dated 9/27/11 indicated, "CT (Computed Tomography - computerized X-ray turned into pictures than can display anatomies not seen in conventional X-rays) MAXILLOFACIAL REGION (involving the head, neck, face jaws)... Soft tissue swelling around nose with a non-displaced fracture involving the left nasal bone..." The facility policy and procedure (P&P) titled "FALL PREVENTION" dated 11/05 indicated "...It is the policy of this Center... to prepare a plan of care to reduce the potential for future falls... All new physician orders [REDACTED]. The undated facility P&P titled, "RESIDENT CARE PLANNING" indicated, "Each resident has a Plan of Care (POC) that is current, individualized... The Plan of Care is always maintained ..."