Every finding on record at Willow Pass Healthcare Center

Based on observation, interview and record review, the facility failed to protect one (Resident 1) of the six sampled residents from verbal abuse. Certified Nursing Assistant 1 (CNA 1) used profanity (irrelevant language and behavior that shows disrespect, used to express anger and frustration), raised his voice, yelled/shouted at Resident 1, when Resident 1 asked CNA 1's help for Resident 2 when Resident 2 was crying out for help in the TV dining area (a common area used for dining and to watch television). This failure resulted in Resident 1 crying and becoming visibly upset after the incident.During a record review of Resident 1's admission record, dated 2/10/26, the record indicated Resident 1 was admitted to the facility on [DATE]. During a record review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used to evaluate a resident's functional capabilities, health needs, and clinical status), dated 3/6/26, the assessment indicated Resident 1 was able to express ideas and wants clearly and was able to understand others clearly. The assessment also indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment for mental status) score was 15 out of 15, indicating the Resident 1's mental status is intact. During an observation and interview on 3/26/26 at 9:44 a.m. with Resident 1, Resident 1 was lying in his bed. Resident 1 stated he was in facility's TV dining room on a Super Bowl Sunday, when a female resident (Resident 2) began crying out for help. Resident 1 stated he saw a CNA (CNA 1) sitting in the room and he called out to him for help. Resident 1 stated CNA 1 in a rude tone of voice said, We got a problem? Resident 1 stated other staff members had to remove CNA 1 from the TV dining room. Resident 1 stated the whole incident made him feel like people should not talk to residents that way, and that CNA 1 should have been fired. Resident 1 stated CNA 1's tone during the incident was, pissed and loud. During an interview on 3/26/26 at 10:26 a.m., with CNA 1, CNA 1 stated that he's been working at the facility for 10 years and previously had been talked to about being professional on the job. CNA 1 stated on 2/8/26, he was sitting in the tv dining room. CNA 1 stated Resident 1 was upset that Resident 2 was upset and crying, while he was watching television. CNA 1 stated Resident 1 wanted me to move Resident 2 out of the TV room, but he told Resident 1 to calm down instead. CNA 1 stated it made Resident 1 more upset. CNA 1 stated he had to raise his voice at Resident 1 because Resident 1 did not back down. CNA 1 stated he should have swallowed his pride instead of raising his voice at Resident 1. During an interview on 3/26/26 at 11:10 am with Director of Staff Development (DSD), the DSD stated CNA 1 had a loud voice and some of the facility residents did not like loud voices. DSD stated having direct care staff talking in a loud voice could make the residents feel hurt or scared. The DSD stated CNA 1 had been talked to about his loud voice previously as well. During an observation and interview on 3/26/26 at 11:56 in tv dining area, Resident 3 was walking out of the dining area. Resident 3 stated CNA 1 could be obnoxious (highly offensive, unpleasant or annoying) at times. Resident 3 stated CNA 1 tries to take on others' job but that's what he had observed about CNA 1. During an interview on 3/26/26 at 12:33 pm with Social Services Director 1 (SSD 1), SSD 1 stated on 2/8/26 around noon time, she heard commotion outside her office door, located near tv dining room. SSD 1 stated when she walked into the TV room, she saw CNA 1 and Resident 1 yelling and shouting at each other. SSD1 stated CNA 1 and Resident 1 were exchanging profanities. SSD 1 stated she did not remember exact words that CNA 1 was using, but it was profanity and he was clearly hot headed at that time. SSD 1 stated she and her coworker had to separate them both. SSD 1 stated she stayed with Resident 1 after this incident and Resident 1 was trembling from anger. During a record review of Resident 1's progress notes dated 2/8/26, SSD 1 documented, Resident [Resident 1] had a verbal altercation with one of the CNAs [CNA 1]. During a record review of witness statement (a written statement by someone who has witnessed the incident) dated 2/8/26, CNA 2 documented, I was at the nursing station and heard yelling.seen [CNA 1] and [Resident 1] arguing.Resident 1 was sitting drinking his coffee while crying. During an interview on 3/30/26 at 3:06 p.m., CNA 2 stated on 2/8/26, she was at the nursing station down the hall from the tv dining room when she heard loud voices, like screaming. CNA 2 stated one of the staff members was walking down the hallway and stated to her, Hey [CNA 1] is in here fighting with a resident. CNA 2 stated she went into the room and saw CNA 1 and Resident 1 arguing. CNA 2 stated CNA 1 was upset; Resident 1 was visibly upset, frustrated and crying after the incident. CNA 2 stated they have had complaints about CNA 1 in the past involving, CNA 1 was a little aggressive with the residents. During a record review of Resident 1's progress notes dated 2/08/26, Licensed Vocational Nurse 1 (LVN 1) documented, Resident [Resident 1] noted in a verbal exchange with a CNA [CNA 1]. [Resident 1] stated that he perceived the [CNA 1]'s tone as rude and loud and verbalized, He [CNA 1] was rude to me. When I asked him to move the other resident who was yelling, he [CNA 1] talked to me in a loud voice. That's not the way they can talk to me. During a record review of the facility policy and procedure (P&P) titled, Abuse, Prevention, dated, 01/01/24, the P&P indicated, Each resident has the right to be free from verbal, sexual, physical, and mental abuse.Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff.

Based on observation, interview and record review, the facility failed to remove Certified Nursing Assistant (CNA 1) from resident care areas for over three hours, after he had an altercation with Resident 1. CNA 1 used profanity (irrelevant language and behavior that shows disrespect, used to express anger and frustration), raised his voice, yelled/shouted at Resident 1 in front of other residents when Resident 1 asked CNA 1's help for Resident 2 when Resident 2 was crying out for help in the TV dining area (a common area used for dining and to watch television). CNA 1 continued to provide direct care to his nine (9) other assigned residents until end of his shift. This failure placed Resident 1 at risk for further abuse and nine other assigned residents at risk for abuse/mistreatment from CNA 1.(Cross Reference F600)During a record review of Resident 1's admission record, dated 2/10/26, the record indicated Resident 1 was admitted to the facility on [DATE]. During a record review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used to evaluate a resident's functional capabilities, health needs, and clinical status), dated 3/6/26, the assessment indicated Resident 1 was able to express ideas and wants; and was able to understand others clearly. The assessment also indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment for mental status) score was 15 out of 15, indicating the Resident's mental status is intact. During an observation and interview on 3/26/26 at 9:44 a.m. with Resident 1, Resident 1 was lying in his bed. Resident 1 stated he was in facility's TV dining room on a Super Bowl Sunday, when a female resident (Resident 2) began crying out for help. Resident 1 stated he saw a CNA (CNA 1) sitting in the room and he called out to him for help. Resident 1 stated CNA 1 in a rude tone of voice said, We got a problem? Resident 1 stated other staff members had to remove CNA 1 from the TV dining room. Resident 1 stated the whole incident made him feel like people should not talk to residents that way, and that CNA 1 should have been fired. Resident 1 stated CNA 1's tone during the incident was, pissed and loud. During an interview on 3/26/26 at 10:26 a.m., with CNA 1, CNA 1 stated that he had been working at the facility for 10 years and previously had been talked to about being professional on the job. CNA 1 stated on 2/8/26, he was sitting in the tv dining room when Resident 1, while watching television. became upset that Resident 2 was upset and crying. CNA 1 stated Resident 1 wanted him to move Resident 2 out of the TV room, but he told Resident 1 to calm down instead. CNA 1 stated it made Resident 1 more upset. CNA 1 stated he had to raise his voice at Resident 1 because Resident 1 did not back down. CNA 1 stated he should have swallowed his pride instead of raising his voice at Resident 1. CNA 1 stated the Director on Nursing (DON), and the Administrator (ADM) spoke to him regarding the incident same day and that an investigation was needed. During an interview on 3/26/26 at 12:33 pm with Social Services Director 1 (SSD 1), SSD 1 stated on 2/8/26 around noon time, she heard commotion outside her office door, located near tv dining room. SSD 1 stated when she walked into the TV room, she saw CNA 1 and Resident 1 yelling and shouting at each other. SSD1 stated CNA 1 and Resident 1 were exchanging profanities. SSD 1 stated she did not remember exact words that CNA 1 was using, but it was profanity and he was clearly hot headed at that time. SSD 1 stated she and her coworker had to separate them both. SSD 1 stated she stayed with Resident 1 after this incident and Resident 1 was trembling from anger. During a record review of Resident 1's progress notes dated 2/8/26, SSD 1 documented, Resident [Resident 1] had a verbal altercation with one of the CNAs [CNA 1]. During an interview on 3/26/26 at 10:48 a.m. with DON, the DON stated he interviewed CNA 1 after the incident. The DON stated CNA 1 had a loud voice in general and had been told to lower his voice and treat the residents with respect in the past. During a review of facility's Nursing Staffing Assignment and Sign-in Sheet dated 2/8/26 indicated, CNA 1 worked between the hours of 7:00 am thru 3:30 pm. The record indicated CNA 1 served as a direct care staff for nine residents throughout the shift on that day. During a record review of CNA 1's timecard, the timecard indicated that CNA 1 clocked into work on 2/08/26 at 7:03 am and did not leave the facility until 3:32 pm, which was over three (3) hours after the incident had occurred between CNA 1 and Resident 1. During an interview and record review on 3/26/26 at 12:59 p.m. with the ADM, facility's investigation report dated 2/10/26 and Abuse prevention policy and procedure (P&P) dated 1/1/24 were reviewed. The ADM stated he was facility's assigned Abuse Coordinator. The ADM first stated, CNA 1 was separated from Resident 1 immediately after the incident and that he did not think CNA 1 was doing anything intentional to Resident 1. ADM stated it's just sometimes people got scared of CNA 1 because he was a big guy. ADM stated facility investigation report indicated the incident occurred on 2/8/26 at around 12 noon. ADM then stated if the incident happened around noon, CNA 1 should have been sent home immediately after the incident and suspended until the investigation was completed for the safety of all residents. The ADM also stated facility's P&P indicated .if the suspected perpetrator is an employee: i. remove employee immediately from the care or vicinity of the resident.

Based on interview and record review, the facility failed to prevent exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion) of one of three sampled residents (Resident 3), when Certified Nursing Assistant (CNA) 1, received a new pair of shoes bought by Resident 3 for CNA 1's personal use.This failure had the potential to cause Resident 3 to be taken advantage of resources, manipulation and abuse.During a review of Resident 3's admission Record (AR), printed 3/11/26, the AR indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included pain in the right knee.During a review of Resident 3's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 1/23/26, the MDS indicated Resident 3's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. The BIMS score indicated Resident 3 was able to recall the correct year, month, and day of the week. During an interview on 3/13/26, at 7:15 a.m., with CNA 1, CNA 1 stated Resident 3 bought a pair of new shoes and gave the shoes to CNA 1. CNA 1 stated Resident 3 saw that CNA 1's feet were swollen, and asked what was wrong with CNA 1's feet. CNA1 stated she told Resident 3 that she had arthritis (a chronic condition causing joint inflammation, pain and stiffness). CNA 1 stated Resident 3 bought the new pair of shoes and gave it to CNA 1. CNA1 stated she did not see anything wrong accepting the new pair of shoes from Resident 3. CNA 1 stated after receiving the shoes CNA 1 gave Resident 3 twenty dollars for the shoes. During an interview on 3/13/26, at 8:28 a.m., with Administrator (Admin) and Director of Nursing (DON), Admin stated he was not aware that CNA 1 received a new pair of shoes bought by Resident 3. Admin stated facility did not expect CNA 1 to receive shoes from Resident 3 for personal use.During a review of the facility's policy and procedure (P&P) titled, Abuse, Prevention of, dated 9/1/2008, the P&P indicated, Abuse, neglect, abandonment, isolation, financial abuse will not be tolerated in this facility at any time.

Based on interview and record review, the facility failed to implement its Care Planning-IDT Care Planning Conference, policy and procedure when: Interdisciplinary Team (IDT-a professional discipline that works together to provide the greatest benefit to the resident which included the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically and appropriate and person-centered) did not develop a care plan that addressed Resident 1's refusal to shower for over a month with appropriate interventions. IDT did not develop a care plan that addressed Resident 1's discharge plan upon admission to the facility. This failure placed Resident 1 at risk for poor hygiene, body odor, transmission of diseases and misunderstanding with discharge process. During a review of Resident 1's admission Record (AR), printed 3/11/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of skin (skin cancer). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 2/16/26, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. MDS indicated Resident 1 had no discharge plan. MDS indicated Resident 1 had clear speech, made self-understood and understood others. During a concurrent observation and interview on 3/11/26, at 12:10 p.m., with Resident 1 in Resident 1's room, Resident 1 lay in bed on his back awake and verbally responsive. Resident 1 stated that he had not showered for some time. Resident 1 stated that he refused to shower at times. During a concurrent interview and record review on 3/11/26, at 1:20 p.m., with Director of Nursing (DON), Resident 1's Shower schedule, Shower record dated 2/10/26 to 3/11/26 and ADL (activities of daily living) care plan were reviewed. Resident 1's shower record indicated Resident 1 had not showered for more than a month. Resident 1's ADL care plan did not address Resident 1's refusal to shower. DON stated Resident 1 was scheduled to shower twice a week. DON stated Resident 1 refused showers. DON stated facility's expectation was to update Resident 1's care plan with refusal to shower with appropriate interventions. During a concurrent interview and record review on 3/11/26, at 1:45 p.m., with Director of Nursing (DON), Resident 1's MDS, Social Services progress notes dated 9/22/25 and care plan conferences dated 8/26/25, 9/22/25, 10/20/25 and 2/19/26 were reviewed. The care plan conference indicated Resident 1 had discharge potential. Care plan conferences indicated Resident 1's family member was not invited to participate in care plan conferences. DON could not provide Resident 1's discharge care plan. DON stated facility addressed discharge plan during care conferences. DON stated Resident 1's family member was not consistently invited to care plan conferences. DON stated Resident 1's discharge plan was not addressed with a care plan upon admission. During a review of the facility's policy and procedure (P&P) titled, Shower for Residents, dated 3/29/12, the P&P indicated, Facility will schedule a shower at least two times a week. Shower will be documented in the ADL flow sheet. If resident refuses a shower, the charge nurse will be involved to encourage regular shower or may offer a bath. If resident continually refuses to shower/bathe, the social services will become involved, and the resident care plan will reflect intervention to remedy the situation. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 9/1/2008, the P&P indicated, To assure that all residents' care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), was provided services to maintain grooming and personal hygiene when: Certified Nursing Assistants (CNAs) did not shave Resident 2's facial hair with showers as scheduled. This failure placed residents at risk for poor hygiene, body odor, infection, and transmission of diseases.During a review of Resident 2's admission Record (AR), printed 3/11/26, the AR indicated, Resident 2, was admitted to the facility on [DATE] with diagnoses that included hip fracture. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/12/26, MDS indicated Resident 2's Brief Interview for Mental Status (BIMS-a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 03 and indicated impaired mental status. The BIMS score indicated Resident 2 was unable to recall the correct year, month, and day of the week. MDS indicated Resident 2 was dependent, needed assistance of two or more helpers with toileting and hygiene and needed maximal assistance, helper does more than half the effort for resident 1's ability to shower/bathe self. During a concurrent observation and interview on 3/11/25, at 11:42 a.m., with Certified Nursing Assistant (CNA) 1 and Registered Nurse (RN) 1, Resident 2 sat up in a wheelchair next to her bed in her room and had facial hairs around her chin. Resident 2 stated she had asked staff before for a shave and would want to be shaved. CNA 1 stated facial hairs were shaved during residents showers. CNA 1 stated she did not know why Resident 2 was not shaved. During a review of Resident 2's Shower Day Skin Inspection (SSI), dated 2/20/26, 2/26/26, and 3/3/26, the SSI indicated, Resident 2 had facial hair. During an interview on 3/11/25, at 11:44 a.m., with Director of Nursing (DON), DON stated facility's expectation was for CNAs offer to shave residents with shower schedule after obtaining consent. DON stated CNAs were expected to notify charge nurses and document residents' refusals to shower or shave. During a review of the facility's policy and procedure (P&P) titled, Shower for Residents, dated 3/29/12, the P&P indicated, Facility will schedule a shower at least two times a week. Shower will be documented in the ADL flow sheet. If resident refuses a shower, the charge nurse will be involved to encourage regular shower or may offer a bath. If resident continually refuses to shower/bathe, the social services will become involved, and the resident care plan will reflect intervention to remedy the situation.

Based on observation and interview, the facility had one shared bathroom for male and female residents (Residents 1 and 2).This failure resulted in Resident 1 feeling unsafe and made Residents 1 and 2 feeling they lacked privacy. During a concurrent observation and interview on 8/8/2025 at 12:31 p.m., with Resident 1 (female) in the resident's room, Resident 1 stated she felt unsafe because she was sharing the bathroom with Resident 2 (male) and further stated there was no bathroom lock. On observation, Resident 1's room was situated beside a room for male residents and there was one shared bathroom inside the two rooms with no locks in the doors. Resident 1 further stated that Resident 2 had to raise his arm outside of the bathroom door so that she knew that Resident 2 was using the bathroom. Stated she was not sure if it was okay for female residents to share bathrooms with male residents. During a review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool) dated 6/5/25, indicated Resident 1 was able to make herself understood by others and was able to understand others. The MDS also indicated Resident 1 only needed set up and clean up assistance in toileting and only needed supervision from the staff when walking a distance of 150 feet. During an interview on 8/8/25 at 12:40 p.m., with Resident 2, the resident stated he shared the bathroom with Resident 1 and stated that there should be a lock for privacy. Stated it was uncomfortable for him to share his bathroom with a female. During a review of Resident 2's MDS, dated [DATE], it indicated Resident 2 usually made himself understood by others and was usually able to understand others. The MDS also indicated Resident only needed supervision from the staff in toileting and when walking a distance of 150 feet. During an interview on 8/8/25 at 1:00 p.m., with the Director of Nursing (DON), the DON acknowledged that female residents should not be sharing bathrooms with male residents. Stated the risk was lack of privacy for the residents. Further stated there should be a bathroom lock to prevent abuse. During a review of the facility's policy and procedure (P&P) titled, quality of life-Homelike Environment, revised February 2021, the P&P indicated, .Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.

Based on observation, interview and record review, the facility failed to ensure two of three sampled residents' (Resident 1 and Resident 3) rooms were maintained in a comfortable and safe temperature level when Resident 1 and 3's room air temperature was at 84 degrees Fahrenheit during a heat wave. This failure had the potential to cause overheating in residents and discomfort during severe hot weather. Findings: During a facility tour on 7/3/24 at 12:06 p.m., with Maintenance Supervisor (MS), the air temperature in Resident 1's room was 84 degrees Fahrenheit. During a review of Resident 1's Minimum Data Set (MDS - Resident assessment and care guide tool), dated 6/11/24, the MDS indicated Resident 1's Basic Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. The MDS indicated Resident 1 was able to recall the correct year, month, and day of the week. The MDS indicated Resident 1 had diagnosis of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). During a concurrent observation and interview on 7/3/24 at 12:06 p.m., Resident 1 laid in bed with loose-fitted clothes, awake and verbally responsive. Resident 1 stated her room was hot and uncomfortable in the afternoon despite the use of fan. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's BIMS, score was 15 and indicated intact mental status. The MDS indicated Resident 2 was able to recall the correct year, month, and day of the week. The MDS indicated Resident 2 had diagnosis of asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe). During an interview on 7/8/24 at 10:40 a.m., Resident 2 stated the facility was hot in the afternoon over the weekend. Resident 2 stated the air condition had been faulty for weeks and not repaired. Resident 2 stated facility does nothing about it. Resident 2 stated sometimes air condition blows cool air sometimes it blows warm air. During a facility tour on 7/9/24 at 10:58 a.m., with MS, the air temperature in Resident 1's room was 84 degrees Fahrenheit. During an interview on 7/9/24 at 10:58 a.m., with Resident 1, Resident 1 stated her room temperature swings from okay to very hot and is not comfortable in the afternoon. Resident 1 stated despite the fan working continuously the room is too warm. Resident 1 stated there was no cool air flow through the vent. Resident stated the air condition had been faulty for some two to three weeks ago. During a facility tour on 7/9/24 at 11:10 a.m., with MS, the air temperature in Resident 3's room was 84 degrees Fahrenheit. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's BIMS score was 08 and indicated impaired mental status. The MDS indicated Resident was unable to recall the correct day of the week but was able to recall the correct week and year. The MDS indicated Resident 3 had diagnosis of Dementia (a group of thinking and social symptoms that interferes with daily functioning). During a concurrent observation and interview on 7/9/24 at 11:10 a.m., Resident 3 was sitting in a wheelchair in the hallway with a portable air condition cooler blowing cool air nearby. Resident 3 stated his room temperature was too warm in the afternoon and made him uncomfortable. During an interview on 7/3/24 at 12:58 p.m., with Administrator (Admin), Director of Nursing (DON) and MS, Admin stated the air condition technician was at the facility to repair the air condition unit. MS stated he checked the air condition unit quarterly and replaced air filters. MS could not provide records of air filter replacements and preventative maintenance records for the facility's air condition units. Admin and MS could not provide preventative maintenance record for the cooling system. Admin stated facility's MS does preventative maintenance of the air conditioning units. During an interview on 7/9/24 at 10:35 a.m., Admin stated the air condition technician made some repair but there were still rooms with air flow problems and not circulating cool air properly. During a review of the facility's policy and procedure (P&P) titled, Maintenance Services, revised December 2004, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. During a review of the Air Condition manufacturer manual titled, DIY AC Maintenance indicated; on an average, filters should be replaced every 90 days depending on where you live and how often your air conditioner operates. However, your HVAC contractor can provide the proper filter replacement schedule for your particular air conditioning unit. Reference: https://www.goodmanmfg.com.

Based on observation, interview and record review, the facility failed to supervise one of three residents (Resident 1) with a history of falls when, Resident 1 was not supervised and assisted to the bathroom. This failure resulted in Resident 1 sustaining a left hip fracture (broken bone), experiencing pain, and transferring to Acute Care Hospital 1 (ACH 1) for follow up care. Findings: During a record review of Resident 1's Admission Record, printed on 4/25/24, the record indicated Resident 1 was admitted to the facility on [DATE], with dementia (memory loss), muscle weakness, abnormalities of gait (a person's manner of walking) and mobility, and abnormal posture. During a record review of Resident 1's Annual Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessment, dated 2/21/24, the MDS assessment indicated Resident 1 used a walker for mobility. The assessment also indicated Resident 1's need for supervision during activities of daily living (Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation (walk, move about), toileting, eating, transferring, and communicating.) and mobilization. The record indicated Resident 1's Brief Interview of Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was nine (9) out of 15, indicating moderately impaired mental status. The BIMS indicated Resident 1 was unable to recall the correct year and day of the week and was able to recall recent information with cueing. During a concurrent observation and interview on 4/25/24, at 9:55 a.m., with Resident 1, Resident 1 was lying in bed and stated the bathroom in her room had an out of order sign, and she fell while trying to use the bathroom. Resident 1 stated she did not know how she fell . Resident 1 then stated she did not remember if she fell and denied pain/discomfort. During a record review of Resident 1's Physician Order, dated 5/25/23, the Physician Order indicated to monitor the resident for wandering [become lost or confused about their location]/ambulation without assistance . redirect as needed every shift for fall precautions. During a record review of Resident 1's Fall Risk Care Plan, initiated on 3/23/23, the Fall Risk Care Plan indicated, The resident is at risk for falls [related to] psychoactive drugs (drugs that change the function of the nervous system and results in alterations of perception, mood, cognition and behavior) use ., staff was to Anticipate and meet the resident's needs ., and The resident needs prompt response to all requests for assistance. During a record review of Resident 1's Morse Fall Scale (a tool which determines the residents' likelihood of falling), dated 12/15/23, the record indicated Resident 1's fall risk score was 70 (scores greater than 45 indicated a high risk for falls (Morse, J.M 1997)). Resident 1's scoring elements included history of falling, use of an ambulatory aid such as a crutch, cane or walker, and when asked, Are you able to go to the bathroom alone, or do you need assistance? , Resident 1 overestimated or forgot limits. During an interview on 4/25/24, at 10:30 a.m., with Certified Nursing Assistant 1 (CNA 1), outside Resident 1's room, CNA 1 stated, on 4/18/24 around 7:10 a.m., he observed Resident 1 walking in the hall without a walker. CNA 1 stated Resident 1 appeared frail and expressed need for bathroom because her bathroom was out of order. CNA 1 stated his back was towards Resident 1 when Resident 1 was in the hallway. CNA 1 stated he heard a loud thump sound, turned around, and saw Resident 1 on the floor in the hallway. During an interview on 4/25/24, at 10:00 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated around 9:00 a.m. on 4/18/24, Resident 1 was screaming in pain. LVN 1 stated she assessed and noted Resident 1's left hip was deformed. LVN 1 stated Resident 1 complained of pain to left thigh and groaned when touched. LVN 1 further stated she called 911 at 9:30 a.m. and Resident 1 was transported to ACH 1. During a concurrent interview and record review on 4/25/24, at 10:20 a.m., with Director of Nursing (DON), Resident 1's Progress Notes and SBAR (Situation, Background, Assessment, Recommendation- a technique that can be used to facilitate prompt and appropriate communication) communication form, dated 4/18/24 at 9:34 a.m., was reviewed. The progress notes indicated, LVN 1 found Resident 1 in distress with a skin tear on Resident 1's left elbow with significant bleeding and Resident 1 stated is hurting really bad to her [left] side of the hip and inner thigh. The progress notes further indicated, upon assessment, Resident 1's left hip was deformed, Resident 1 had severe pain to touch, and Resident 1 was unable to sit or move their extremity while lying in bed. Resident 1's SBAR indicated Resident 1 had a fall, sustained a laceration (cut) to her left arm, and complained of new pain at a level of 6 out of 10 (10 being worse experienced pain). During a record review of Resident 1's ACH 1 Hospital Discharge Summary, dated 4/18/24, the record indicated Resident 1 had a fall with left hip fracture (broken bone) and underwent subliminary nailing (type of surgery for hip fracture repair) procedure.

Based on observation, interview and record review, the facility failed to provide one of one sampled resident (Resident 1) a functioning toilet that can be accessed quickly, when Resident 1 needed to use the toilet, but her bathroom was Out-of-Order and she did not have a bedside commode. This failure potentially resulted in Resident 1 sustaining a fall while looking for an alternate bathroom, resulting in left hip fracture (broken bone), pain, and transfer to Acute Care Hospital (ACH 1) for follow up care. (Cross reference F689) Findings: During a record review of Resident 1's Admission Record printed on 4/25/24, the record indicated Resident 1 was admitted to the facility on [DATE], with dementia (memory loss), muscle weakness, abnormalities of gait (a person's manner of walking) and mobility, and abnormal posture. During a record review of Resident 1's Annual Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessment, dated 2/21/24, the MDS indicated Resident 1 was occasionally incontinent with bladder. The MDS further indicated Resident 1's Brief Interview of Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was nine (9) out of 15, and indicated moderately impaired mental status. The MDS indicated Resident 1 was unable to recall the correct year and day of the week and was able to recall recent information with cueing. During a concurrent observation and interview on 4/25/24, at 9:55 a.m., with Resident 1 lying in bed, Resident 1 stated the bathroom in her room had an out-of-order sign, and she fell while trying to use the bathroom. Resident 1 stated she did not know how she fell . Resident 1 then stated she did not remember if she fell and denied pain/discomfort. During an interview on 4/25/24, at 10:30 a.m., with Certified Nursing Assistant (CNA 1), outside Resident 1's room, CNA 1 stated, on 4/18/24 around 7:10 a.m., CNA 1 observed Resident 1 walking in the hall without a walker. CNA 1 stated Resident 1 appeared frail and expressed need for bathroom because her bathroom was out-of-order. CNA 1 stated he checked Resident 1's room and found out-of-order signage on the bathroom door and there was no bed side commode in her room as an alternate for a nonfunctional bathroom. CNA 1 stated he proceeded to find an alternate bathroom for Resident 1. CNA 1 stated his back was towards Resident 1 when Resident 1 was in the hallway. CNA 1 stated he heard a loud thump sound, turned around, and saw Resident 1 on the floor in the hallway. During an interview and record review on 4/25/24, 11:00 a.m., with Maintenance Supervisor (MS 1), Maintenance log binder was reviewed. MS 1 stated he learned Resident 1's bathroom was out of order during a meeting on 4/18/24 at approximately 9:30 am. MS 1 stated there was no report of Resident 1's bathroom issue in the maintenance log. MS 1 stated Resident 1's toilet was clogged with toilet wipes and was not flushable. During an interview on 4/25/24, at 11:30 a.m., with the Director of Nursing (DON), the DON stated if residents' bathroom was not functional, a bed side commode could be offered, and staff should check on residents more often and ask them if they needed to go to the bathroom. The DON further stated staff should consider fall risk factors such as resident's mental state, slippery floors, syncope (fainting, or a sudden temporary loss of consciousness), balance disturbances, and were expected to meet and anticipate residents' needs to prevent falls.

Based on observation, interview and record review, the facility failed to protect one (Resident 1) of three sampled residents' right to be free from verbal and physical abuse when, Resident 2 yelled and punched Resident 1 in the face. Resident 1 sustained skin tear with flap (a traumatic wound that is caused by direct contact between the skin and another object) during an altercation in the courtyard. This failure resulted in Resident 1's increased anger and fear for his safety at the facility from Resident 2. Findings: Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 3/26/24, indicated. Resident 1 had clear speech, able to express his ideas and wants, made self-understood and understood others. Resident 1 had no physical or verbal behavioral symptoms such as hitting, kicking, pushing, screaming, cursing, and threatening others. Resident 1 used wheelchair for mobility. Resident 1's diagnosis included depression and quadriplegia (a form of paralysis that affects all four limbs plus torso from neck down). During an interview on 4/11/24, at 11:15 a.m., Resident 1 stated he was outside in the courtyard patio when Resident 2 came to the patio and made a profanity statement about beating another resident. Resident 1 stated he told Resident 2 he will not beat anyone when Resident 1 was present. Resident 1 stated Resident 2 then punched him on the left side of his head eight times and scratched his face. Resident 1 stated there was no staff present during the altercation. Resident 1 stated he was angry and fearful for his safety at the facility from Resident 2. Review of Resident 2's Minimum Data Set, dated dated [DATE], indicated Resident 2 had clear speech, able to express his ideas and wants, and understood what others said to him. Resident 2 used wheelchair for mobility. Resident 2's diagnosis included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). During an interview on 4/11/24, at 11:25 a.m., Resident 2 stated Resident 1 called him a derogatory name. Resident 2 stated Resident 1 made him mad. Resident 2 said he hit Resident 1 in the face. Resident 2 said he tried to avoid Resident 1 every time he saw him. Review of Resident 2's IDT (IDT - interdisciplinary team is a group of health care professionals with various areas of expertise who work together toward the goals of their clients) notes dated 3/13/24 indicated licensed nurse heard a loud verbal altercation from down the hall and noted Resident 1 and Resident 2 outside in the courtyard yelling at each other. Resident 2 stated Resident 1 hit him first. Resident 1 was noted with a small skin tear flap to the face. Resident 2 was noted with bleeding from two small skin tears in-between knuckles of the right hand. Incident was not witnessed by staff. During an observation of the courtyard, on 4/11/24, at 1:10 p.m., with Administrator (Admin) and Director of Nursing (DON), the courtyard had no visual oversight by the nursing staff. Admin stated there was no staff presence during the resident-to-resident altercation. Review of Resident 2's behavior care plan, initiated 5/31/23, indicated Resident 2 had behavior problems; easily get angry, yelling and cursing at other residents and staff. Resident 2 had the followings episodes of verbal and physical altercation: 7/11/23 - encounter with another resident holding him on his wrist and calling him names; 7/16/23 - Resident 2 had verbal altercation with another resident; 11/11/23 - Resident 2 had alleged physical encounter with another resident both denied touching each other; 11/18/23 - Resident 2 had alleged physical altercation with another resident; 1/8/24 - Resident 2 had alleged physical altercation; 3/12/24 - Resident 2 had resident to resident altercation; Resident 2's care plan intervention included anticipate and meet resident's needs. Review of Resident 1's psychosocial well-being care plan, initiated 7/16/23, indicated Resident 1 had potential for verbal altercation with another resident. During an interview on 4/11/24, at 2:35 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated she heard screaming from the courtyard patio and went to the area. LVN 1 said Resident 1 stated Resident 2 hit and punched him in the face. Resident 1 sustained skin tear to the face. LVN 1 stated there was no staff presence at the patio during the altercation. LVN 1 stated she did not remember if she updated Resident 1's care plan to address the altercation and injury sustained. LVN 1 stated she did not call the police but called the Administrator. During a concurrent interview with DON and clinical record review, on 4/11/24, at 12:15 p.m., DON stated Resident 1's care plan was not revised and updated to address verbal and physical altercation with Resident 2. DON said Resident 1's injury to face was not addressed on his care plan. DON stated she thought the focus was on Resident 2. During a review of the facility's policy and procedure (P&P) titled, Abuse, Prevention, dated 9/1/2008, the P&P indicated, Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .

Based on observation, interview, and record review, the facility failed to promote one of three sampled residents (Resident 1) right to privacy when the licensed social worker (SW) discussed Resident 1 ' s personal care with Resident 1 ' s family without Resident 1 ' s consent. This failure resulted in Resident 1 feeling emotional distress. Findings: During a review of Resident 1 ' s facility Admission Record on 2/7/2024 at 11:15 a.m., the Admission Record indicated Resident 1 was admitted in July 2022 with a diagnosis of muscle weakness. The Admission Record indicated Resident 1 was his own responsible party. A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) indicated Resident 1 was alert and oriented to the day, year, month and could recall words presented to him. During an interview on 2/7/2024 at 10:35 a.m., with the facility ' s Director of Nursing (DON), the DON stated the facility had wanted to deep clean Resident 1 ' s room, but Resident 1 often stayed in bed and did not like the smell of the cleaning agents, which made deep cleaning Resident 1 ' s room difficult. The DON stated the suggestion of involving family members to encourage Resident 1 to get out of bed more and participate in his own care had been discussed with the Social Worker (SW). The DON stated after that discussion with the SW, Resident 1 had complained the facility social worker had spoken to one of Resident 1 ' s family members, FM 1, about encouraging Resident 1 to get out of bed more. The DON stated had told Resident 1 the facility would talk to family members in order to encourage residents. The DON stated Resident 1 had told the DON that Resident 1 did not like that, and it was no one else ' s business. During an observation and concurrent interview on 2/7/2024 at 10:50 a.m., with Resident 1, in Resident 1 ' s room, Resident 1 lay in bed, under the bedcovers. Resident 1 stated he stayed in bed because it was a hassle to get up and into the wheelchair. Resident 1 stated the facility social worker had talked to Resident 1 ' s family without his OK and it bothered him a lot. The social worker was not available for interview during the abbreviated survey. During an interview on 2/21/2024 at 10:07 a.m., with FM 1, FM 1 stated Resident 1 wanted to keep FM 1 out of his business. FM 1 stated the social worker told FM 1 Resident 1 had refused showers for the last year and had only had bed baths. FM 1 stated Resident 1 was upset staff had shared the information with FM 1. During a record review of the facility policy and procedure (PNP) titled, Resident Rights, dated 9/1/2008, the PNP indicated, The Resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of family and Resident groups .

Based on observation, interview, and record review, the facility failed to ensure the care plan for Resident 1 to receive a consult with psychiatric (specialist in providing mental, emotional, medical or behavioral care) services were implemented. This failure resulted in the potential for Resident 1 to have compromised psychosocial well-being and at risk of another altercation with another resident. Findings: Review of the clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others). A review of Resident 1's behavior care plan initiated on 7/11/23, by the Director of Nursing (DON), indicated Resident 1 was at risk of having psychosocial well-being problems because of an encounter with another resident. The care plan indicated an intervention for Resident 1 to have a consult with psychiatric services. A review of Resident 1's behavior care plan initiated on 7/16/23 by the DON, indicated Resident 1 had another altercation with another resident. The care plan again indicated the same intervention for Resident 1 to have consult with psychiatric services. During an interview on 7/31/23, at 2:22 p.m., with Licensed vocational nurse (LVN 1), LVN 1 stated, Resident 1 had a verbal altercation with Resident 2 on 7/11/23. LVN further stated Resident 1 had the behavior of getting verbally aggressive. During an interview on 7/31/23, at 2:55 p.m., with Social Services Director, SSD stated, Resident 1 has a behavior of picking a fight and wanted to go to anger management (class). SSD acknowledged that Resident 1 should have had the psychiatric services consultation. During an interview on 7/31/23, at 4:16 p.m., DON stated Resident 1 was not referred for psychiatric services yet. During a review of the facility's policy and procedure (P&P) titled, Care Planning-IDT Care Planning Conference, dated 2008, the P&P indicated, To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions.

Based on observation, interview and document review, the facility failed to ensure one (room [ROOM NUMBER]) of three residents ' showers inspected, was cleaned and disinfected after use. A pile of clean towels were in the bathroom sink and plastic bags with soiled items were on the floor. These failures exposed residents to contamination. Findings: During an interview on 5/2/23 at 11:21 a.m., Resident 1 stated the shower in her room was not regularly sanitized and asked staff to clean it before her showers. Resident 1 stated she was concerned with athletic (athletes) feet- a contagious condition spread through contaminated floors, towels, or clothing. Resident 1 stated she was scared she might develop toe fungus when she stepped on the shower floor with her bare feet. During an observation on 5/2/23 at 11:27 a.m., a moist, green matter, approximately the size of a half dollar, was on the shower floor in Resident 1 ' s bathroom. Inside the sink was a pile of clean towels. Underneath the sink and on the floor was a plastic bag with a resident gown inside. A pink wash basin was on top of the plastic bag. During an interview on 5/2/23 at 11:32 a.m., the Licensed Vocational Nurse (LVN) described the green matter on the shower floor as poo-poo. LVN stated clean towels did not belong in the sink and the plastic bag is supposed to go to the laundry room. During an interview on 5/2/23 at 12:17 p.m., the Certified Nursing Assistant (CNA) 1 stated she was not aware of the current state of the bathroom in room [ROOM NUMBER]. CNA 1 stated the bathroom was used by other residents that did not have showers in their own rooms. CNA 1 stated the sink is a dirty area where clean items are not placed. CNA 1 stated dirty linen in the plastic bag are supposed to be walked over to the hallway closet and placed in a barrel. During an interview on 5/2/23 at 12:57 p.m., the Infection Control nurse (ICN) stated dirty linen goes to the laundry room. In room [ROOM NUMBER] ' s bathroom, ICN identified a resident ' s dirty brief inside a plastic bag and identified the green matter on the shower floor as poop and it was not sanitary. During an interview on 5/2/23 at 1:26 p.m., CNA 3 stated when he gave his resident a shower in room [ROOM NUMBER], the towels in the sink and plastic bags were already there. CNA 3 stated the towels in the sink should not be used for residents because it was dirty and did not inform housekeeping to clean the shower floor after giving his resident a shower.

Based on record review and interview, the facility failed to follow infection control policies and procedures when: 1. staff did not answer COVID-19 screening questions before entering the facility; 2. Resident 14 and Resident 54's nasal cannula and bilevel positive airway pressure (BiPAP, a machine used to deliver pressured air to lungs) mask were not bagged and touching the floor; 3. Resident 54's BiPAP mask had brown matter sticking to the mask; and 4. staff did not clean the morphine sulfate (MS- medication to relieve moderate to severe pain) solution re-usable syringe for Resident 377 after use. This deficient practice had the potential to spread infection. Findings: 1. During a concurrent record review and interview of the facility document, Willow Pass Healthcare Center Visitor Symptoms Screening Log with Infection Preventionist (IP) on 10/13/22, at 1:13 p.m., nocturnal shift staff were not screened before their shifts from 10/5/22 through 10/13/22. IP stated this document was for all visitors who entered the facility, including staff. IP stated there were no records of nocturnal shift staff being screened from 10/5/22 through 10/13/22. IP further stated it is important for everyone entering the facility to be screened for COVID-19 to prevent the spread of infection. A review of the facility's undated document titled, COVID-1: Clinical Protocol, indicated, Screening for Health care staff 1. All staff will be required to answer screening questionnaire and have their temperature checked before the beginning of the shift or start of work. 47382 2. During a review of Resident 14's Admission Record, dated 10/10/22, the record indicated Resident 14 was admitted to the facility in 6/2022. During a record review of Resident 14's physician order dated 9/21/22, the order indicated to administer oxygen (O2) at 2 liters/minute as needed via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels). During a record review of Resident 54's Admission Record, dated 10/10/22, the record indicated Resident 54 was admitted to the facility in 2014. During a record review of Resident 54's physician order dated 12/13/18, the ordered indicated to administer BiPAP during naps and at bedtime for Resident 54. During an observation with IP present, on 10/10/22 at 10:03 a.m., Resident 54 and 14's shared room was observed. Resident 54's BiPAP mask and tubing were found hanging from the left side bedrail of Resident 54's bed and was touching the floor. Resident 14's O2 tubing was connected to the O2 concentrator and nasal cannula was on the floor next to left side of Resident 14's bed. During a follow up observation and interview with Licensed Vocational Nurse (LVN) 2 on 10/10/22, at 10:40 a.m., LVN 2 stated she had changed Resident 14's O2 tubing. The O2 tubing was still unbagged, coiled up on top of the O2 delivery unit/O2 concentrator. LVN 2 was unable to state any risks related to keeping the O2 tubing/NC being unbagged and on the floor. 3. During an observation and interview with IP, on 10/10/22 at 10:03 a.m., Resident 54's BiPAP mask was open to air, not bagged, and had beige-brown residue on the inside of the mask. IP stated Resident 54's BiPAP mask should be cleaned after each use, otherwise it placed Resident 54 at a risk for respiratory infection. During a record review of Policy and Procedure (P&P) titled Oxygen Storage and Use dated 9/01/08, the P&P showed, the oxygen cannula, mask, etc. shall be changed when soiled. The cannula, mask, etc. shall be stored in a plastic bag when not in use. 46604 4. During a medication administration observation on 10/12/22, at 9:05 a.m., Licensed Vocational Nurse (LVN) 6 sanitized hands, unlocked narcotic drawer, took out the morphine sulfate solution for Resident 377, pulled out the used syringe in the box, bluish solution in appearance was still left in the hub of the syringe, reused the syringe without cleaning, to draw up 0.5 ml (a unit of measure) of the medication. LVN 6 then squirted the drawn-up bluish solution into a medicine cup, put the used syringe back in the box, and placed it back in the locked drawer. A review of Resident 377's Admission Record, dated 10/14/22, indicated Resident 377 was admitted to the facility on [DATE] with diagnoses of cancer of pancreas and placed under hospice care. A review of Resident 377's Nursing Admission Screening History, dated 10/6/22, indicated Resident 377's cognitive status was intact. It further indicated Resident 377's pain assessment indicated almost constant pain, difficulty to sleep at night, limited day to day activities because of pain, and pain level at 6 (moderate pain) at the time of assessment. A review of Resident 377's Order Summary Report, dated 10/13/22, indicated order for Morphine Sulfate Solution 20 mg/ml (a unit of measure), give 0.5 ml by mouth every hour as needed for severe pain (7-8). During an interview with LVN 6 on 10/12/22 at 9:05 a.m., LVN 6 stated she should have washed the syringe after use. When asked what if syringe fell to the floor the LVN 6 stated will use a new syringe. During an interview with Infection Preventionist (IP) on 10/12/22 at 2:00 p.m., the IP stated when drawing up medicine from multi-vial dose old syringe, the syringe should be discarded, and a new syringe should be used to prevent cross contamination and infection. IP further stated extra syringes should be in the medication cart. No new syringes were in the medication cart. During an interview with Director of Nursing (DON) on 10/12/22 at 2:30 p.m., DON stated Morphine Sulfate oral solution is packaged with a re-usable syringe. DON stated the syringe should be cleaned with each use, and covered in a plastic bag. DON further stated also nurses should have extra syringes in the medication cart. A review of the facility's policy and procedure (P&P) titled, Medication Administration Preparation of Medication Administration, dated 10/2007, indicated, The nurse or authorized staff member on duty ensures equipment and supplies relating to medication storage and use are clean and orderly. The following equipment and supplies include oral syringes, droppers, medication cups .

Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment to three of three sampled residents (Resident 14, 54, and 6) when 1. Resident 14 and Resident 54's standing/ table fans had visible dust, dirt and debris; and 2. Resident 6 had rodent droppings next to her beds for three days. These failures placed Residents 6, 14, 54 at risk for infection and loss of a homelike environment due to unclean and unsanitary conditions. Findings: 1. During a concurrent observation and interview on 10/10/22, at 10:30 a.m., with Certified Nurse Assistant (CNA) 1, Resident 6 and Resident 14's shared room was observed. Resident 6 had a black standing fan next to the bedside table directed towards her. Resident 6's fan had dust, dirt and white papery debris on the fan casing. Resident 14 had a large white colored square fan sitting on top of her bedside table pointed at her. Resident 14's fan had a thick dark brown layer of dust over the fan casing. CNA 1 stated the fans were personal belongings of Resident 6 and Resident 14 and she did not know the cleaning schedule for residents' personal items. CNA 1 also stated she had never seen Resident 14's fan being cleaned in the last six months since Resident 14 was admitted to the facility. During observation and interview accompanied by Housekeeper (HSKP) 1, and CNA 3 on 10/12/22, at 1:32 p.m., Resident 14 stated the dirt on her fan bothered her and it blows on my face. Resident 14 stated it affected her breathing and made her worried that she breathed it into her lungs. CNA 3 stated she reported Resident 14's dirty fan to a registered nurse, whom she could not recall, approximately one month ago. CNA 3 stated she noticed Resident 6 and Resident 14's fans had the dirt and residue since she first started working at the facility about three months ago. HSKP 1 stated it was the environmental services staff's responsibility to clean the fans. 2. During a concurrent observation and interview with CNA 1 on 10/10/22, at 11:46 a.m., CNA 1 shined a cell phone light into the corner of the room by Resident 6's bedside table. The floor had multiple black colored matter about one-half inch long matter, along with about one-fourth inch size bread piece. CNA 1 stated the black matter were rodent droppings. During a follow up observation on 10/11/22, at 8:50 a.m., rodent droppings and a piece of bread was still present in corner near Resident 6's bedside table. During another follow up observation of Resident 6, 14, and 54's room on 10/12/22 at 9:00 a.m., rodent droppings and bread piece was still in corner near Resident 6's bedside table. During an interview with HSKP 1 on 10/12/22 at 1:30 p.m., HSKP 1 stated she had not cleaned Residents 6, 14, and 54's shared room yet and was not aware of the rodent droppings in the corner of the room next to Resident 6's bedside table. During an interview with Maintenance Supervisor (MS) on 10/13/22 at 9:03 a.m., MS stated day shift housekeeping staff were responsible to clean the furniture and rooms. During a record review of facility's Policy and Procedures (P&P) titled Resident Rights dated 9/01/08, P&P stated the facility shall be clean, sanitary, and in good repair at all times.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care for one of one sampled resident (Resident 14) who required extensive assistance when Resident 14's scheduled showers and bed baths were missed. This failure placed Resident 14 at risk for infection and skin breakdown. Findings: During a record review of Resident 14's Admission Record, dated 10/10/22, the record indicated Resident 14 was originally admitted to the facility in 6/2022. During a record review of the Minimum Data Set (MDS - an assessment tool used to guide care) dated 7/04/22, it indicated Resident 14 was alert and able to make her needs known. The MDS assessment also indicated Resident 14 required one staff's extensive physical assistance for bathing and showers. During a review of Resident 14's Activities of Daily Living Care Plan, dated 6/27/22, the care plan indicated, the goal was to maintain or develop clean and intact skin. During a concurrent observation and interview on 10/10/22, at 11:50 a.m., Resident 14 was observed lying in bed. Resident 14's skin on visible areas including face, arms and lower legs was dry. Resident 14's hair was tangled. Resident 14 stated she did not always get to wash because staff were too busy to help her, and Resident 14 did not receive a shower or bath on 10/10/22. During a record review of facility's undated document titled, Shower schedule, indicated B (location of the bed in a multi-occupancy resident room) bed showers were scheduled for Tuesdays and Fridays. The shower schedule indicated, If patient refuses [shower] try Bed bath .please let medical records know and medical records follows up with supervisor, patient can get shower next day. During a concurrent interview and record review on 10/12/22, at 9:06 a.m., with Certified Nursing Assistant (CNA) 3, facility's binder for shower sheets were reviewed. CNA 3 stated staff kept the documentation for shower day skin inspection sheets in the binder. CNA 3 stated Resident 14 was scheduled to receive shower on Tuesdays and Fridays and bed bath on non-shower days. CNA 3 stated documentation of shower or bath completion or refusal was kept in a binder at nurse's station. CNA 3 stated the licensed nurse was expected to review the completed shower sheets. CNA 3 stated she was Resident 14's assigned assistant on that day and was familiar with her care. CNA 3 stated Resident 14 at times refused showers or bed baths but staff did not explain the risks and benefits of receiving showers or bed baths due to her belief that Resident 14 didn't want to hear it. CNA 3 stated the risk of not bathing and providing showers to Resident 14 were skin breakdown and infection. During a record review the facility's Shower Day Skin Inspection binder sheets from 7/1/22 to 9/30/22, it indicated there was no documentation for Resident 14 showers or bed baths on Tuesdays/ Fridays falling on 7/22/22, 8/2/22, 8/9/22, 8/12/22, 8/19/22, 8/26/22, 8/30/22, 9/2/22, 9/6/22, 9/9/22, 9/13/22, 9/16/22, and 9/30/22. During a concurrent interview and record review with the Director of Nursing (DON) on 10/12/22, at 1:51 p.m., Resident 14's progress notes from 7/1/22 to 10/12/22 were reviewed. DON stated nurses were responsible to document the implemented interventions for refusal of care in progress notes. DON stated she was not able to locate nursing shower and bath documentation in progress notes and will keep looking. During a follow up interview with DON on 10/14/22, at 08:15 a.m., DON stated she was unable to find nursing documentation related to their interventions based on Resident 14's refusal to shower or bathe in past three months. Record review of the policy and procedure (P&P), Activities of Daily Living Supporting dated March 2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The P&P further indicated if the resident refused care and treatment, the resident will be informed of the risk and benefits of the proposed care or treatment, and the refusal and information are documented in the resident's clinical record.

Based on observation, interview and record review, the facility failed to follow its policies and procedures for oxygen administration for two (Resident 14 and Resident 68) of four sampled residents receiving oxygen therapy when there was no sign outside of Resident 14 and Resident 68's room stating Oxygen in Use and when Resident 68 was receiving oxygen therapy without a doctors order. These deficient practices may result in placing all individuals in the facility at risk of potential harm in the event smoke or fire in the vicinity of the oxygen container and ineffective oxygen therapy for Resident 68. Findings: A review of Resident 68's Admission Record, dated 10/11/22 indicated Resident 68 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (a chronic condition in which the heard doesn't pump blood as well as it should). A review of Resident 68's Minimum Data Set (MDS- an assessment tool) dated 9/18/22 indicated Resident 68 receives oxygen therapy while a resident in the facility. During a concurrent observation and interview on 10/10/22 at 10:10 a.m., Resident 68 was receiving oxygen at 5 liters per minute. A Oxygen in Use sign was not present outside of Resident 68's room. RN 1 acknowledged Resident 68 was receiving oxygen and a Oxygen in Use sign was not present outside of Resident 68's room. During a concurrent record review and interview on 10/11/22 at 9:30 a.m. of Resident 68's doctor's orders with DON, DON stated Resident 68's new oxygen order's were added on 10/10/22 at 6:32 p.m. DON further stated Resident 68 was receiving oxygen on 10/10/22 at 10:10 a.m. without a doctor's order. DON stated the Oxygen in Use sign should be placed outside of Resident 68's room for safety reasons because the facility has resident's who smoke. 47382 During a record review of Resident 14's Admission Record dated 10/10/22, the record indicated Resident 14 was originally admitted to the facility in 6/2022. During an observation on 10/11/22, at 08:50 a.m., at Resident 14's bedside, Resident 14 was asleep and received oxygen (O2) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). There was no signage posted outside Resident 14's room, indicating O2 was in use. During a record review of Resident 14's physician order dated 9/21/22, the order indicated to administer O2 at 2 Liters/minute as needed via nasal cannula. During an observation and interview on 10/11/22, at 11:44 a.m., with Infection Preventionist/Nurse Manager (IP/NM), Resident 14's room was observed. IP/NM stated the signage for oxygen use was not posted outside the room. IP/NM 1 stated the importance of signage for oxygen in use was for safety of the residents because oxygen is a fire hazard. IP/NM then brought a No Smoking/Oxygen in Use signage and put it up on the door frame for Resident 14's room. During an interview with DON on 10/12/22, at 1:51 p.m., DON stated failure to put signage up was a safety risk because oxygen is volatile and a fire hazard. During a record review of facility's undated Policy and Procedures (P&P) titled, Oxygen Administration, indicated the Oxygen in Use sign shall be placed on the room entrance door. During a record review of facility's P&P titled Oxygen Storage And Use dated 9/1/08, the P&P indicated, a No Smoking sign shall be placed on the resident's door when oxygen is ordered.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled (those with high potential for abuse or addiction) and non-controlled medications when: 1. Random controlled medication use audits for five out of 5 residents (Residents 8, 14, 29, 45 and 63) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents; 2. An emergency kit (e-kit, a kit containing medications and supplies for immediate use during a medical emergency) containing oral medications had medication removed without the required documentation of the removal in accordance with the facility policy and procedures (P&P); and 3. Medications for disposal were not rendered unusable, irretrievable, and were not securely stored when old, clear plastic beverage bottles with holes cut out were used for drug disposal in 2 of 2 medication carts inspected. These failures had the potential for the facility to not have accurate accountability of controlled and non-controlled medications and abuse or misuse of these medications. Findings: 1. The controlled medication CDR for five random residents receiving controlled medications were requested for review during the survey. During an interview on 10/11/22, at 1:52 p.m., with Director of Nursing (DON), DON confirmed the expectation was anytime a nurse administered a controlled medication, they were expected to sign it out of the CDR and document it on the MAR. 1a. Resident 45 had a physician's order for Norco 5/325 milligram (mg) (a pain medication), 2 tablets every 8 hours as needed for pain, dated 6/29/22. During a concurrent interview and record review on 10/11/22, at 1:57 p.m., with DON, a review of Resident 45's CDR for Norco and 7/2022, 8/2022, 9/2022 and 10/2022 MAR indicated nursing staff removed the following from the medication cart and documented on the CDR without documenting the respective administration on the MAR: 2 tablets on 8/4/2022, 2 tablets on 8/6/2022, and 2 tablets on 9/26/2022. The MAR indicated 2 tablets were administered on 8/11/2022 but were not documented on the CDR. DON verified this finding and confirmed they should have been documented in both the CDR and the MAR. 1b. Resident 8 had a physician's order for methadone (a medication used to treat opioid addiction) 5 mg, 1 tablet via J-tube (a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) two times a day for chronic pain, dated 7/21/21. During a concurrent interview and record review on 10/11/22, at 2:08 p.m., with DON, a review of Resident 8's CDR for methadone and 9/2022 and 10/2022 MAR indicated nursing staff removed 2 tablets on 9/20/22 from the medication cart and documented on the CDR without documenting the respective administration on the MAR. DON confirmed the finding. 1c. Resident 63 had a physician's order for oxycodone (a pain medication) 5 mg, 1 tablet every 8 hours as needed for pain, dated 5/3/21. During a concurrent interview and record review on 10/11/22, at 2:12 p.m., with DON, a review of Resident 63's CDR for oxycodone and May 2021 through May 2022 MAR indicated nursing staff removed 1 tablet on 6/16/21 and 1 tablet on 4/10/22 from the medication cart and documented on the CDR without documenting the respective administration on the MAR. DON confirmed the finding and agreed the nurse should have documented the doses in both the CDR and MAR. 1d. Resident 29 had a physician's order for hydrocodone/acetaminophen (a pain medication) 5/325 mg, 1 tablet every 4 hours as needed for moderate to severe pain, dated 11/2/21. During a concurrent interview and record review on 10/11/22, at 2:29 p.m., with DON, a review Resident 29's CDR for hydrocodone/acetaminophen and 9/2022 and 10/2022 MAR indicated nursing staff removed the following from the medication cart and documented on the CDR without documenting the respective administration on the MAR: 1 tablet on 9/28/22, 1 tablet on 10/11/22, 1 tablet on 10/2/22, 2 tablets on 10/3/22, 1 tablet on 10/4/22, and 1 tablet on 10/8/22. The MAR indicated 2 tablets were administered on 10/9/22 but were not documented on the CDR. DON verified and confirmed the finding. 1e. Resident 14 had a physician's order for tramadol 50 mg, 1 tablet every 6 hours as needed for pain, dated 10/9/22. During a concurrent interview and record review on 10/11/22, at 2:38 p.m., with DON, a review of Resident 14's CDR for tramadol and 8/2022, 9/2022, and 10/2022 MAR indicated nursing staff removed the following from the medication cart and documented on the CDR without documenting the respective administration on the MAR: 1 tablet on 8/27/22, 1 tablet on 8/31/22, 2 tablets on 9/6/22, 1 tablet on 9/13/22, 2 tablets on 9/24/22, 1 tablet on 9/26/22, and 1 tablet on 9/29/22. The MAR indicated 1 tablet was administered on 10/2/22 but was not documented on the CDR. DON verified the finding. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Controlled Substances, dated 11/17, indicated, 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: . a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose. 5. Administer the controlled medication and document dose administration on the MAR. 2. On 10/10/22 at 2:07 p.m., an inspection of the facility's e-kits alongside Registered Nurse 2 (RN 2) identified an oral e-kit with red tags, indicating the e-kit had been opened by the facility since delivery from the pharmacy. During an interview on 10/10/22, at 2:07 p.m., with RN 2, RN 2 stated whenever an e-kit was opened and medication was removed, a form was to be filled out and included inside the e-kit to document what medication was removed. She confirmed the documentation would then be sent to the provider pharmacy to notify them of the drug removal. She acknowledged the importance of the documentation and stated, We need a copy in here [the e-kit] so that we can keep track. During a concurrent record review and inspection on 10/10/22, at 2:12 p.m., the list of medications contained in the e-kit, the physical contents of the e-kit, and the emergency medication administration log were examined and compared. The oral e-kit was identified to have 3 tablets of amoxicillin/clavulanic acid (an antibiotic) 875 milligrams (mg, a measurement) missing. There was no documentation inside the e-kit or in the emergency medication administration log to identify the removal of these tablets. During a telephone interview on 10/11/22, at 11:02 a.m., with Pharmacy Technician (PH.T), PH.T confirmed each time the facility removed medication from an e-kit, a record of what was removed, the date and time of drug removal, and the name of which resident the medication was used for was to be sent to the pharmacy. She confirmed the facility did not send documentation to the pharmacy for the amoxicillin/clavulanic acid tablets that were identified as missing from the e-kit. During an interview on 10/11/22, at 12:58 p.m., with DON, DON agreed and confirmed the process for each time a medication was removed from the e-kit was to fill out the form provided inside the e-kit, fax it to the pharmacy, and reorder the e-kit. She acknowledged and agreed to the importance of documenting any drug removal and ensuring the timely replenishment of the e-kit. During a review of the facility's P&P titled, Emergency Medications, dated April 2007, indicated, Any medication that is removed from the emergency medication kit must be documented on the emergency medication administration log. 3. On 10/10/22 at 2:57 p.m., an inspection of the Middle Run Medication Cart with LVN 2 identified a clear plastic beverage bottle, capped, with a piece of white paper taped around it. On the white piece of paper in black handwriting were the words, Wasted Meds, with an arrow pointing up towards the cap, indicating a hole cut out in the shape of a rectangle. Inside the bottle was whole tablets that could have been shaken out of the hole with ease. When asked if she could explain the process of medication disposal, LVN 2 stated, What's wrong with the container the DON made? LVN 2 stated any non-controlled medications that were refused doses or loose pills found in the medication cart were to be discarded in the plastic bottle. LVN 2 agreed the medications inside the plastic bottle were easily retrievable and were not rendered unusable. On 10/11/22 at 9:08 a.m., an inspection of Medication Cart 3 with LVN 3 identified a second clear plastic beverage bottle, prepared in the same manner as the bottle in the Middle Run Medication Cart, for drug disposal. LVN 3 confirmed the bottle was used to dispose of refused doses of medication and loose pills found in the medication cart. She acknowledged and agreed the bottle was not secure and the pills inside could easily be removed or diverted. During an interview on 10/11/22, at 12:46 p.m., with DON, DON stated the facility was waiting for the supplier pharmacy to provide secure containers for drug disposal. When asked if she thought it was an acceptable method of drug disposal if the medications were still usable and retrievable, she stated, No, it's our temporary method. During a review of the facility's P&P titled, Disposal of Medications, Syringes and Needles: Disposal of Medications, dated 12/12, indicated, The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up.

Based on observation, interview, and record review, the facility had a 31.03% error rate when nine medication errors out of 29 opportunities were observed during a medication pass for four of eight residents (Residents 4, 22, 53 and 63). These failures resulted in medications not given in accordance with the prescriber's orders and may affect the residents' clinical conditions. Findings: During a medication pass observation on 10/10/22, at 9:21 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing eight medications, including oyster shell calcium 500 milligrams (mg, a unit of measure) plus vitamin D 5 micrograms (mcg, a unit of measure) tablet, multivitamin with minerals, and losartan (medication to treat high blood pressure) 100 mg for Resident 53. A review of Resident 53's medical record indicated the following physician's orders: - Calcium 500 mg: 1 tablet two times a day, dated 4/21/16 - Multivitamin: 1 tablet one time a day, dated 8/24/18 - Losartan 100 mg: 1 tablet one time a day, hold for SBP (systolic blood pressure, a measurement of blood pressure) less than 105 During an interview on 10/10/22, at 1:15 p.m., with LVN 1, LVN 1 confirmed Resident 53's order for calcium did not include a vitamin D and acknowledged she had administered the incorrect formulation. LVN 1 acknowledged the physician's order for multivitamin did not include minerals and was for a plain multivitamin. When asked if the resident's blood pressure was taken prior to administering losartan, LVN 1 confirmed it had not but should have been, as indicated by the order. During an interview on 10/11/22, at 12:07 p.m., with LVN 2, LVN 2 stated whenever a medication had hold parameters (physician's instructions indicating whether or not to administer medication based on a measurement) for blood pressure, it was important to take the blood pressure reading before administering the medication. She confirmed it was unacceptable to take the blood pressure reading afterwards. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 9/1/2008, indicated, When administration of the drug is dependent upon vital signs or testing, the vital signs/testing shall be completed prior to administration of the medication and recorded in the medical record i.e. BP [blood pressure], pulse, finger stick blood glucose monitoring etc. During a medication pass observation on 10/10/22, at 9:35 a.m., with LVN 1, LVN 1 was observed preparing five medications, including 3 tablets of metoprolol tartrate 50 mg (medication to treat high blood pressure) poured from a bubble pack (a resident specific prepackaged medication), for a total of 150 mg, for Resident 22. A review of Resident 22's medical record indicated a physician's order for metoprolol tartrate 100 mg two times a day, dated 5/22/22. During an interview on 10/10/22, at 1:21 p.m., with LVN 1, LVN 1 confirmed the resident's order for metoprolol tartrate was 100 mg, not 150 mg as administered. LVN 1 acknowledged and agreed the most recent physician's orders were to be checked with the contents of the bubble pack before pouring them into the medication dosing cup for administration. During a medication pass observation on 10/10/22, at 9:56 a.m., with LVN 1, LVN 1 was observed preparing four medications, including aspirin 81 mg chewable tablet, for Resident 63. A review of Resident 63's medical record indicated a physician's order for aspirin enteric coated (E.C., a coating formulation that allows aspirin to pass through the stomach to the small intestine before dissolving) 81 mg, dated 8/30/22. During an interview on 10/10/22, at 1:48 p.m., with LVN 1, LVN 1 verified the physician's order indicated an enteric coated aspirin formulation, not chewable. LVN 1 acknowledged she had incorrectly administered chewable aspirin. During a medication pass observation on 10/10/22, at 10:08 a.m., with LVN 1, LVN 1 was observed preparing ten medications for Resident 4 including aspirin 81 mg chewable, folic acid 400 mcg, albuterol (medication to treat asthma) 90 mcg inhaler, and fluticasone propionate (medication to treat allergies) 50 mcg/spray nasal spray. During an observation on 10/10/22, at 10:22 a.m., with LVN 1, LVN 1 shook the albuterol inhaler and administered two sprays into Resident 4's mouth back-to-back, without pause. LVN 1 then shook the fluticasone nasal spray, removed the cap, and administered one spray into each of Resident 4's nostrils. A review of Resident 4's medial record indicated the following physician's orders: - Ecotrin (brand name for enteric coated aspirin) low strength tablet delayed release 81 mg: 1 tablet a day on Mondays, Wednesdays and Fridays, dated 12/13/19 - Folic acid 1 mg: 1 tablet once daily, dated 12/18/19 - Albuterol 90 mcg inhaler: 2 puffs every 4 hours as needed for wheezing/SOB (shortness of breath) Rinse mouth well after use, dated 7/14/22 - Fluticasone propionate 50 mcg/spray nasal spray: 2 sprays in each nostril one time a day, dated 1/30/21 During an interview on 10/10/22, at 1:25 p.m., with LVN 1, LVN 1 acknowledged she administered chewable aspirin instead of enteric coated. When asked to confirm which folic acid product she administered, LVN 1 removed folic acid 400 mcg from the medication cart and acknowledged the strength did not match the physician's order. When LVN 1 was asked how long she waited between each puff of albuterol administered, LVN 1 stated, two to three seconds. A review of Lexi-Comp, a nationally recognized drug information resource, indicated, If prescribed dose is more than 1 inhalation, wait 1 minute between each inhalation. (www.lexicomp.com; accessed 10/18/2022) During an interview on 10/11/22, at 12:50 p.m., with Director of Nursing (DON), DON stated the nurse administering medication to a resident was responsible for ensuring the physician's orders and manufacturer specifications were followed. When asked if nursing staff were allowed to make substitutions she stated, No, unless there's an order . whatever the [physician's] order states is how medication should be given. During a review of the facility's P&P titled, Medication Administration, dated 9/1/2008, indicated, Medications shall be administered as ordered by a licensed nurse upon the order of a physician/licensed independent practitioner. 46712

Based on observation, interview, and record review, the facility failed to ensure: -Thirteen expired medications were not available for resident use; -Three medications were labeled properly with a pharmacy label to ensure it was used for the right resident; -Two multi-dose injectable insulin (medication to lower blood sugar level) products were dated with an open and discard date, to ensure they were not used beyond the discard date; -One medication had a legible expiration date; and -Six medications with discontinued physician's orders were removed from facility stock. The deficient practices had the potential for residents to receive the wrong medication or medications that were unsafe or with reduced potency from being used past their discard date. Findings: On 10/10/22 at 10:46 a.m., an inspection of the medication storage room and refrigerator with Infection Preventionist/Nurse Manager (IP/NM) identified and confirmed the following: - Expired medications: o 1 vial Tubersol (an injectable solution used to test for tuberculosis), expired 9/1/2022 o 1 container Tucks medicated cooling pads (medicated pads to treat hemorrhoids), expired 6/2022 o 1 vial Novolin N (a type of insulin to treat diabetes), expired 7/2022 o 2 boxes nicotine transdermal system patch 14 milligrams (mg), expired 9/2022 o 1 box nicotine transdermal system patch 7 mg, expired 7/2022 o 1 bottle ketoconazole (medication to treat dandruff) 2 percent (%, a measurement) shampoo, expired 6/2022 o 2 bottles selenium sulfide (medication to treat dandruff) 1% shampoo, expired 8/2022 o 3 bottles magnesium citrate saline laxative, expired 6/2022 - Unlabeled with a pharmacy label: o 2 Lantus SoloStar (a type of insulin to treat diabetes) injectable pens, unlabeled with a pharmacy label o Lorazepam (medication to treat anxiety) 2 milligrams/milliliter (mg/ml, a measurement) concentrate, unlabeled with a pharmacy label -1 tube clotrimazole (medication to treat yeast infection of the skin) 2% vaginal cream, discontinued order During an interview on 10/10/22, at 11:01 a.m., with IP/NM, IP/NM 1 agreed the vial of Tubersol should have been discarded 30 days after it was opened. IP/NM stated if the solution were used to test for tuberculosis after the expiration date, the results could potentially be unreliable. IP/NM confirmed the expired and discontinued medications observed should have been removed from the facility's stock and placed in the medication disposal bin for destruction. IP/NM acknowledged and agreed the Lantus SoloStar and lorazepam 2mg/ml concentrate should have had pharmacy labels on them in order to correctly identify which residents they were for. A review of the product labeling from the manufacturer for Tubersol, dated 10/2/12, indicated, A vial of Tubersol which has been entered and in use for 30 days should be discarded. On 10/10/22 at 2:42 p.m., an inspection of Medication Cart 3 with Licensed Vocational Nurse 1 (LVN 1) identified and confirmed the following: - 1 bottle vitamin C 500 mg, expired 9/2022 - 1 vial insulin glargine (a type of insulin to treat diabetes), opened and undated with open date - 1 box enoxaparin (a medication used to prevent blood clots) 40 mg/0.4 ml injectable, discontinued order LVN 1 verified the insulin glargine did not have an opened date and acknowledged that without an opened date, one does not know when it was due to expire. LVN 1 also confirmed the enoxaparin injectable should have been removed from the medication cart and disposed of as soon as the order for it was discontinued. On 10/10/22 at 2:46 p.m., an inspection of the Middle Run Medication Cart with LVN 2 identified and confirmed the following: - 4 boxes olanzapine (a medication used to treat mood disorders) orally disintegrating tablet (ODT) 5 mg, discontinued order - 1 insulin glargine injectable pen, opened and unlabeled with open date - 1 bottle iron supplement 220 mg/5 ml, illegible expiration date A review of the manufacturer labeling for insulin glargine insulin pen, undated, indicated, Once you take your insulin glargine injection pen out of cool storage, for use or as a spare, you can use it for up to 28 days . Do not use it after this time . LVN 2 confirmed the discontinued medications should have been removed from the medication cart and the insulin pen should have had an opened date so as to know when it was to expire. She acknowledged and agreed the iron supplement expiration date was illegible and should have been discarded and replaced. During an interview on 10/11/22, at 12:20 p.m., with Director of Nursing (DON), DON stated discontinued and expired medications were to be removed from the facility's medication stock and disposed of right away. DON acknowledged and agreed insulin pens should be individually labeled to prevent use for the wrong resident. She confirmed medications with shorter expiration dates after first use were to be labeled with an open date. A review of the facility's policy and procedure (P&P) titled, Medication Storage: Storage of Medication, dated 11/17, indicated, Outdated, contaminated, discontinued or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal ., and reordered from the pharmacy . if a current order exists. A review of the facility's P&P titled, Labeling of Medication Containers, dated April 2007, indicated: 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; e. The prescription number (if applicable); f. The date that the medication was dispensed; g. Appropriate accessory and cautionary statements; h. The expiration date when applicable; and i. Directions for use . 5. Labels for each single unit dose package shall include all necessary information, such as: a. The name and strength of the drug; b. The lot or control number; c. The date drug dispensed; d. Appropriate accessory and cautionary statements; e. The expiration date when applicable; f. The name of the resident and physician. (Note: The names of the resident and physician do not have to be on each unit dose package, but they must be identified with the package in such a manner as to ensure that the drug is administered to the right resident); g. The prescription number; h. The name, address, and telephone number of pharmacy dispensing the drug; and j. Directions for use 46712

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 received treatment and services consistent with professional standards of practice to promote healing of a pressure ulcer (otherwise known as bed sore, a skin injury that result from unrelieved pressure on a body part, usually on a bony prominence like the tailbone, buttocks and hips) and prevent new pressure ulcers from developing when: -the facility staff did not continuously provide assessment, monitoring and physician ordered treatment to an existing Stage II (partial thickness skin loss that involves the deeper layers of the skin, may appear as a shallow crater) pressure ulcer on the coccyx (tailbone). This failure resulted in the worsening of Resident 1's pressure ulcer from Stage II to Stage IV (full thickness skin loss with extensive destruction, tissue necrosis [tissue death], or damage to bone, muscles or tendons); and -the facility staff did not provide treatment and did not monitor the development of a new Stage II pressure ulcer on the left buttock. This failure had the potential to result in delayed management and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: Review of Resident 1's Admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Situation, Background, Appearance, Review (SBAR, a communication tool among health practitioners) Communication Form and Progress Note, dated [DATE] indicated, Resident 1 was transferred to the acute hospital due to low oxygen saturation (amount of oxygen in the blood) level reading of 81 percent (%, normal range is 95% to 100%) at room air. The Progress Note indicated Resident 1 had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Nursing Admission Screening/History, dated [DATE], indicated Resident 1 was re admitted to the facility from the hospital with a Stage II pressure ulcer on the coccyx. The Nursing Admission Screening/History did not indicate measurement of Resident 1s pressure ulcer on the coccyx. Resident 1 was re admitted on hospice care (compassionate care focusing on the quality of life so that the person's last days may be spent with dignity and quality). During an interview and concurrent review of Resident 1's Nursing Admission Screening/History, dated [DATE], and Weekly Wound Observation Tool, dated [DATE], with Registered Nurse Consultant (RNC), on [DATE], at 2:56 p.m., RNC stated, Resident 1's pressure ulcer should have been measured for the staff to know the baseline and to be able to monitor whether the wound is worsening or improving, that way, appropriate treatment and intervention could be provided. RNC stated, aside from the Weekly Wound Observation assessment dated [DATE], Resident 1's clinical record did not indicate a wound assessment was done after [DATE]. RNC stated there should have been a weekly wound assessment for every pressure ulcer. Review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated Resident 1 was at High Risk for developing pressure ulcer. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated [DATE], indicated Resident 1 had a Stage II pressure ulcer and was at risk of developing pressure ulcer. During an interview and concurrent review of Resident 1's clinical record with Treatment Nurse (TN), on [DATE], at 11:20 a.m., TN stated, there was no pressure ulcer care plan to address Resident 1's pressure ulcer despite a high pressure sore risk based on Braden Scale assessment and MDS assessment. TN stated licensed staff should have developed a pressure ulcer care plan. Review of Resident 1's Skin Impairment Assessment by Hospice Nurse (HN) 1 dated [DATE], indicated, Resident 1's Stage II pressure ulcer on the coccyx measured 2.1 centimeters (cm) x 1.4 cm x 0.1 cm. The skin assessment indicated, Noted with [Stage II] pressure injury to coccyx treatment initiated cleanse pressure injury to coccyx with NS [normal saline] pat dry apply med honey [[MEDICATION(S)], used to treat partial to full thickness pressure ulcers with moderate amount of drainage] cover with [dry] dressing daily until healed. Review of Resident 1's Treatment Administration Record (TAR) for [DATE] indicated there was no treatment done on Resident 1's coccyx pressure ulcer for three days from [DATE] to [DATE]. The TAR indicated that treatment order for [MEDICATION(S)], as initiated by HN 1 on [DATE] was not carried out. Review of a telephone visit by Hospice Nurse 4 (HN 4), titled, Visit Note LVN, dated [DATE], indicated current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 1's TAR for [DATE] indicated wound gel treatment order for the coccyx pressure ulcer, as indicated in hospice Visit Note LVN dated [DATE], was not initiated until [DATE]. Review of Resident 1's Medication Review Report for [DATE] indicated an order dated [DATE] to Apply skin barrier to peri area (between genitals and anus) as preventative measure every shift. Another order dated [DATE] indicated, Sacral [a large, triangular bone at the bottom of the spine and between the two hip bones] coccyx: Cleanse with NS, pat dry, apply wound gel (treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The report did not indicate the treatment initiated by HN 1 on [DATE] (day of re-admission) to apply [MEDICATION(S)] on the pressure ulcer. During an interview and concurrent review of Resident 1's clinical record with TN, on [DATE], at 1:09 p.m., another Braden Scale for Predicting Pressure Sore Risk dated [DATE] indicated Resident 1's pressure sore risk went down from High Risk (from [DATE] assessment) to Moderate Risk. TN stated the assessment of Resident 1's sore risk was not accurate and written by Maybe one of the registry nurses who would just throw in numbers. TN stated, Resident 1's Nutritional Screening dated [DATE] indicated Resident 1 had poor appetite and consumed only soups during meals, an information that would have increased Resident 1's risk. Review of RD (Registered Dietician) Note dated [DATE] indicated, under skin, Pressure ulcer. No pressure injuries and no [CONDITION(S)] per nursing weekly summary ,d+[DATE]. RD's recommendation was for monthly weight monitoring per hospice protocol. There was no recommendation for nutritional intervention to address an existing pressure ulcer. During an interview and concurrent review of Resident 1's Weekly Wound Observation Tool, dated [DATE], with TN, on [DATE], at 1:09 p.m., the observation tool indicated Resident 1's pressure ulcer on the sacrococcyx (fused tailbone and sacrum, the triangular bone just above the tailbone) area was a Stage II that measured 3.5 cm x 3.5 cm, unable to determine depth. The tool indicated Resident 1's wound was Worsening and had slough (yellow, tan, white stringy tissue). TN stated, the pressure ulcer should not have been a Stage II because of the presence of slough that indicated wound is worse than a Stage II. The tool listed the current treatment plan as; cleanse with normal saline, pat dry and apply [MEDICATION(S)] to wound bed and cover with dry dressing. The licensed staff who completed the observation tool and signed off on the TAR was not available for interview. Review of Resident 1's Visit Note LVN dated [DATE], indicated [HN 4] Spoke with tx [wound treatment] nurse. New left buttock wound deteriorating. Review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Then cover with a foam dressing daily. Review of Resident 1's TAR for [DATE] indicated physician ordered treatments from hospice for the existing pressure ulcer on the coccyx and the new pressure ulcer on the left buttock were not provided from [DATE] to [DATE]. Review of Resident 1's TAR for February 2021 indicated the physician ordered treatment from hospice for Resident 1's left buttock pressure ulcer was not provided from [DATE] to [DATE]. Review of Resident 1's Skin Impairment Assessment by Hospice Nurse (HN) 2 dated [DATE] indicated Resident 1 had two pressure ulcers, one with an open date of [DATE], and a new one with an open date of [DATE]. The assessment indicated the following: #1, open date [DATE], coccyx area, Stage IV pressure injury that measured 3.5 cm x 3.5 cm x 0.4 cm. #2, open date [DATE], left buttock area, Stage II pressure injury that measured 2.5 cm x 1.7 cm x 0.1 cm. During a telephone interview with Registered Nurse Supervisor (RNS) on [DATE] at 2:53 p.m., RNS stated Resident 1's clinical record did not have any documentation of a new open area on left buttock. Review of Resident 1's Health Status Notes dated [DATE] indicated Resident 1died on [DATE]. Review of Resident 1's Situation, Background, Appearance, Review (SBAR, a communication tool among health practitioners) Communication Form and Progress Note, dated [DATE], indicated, Resident 1 was transferred to the acute care hospital due to low oxygen saturation (amount of oxygen in the blood) level reading of 81 percent (%, normal range is 95% to 100%) at room air. The Progress Note indicated Resident 1 had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview with Hospice Nurse (HN) 3 on [DATE] at 3:02 p.m., HN 3 stated, on [DATE], when Resident 1 died , Resident 1's pressure on the sacrococcyx area looked big and really bad and had odor to it. HN 1 also stated, there was part of the ulcer that was black. During an interview and concurrent review of the facility's undated T time (turning schedule, when residents are turned and repositioned) schedule with TN on [DATE] at 1:09 p.m., TN stated, for all residents who had pressure ulcers, T Time was implemented. TN stated all staff, licensed nurses and Certified Nursing Assistants (CNAs), made rounds every two hours to make sure residents were in a certain position while in bed (i.e., at 2:00 p.m., residents were to face the window, at 4:00 p.m., the residents were to be on their back, etc.). TN stated, because T time was universal for all residents regardless of where the pressure ulcer was located, it was not applicable for Resident 1 because of the location of the ulcer. TN stated, Resident 1 was to be positioned on the back only to eat, otherwise, Resident 1 should be on either side to reduce pressure on the buttock area and tailbone. Review of the facility's T time would have Resident 1 positioned on the back, two hours at a time, for a total of over nine hours a day. During an interview with Restorative Nursing Assistant (RNA) 1 on [DATE], at 2:48 p.m., Resident 1 was one of the residents who was turned and repositioned every two hours because Resident 1 required total assist with all activities of daily living (like turning and repositioning while in bed). RNA 1 stated, around lunch time, residents that included Resident 1, needed to be on their back, after two hours, they were repositioned to face the window. During a review of the facility's policy and procedure (P&P) titled, Wound and Skin Management, released on [DATE], the P&P indicated all staff are responsible for the prompt reporting of any skin related problems and any resident who has pressure sores will receive the necessary treatment and services to promote healing and prevent ulcers from developing. The P&P indicated under assessments, the procedures included, licensed nurse will assess each resident's skin condition weekly and document findings in the weekly progress notes and/or the skin sheet. Interdisciplinary team (IDT, a group composed of individuals representing different departments of the facility) and licensed nurse will assure care plans and progress notes reflect resident's current status and appropriate interventions. Licensed nurse will refer newly identified pressure ulcer to IDT for further assessment and care planning. The P&P also indicated, licensed nurses will document pressure ulcer status at least every seven days and should record the status of the ulcer, location, size and stage. IDT will enter all skin related issues on the resident's care plan and there will be an interdisciplinary approach to skin care.

Based on observation, interview and record review sampled residents (Resident 13), the facility failed to give medications appropriately in order to absorb phosphorus from food and prevent complications for one of one resident getting [MEDICAL TREATMENT] treatment. The facility did not give Resident 13 [MEDICATION NAME] ([MEDICATION NAME] binder-medicine that lowers blood phosphorous for patients with kidney disease). This failure led to Resident 13's abnormally elevated blood serum phosphorus (a mineral contained in most foods) levels, placing Resident 13 at risk for renal osteodystrophy (loss of calcium in the bones), calcification of the heart vessels and death. Findings: Review of the clinical record on 10/6/14 showed Resident 13 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 13 was receiving [MEDICAL TREATMENT] treatment (cleans and filters waste from the blood when the kidneys cannot do this adequately). The physician's orders [REDACTED]. Review of [MEDICATION NAME]'s prescribing information showed [MEDICATION NAME] should be taken with, or immediately after, meals. [MEDICATION NAME] is not effective if given at any other time. According to the National Kidney Foundation, phosphorus, along with calcium (another mineral), is needed for building healthy strong bones and keeping other parts of the body healthy. Normally, kidneys can remove excess phosphorus from the blood and if the kidneys are not well enough, they cannot remove phosphorus very well. High phosphorus levels can cause damage to the body and pulls calcium out of the bones making them weak. "High phosphorus and calcium levels also lead to dangerous calcium deposits in blood vessels, eyes, and heart." Normal phosphorus level is 2.5-4.5 milligram per deciliter (mg/dcl). (Reference: <http://www.kidney.org/atoz/content/phosphorus>). In an interview on 10/8/14 at 3:10 p.m., Licensed Vocational Nurse (LVN) 1 stated that he gave the [MEDICATION NAME] after Resident 13 ate her meals because Resident 13 did not want to take her medications until she finished eating. LVN 1 said, "I don't know if I should hold that medication when she's going to [MEDICAL TREATMENT], right?" During an interview on 10/8/14 at 4 p.m., Resident 13 stated, through an interpreter, she had been taking her medication after she ate her meals. She said the nurses are busy and she had to wait until they passed medications to other residents before her. Resident 13 stated she never took any medication while she ate her meals. She said when she went out for her [MEDICAL TREATMENT] treatments, the facility gave her dinner at 3:30 p.m. When asked if she was given any medication with her 3:30 p.m. meal, she said, "No," and when she came back from [MEDICAL TREATMENT] around 9:00 p.m., her nurse would give her the medication ([MEDICATION NAME]). In an interview on 10/8/14 at 4:25 p.m., LVN 2 confirmed on [MEDICAL TREATMENT] days, Resident 13 took her dinner at 3:30 p.m., left for [MEDICAL TREATMENT] at 4:00 p.m., and returned to the facility at 9:00 p.m. LVN 2 said she did not give Resident 13 [MEDICATION NAME] with the 3:30 p.m. meal, but gave it when she returned to facility at 9:00 p.m. LVN 2 said "I give the [MEDICATION NAME] with Nepro (nutritional supplement) that's considered food." 10/9/14 at 9:20 a.m., during an interview with LVN 3, she stated once a week she would take care of Resident 13 and she had given [MEDICATION NAME] after Resident 13 had her meals. When it was pointed out the order read, "With meals," LVN 3 said, "I'm giving it with applesauce." Review of Resident 13's clinical record and concurrent interview on 10/8/14 at 4:30 p.m., the Medical Records Director (MRD) confirmed that the clinical record only showed laboratory results for 2/2014 and 7/2014. In an interview on 10/9/14 at 9:20 a.m., LVN 3 said that the charge nurses had the responsibility to call the [MEDICAL TREATMENT] center to follow up laboratory results. Review of Resident 13's [MEDICAL TREATMENT] care plan, revised on 9/3/14, showed that one of the approaches planned in her care was to, "Interface with [MEDICAL TREATMENT] unit re: labs, weights and RD (registered dietician) input." Missing laboratory results were requested from the [MEDICAL TREATMENT] center and reviewed on 10/8/14 at 4:10 p.m. The Laboratory Results showed the following increased phosphorus levels (normal range was 2.6-4.5 mg/dcl) 8/5/14- Resident 13's phosphorus level was at 5.1 milligram per deciliter (mg/dcl); 8/19/14-phosphorus level increased to 6.1 mg/dcl; 9/2/14- phosphorus level increased to 6.3 mg/dcl. According to the Clinical Journal of the American Society of Nephrology published February 2011, "[MEDICATION NAME] retention and, later, [MEDICATION NAME] (high level of phosphorous in the blood) are key contributors to [MEDICAL CONDITION] (CKD)-mineral and bone disorder (MBD) ...increased serum phosphorus ...individually contribute to bone disease, vascular (blood vessel) calcification, and cardiovascular (heart/vessel) disease."